Chapter 4

Bone Marrow Examination

Where
are the blood cells coming from ?

How about it ?
 Cell Lines in Blood Cell Formation

• Genesis of erythrocytes
– Committed cells are
proerythroblasts
– Remain in the reticulocyte
stage for 1–2 days in
circulation
– Make up about 1–2% of all
erythrocytes
• Formation of leukocytes
– Granulocytes form from
myeloblasts
– Monoblasts enlarge and
form monocytes
• Platelet-forming cells from
megakaryoblasts, break
apart into platelets
COMPONENTS:BM ideally consists of evaluating of these components

Peripheral blood
 CBC
 Differential count Bone marrow tissue section
 Reticulocyte count  Trephine biopsy
 Blood smear morphology  Clot section

COMPONENTS

Laboratory studies-miscellaneous
Bone marrow aspirate  Iron studies
 Morphology  B12/folate
 cytochemical stains  Hemoglobin electrophoresis
 Flow cytometric immunophenowping  Immunoelectrophoresis
 cytogenetic analysis  LDH
 Molecular biological studies  Coomb's test
 Microbiology culture/serology results
 Miscellaneous
 Why do
Click to edit title style
INDICATION FOR BONE MARROW EVALUATION we
exam
bone
marrow
?
Evaluation for Primary hernatologic disorder;Staging for
ma|ignancy Hodgkin's disease;Staging for non-Hodgkin's
lymphoma;Metastatic tumor (nonhematopoietic)

Postchemotherapy
Monitoring
Postbone marrow transplantation .
therapy

Marrow production problem

Evaluation of
Peripheral destruction; inadequate/ ineffective
cytopenias
marrow release

Culture (fever of unknown origin)

Miscellaneous

Why do we exam bone marrow?

Why do we exam bone marrow?
Special aspiration needles are available for
Bone marrow aspirations procedure.
 It involves using
a needle to take
A pathologist of the a sample

physician performs
the biopsy and
aspiration procedure
while the hematology
practitioner prepares
the sample for
processing.
Position of bone marrow aspiration

• sternum

• anterior iliac crest

• posterior iliac crest

• the medial surface of the
tibia in babies up to the age
of 18months.
 contraindication for bone marrow
aspiration

• Hemorrhage disease due to serious lack of

coagulation factors
• Punctured location has infection or
malformation.
• Be careful when the women with gestation
have bone marrow examination （ to
prevent miscarriage ）
Dry tap often happens when a marrow
is:

fibrotic
 myelosis(leukemia\polycythemia
vera )
 myeloproliferative reduce(aplastic
anemia )
 tumor bone marrow infiltration
 Bone Marrow Aspiration
and Biopsy
• Bone marrow aspiration removes a small
amount of bone marrow fluid and cells
through a needle put into a bone. The bone
marrow fluid and cells are checked for
problems with any of the blood cells made in
the bone marrow. Cells can be checked for
chromosome problems. Cultures can also be
done to look for infection.
• A bone marrow biopsy removes bone with
the marrow inside to look at under a
microscope. The aspiration (taking fluid) is
usually done first, and then the biopsy
 PEROXIDASE STAIN ( POX )

1.Distinguishing the different types of acute

leukemia.AML- PositiveAMOL- Faintly
positive
ALL – Negative,ALL can be ruled out in POX
positive case.AML and AMOL can not be
ruled out in POX negative case.
2.Distinguishing APL and AMOL
 NEUTROPHIL ALKALINE
PHOSPHATASE STAIN (NAP)

NAP ↓(1)Leukemoid
NAP ↑:
Reaction and CML
Bacterial infections
(2) Bacterial infections and
Leukemoid Reaction
virual infections
Polycythemia vera
(3) Aplastic anemia and
Aplastic anemia
PNH
Acute lymphocytic
(4) Acute lymphocytic
leukemia
leukemia and AML
 Specific Esterase Stain
（ AS-D NCE stain ）
This stain is used to help differential leukemias.
(1) AML (2) AmoL
(3) ALL (4) AMMoL
 NON Specific Esterase Stain
（  a -NBE stain ）
[Clinical Value ]
Identify different types of acute leukemia.
AMOL: Monoblasts (+) inhibited by NaF.
AML: Myeloblasts (-) or (+) not inhibited.
ALL: Lymphoblasts (-) or (+) not inhibited.
Erythremia, EL: Normablasts (+) not
inhibited.
 Interpretation of Bone Marrow Studies

