pathology haematology

1. Haemopoiesis, blood
malignancies, coagulation and
platelet function defects
Dr H.M.D.Moratuwagama
Department of Pathology
Faculty of Medicine-Ragama

2. Haemopoiesis

3. Sites of Haemopoiesis
• Yolk sac
• Liver and spleen
• Bone marrow
– Gradual replacement
of active (red) marrow
by inactive (fatty)
tissue
– Expansion can occur
during increased need
for cell production

4. Sites of Haemopoiesis
• Fetus- 2 months –Yolk sac
2-7 months-Liver/Spleen
5-9 months-BM
• Infants-BM
• Adult-Axial skeleton

5. Components of Haemopoiesis
• Cells
• Bone marrow stroma
• Growth factors

6. Cells
• Stem cells
• Self renewal
• Plasticity
• Progenitor cells
• Developmentally-restricted cells
• Mature cells
• Mature cell production takes place from the more
developmentally-restricted progenitors

7. Haemopoiesis
Common myeloid progenitor cell
Common lymphoid progenitor cell

8. BM
• Stromal cells
-adipocytes,fibroblasts,osteoblasts,endothelial
cells ,macrophages
• Microvascular network

9. Regulation of haemopoiesis
• Transcription factors
-CEBP-Myeloid
-GATA 1-Erythroid
• Growth factors

10. Haemopoietic growth factors
• Glycoprotein hormones
• GM-CSF
• Granulocyte-Macrophage colony stimulating factor
• G-CSF
Granulocyte colony stimulating factor
• M-CSF
• Macrophage colony stimulating factor
• Erythropoietin(kidney)
• Erythropoiesis stimulating hormone
(These factors have the capacity to stimulate the proliferation of their target
progenitor cells when used as a sole source of stimulation)
• Thrombopoietin(liver)
• Stimulates megakaryopoiesis

11. Haemopoietic growth factors cont.
• Cytokines
•
•
•
•
•
•
•
IL 1 (Interleukin 1)
IL 3
IL 5
IL 6
TNF
SCF (Stem cell factor, also known as kit-ligand)
TGF-β/IFN-γ-Negative effect

12. Role of growth factors in normal
haemopoiesis

13. Erythropoiesis and erythrocytes
• Lifespan – 120 days
• Non nucleated
• Biconcave disc
• Production regulated by Epo
• Needs Fe, B12, folate & other
elements for development

14. Granulopoiesis
• Granulocytes
E
– Neutrophils
– Eosinophils
– Basophils
• Only mature cells are
present in peripheral
blood
N
B

15. Granulopoiesis
• Neutrophil
– 2-5 lobe nucleus
– Primary or secondary
granules
• Pink (azurophilic granules)
• Grey-blue granules
– Life 10 hours
• Precursors
–
–
–
–
–
Myeloblast <4%
Pro myelocytes
Myelocytes
Metamyelocytes
Band form (stab form)

16. Monocytes
• Larger than lymphocyte
• Oval or indented nucleus
• Monocytes >>>>to
macrophage
• Specific function depends
on the tissue type

17. Lymphopoiesis

18. Thrombopoiesis
• Platelet play a major
role in primary
hemostasis
• Life span 7-10 days
• Production, fragmentati
on of cytoplasm
• Megakaryocytes
undergoes endomitotic
division

19. Summary
• Normal haemopoiesis is necessary for the
survival
• It is under the control of multiple factors
• Normal bone marrow environment is
necessary for normal haemopoiesis
• Decreased production results in cytopenias

20. Blood malignancies

21. Blood malignancies
LEUKAEMIA
LYMPHOMA

22. Blood malignancies
Leukaemia
Acute
Chronic
Myeloid Lymphoid Myeloid
Lymphoid
AML
ALL
CML
CLL

23. Aetiology of haemopoietic
malignancies
• Idiopathic
• Inherited factors-Down’s syn.,Blooms
syn.,Fanconi’s anaemia
• Chemicals-ex:Benzene
• Drugs-Alkylating agents
• Radiation
• Infections-viruses-HTLV-1/EBV/HHV8
Bacteria-H pylori-MALT Lymphoma

24. Leukemia
• Acute leukemias: rapid onset, rapid death if
treatment is not successful
• Chronic leukemias: natural history measured
in years, even without initial treatment

25. Two-hit model of leukemogenesis
Loss of function of
transcription factors needed
for differentiation
eg. FLT3, c-KIT mutations
N- and K-RAS mutations
BCR-ABL
TEL-PDGF R
eg. AML1-ETO
CBF -SMMHC
PML-RAR
differentiation
block
Gain of function mutations of
tyrosine kinases
+
enhanced
proliferation
Acute
Leukemia

