01 BM
01 BM
01 BM
HEMATOPOIESIS
A lecture by: Maximo B. Axibal, Jr. MD FPSP MMHA
HEMATOPOIESIS
HEMATOPOIESIS
Medullary
vs
Extramedullary
Synchronous vs
Asynchronous
Introduction
BM largest tissue in the body Adult: 4 L; Child: 1. 6 L BM 1 site for blood cell formation
2.5 billion RBCs / kg / day 2.5 billion platelets / kg / day 1 billion granulocytes / kg / day
Introduction
Monopheletic (Downey, Ferat & Pappenheim) Polypheletic (Piney, Naegali, Schilling, Rosenthal, Osgood, Sabin, Cunningham & Doan) Naegali Modification of Schilling Sabin & her co-workers
Start: 4th wk AOG End: 2nd mon AOG Products: Nucleated megaloblastic RBC's (2 wks AOG) Minor production of MKs
Nurse Cell
Nursing Mother
Start: End of 11th wk AOG End: 6th mon AOG Products: Extravascular erythroblasts & anucleated macrocytic RBC's Megakaryocytes- 6th wk AOG Granulocytes6th wk AOG Lymphocytes4th mon AOG Monocytes5th mon AOG
Products: RBC's- 10th wk AOG Thrombocytes Granulocytes/ monocytes Lymphocytes- w/ contributions from thymus, L.N. & spleen (Ag independent)
RBC - Alpha 1 & alpha2 beta2 3 wks postpartum BM (Medullary) 4th y - rate of BM production exceeds need for blood cells
Parenchyma Stroma
Erythropoiesis- erythropoietic islands (Histiocyte + Normoblasts) Granulopoiesis- around reticular cell Megakaryopoiesis- subjacent to sinus endothelium Immunocytes
Histiocyte (Nurse cell): perisinusoidal; center of RBCpoiesis; (+) ACP Reticulum cell: adventitial; center of WBC-poiesis; (+) Silver stain; (+) ALP
Fat cell: Variable amount 0% (NB & infants) 3 y/o discernable fat 40%- 50%- adults
Endothelial cell: More visible in hypoplastic marrow Differentiate from tumor cells
Osteoblasts: In groups Resembles plasma cells But larger, w/ fine chromatin, w/ nucleolus & hof (+) ALP
Osteoblast
Plasma cell
Osteoclasts: Multinucleated giant cells Resembles MKs (lobated nucleus) But nucleus separated by granular cytoplasm
Osteoclast
MKs
BMA Indications
Anemias, erthrocytosis, polycythemia Leucopenia, leucocytosis, immature or abnormal cells in circulation Thrombocytopenia, thrombocytosis
Malignant tumors
Lymphoma, ca & sarcoma mets to BM Staging & prognosis Granulomas Focal necrosis Histiocytic proliferartion w/ intracytoplasmic organisms Gaucher's Sea Blue Histiocytosis
Infections ("FUO")
Aspirate Specimen
Types of needle Sites of puncture Precautions Types of Smears (BM ASPIRATES) Staining of Bone Marrow Smears BONE BIOPSY QUANTITATIVE MEASUREMENT OF BMA
Types of needle:
Sites of puncture:
Anterior Superior Iliac Crest Posterior Superior Iliac Crest (adults) Sternum (most common) Spinal processes (L3) or vertebral bodies Proximal end of tibial bone (infants)
ASIC
PoSIC
BM Biopsy
BM Aspiration
Precautions:
Signed informed consent from patient if adult; parent or guardian if a child w/ matching witness. Explain indications, risks & benefits of procedure. Observe asepsis. Do procedure in the presence of a RN (assistant) & RMT (proper collection & handling of 1- 1.5 cc).
Precautions:
Prompt & swift. Avoid clotting (fibrin strips cytoplasm of cells). 1st part of specimen for smear prep; the rest in EDTA tubes
Clotted specimens good only for histopath purposes if properly preserved in 10% formalin
BMA Procedure:
BMA Procedure:
Done as in PBS Ideal for morphologic studies Ideal for cell to cell relationship & cellularity Done as in PBS but pre- selection of sample in petri dish Fe staining (Prussian Blue)
Air dry smears Fix (Absolute Methanol) for 3- 5 mins. ASAP Stain: 3- 6 mins
BMB
Done routinely w/ aspirates. Dry tap aspirates. Diagnosis of neoplastic/ granulomatous diseases (bilateral POSiC biopsy for clinical staging of lymphomas & Ca)
Touch prep- bone core in between blades of forcep touched several times in 2- 3 clean slides; no rubbing; done as BM smears
Histopath section- fixed in 10% formalin/ Zenker's/ Carnoys; undergoes standard histologic processing including decalcification; 2- 3 u thick; stained w/ H & E or special stains
Most ideal for assessment of cellularity Advantage: Represents marrow structures in its natural relationship Disadvantage: Fine cellular details lost; little value in dX of leukemia & refractory anemias
EDTA anticoagulated aspirate 1 ml transferred into Wintrobe tube Centrifuge at 2800 g x 8 min Layers measured as %age from Wintrobe tube
Fat & perivascular cells- Fe content Plasma Buffy coat FOR morphology & M:E RBC
Wright's stain
Scan at LPO: Look for marrow spicule Evaluate cellularity Estimate for megakaryocytes Determine presence or absence of predominance of one cell line (monotony) Scan for abnormal cells; Look for metastatic clumps (black ball)
BM EXAMINATION at LPO
Area well spread, intact cells, not diluted by sinusoidal blood Periphery of BM particlesevaluation of cellularity # & distribution of MK (3/ LPO adjacent to spicule up to 10/ LPO) Tumor cells- larger than RBC & WBC precursors; in clusters