• Bone marrow cellularity is best determined on the

bone marrow tissue sections but can be estimated
from the bone marrow aspirate smear
• The next step in evaluating bone marrow is
determining the distribution of cells within the
marrow.
• The next step in the evaluation of bone marrow
is assessing myeloid and erythroid development
both quantitatively and qualitatively.
• Other cell types and lesions may be identified
within the bone marrow and must be assessed
including the presence or absence of
granuloma, necrosis, lymphoma, metastatic
neoplasia, bone marrow fibrosis, lipid storage
disease, benign lymphoid aggregates, and bone
abnormalities such as osteosclerosis and
osteoporosis.
 LEUKEMIA
Leukemia is an abonormal, uncontrolled
proliferation of one or more of the hemopoietic cells, it
is a malignant hemopathy.
It is a group of clonal and hetergenous maliganancy
of hemapoietic tissue characterized by an
overproduction ,
differentation or maturation aressted and apoptosis
reduced of leukemic cell in the marrow and impaired
production normal blood cells resulting in
grannulocytopenia anemia and thrombocytopenia
Leukemic cells present: qualitative change—morphologic
--functional
quatitative abnormality
 Platelet
Pictures Of Blood CellPlatelet
White Cell Red Cell Red Cell Blasts
White Cell

Normal human blood Blood with leukemia

overproduction
leukemia was first indentified in 1845 by two independent observers.
Normal overproduction
 Development of Leukemia in the
Bloodstream

Stage 1- Normal Stage 2- Symptoms Stage 3- Diagnosis

Legend
White Cell Stage 5a- Anemia

Red Cell
Platelet Stage 4- Worsening
Blast
Germ Sources from Leukemia, by D. Newton and D. Siegel
Stage 5b- Infection
 3. Symptoms

• When there are too many WBC ： Infections

• When there are few RBC: Paleness / Anemia
• When there are few PLT: bleeding
 Leukemias, in general, are defined as malignant neoplasms
of the hematopoietic system arising in the bone marrow.
In a simplistic fashion, it is easiest to classify leukemias based on

1)the natural course MICM

of disease

acute M
versus chronic I
2)the basic cell
Acute leukemia (AL): type involved C
immature ， early <6M
Chronic leukemia (CL): M
mature, late>1Year lymphoid
versus myeloid
 Classification of leukemias

Acute Chronic
Myeloid Acute Myeloid Chronic Myeloid Leukemia
origin Leukemia 45%(AML) 15%(CML)

Lymphoid Acute Lymphoblastic Chronic Lymphocytic

Leukemia 10%(ALL) Leukemia30% (CLL)
origin
FAB （ FAB classification ）

F-A- B cooperative group has classified AL on the basis of t

he morphologic feature and numbers of blast cells in 1976
How about quantity?

blast
>30
 Blood & BONE MARROW

Blood:
A variable WBC count (elevated in most cases) with or without blasts in the circulation
blood. (leukemic leukemia or aleukemic leukemia).
Normochromic, normocytic anemia with anisocytosis, poikilocytosis and nucleated red cells.
Often a severe thrombocytopenia (elevated in early stage of CML).
Bone marrow aspirate:
BM is essential to establish the diagnosis and determine the precise cytologic type.
Sometime aspiration is difficult (dry tap or marrow necrosis).
Abnormal number:
--Marked/moderate hypercellularity.
--Related leukemic cells proliferation.
--Normal hemapoietic cells decreased.
--Hiatus leukemicus (in acute leukemia).
2. Morphologic abnormality.
--Leukemic cells appear to be highly polymorphic
急性白血病常用细胞化学染色

POX染色
急 淋 (-) 急粒 急 单(+~+++)
( + ) (+)

醋酸AS-D染色 或α丁酸萘酚酯酶染色
CYTOCHEMICAL STAIN In the AL
PEROXIDASE STAIN ( POX )

(-) (+~++++)
Acute Lymphoblastic M2, AML with
maturation M4, Acute
Leukemia Al
M3, Acute myelomonocytic
promyelocytic leukemia
leukemia (APL) M5a, Acute
M3v, monoblastic leukemia
Hypogranular variant
of APL

