Deck 16: Introduction to Leukemia and the Acute Leukemias

Question 1

What clinical features suggest a chronic leukemia?

A) Insidious clinical onset
B) Mild organomegaly and presence of immature leukemic cells
C) Variable white blood cell (WBC) count
D) Low WBC count
E) All of the above

Answer 1

Insidious clinical onset

Question 2

Five percent to 10% of cases of acute myeloblastic leukemia (AML) are preceded by a recognizable "preleukemic" __________ syndrome.

A) Myelodysplastic
B) Thalassemia
C) Aplastic
D) Microangiopathic
E) None of the above

Answer 2

Myelodysplastic

Question 3

Bone marrow failure in acute leukemia is associated with which of the following complications?

A) Anemia
B) Thrombocytopenia
C) Granulocytopenia
D) All of the above
E) None of the above

Answer 3

All of the above

Question 4

Cell __________ is used to distinguish between acute and chronic forms of leukemia.

A) Maturity
B) Lineage
C) Count
D) Kinetics
E) None of the above

Question 5

What percentage of blasts is recommended by the French-American-British (FAB) classification system for a diagnosis of acute leukemia?

A) 30%
B) 50%
C) 20%
D) 10%
E) None of the above

Question 6

When a leukemia is suspected in a patient, what laboratory test should be required for the initial diagnosis?

A) CBC, differential, platelet count
B) Cytochemical stains
C) Immunologic surface markers
D) All of the above
E) None of the above

Question 7

A 35-year-old man presents with anemia, neutropenia, thrombocytopenia, myeloblasts with the presence of Auer rods, and one or two distinct nucleoli and promyelocytes. Cytochemistry examination demonstrates peroxidase and Sudan black B (SBB) positive and TdT terminal deoxynucleotidyl transferase (TdT) negative. This hematologic picture is consistent with:

A) Acute lymphoblastic leukemia (ALL)
B) Acute myeloblastic leukemia (AML)
C) Chronic myelocytic leukemia (CML)
D) Chronic lymphocytic leukemia (CLL)
E) None of the above

Question 8

A 5-year-old girl presents with anemia, neutropenia, thrombocytopenia, lymphoblasts, and prolymphocytes. Cytochemical examination shows myeloperoxidase and SBB negative, and a positive for TdT. This hematologic picture is consistent with:

A) ALL
B) AML
C) CML
D) CLL
E) None of the above

Question 9

"Pre-leukemia" myelodysplastic features in acute myeloid leukemia may include:

A) Hypergranular neutrophils
B) Hypogranular neutrophils
C) Monocytoid cells
D) Plasmacytoid cells
E) None of the above

Question 10

A clinical feature of acute leukemia is:

A) Sudden onset
B) Untreated course < 6 months
C) Presence of immature leukemic cells
D) All of the above
E) None of the above

Question 11

Leukemia of the myeloid lineage may include:

A) Granulocytic leukemia
B) Monocytic leukemia
C) Megakaryocytic leukemia
D) All of the above
E) None of the above

Question 12

The presence of Auer rods in the cytoplasm of cells rules out __________.

A) ALL
B) AML
C) Myelodysplastic syndrome
D) Acute promyelocytic leukemia
E) None of the above

Question 13

Leukemia cells are frequently present in the peripheral blood and commonly invade the reticuloendothelial tissue which includes the __________.

A) Spleen
B) Liver
C) Lymph nodes
D) All of the above
E) None of the above

Question 14

In leukemia, the presence of immature malignant cells is classified as __________.

A) Chronic
B) Myeloid
C) Acute
D) Lymphoid
E) Myeloid metaplasia

Question 15

What is the ratio of development of leukemia in adults versus children?

A) 5:1
B) 10:1
C) 1:10
D) 1:5
E) None of the above

Question 16

Anemia in acute leukemia is generally __________.

A) Microcytic/normochromic
B) Normocytic/normochromic
C) Microcytic/hypochromic
D) Macrocytic/normochromic
E) None of the above

Question 17

Which host factor(s) is/are associated with an increased risk of developing leukemia?

A) Chromosomal abnormalities
B) Immunodeficiency states
C) Chronic marrow dysfunction syndromes
D) Inherited predisposition
E) All of the above

Question 18

In leukemia, the presence of predominantly mature malignant cells is classified as: __________.

