Can leukemia be missed on 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 virus causes Hodgkin's lymphoma?

Viruses: The Epstein-Barr virus, the same virus that causes infectious mononucleosis (mono), has been implicated as a cause of Hodgkin lymphoma. The presence of the genome of this virus is seen in 20%-80% of Hodgkin lymphoma tumors.

webmd.com - Understanding Hodgkin Lymphoma -- the Basics - WebMD

What Is Hodgkin Lymphoma?

Hodgkin lymphoma, also known as Hodgkin's disease, is a type of lymphoma, a cancer of the lymphatic system. The lymphatic system is a network of nodes (knots of tissue) connected by vessels that drain fluid and waste products from the body. The lymph nodes act as tiny filters, straining out foreign organisms and cells. The lymphatic system also is involved in producing important white blood cells called lymphocytes that help protect you against various infections caused by bacteria, viruses, and fungi. When the lymphatic system is fighting an active infection, you may notice that some of your lymph nodes and tissue in the area of the infection become swollen and tender. This is the body's normal reaction to infection. Lymphoma occurs when the lymph node cells or the lymphocytes begin to multiply uncontrollably, producing malignant cells that have the abnormal ability to invade other tissues throughout your body. The two main types of lymphoma are Hodgkin lymphoma and non-Hodgkin lymphoma, which are classified by certain unique characteristics of the cancer cells. Hodgkin disease is most common in two different age groups: young adults (ages 15 to 35) and older adults (over age 50). It is somewhat more common in males than females, and more common in Caucasians than in African-Americans. Because of progress in treating Hodgkin lymphoma, most people with a diagnosis of Hodgkin lymphoma will be long-time survivors.

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