Bone Marrow Examination
Bone Marrow Examination
Bone Marrow Examination
How about it ?
Cell Lines in Blood Cell Formation
Genesis of erythrocytes
• Committed cells are proerythroblasts
➢ aspirate
Morphology ➢ Iron studies
➢ cytochemical stains ➢ B12/folate
➢ Flow cytometric immunophenowping ➢ Hemoglobin electrophoresis
➢ cytogenetic analysis ➢ Immunoelectrophoresis
➢ Molecular biological studies ➢ LDH
➢ Coomb's test
➢ Microbiology culture/serology results
➢ Miscellaneous
Indication For Bone Marrow Evaluation
Evaluation for Primary hernatologic disorder;Staging for
ma|ignancy Hodgkin's disease;Staging for non-Hodgkin's
lymphoma;Metastatic tumor (nonhematopoietic)
Monitoring Post-chemotherapy
therapy Post-bone marrow transplantation
.
• sternum
fibrotic
□myelosis(leukemia\polycythemia vera )
□myeloproliferative reduce(aplastic
anemia )
□tumor bone marrow infiltration
NEUTROPHIL ALKALINE PHOSPHATASE
STAIN (NAP)
NAP ↑: NAP ↓
➢ Leukemoid
Reaction
➢ Bacterial infections CML
➢ Polycythemia vera virual infections
➢ Aplastic anemia PNH
➢ Acute lymphocytic AML
leukemia
AS-D NCE
a -NBE stain
POX stain
NON Specific
PEROXIDASE Specific Esterase Stain
STAIN Esterase Stain ➢ AMOL:
1.Distinguishing the help differential Monoblasts (+)
different types of leukemias inhibited by
acute (1) AML NaF.
leukemia.AML- (2) AMOL/M5 AML:
Positive,AMOL-
(3) ALL Myeloblasts (-)
Faintly positive; ALL or (+) not
– Negative,ALL can
(4) AMMOL /M4
inhibited.
be ruled out in POX
➢ ALL:
positive case. AML
and AMOL can not
Lymphoblasts
be ruled out in POX (-) or (+) not
negative case. inhibited.
2.Distinguishing APL Erythremia
and AMOL Normablast
Interpretation of Bone Marrow Studies
1) of disease
• Acute lymphoid
• chronic myeloid
Acute leukemia (AL):
immature,early <6M
Chronic leukemia
(CL):mature,late>1Year
Classification of leukemias
Acute Chronic
Myeloid Acute Myeloid Chronic Myeloid Leukemia
origin Leukemia 45%(AML) 15%(CML)
MICM Cytogenetics
Molecular biololgy
Immunological
Morphorlogy
Cytochemical Stain In The AML
PEROXIDASE STAIN ( POX )
(-) (+~++++)
Acute Lymphoblastic M1AMLwithout
Leukemia Al M4, Acute
maturation; M2, AML
myelomonocytic
with maturation;M3,
leukemia
Acute promyelocytic
M5a, Acute
leukemia M4 Acute
monoblastic leukemia
myelomonocytic
leukemia
Relatively specific
M2 t(8;21)(q22;q22)
M3 t(15;17)(q22;q21)
M4Eo inv(16)(p13q22) or del(16)(q22)
M4,M5 t(8;16)(p11;p13)
M4,M5 t(9;11) (p21;q23)
M2,M4 t(6;9)(p23,q34)
Acute Myeloid Leukemia
FAB Chromosomal Molecular
Subtype translocation target
Blood: Anemia is usual .The total leukocyte count is usually raised with
lymphoblasts present. The granulocyte count is usually reduced. The
PLTcount is usually low.Bone Marrow: The bone marrow is hypercellular
consisting almost entirely of lymphoblasts.
FAB CLASSEFICATION OF ALL
L1 L2 L3
Size Predominant small cells Heterogeneous, Large cells
intermediate to large
cells
L2
cell L3
cell
L2
cell
T cell ALL may show ACP stain
positive. PAS stain is often positive.
NAP↑
This schematic diagram outlines the relationship of the acute and
chronic myeloid and lymphoid leukemias to normal hematopoietic
and lymphoid development.
WHO > 20
FAB CLASSIFICATION OF AML
M0 Acute leukemia, undifferentiated; myeloid immunophenotype
FABgroup on acute leukemia has morphologically subclassified the AMLs into seven major
subtypes: FAB-M1 to FAB-M7.The FAB classification of AML basically relies on the degree of
granulocytic, monocytic, erythroid, and megakaryocytic differentiation
FAB-MO: minimally differentiated AML
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.
Cytochemical staining
with MP0,Sudan black B
(SBB),and nonspecific
esterase(NSE)is
negative.
AML - M0 (minimally differentiated AML)
2-3%(AML)
➢Morphology: Blasts ≥30% (without Auer rods)
➢Cytochemistry: POX, SBB (+) <3%
➢Immunology:MPO+,CD13, CD33, CD14, CD15,
CD11b
➢Cytogenetics and Molecular Biologic
➢Ultrastructure: MPO (+), PPO (-)
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
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
FAB-M2: AML with Maturation
BM hypercellular
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 Faggot cells
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
FAB-M3: Acute Promyelocytic
Leukemia,APL
BM hypercellular
Pancytopenia in partial cases.
Hyperplasia of abnormal promyelocytes (>30% NEC) in BM.
M3v:micro-granular variant
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.
eosinophi
ls
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 Monoblast and
nucleus.The sole promonocyte
criterion for diagnosis
of FAB-M5a is the
existence of more than
80% monoblasts in the Acute myelogenous leukemia
bone marrow.
M5a.
Acute myelogenous leukemia M5b.
FAB-M5b, in which more
than 80% of the marrow
cells are monoblasts,
promonocytes, or
monocytes but less than
Promonocyte and
80% of the marrow cells
are monoblasts. In other monocyte
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.
BM hypercellular
M5a: monoblast >80% (NEC).
M5b: monoblast<80%(NEC)
Cytochem NSE cytochemical stains are positive in the FAB-M5
istry 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.
Other 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. 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.
Acute myelogenous leukemia M6
(erythemic myelosis).
erythroid hyperplasia
erythroblast
myeloblast
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
CLASSIFICATEON OF AML
summery
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
➢Marked hypercellularity.
G/E↑↑
➢Hyperplasia of myeloid series with more
matured elements later than myelocytes.
myelocytes and metamyelocytes↑↑
24
2 Clinical significance of WBC count
Neutrophilia is often seen as a consequence of bacterial
infection, drug, marrow damage,an enlarged spleen.
Eosinophilia are infections by parasites, allergic conditions, and
dermatologic disorder.
Basophilia is occasionally a clue to the presence of either
chronic myelocytic leukemia or one of the other
myeloproliferative disorders.
3 The common tests for the diagnosis of anemias