A) Chronic
B) Myeloid
C) Acute
D) Lymphoid
E) Myeloid metaplasia

Question 19

Cell __________ is used to distinguish between lymphoid and myeloid groups in leukemia.

A) Maturity
B) Lineage
C) Count
D) Kinetics
E) None of the above

Question 20

Cell morphology is evaluated on a Romanowsky (Wright-Giemsa)-stained blood or bone marrow smear in a carefully chosen area in which cells are:

A) Overcrowded
B) Distorted
C) Swelled
D) Evenly distributed
E) None of the above

Question 21

Surface marker studies must use fresh specimens from either peripheral blood or bone marrow aspirates with __________ cells.

A) Macrocytic
B) Crenated
C) Viable
D) Nonviable
E) None of the above

Question 22

The cytochemical reactions are performed by applying staining techniques to __________ smears.

A) Peripheral blood
B) Bone marrow
C) Touch preparation
D) All of the above
E) None of the above

Question 23

A positive nonspecific esterase stain indicates __________ differentiation.

A) Megakaryocytoid
B) Monocytic
C) Lymphoid
D) Plasmacytoid
E) Erythrocytic

Question 24

Which cytochemical stain, more specific than SBB stain, should be recommended for granulocytic differentiation?

A) Specific esterase
B) Myeloperoxidase
C) Nonspecific esterase
D) PAS
E) Alpha-naphthyl butyrate

Question 25

The SBB stain is the most sensitive stain for granulocytic precursors with a staining pattern which parallels the __________ stain.

A) Terminal deoxynucleotidyl transferase
B) Periodic acid-Schiff (PAS)
C) Myeloperoxidase
D) Alpha-naphthyl butyrate
E) None of the above

Question 26

On Romanowsky-stained smears, Auer rods appear as:

A) Brown staining rods
B) Orange staining rods
C) Pink or purple staining rods
D) Blue staining rods
E) None of the above

Question 27

Anti-leukemia therapy consists of:

A) Cytotoxic chemotherapy
B) Radiotherapy
C) Bone marrow transplantation
D) Hematopoietic stem cell transplant
E) All of the above

Question 28

Which precursor B-cell marker is used exclusively in the work-up of acute leukemia in studying B lineage ALL?

A) Mu (µ) heavy chain
B) Epsilon () heavy chain
C) Lambda () heavy chain
D) Delta () heavy chain
E) None of the above

Question 29

A positive myeloperoxidase or SBB stain indicates __________ differentiation.

A) Myeloid
B) Lymphoid
C) Megakaryocytoid
D) Plasmacytoid
E) None of the above

Question 30

What is meant by the FAB classification?

A) A system devised by French, American, and British hematologists to standardize morphologic classification of acute myeloid and lymphoid leukemias
B) A system devised by French, American, and British hematologists to standardize chronic myeloid and lymphoid leukemias
C) A system devised by French, American, and British hematologists to standardize hemolytic anemias
D) A system devised by French, American, and British hematologists to standardize lymphomas
E) None of the above

Question 31

The alpha-naphthyl butyrate stain is used to identify __________ cells.

A) Monocytic
B) Granulocytic
C) Megakaryocytic
D) B lymphocytes
E) None of the above

Question 32

Which of the following cytochemical stains differentiates AML from ALL?

A) Myeloperoxidase
B) PAS
C) Nonspecific esterase
D) All of the above
E) None of the above

Question 33

In immunologic surface marker studies, __________ are used to detect markers associated with cell lineage and maturation stage.

A) Enzymes
B) Antigens
C) Antibodies
D) Haptens
E) None of the above

Question 34

Cytoplasmic marker studies are useful in assessing cell lineage in:

A) ALL
B) AML
C) CLL
D) CML
E) Myeloid metaplasia

Question 35

A 49-year-old woman was admitted to the hospital for easy bruising and menorrhagia. She had evidence of disseminated intravascular coagulation. Her white blood cell count is 3  10⁹/L with 95% large, atypical mononuclear cells and some atypical bilobed cells. Many of these cells are packed with larger, purple-staining granules; some have multiple Auer rods; and all are strongly peroxidase-positive. What is the diagnosis?

