1. Terry Kotrla, MS, MT(ASCP)BB Topic 3 Autoimmunity Part 8 Immunoproliferative Diseases

2. Immunoproliferative Diseases Focus on malignancies of the immune system, lymphoid cell line. Broadly classified as lymphomas and leukemias. Leukemias malignant cells present in bone marrow and peripheral blood. Lymphomas, malignant cells arise in lymphoid tissues: Lymph nodes Tonsils Spleen Classified according to site malignancy first arose.

3. Immunoproliferative Diseases Plasma cell dyscrasias Multiple myeloma (MM) Waldenstrom’s macroglobulinemia Involve bone marrow, lymphoid organs and other non- lymphoid tissue. Biologically distinct, NOT classified as either lymphoma or leukemia. Plasma cells may be found in blood later in myeloma, then classified as plasma cell leukemia.

4. Malignant Transformation Malignancy characterized by excess accumulation of cells. Rapidly proliferating cells. Normal proliferation but do not undergo apoptosis (programmed cell death). Rapid cell proliferation normal process of the immune system to respond to antigenic stimulus. Malignancy occurs when regulatory processes fail or mutations occur. Malignant cells “stuck” at early stage of differentiation. May require altered or abnormal genes. May be triggered by viral infection or other stimulus.

5. Malignant Transformation Malignant and premalignant proliferation of cells can occur at any stage of differentiation. Malignant cells may retain some or all of morphological and functional characteristics. Cell surface antigens Secretion of antibody Used to classify

6. Malignant Transformation - Lymphoma Arise due to persistent immunostimulation coincides with immune deficiency. Provokes continuous proliferation and mutations in lymphoid precursors. Immune deficiencies play two roles: Ineffective immune response causes persistent stimulation to clear infection. Immune surveillance for malignancy fails, especially in response to viral infections.

7. Malignant Transformation Immune system has diverse response to antigenic challenge, “polyclonal response”. Malignancy may arise from excessive proliferation of SINGLE genetically identical cell line or CLONE of cells. Malignancy occurs with population of uniform cells. Presence of a large amount of single immunoglobulin type. Increase in total amount of immunoglobulin. Malignancy diagnosed when lymphocytic cells in bloodstream, bone marrow or lymphoid tissues consist of a uniform population of cells. Specific mutations not known for most malignancies but more are being identified every day, may lead to effective treatment.

8. Immunoproliferative Diseases B-cell immunoproliferative disorders most commonly evaluated. B-cell lineage develop into plasma cells Urine antibodies used to diagnose and evaluate certain B-cell proliferations B-cells produce one antibody specificity (monoclonal). Persistent presence of large amounts of a single immunoglobulin suggests malignancy. Increase in total amount of one specific clone characteristic of benign reactive immunoproliferative disease.

9. Lymphomas Hodgkin’s lymphoma Non-Hodgkin’s lymphoma Historically difficult to classify, no one gold standard. Revised European-American Lymphoma (REAL) classification adopted by WHO. Cell origins Morphology Immunophenotype Genetic features Clinical features

10. Hodgkin’s Lymphoma Highly treatable and curable. Occurs in young adults (15-35) and elderly (over 55). Characterized by orderly spread of disease from one lymph node group to another. Symptoms Fever Night sweats Weight loss Enlarged lymph nodes Hepatomegaly, splenomegaly or hepatosplenomegaly

11. Hodgkin’s Lymphoma Characterized by presence of Reed-Sternberg cells. Abnormal lymphocyte which contains more than one nucleus Found in affected lymph nodes and lymphoid organs B-cell lineage

12. Hodgkin’s Lymphoma – Diagnosis and Treatment In some cases there appears to be a correlation between HL and infection with Epstein-Barr virus (EBV) infection Determine EBV antibody level Test for EBV virus Histological examination of lymph node biopsy Four types of HL differentiation based on cell determinants (CD) found on the affected cells. Treatment Radiation therapy Chemotherapy Stem cell transplant

13. Non-Hodgkin’s Lymphoma - NHL Wide range of neoplasms that can include any type of lymphoma EXCEPT Hodgkin’s B-cell lymphomas – most prevalent type 85% T- cell lymphomas Prognosis varies significantly in severity. Slow progression – long term survival good Highly aggressive – fatal

14. Non-Hodgkin’s Lymphoma - NHL As lymphoma progresses and cancerous lymphs spread beyond lymphatics body loses ability to fight infection. Symptoms depend on type of NHL Lymphadenopathy Fever Night sweats Weight loss Loss of apetite Red patches on the skin Severely itchy skin, often affecting legs/feet

15. Non-Hodgkin’s Lymphoma - N Diagnosis Tissue biopsy Flow cytometry Imaging tests to determine where tumors are located. Treatment Watch and wait Radiation therapy Chemotherapy Targeted therapy – use monoclonal antibodies to target specific marker on cells where cancer starts.

