Can leukemia be missed in a CBC?

emedicine.medscape.com - Ophthalmologic Manifestations of Leukemias Workup

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CBC and differential

CBC is the most useful initial laboratory test in patients suspected of having leukemia. Most patients will show some abnormality in the CBC and some blasts will be seen in the peripheral smear in patients with acute leukemias. To diagnose CLL, a lymphocytosis of greater than 5000/mm3 must be present. The absolute neutrophil count usually is normal (see the Absolute Neutrophil Count calculator) and red blood cell counts and platelet counts are mildly decreased. In addition, the peripheral smear or bone marrow should show normal mature small lymphocytes with less than 55% atypical or blast forms. CML is defined by its peripheral WBC count. Typically, leukocytosis is in excess of 100,000/mm3. The differential count shows that neutrophil precursors are present. This is accompanied by basophilia and eosinophilia. Unlike those in AML, these cells are mature and functional.

Bone marrow aspiration

Bone marrow aspiration establishes the diagnosis of leukemia. The morphology of blasts usually can differentiate between ALL and AML. In ALL, a homogeneous infiltrate of lymphoblasts replaces the normal bone marrow elements. Lymphoblasts usually are small and measure approximately 14 µm in diameter. They have scant cytoplasm with no granules. The nucleus has no nucleoli or a small indistinct one. For the diagnosis of AML, 30% of the nucleated cells in the aspirate must be blast cells of myeloid origin. Multiple large nucleoli, delicate chromatin, gray-blue cytoplasm, and Auer rods characterize myeloblasts. The presence of Auer rods is virtually diagnostic of AML, because these condensed lysosomal cytoplasmic azurophilic rod-shaped structures do not appear in ALL. In CLL, bone marrow infiltration exceeds 30% lymphocytes. The lymphocytes are mature with less than 55% atypical or blast forms. The nuclei are round, cytoplasm is scant, chromatin is compact, nucleoli are inconspicuous, and mitotic figures are rare.

Immunophenotyping

Immunophenotyping using multiparameter flow cytometry following labeling with monoclonal antibodies to cell-surface antigens identifies the B or T cell origin of the lymphoblasts. Based on the expression of B lineage-restricted antigens and clonal rearrangements of immunoglobulin heavy and light chain genes, it has been estimated that up to 80% of ALL cases arise from B-cell precursors. The majority possesses a common ALL antigen (CALLA) that is present only on leukemic cells. T-cell ALL possesses receptors for sheep erythrocytes, and, when these are combined, they form E-rosettes. A final subset of ALL lacks B- or T-cell characteristics and is referred to as null-cell ALL. Certain myeloid-specific antigens, such as CD13, CD33, and CD41, have been used to diagnose AML. The malignant cells in CLL correspond to a minor subpopulation of B cells that express cell surface immunoglobulin M (IgM) and immunoglobulin D (IgD) and the T-cell associated antigen CD5.

Histochemical stains

Histochemical stains for myeloperoxidase (Leder stain) and nonspecific esterase have a strong affinity for myelogenous precursors but fail to stain lymphocytic forerunners. Demonstration of nuclear DNA polymerizing enzyme terminal deoxynucleotidyl transferase (TdT) is indicative of a lymphoid origin. However, up to 2-5% of patients with AML exhibit this enzyme. Exceptions may occur when a malignant clone arises from multipotent cells that may express both myelogenous characteristics and lymphocytic characteristics.

Chromosomal analysis

Chromosomal analysis also plays an important role. The diagnosis of CML is established by identifying cytogenetically or molecularly a clonal expansion of a hematopoietic stem cell possessing a reciprocal translocation between chromosomes 9 and 22. Chromosomal analysis of the leukemic cell currently provides the most important pretreatment prognostic information in AML.

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What is the most diagnosed form of cancer?

The most common type of cancer on the list is breast cancer, with 290,560 new cases expected in the United States in 2022. The next most common cancers are prostate cancer and lung cancer. Because colon and rectal cancers are often referred to as "colorectal cancers," these two cancer types are combined for the list.

cancer.gov - Common Cancer Types - NCI

This list of common cancer types includes cancers that are diagnosed with the greatest frequency in the United States, excluding nonmelanoma skin cancers: Cancer incidence and mortality statistics reported by the National Cancer Institute and other resources were used to create the list.1 To qualify as a common cancer for the list, the estimated annual incidence for 2022 had to be 40,000 cases or more. The most common type of cancer on the list is breast cancer, with 290,560 new cases expected in the United States in 2022. The next most common cancers are prostate cancer and lung cancer. Because colon and rectal cancers are often referred to as "colorectal cancers," these two cancer types are combined for the list. For 2022, the estimated number of new cases of colon cancer and rectal cancer are 106,180 and 44,850, respectively, adding to a total of 151,030 new cases of colorectal cancer. The following table gives the estimated numbers of new cases and deaths for each common cancer type in 2022: Cancer Type Estimated New Cases Estimated Deaths Bladder 81,180 17,100 Breast (Female – Male) 287,850 – 2,710 43,250 – 530 Colon and Rectal (Combined) 151,030 52,580 Endometrial 65,950 12,550 Kidney (Renal Cell and Renal Pelvis) 79,000 13,920 Leukemia (All Types) 60,650 24,000 Liver and Intrahepatic Bile Duct 41,260 30,520 Lung (Including Bronchus) 236,740 130,180 Melanoma 99,780 7,650 Non-Hodgkin Lymphoma 80,470 20,250 Pancreatic 62,210 49,830 Prostate 268,490 34,500 Thyroid 43,800 2,230

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