Specific Esterase Stain NON Specific Esterase Stain

（  a -NBE stain ）
 MICM

MICM Cytogenetics
Molecular bilolgy

Immunological

Morphorlogy
 Acute Lymphoblastic Leukemia ALL
• is a malignant proliferation of lymphoblasts and
prelymphocytes within the blood and marrow,
• The onset of symptoms in patients with ALL is
usually acute and rapidly progressive.
• The clinical manifestations of ALL relate primarily to
the suppression of normal bone marrow elements:
weakness, fatigue, and malaise owing to anemia;
fever, infection, and unresponsiveness to antibiotics
owing to leukopenia; and bleeding owing to
thrombocytopenia. Skeletal pain as a result of
marrow expansion is also not an uncommon
• Laboratory Findings
Although we typically equate leukemia
with disorders having markedly elevated
white blood counts (WBCs),the absence of
leukocytosis does not eliminate the
possible diagnosis of acute leukemia.
Acute Lymphoblastic Leukemia
 Morphology and FAB Classfication

ALL can be classified either morphologically

or immunologically. The French-American-British
(FAB) morphologic classification of acute
leukemia has designated subtypes FAB-L1,-L2,
and -L3(Table 4-5).The revised FAB
classification of ALL is based on weighing
various criteria: nuclear-to-cytoplasmic ratio, the
number of nucleoli, nuclear membrane
irreguiarity, and cell size (Table4-6).
 TABLE 4-5 FAB CLASSEFICAHON OF ACUTE
LYMPHOBLASTIC LEUKEMIA
L1 L2 L3

Size Predominant small cells Heterogeneous, Large cells

intermediate to large
cells

cytoplasm Scant Variable to moderately Moderately abundant

abundant

Nucleoli small/inconspicuous ≥1;prominent to large ≥1;prominent to large

Nuclear chromatin Homogeneous and Heterogeneous with Finely reticular

intermediate reticular some having finely
reticular chromatin

Nuclear shape Regular and round lrregular Regular to round

Basophilic cytoplasm Slight to none Slight to none intense

vacuolation Slight to none Slight to none Prominent; sharply

punched out
Fig. 4-1 Bone marrow with primarily L1 blasts
and occasional L2 blasts.
L1 cell

L2 cell
Fig. 4-2 Acute lymphoblastic leukemia L3-Burkitt’s
Leukemia/lymphoma.

L3 cell
• Morphologic Variants
Uncommon morphologic variants of ALL have
been recognized. A "hand-mirror" cell variant of ALL
has been described in which the cytoplasm loses its
spherical shape and appears to have a handle. The
elongated cytoplasmic handle has been described as
the result of cellular motility or locomotion and has
been regarded by some as a poor prognostic sign in
ALL. This has not been widely accepted and is likely
to be more of a laboratory artifact rather than having
true biological significance.
 Cytochemical stain

The lymphoblasts are Sudan Black and POX negative (

myeloid markers ).

Most cases are non specific estarase negative (α-

NBE negative).

T cell ALL may show ACP stain positive. PAS stain is

often positive. NAP↑
 淋巴细胞免疫学标志

系列 一线单抗 二线单抗

T 淋巴系 CD2 、 CyCD3 、 CD CD1 、 CD4 、 CD5 、 CD

7 8

CD10 、 CD19 、
B 淋巴系 CD20 、 CD24 、 Cyμ 、
CyCD22 、 CyD79a SmIg
• Immunophenotype
The most consistent and effective means of
classifying ALL is based on immunophenotyping data.
Approximately 80% to 85% of ALIs can be classified as
malignant counterparts of bone marrow B-precursor
cells. Ten percent to 15% of ALL will be identified as T-
cell ALL, thus having immunologic characteristics of
immature T cells or thymocytes. The remining l% to 3%
of ALLs will immunologically represent mature B cells
having surface immunoglobulin and correspond to the
FAB-L3 subgroup or Burkitt’s leukemia/lymphoma
Cytogenetics and molecular biologic

Chromosomal Molecular
translocation target
B-lineage ALL t(9;22) BCR-ABL
t(1;19) E2A-PBX1
t(17;19) HLF-E2A
t(4;11) AF4-MLL
t(8;14) MYC-IgH
T-lineage ALL t(11;14) RHOM2-TCRδ
t(1;14) TAL1-TCR δ
t(10;14) HOX11-TCR δ
 Acute Myelogenous Leukemia