26. ALL
naïve
B-lymphocytes
Lymphoid
progenitor
Plasma
cells
T-lymphocytes
AML
Hematopoietic
stem cell
Myeloid
progenitor
Neutrophils
Eosinophils
Basophils
Monocytes
Platelets
Red cells

27. Myeloid maturation
myeloblast
promyelocyte
myelocyte
metamyelocyte
band
neutrophil
MATURATION
Adapted and modified from U Va website

28. Acute Leukemia
• accumulation of blasts in the PB/BM

29. AML

30. Auer rods in AML

31. ALL

32. Classification of acute leukemias
ALL
AML
• mainly children
• curable in 85% of
children
• curable in minority of
adults
• mainly adults
• curable in minority of
adults

33. Clincal manifestations
• symptoms due to:
– marrow failure
– tissue infiltration
– leukostasis
– constitutional symptoms
– Others- DIC (acute promyelocytic leukaemia)
• usually short duration of symptoms

34. Marrow failure
• Neutropenia: :infections, sepsis
• Anaemia
: fatigue, pallor
• Thrombocytopenia: bleeding

35. Infiltration of tissues/organs
• enlargement of liver, spleen, lymph nodes
• gum hypertrophy
• bone pain
• other organs: CNS, skin, testis, any organ

36. Constitutional symptoms
•
•
•
•
Fever
sweats
weight loss
LOA

37. Investigations
•
•
•
•
•
FBC+BP
Bone marrow aspiration & trephine biopsy
Special stains-Sudan black/PAS
Flow cytometry
Cytogenetics-t(15,17)-Acute promyelocytic
leukaemia

38. Principles of treatment
• combination chemotherapy
– first goal is complete remission
– further Rx to prevent relapse
• supportive medical care
– transfusions, antibiotics, nutrition
• psychosocial support
– patient and family

39. CML
•
•
•
•
Clonal disorder of pluripotent stem cell
Philadelphia chromasome t(9,22)
Enhanced thyrosine kinase activity(TK)
Clnical features: due to
hypermetabolism, splenomegaly,BMF,leukosta
sis
Treatment-TKI

40. CLL
• Common in elderly/west

41. Lymphoma
Clonal proliferation of lymphoid cells
Non Hodgkin
B cell
T cell
Follicular
Mantle
DLBCL
Hodgkin

42. Clinical presentation
•
•
•
•
Lymphadenopathy
Bone marrow failure
Organ involvement
Constitutional symptoms(B symptoms)

43. Investigations
•
•
•
•
•
•
•
FBC+BP
ESR
LDH
Radiology
Biopsy
Flow cytometry
Immunohistochemistry

44. Management
•
•
•
•
Aggressive/indolent
Stage-early/advanced
Patient factors
Options-watch and wait
Chemotherapy
Radiotherapy
Immunotherapy
BMT

45. Haemostasis

46. HEMOSTASIS
Definition
• Hemostasis: drives from the Greek
meaning “The stoppage of blood flow”.
• Components involved in haemostasis
*Blood vessel
*Platelets
*Coagulation factors
*Coagulation inhibitors
*Fibrinolysis

47. Vessel wall, Blood flow & Coagulation Substances
drmsaiem

48. In Case if there is an Endothelial Injury
(Bleeding must be prevented at site of injury)
drmsaiem

49. HEMOSTASIS
Under normal conditions, the formation and
dissolution of thrombi is maintained in a
delicate balance.

51. Clotting cascade

52. Fibrinolysis

54. Tests used in coagulation disorders
Screening tests
1.FBC+BP
2.BT
3.PT
4.APTT
5.TT
6.Fibrinogen
Others: Factor assays/VWF assays/platelet function
tests/D-dimer/PFA 100/TEG ect.

55. Abnormal bleeding
• Vascular disorders
• Platelet disorders-Thrombocytopenia
Platelet function defects
• Defective coagulation

56. Platelet function disorders
Congenital
• Glanzmann’s disease
/Thrombasthenia
• Bernard- Soulier syndrome
• Storage pool diseases
Acquired
• Anti platelet drugs
• Hyperglobulinaemia
• MPD/MDS
• Uraemia

57. Glanzmann’s disease /Thrombasthenia
• Def. Gp 11b/111a
• Platelet aggregation –only with ristocetin
Bernard-Soulier syndrome
• Gp 1b def.
• Large platelet
• Thrombocytopenia
• Platelet aggregation-not with ristocetin

58. Bernard-Soulier vs Glanzmann’s

59. Coagulation disorders
Congenital
• Haemophilia A(F VIII)
• Haemophilia B(F IX)
• VWD
• Fibrinogen,XI,X,V,II def
Acquired
• Liver disease
• DIC
• Vit K def

60. THANK YOU