A) AML, FAB M2
B) AML, FAB M3
C) AML, FAB M4
D) AML, FAB M5
E) AML, FAB M6

Question 36

A strong PAS reaction supports the diagnosis of __________.

A) Sickle cell anemia
B) Type L3 ALL
C) Pernicious anemia
D) Erythroleukemia
E) None of the above

Question 37

TdT terminal deoxynucleotidyl transferase is found in 90% of acute __________ leukemia.

A) Myelocytic
B) Lymphoblastic
C) Promyelocytic
D) Monocytic
E) None of the above

Question 38

In performing surface marker analysis for FAB classification M4 and M5, monoclonal antibodies specific for __________ cells would be detected by flow cytometry.

A) Lymphoid
B) Monocytic
C) Erythroid
D) Megakaryocytoid
E) None of the above

Question 39

The objective in treatment of leukemia is to:

A) Eradicate the leukemic cell mass
B) Provide supportive care
C) Lower the WBC count
D) All of the above
E) None of the above

Question 40

The most common structural chromosomal abnormalities in acute leukemia are __________.

A) Duplications
B) Inversions
C) Translocations
D) Deletions
E) None of the above

Question 41

In acute monocytic leukemia (M5a), which cell predominates in the bone marrow and peripheral blood?

A) Monocytes
B) Promonocytes
C) Monoblasts
D) Myeloblasts
E) All of the above

Question 42

The most common acute leukemia FAB classification diagnosed is __________.

A) M2
B) M4
C) M5
D) M6
E) None of the above

Question 43

Which cytochemical stain is used to detect acute megakaryoblastic leukemia (M7)?

A) Myeloperoxidase
B) SBB
C) Platelet peroxidase
D) TdT
E) None of the above

Question 44

Acute erythroleukemia (M6) is characterized by an abnormal proliferation of __________ and __________ precursors.

A) Erythroid/lymphoid
B) Erythroid/myeloid
C) Erythroid/megakaryocytoid
D) Erythroid/plasmacytoid
E) None of the above

Question 45

Lack of a significant increase in reticulocytes in erythroleukemia is due to:

A) Extramedullary hematopoiesis
B) Intramedullary hematopoiesis
C) Ineffective erythropoiesis
D) Ineffective hematopoiesis
E) None of the above

Question 46

Acute monocytic leukemia (M5a) is characterized by the presence of:

A) Promonocytes
B) Monocytes
C) Monoblasts
D) Promyelocytes
E) None of the above

Question 47

The morphology of acute lymphoblastic leukemia is evaluated on a __________ smear.

A) Peripheral blood
B) Bone marrow aspirate
C) Cytoprep smear
D) Fine needle aspiration
E) None of the above

Question 48

Which FAB classification demonstrates at least 3% positivity with peroxidase or SBB, <20% positivity with nonspecific esterase, and contains primarily myeloblasts with distinct nucleoli?

A) M2
B) M1
C) M4
D) M3
E) None of the above

Question 49

The FAB classification M7 in acute leukemia is characterized by the extensive proliferation of __________.

A) Erythroblasts
B) Megakaryoblasts
C) Myeloblasts
D) Monoblasts
E) None of the above

Question 50

Which definitive laboratory findings in acute myelomonocytic leukemia aid in the differentiation of M4 and M2?

A) Increased serum lysozyme level
B) Negative SBB stain
C) Positive peroxidase
D) WBC count
E) Hematocrit

Question 51

Which translocation and associated hybrid gene formation is exclusively found in acute promyelocytic leukemia?

A) t(8;21) AML1-ETO
B) t(4;11) AF4-MLL
C) t(9;22) BCR-ABL
D) t(15;17) PML-RAR
E) t(22;9) MDR1

Question 52

Which cytochemical stains show strong positivity in acute monocytic leukemia (M5)?

A) Peroxidase
B) Nonspecific esterase
C) SBB
D) TdT
E) None of the above

Question 53

This acute leukemia contains primarily abnormal promyelocytes with heavy granulation, and the presence of Auer rods is abundant. The cells react near 100% with Sudan black and peroxidase; however, the reaction is negative for non-specific esterase. Disseminating intravascular coagulation (DIC) is frequently associated with this disorder. What is the FAB classification?