The acute myelogenous leukemia （ AML

s ） are a heterogeneous group of
malignancies originating in the hematopoietic,
or myeloid, stem cell. The neoplastic
proliferation seen in AML consists of
myeloblasts or partially differentiated myeloid
cells.
 Thus, referring to Fig.4-3,one can rationalize
the existence of the various morphologic subtypes
of AML based on whether the granulocytic,
monocytic, erythroid, or megakaryocytic arm of
myeloid differentiation is involved.
Fig.4-3 This schematic diagram outlines the relationship of the acute
and chronic myeloid and lymphoid leukemias to normal
hematopoietic and lymphoid development.
• Laboratory Findings
In AML the WBC is elevated in more than half
of patients at the time of diagnosis. pancytopenia
is a constant feature of this leukemia.
As many as 10% of patients will have WBC
counts that are greater than l00.0×109/L with
some patients approaching 500.0×109/L Patients
with WBCs greater than 50.0 to 100.0×109/L are
at risk of developing complications owing to
hyperleukocytosis.
• Morphology and FAB Classification
The French-American-British (FAB)group on
acute leukemia has morphologically subclassified the
AMLs into seven major subtypes: FAB-M1 to FAB-
M7(Table 4-7).The FAB classification of AML
basically relies on the degree of granulocytic,
monocytic, erythroid, and megakaryocytic
differentiation.
 TABLE4-7 FAB CLASSIFICATION OF ACUTE
MYELOGENOUS LEUKEMIA
M0 Acute leukemia, undifferentiated; myeloid immunophenotype

M1 Acute myelogenous leukemia(AML)without maturation

M2 AML with maturation

M3 Acute promyelocytic leukemia (APL)
M3v Hypogranular variant of APL
M4 Acute myelomonocytic leukemia
M4 e M4 with eosinophilia
M5a Acute monoblastic leukemia
M5b Acute monocytic leukemia
M6 Acute erythroleukemia
M7 Acute megakaryoblastic leukernia
• The basic definition of an AML is a
leukemia that has more than 30% myeloblasts
in the bone marrow. However, the recent
WHO classification, the required percentage of
blasts for diagnosis of AML is decreased to
20%in the bone marrow and peripheral blood.
Myeloblasts may be grouped into three
different subtypes: I, II and III.
• Type I myeloblasts are undifferentiated blasts that
have no evidence of granulocytic differentiation, i.e.,
they contain no cytoplasmic granulation or Auer rods#.
• Type II blasts are leukemic blasts that have relatively few
cytoplasmic granules. It is too rigid to specify the exact number of
these granules; however, most morphologists would define type II
blasts as having fewer than eight to 12 granules per cell.
#Auer rods are absolutely specific for a leukemic
myelogenous process and consist of abnormally fused
primary granules.Auer rods are needle-to fusiformlike
eosinophilic rods that are found in the cytoplasm of
leukemic myeloid cells and stain red to purple with
Wright-Giemsa stain.
• The type III blast are cells intermediate
between type II blasts and promyelocytes.
Obviously, this distinction may be quite
difficult to make at times, but it is generally-
relegated to cells that have the nuclear
characteristics of blasts(fine chromatin and
prominent nucleoli)but with more granules
than in the type II blasts. The cytoplasm
retains its basophilic appearance
 TABLE4-9 CLASSIFICATEON OF ACUTE
MYELOGENOUS LEUKEMIA
FAB Diagnostic Criteria
Subtype
M0 No morphologic evidence of differentiation
Negative cytochemical staining with MPO/SBB/NSE
Positivity with myeloid markers (CD13,CD33, etc.)and negative
lymphoid markers

M1 ≥90%blasts in bone marrow

＜ 10%of marrow showing granulocytic differentiation
＞ 3%of blasts with MPO or SBB positivity

M2 ≥20%blasts and ＜ 90%blasts in marrow;

≥10%of marrow showing granulocytic differentiation
≤20%monocytic cells

M3 ≥20%of marrow or abnormal promyelocytes

M3v Same as M3 except composed of hypogranular variants
FAB Diagnostic Criteria
Subtype
M4 ≥20%blasts
≤80%myeloblasts and granulocytic precursors in rnarrow
＞ 20%monocytic cells in marrow (morphology/NSE stain/serum
lysozyme)
M4e Same as M4 with increased number of atypical/immature
marrow eosinophils
M5a ≥80%monoblasts
M5b ≥80%of monoblasts /promonocytes /monocytes ＜
80%monoblasts in marrow
M6 ≥50%nucleated RBC
Prominent dyserythropoiesis
≥20%rnyeloblasts in nonerythroid cells
M7 ≥20%blasts
Identification of megakaryoblasts by ultrastructurai cytochemistry
or by immunophenotyping
 FAB-MO: AML Without Maturation

• The FAB-M0 group of AML is myeloid

leukemia with a minimal differentiation that
has a demonstrable myeloid lineage by
immunophenotyping or ultrastructural studies.
These AMLs consist of small-to intermediate-
size leukemic blasts without any evidence of
granulocytic differentiation(Fig.4-4).
Cytochemical staining with MP0,Sudan black
B (SBB),and nonspecific esterase(NSE)is
negative.
Fig. 4-4 Acute myelogenous leukemia M0.