16. Lymphoblastic Leukemias Covered in Hematology, will not be covered in this course. No questions for exams. Expected to know the material for future exams and exit exam. Use material in textbook to enhance review of the material.

17. Plasma Cell Dyscrasias Characteristic is over production of a single immunoglobulin component. Paraprotein or myeloma protein. Diagnosis and monitoring dependent on detecting and quantitating the paraprotein. Screening and confirmatory tests performed in most clinical laboratories.

18. Plasma Cell Dyscrasias Include several related syndromes: Multiple myeloma Waldenstrom’s macroglobulinemia Light-chain disease Heavy-chain disease Monoclonal gammopathy of undetermined significance.

19. Multiple Myeloma Malignancy of mature plasma cells. Most serious and common of plasma cell dyscrasias. Age of diagnosis 40 to 70 years, found in blacks twice as frequently as whites, and men twice as likely as women. Have excess of plasma cells in the bone marrow. Level of normal immunoglobulin decreased in proportion to abnormal immunoglobulin.

20. Multiple Myeloma Immunoglobulin produced by malignant clone, can be of any class, IgG most common. Important diagnostic feature is presence of Bence Jones protein in the urine. Abnormal production of free immunoglobulin light chains, kappa or lambda. Can be detected by immunoelectrophoresis or heat precipitation.

21. Multiple Myeloma - Symptoms The presence of unexplained Anemia Kidney dysfunction Elevated ESR Broken bones -lytic lesions cause bone pain and fractures. Hemorrhage can occur due to thrombocytopenia and paraprotein interferes in normal hemostasis. Deposition of antibody derived material leads to organ dysfunctions, with kidneys most commonly involved.

22. Laboratory 10% or higher plasma cells in bone marrow. High serum protein level Bence-Jones proteins being present in 60-70% of the cases. Hyperviscosity develops when protein levels are high, especially with IgM producing tumors. High levels of immunoglobulins lead to rouleaux formation being noted on blood smear. Failure of bone marrow to produce normal number of hematopoietic cells leads to: Anemia Thrombocytopenia Neutropenia

23. Multiple Myeloma Bone Marrow – Malignant plasma cells Peripheral smear – pathologic rouleaux

24. Waldenstrom’s Macroglobulinemia Malignant proliferation of IgM producing lymphocytes Malignant cells more immature than plasma cells, with appearance being between small lymph and plasma cell. Plasmacytoid lymphs infiltrate bone marrow, spleen and lymph nodes. Some IgM paraproteins behave as cryoglobulins, precipitate at cold temperatures. Occlude small vessels in patient’s extremities in cold weather. Leads to skin sores and necrosis of fingers and toes.

25. Waldenstrom’s Macroglobulinemia Patients with stable production of monoclonal IgM without infiltration of marrow or lymphoid tissue are considered to have cold agglutinin syndrome.

26. Waldenstrom’s Macroglobulinemia Symptoms Anemia Hyperviscosity Fatigue Mucosal or GI bleeding Nausea Treatment Plasmapheresis Chemotherapy Stem cell transplant Median survival 5 years versus multiple myeloma, 3 years.

27. Waldenstrom’s Macroglobulinemia Cryoglobulins detected in blood or plasma by placing the sample in a refrigerator in the clinical laboratory. Precipitate forms at low temperatures (4C). Dissolves upon rewarming. May be associated with a cold red cell autoantibody directed against the I antigen on the patient’s own red blood cells, may result in hemolytic anemia.

28. Laboratory Diagnosis Measurement of immunoglobulin levels in serum. Serum protein electrophoresis to separate and detect abnormal levels, myelomas which produce only light chains may be missed.

29. Laboratory Diagnosis Immunoelectrophoresis used to evaluate monoclonal gammopathies detected by SPE. Immunofixation electrophoresis also used to evaluate monoclonal gammopathies. Serum viscosity measurements useful for Waldenstrom’s macroglobulinemia or high levels of IgG or IgA paraproteins. Bone marrow biopsy to establish diagnosis of lymphoproliferative disorder and determine extent of bone marrow replacement by malignancy.

30. Laboratory Role Perform specialized tests such as Immunophenotyping by flow cytometry Evaluation of immunoglobulins Serum protein electrophoresis Immunofixation electrophoresis Evaluation of genetic and chromosomal abnormalities. May require additional education to be qualified to perform.

31. References http://www.ucl.ac.uk/~regfjxe/Arthritis.htm http://www.haps.nsw.gov.au/edrsrch/edinfo/lupus.html http://pathmicro.med.sc.edu/ghaffar/tolerance2000.htm http://repro-med.net/info/cat4.php http://stemcells.nih.gov/info/scireport/chapter6.asp http://www-ermm.cbcu.cam.ac.uk/04008427h.htm http://www.biotest.de/ww/en/pub/folder_pharma/fields_of_use/autoimmune_disease.htm http://72.14.203.104/search?q=cache:H7KcpVQ4xkYJ:www.peppypaws.com/Glossary.html+Forbidden+clone+theory&hl=en&client=firefox-a

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