A) M1
B) M6
C) M2
D) M3
E) M4

Question 54

Promyelocytes constitute 10% of this acute leukemia with more than 50% of leukemia cells positive for peroxidase or SBB. What is the FAB leukemia classification?

A) M1
B) M2
C) M3
D) M4
E) None of the above

Question 55

Which of the following disorders could mimic a case of erythroleukemia?

A) Megaloblastic anemia
B) Congenital dyserythropoietic
C) Myelodysplastic syndrome
D) All of the above
E) None of the above

Question 56

Schistocytes or fragmented cells present in promyelocytic acute leukemia (M3) is suggestive of which condition?

A) Hematuria
B) DIC
C) Liver disease
D) Splenomegaly
E) None of the above

Question 57

The FAB classification system separates acute myeloblastic leukemia into __________ morphologic groups.

A) Three
B) Six
C) Five
D) Seven
E) None of the above

Question 58

The FAB classification system separates acute lymphoblastic leukemia into __________ morphologic groups.

A) One
B) Two
C) Three
D) Four
E) None of the above

Question 59

Which of the following hematologic findings are consistent with a case of erythroleukemia?

A) Hypercellular bone marrow with marked erythroid hyperplasia
B) > 50% of all nucleated cells in bone marrow are abnormal erythroid forms
C) Erythroid/megakaryocytoid
D) Auer rods present
E) All of the above

Question 60

Which FAB classification is used to describe an acute leukemia with a spectrum of monocyte differentiation, including promonocytes and monocytes?

A) M5a
B) M3m
C) M4
D) M4Eo
E) M5b

Question 61

Cytoplasmic µ, in the immunologic classification of ALL, is expressed in __________ ALL.

A) Common ALL
B) T-cell
C) Precursor B-cell
D) B-cell
E) Burkitt's lymphoma

Question 62

Which French-American-British classification of ALL typically demonstrates a predominantly uniform population of small blasts with scant cytoplasm, clefting of the nucleus, and variable cytoplasmic vacuolation?

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 63

Most precursor B-cell leukemias express CALLA (common ALL antigen) (CD10) on the surface and are therefore referred to as __________ ALL.

A) B-cell
B) Common
C) Pre-B cell
D) CD10
E) None of the above

Question 64

Which FAB classification of ALL represents a heterogeneous population and is morphologically similar to AML, type M1?

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 65

A 14-year-old male presents with a mediastinal mass, a WBC of 110  10⁹/L, hepatosplenomegaly, and early central nervous system involvement. Both L1 and L2 morphology are seen, and surface markers CD7, CD2, and CD5 are expressed. Which type of ALL is present?

A) Precursor B-cell
B) T-cell
C) B-cell
D) Null cell
E) None of the above

Question 66

Which type of ALL occurs primarily in adults?

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 67

The lymphoblasts found in cases of B-cell acute lymphoblastic leukemia are indistinguishable by cytologic, cytochemical, and immunologic criteria from tumor cells found in __________.

A) Hodgkin's lymphoma
B) Chronic lymphocytic leukemia
C) Burkitt's lymphoma
D) Lymphosarcoma
E) L1 ALL

Question 68

Pure cases of L1 ALL are characterized by the presence of __________ L1 blasts.

A) >30%
B) >50%
C) >90%
D) <30%
E) None of the above

Question 69

Cases of pure __________ ALL have the worst prognosis.

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 70

Which percentage of blasts does the WHO classification system recommend for a diagnosis of acute leukemia?

A) 10%
B) 20%
C) 30%
D) 25%
E) 15%

Question 71

Cases of pure __________ ALL have the best prognosis.

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 72

Which type of ALL occurs primarily in the pediatric age group?

A) L1
B) L2
C) L3
D) L4
E) None of the above

Question 73

Which of the following indicators correlate to children with a poor prognosis for ALL?

A) Older age (>13 years)
B) L2 and L3 morphology
C) High WBC count
D) Chromosome abnormalities
E) All of the above

Question 74

L3 acute lymphoblastic leukemia is referred to as __________ type.

A) Precursor B-cell
B) T-cell
C) Burkitt's
D) B-cell
E) None of the above