Type 1 blast cells

• However, by flow cytometric
immunophenotyping, these cases show
reactivity with one or more myeloid-associated
markers, such as CD117(C-kit),
CD13,CD33,or CD15, while lacking any
expression of lymphoid-associated markers.
 FAB-M1: AML Without Maturation

• In these AML s without maturation, there is

minimal evidence of cytoplasmic granulation
and minimal numbers of Auer rods. The blasts
are intermediate in size with finely reticular
chromatin, small amounts of grayish-blue
cytoplasm, and typically one or more
prominent nucleoli (Fig.4-5).
Fig. 4-5 Acute myelogenous leukemia M1

Type 1 blast cells

 Basic FAB criteria for AML-M1 include the
following (1)the sum of total blasts is greater than
90% of the bone marrow cells;(2)less than 10%of
bone marrow cells shows evidence of granulocytic
differentiation at or beyond the promyelocyrte stage;
and (3)at least 3% of the leukemic blasts demonstrate
MPO and/or SBB positivity. The differential
diagnosis in this disorder includes ALL-L2,AML-
M5a,and AML-M7.Immunophenotyping and
cytochemical staining are usually necessary to make
the distinction between these subtypes of leukemias.
 FAB-M2: AML with Maturation

• The AMLs with maturation are the most

common subtype of AML These leukemias
show clear evidence of differentiation at or
beyond the promyelocyte stage, and Auer rods
are commonly identified(Fig.4-6).
Fig. 4-6 Acute myelogenous leukemia M2 with
numerous single Auer rods.

Type II blast cells

with Auer rods
• The basic FAB criteria for FAB-M2
include the following:(1)the sum of blasts is
20% or greater but less than 90% of the bone
marrow cells;(2)more than10% of the bone
marrow cells shows evidence of grannlocytic
differentiation; and (3) monocytic cells
constitute fewer than 20% of the bone marrow
cells.
• The differential diagnosis of FAB-M2 would include a
leukemoid reaction, a MDS that does not meet the criteria of AML
and possibly other types of AML having a granulocytic
component such as FAB-M3,FAB-M4,or possibly FAB-M6.
• A specific bone marrow chromosome abnormality, t(8;21),has
been observed in some cases of FAB-M2.The percentage of
patients with the t(8;21)translocation has varied from 30% to less
than 5% of FAB-M2s in various report in the literature. Patients
having AML-M2 with a t(8;21)are believed to have a good
prognosis.
• This dysmyelopoiesis has been described as a "crushed" orange
granularity in the cytoplasm of the granulocytic cells. These
patients usually aberrantly express CD 19and/or CD56.
 FAB-M3: Acute Promyelocytic Leukemia

• Acute promycloqrtic leukemia (APL)can be

diagnosed when 20% or mom of the bone
marrow cells are abnormal promyelocyte.
These promyelocytes have abnormally dense
and heavy granulation. One of the
characteristic features of APL are the so-called
faggot cells, which are cells that contain
multiple Auer rods that may be bundled,
intertwined, or fused together (Figs.4-7).
Fig. 4-7 Acute myelogenous leukemia M3 (acute
Promyelocytic leukemia Faggot cell).

Faggot cells
• The differential diagnosis of APL includes other
types of AML with granulocytic components, such as
FAB-M2, FAB-M4/M5,and benign-agranulocytosis
with a promyelocyte arrest.
• The major difficulty in the diagnosis of APL is the
distinction of microgranular APL(M3v) from FAB-
M4 or M5b.
• Evaluation with cytogenetic and molecular
studies typically resolves this issue.
Demonstration of t(15;17)(q22;q12,21)or
t(11;17)is diagnostic of APL and essential for
diagnosis. The immunophenotic studies in
typical APL include myeloid
phenotype(CD13,CD33)and lack of
HIADR,CD34.
 FAB-M4: Acute Myelomonocytic Leukemia

• Acute myelomonocytic leukemia and FAB-M2 are

the most common AMLs, together accounting for
approximately two thirds of all AML cases. The
FAB-M4 subgroup of AML is probably the most
difficult subgroup of AML in which to perform a
reliable differential count, as this is a very
heterogeneous-appearing leukemia. Both granulocytic
and monocytic differentiation are present in varying
proportions in the bone marrow (Fig4-8).
Fig. 4-8 Acute myelogenous leukemia M4

Monoblast cells

Myeloblast cells
• The criteria hr the diagnosis of FAB-M4 inchldes
the following elements(1)the sum of all blasts is
greater than 20%; (2)the sum of myeloblasts and
granulocytic precursor cells account for less than
80% of the bone marrow cells;(3)more than 20% of
the bone marrow cells are of the monocytic lineage as
demonstrated by morphology, NSE cytochemical
stain, or elevated scrum lysozyme level (three times
normal).
• A variant of FAB-M4 exists, which has been called FAB-
M4 with eosinophiiia(M4eos).Criteria for diagnosis include
the usual diagnostic criteria for FAB-M4 and an increased
number of atypical immature bone marrow eosinophils(Fig.4-
9).
• Abnormalities of chromosome l6,including
inversion of 16(p13;q22) or deletion of 16q22, are
consistently identified in this variant. This type of
leukemia has a high rate of remission after the initial
induction of therapy compared with other types of
AML and diagnosis of this variant is considered a
good prognostic sign..
Fig. 4-9 Acute myelogenous leukemia M4 with
eosinophilia(M4eos)

eosinophils
FAB-M5a: Acute Monoblastic Leukemia and FAB-
M5b:Acute Monocytic Leukemia

• FAB-M5a is characterized by a predominance of

monoblasts that are large and have relatively
abundant cytoplasm. Some azurophilic granules may
be identified in the cytoplasm that are MPO negative.
• Typically, the nucleus is displaced to one
side with an ample amount of cytoplasm
wrapping around the nucleus (Fig.4-10).The
sole criterion for diagnosis of FAB-M5a is the
existence of more than 80% monoblasts in the
bone marrow.
Fig. 4-10 Acute myelogenous leukemia M5a.

Monoblast and promonocyte

• FAB-M5b, in which more than 80% of the
marrow cells are monoblasts, promonocytes,
or monocytes but less than 80% of the marrow
cells are monoblasts. In other words, FAB-
M5b shows more differentiation than FAB-
M5a. .Nuclear folding and irregularity are
common in FAB-M5b,and more azurophilic
granulation is identified than in FAB-
M5a(Fig.4-11).
Fig. 4-11 Acute myelogenous leukemia M5b.

Promonocyte and monocyte

• FAB-M5a and FAB-M5b are associated with a
high incidence of exatramedullary infiltration; DIC
may also develop in patients with FAB-M5, second in
incidence only to FAB-M3 among classes of AML.
NSE cytochemical stains are positive in the FAB-M5
leukemias. Auer rods may be seen in a small
percentage of monoblasts but are certainly much less
frequent than in the granulocytic types of AML.
AML-M5a is more commonly diagnosed in the
pediatric age group.
 FAB-M6: Acute Erythroleukemia (Di Guglielmo’s Syndrome)

• Acute erythroleukemia is a relatively

uncommon variant of AML and may have
multiple presenting appearances. One form,
which has previously been called erythemic
myelosis, is characterized by bizarre and
markedly atypical megablastoid changes
accompanied by extreme erythroid hyperplasia
within the bone marrow (Fig.4-12).
Fig. 4-12 Acute myelogenous leukemia M6 (erythemic myelosis).

erythroid hyperplasia
• In other cases of FAB-M6, the marrow
contains more differentiated, albeit dysplastic,
erythroblasts at the time of presentation along
with a definite population of granulocytic
cells, including myeloblasts(Fig.4-13).
Fig. 4-13 Acute myelogenous leukemia M6.

erythroblast

myeloblast
• The following criteria were established by the
FAB group for the diagnosis of erythroleukemia
in determining blast percentage:(1)50% or more
of all nucleated bone marrow cells must be
erythroblasts;(2)dyserythropoiesis is prominent;
(3) 20% or more of the nonerythroid cells in the
bone marrow are myeloblasts.
• The differential diagnosis for erythroleukemia
includes B12/folate deficiency, heavy metal
intoxication (such as arsenic),drug effects (such as with
antineoplastic agents or chloramphenicol),congenital
dyserythropoietic syndromes, MDSs, and potentially
other types of AML.
• The dysplastic erythroblasts are typically PAS
positive, which reflects a cytoplasmic maturation
defect. This cytochemical finding is not restricted to
leukemia and can be identified in benign-disorders,
much as βthalassemia, iron deficiency, sideroblastic
anemia, and heavy metal intoxication.
 FAB-M7: Acute Megakaryoblastic leukemia

• Acute megakaryoblastic leukemia has only

recently been added to the FAB classification. The
diagnostic criteria for diagnosis
includes （ 1 ） more than 20% blasts in the bone
marrow and (2) definitive identification of
megakaryoblastic involvement by a platelet
peroxidase reaction by electron microscopy or
reactivity with megakaryocyte-speciflc monoclonal
antibodies. The differential diagnosis of
megakaryoblastic leukemia includes ALL-L2, AML-
M0,AML-M1 and AML-M5a.
• There is typically scanty basophilic cytoplasm,
which may or may not be vacuolated. Indeed,
the degree of basophilia may be comparable
with that found in erythroleukmia, reflecting the
close developmental relationship between
erythroid and megakaryoblastic precursors.
• Very fine granulation can be identified in the
cytoplasm of some basts. Intermediate forms
between undifferentiated blasts and definitive
micromegakaryocytes may also be seen (Fig.4-
14).
• Cytochemically, megakaryoblasts show no
reactivity with MPO or SBB. A diffuse, coarse
granular positivity is typically seen with PAS, not to
be confused with the chunky staining seen in ALL.
• Immunophenotyping with monoclonal antibodies
reactive with platelet glycoprotein(Gp)IIb/IIIa or Gp
IIIa(CD4land CD61)has provided a more sensitive
and reproducible method of detecting
megakaryoblasts.
 MYELODYSPLASTIC SYNDROMES
• The MDSs are a heterogeneous group of bone
marrow disorders generally characterized by
cytopenias and morphologic abnormalities of the
erythroid, granulocytic, and megakaryocytic cell
lines within a hypercellular bone marrow.
• MDS usually occurs in individuals older than the
age of 50, although genuine cases of MDS may
rarely be seen in the pediatric age group. In
general, however, the diagnosis of MDS in
children should be made very cautiously.
• Historical terms that have been used to
describe MDS in, elude preleukemia, early
leukemia, smoldering leukemia, subacute
leukemia, atypical leukemia, and
hematopoietic dysplasia.
• Bone marrow myeloblasts may be
increased but do not reach the 20% blast
level necessary for a diagnosis of AML.
 Diagnosis
• Most MDSs will show quantitative and
qualitative evidence of dyserythropoiesis,
dysgranulopoiesis, and dysmegakaryopoiesis.
An iron stain for ringed sideroblasts, and the
percentage of blood and bone marrow
myeloblasts are essential in accurately
classifying the MDS. These and other features
are listed in Table 4-10 and are described
below.
MORPHOLOGIC FEATURES OF
MYELODYSPLASIA
Dyserythropoiesis
Megaloblastoid changes
Multinucleation
Nuclear/cytoplasmic asynchrony
Nuclear karyorrhexis
Ringed sideroblasts
Dysgranulopoiesis
Pseudo Pelger-Huet changes
Hypogranulation
Abnormal granules
Basophilia
Decreased or absent myeloperoxidase
Decreased leukocyte alkaline phosphatase
Dysmegakaryopoiesis
Large, bizarre platelets
Hypogranular platelets
Bizarre megakaryocytes
Uninuclear megakaryocytes
 FAB CLASSEFECATEON OF
MYELODYSPLASTIC SYNDROMES

Refractory anemia
Idiopathic refractory sidemblastic anemia
Refractory anemia with excess blasts (RAEB)
RAEB in transformation
Chronic myelomonocytic leukemia
Myelodysplastic syndrome,unclassified(NOS)
Therapy-related myelodysplasia
PROPOSED WORLD HEALTH ORGANIZATION
CLASSIFICATION OF MYELODYSPLASHC SYNDROMES

Refractory anemia
Refractory anemia with ringed sideroblasts
Refractory cytopenia with multilineage
dysplasia
Refractory anemia with excess blasts
Type1: 5% to 9%blasts in blood or marrow
Type2:10% to19%blasts in blood or marrow
5q-syndrome
Therapy-related myelodysplastic syndrome
Myelodysplastic syndrome, unclassified
CHRONIC LYMPHOCYTIC LEUKEMIA

Chronic lymphocytic leukemia(CLL) is a common

neoplastic disease characterized by proliferation of
small, morphologically mature lymphocytes.
CLL involves the blood and bone marrow, and also
frequently the lymph nodes, spleen, and liver. It is a
disease with a male predominance and a median age
approximately 65,being rarely seen in individuals less
than 40 years of Most cases of CLL are of B-cell
type, and the following discussion applies to B-cell
CLL. T-cell CLL which is very rare, is biologically
distinctly different from B-cell CLL and will be
discussed in a subsequent section.
 CLASSIFICATION OF
LYMPHOPROLIFERATIVE DISORDERS(1)
Chronic Lymphoproliferative
Disorders
Peripheral B-cell
Chronic lymphocytic leukemia
prolymphocytic leukemia
Hairy-cell leukemia
Peripheral T-cell
Chronic lymphocytic leukemia
prolymphocytic leukemia
Large grannlar lymphocyte leukemia
Sezary syndrome
Adult T-cell leukemia/lymphoma
 CLASSIFICATION OF
LYMPHOPROLIFERATIVE
Immunoproliferative Disorders DISORDERS(2)
Plasma cell myelorna
Plasmacytoma
Waldenström's macroglobulinemia
Heavy chain disease
Benign monoclonal gammopathy
Amyloidosis
Malignant Lymphomas
Non-Hodgkin's lymphoma
B-cell lymphomas
T-cell and NK-cell lymphomas
Hodgkin's disease
Postransplant lymphoproliferative disorders
Acute Lymphocytic Leukemia (derived from precursor B-and T-
cells)
will be discussed in a separate chapter
 PLASMA-CELL MYELOMA

• Plasma-cell myeloma is a relatively common

hematologic disease characterized by
proliferation of clusters and sheets of
neoplastic plasma cells primarily in the bone
marrow, resulting in focal bone lesions, diffuse
osteoporosis, bone pain, fractures, and
cytopenia.
Fig PLASMA-CELL MYELOMA

Immuature
plasma cells

Immuature
plasma cells

Cytoplasmic
Monoclonal immunoglobulin light
chain expression by
gammopathy immunofluorescence
CLINICAL PATHOLOGEC CRITERIA FOR INCLUSION IN
STUDIES OF PLASMA-CELL MYELOMA

Major Criteria
I Plasmacytomas by biopsy
II ＞ 30% marrow plasmacytosis
III Monoclonal gammopathy
＞ 3.5 g/dl of lgG
＞ 2.0 g/dl of lgA or
＞ 1 gm/day κ or λ chains in urine without other
significant
proteinuria
CLINICAL PATHOLOGEC CRITERIA FOR INCLUSION IN
STUDIES OF PLASMA-CELL MYELOMA
Minor Criteria
A. 10%-30% marrow plasmacytosis
B. Monoclonal gammopathy with values less than in
III
C. Lytic bone lesions
D. Suppressed normal immunoglobulins
＜ 5O mg/dL IgM,
＜ 100 mg/dL IgA or
＜ 600 mg/dL IgG
Symptomatic patient and
I plus B, C or D
II plus B, C, or D
III A, B, and C
A, B, and D
 CHRONIC MYELOGENOUS LEUKEMIA

• CML is the best characterized and most

common of all the CM-PDs. This disease is
defined by a molecular marker, the
Philadelphia chromosome (Ph)with the
breakpoint duster region-Abelson murine
leukemia virus (BCR-ABL)fusion gene that
results from the translocation of chromosomes
9and 22[t(9;22) (q34;q11)]
 Bone Marrow Finding

• Morphologic findings in the bone marrow

biopsy do not add significant information for
diagnostic purposes.
• The cellularity is markedly increased, and a
marked granulocytic hyperplasia is present
with a myeloid to erythroid ratio of 10:1 or
greater (Fig.4-16).Megakaryocytes are
increased and typically small and hypolobated,
in contrast to other CMPDs.
 Fig. 4-16 Bone marrow biopsy of
chronic myelogenous leukemia

marked hypercellularity and

marked myeloid hyperplasia.
 Acute Biphenotypic Leukemia

• Figure 4-15 is a schematic drawing outlining the

diverse groups that compose what we have called
biphenotypic leukemia. Leukemias with the
Philadelphia chromosome or 1lq23 translocations
have clearly been associated with biphenotypic
processes. Identification of other immunologic and
cytogenetic subgroups will be essential in further
characterizing and understanding these intriguing
leukemias and the cellular counterparts from which
they arise.