BM EXAMINATION at LPO
Marrow cellularity estimate (hematopoietic: fat cells) Area of examination- between 2 uncrushed particles For diagnosis of aplasia > 1 sample from different sites Correlate w/ M:E (3 4 : 1)
BM EXAMINATION at LPO
Shift to OIO: Find area where cells are well spread Determine proportion of differentiated granulocytes Determine M:E (3- 4:1) Evaluate for orderly granulopoiesis Evaluate erythropoiesis
BM EXAMINATION at OIO
At LPO, examine Prussian Blue stained smear for iron particles At OIO, look for ringed sideroblasts if stained iron is increased
BM EXAMINATION: Fe STORES
Indication: dx of anemia
Refractory Dyserythropoietic
Use EDTA chelating agts for decalcification than acid agts to preserve Fe in hemosiderin form
BM EXAMINATION: Fe STORES
0- 5 w/ 2 representing normal
Scan at LPO:
Look for marrow spicule Evaluate cellularity Estimate for megakaryocytes Determine presence or absence of predominance of one cell line (monotony) Scan for abnormal cells; Look for metastatic clumps (black ball)
Scan at LPO:
Look for marrow spicule Evaluate cellularity Estimate for megakaryocytes Determine presence or absence of predominance of one cell line (monotony) Scan for abnormal cells; Look for metastatic clumps (black ball)
Hypocellular BM
BM Core Biopsy
>95% cellularity
20% cellularity
Scan at LPO:
Look for marrow spicule Evaluate cellularity Estimate for megakaryocytes Determine presence or absence of predominance of one cell line (monotony) Scan for abnormal cells; Look for metastatic clumps (black ball)
Shift to OIO:
Find area where cells are well spread Determine proportion of differentiated granulocytes Determine M:E (3- 4:1) Evaluate for orderly granulopoiesis Evaluate erythropoiesis
Bad
Granulocytic maturation
Erythrocytic maturation
4% 8% 18%
13 granulocytes
1 4 1 5 2
6 normoblast:
4 orthochromic NB 2 NB polychromatophilic
Shift to OIO:
Find area where cells are well spread Determine proportion of differentiated granulocytes Determine M:E (3- 4:1) Evaluate for orderly granulopoiesis Evaluate erythropoiesis
Determine M:E
Shift to OIO:
Find area where cells are well spread Determine proportion of differentiated granulocytes Determine M:E (3- 4:1) Evaluate for orderly granulopoiesis Evaluate erythropoiesis
Erythropoeisis type?
Other Cells:
Gaucher cell
Basophilic MK (MK1)
Granular MK (MK2)
Plasma cells
At LPO, examine Prussian Blue stained smear for iron particles At OIO, look for ringed sideroblasts if stained iron is increased
If normal amount of iron is present, patient is not iron def If iron is absent, patient is iron def
Patient's addressograph data, age & relevant clinical history Description of material received CBC, WBC, Differential, Platelet & reticulocyte counts w/ PBS taken on the day of the marrow sampling B.M. Differential count Cellularity M:E
Bone Marrow Biopsy Report Sample of actual Report Stanford Hospital and Clinics 300 Pasteur Drive, Stanford, CA 94305
Name: XXXXXXXXXX (CROSSED OUT) CLINICAL HISTORY: 32-year-old male with a history of APL (SHS-01-29962). A recent biopsy showed no morphologic evidence of residual disease (SHS 01-37736). ORDER DOCTOR: OPERATION: MARTIN, BETH
GROSS DESCRIPTION: The specimen "left PSIC bone marrow biopsy" is received in Bouin's solution and consists of one elongated cylindrical tan-brown fragment of bony material that measures 1.5 x 0.2 x 0.2 cm. The specimen is submitted entirely between sponges in a single cassette following decalcification (MARROW HEME tag). Estrada for Morgan/pal LABORATORY DATA: WBC: 6.4 K/uL HGB: 11.0 g/dL HCT: 34.0 % MCV: 74.2 fL PLT: 358 K/uL RDW: 14.5% ABS NEUT: 3.92 K/uL ABS LYM: 1.70 K/uL PERIPHERAL BLOOD SMEAR: Red blood cells are normochromic and range from microcytic to normocytic. There is occasional polychromasia. A few scattered teardrop forms are identified. Platelets are normal in number with occasional large and hypogranular forms. -White blood cells are normal in number, with a normal absolute number of neutrophils. White blood cells are predominantly normal appearing segmented and band neutrophils, with fewer numbers of lymphocytes and monocytes. BONE MARROW ASPIRATE: The bone marrow aspirate is adequate. Megakaryocytes are present in normal numbers with normal morphology . The M:E ratio is 2-3:1. Myeloid precursors are normal in number and are left-shifted without a relative increase in the number of promyelocytes or blasts. Erythroid precursors are present in normal numbers and are also mildly left-shifted . Iron stores are present within histiocytes, no ringed sideroblasts are identified.
BONE MARROW BIOPSY: The bone marrow biopsy is mildly hypercellular for age, approximately 70%. Megakaryocytes are present in normal numbers and morphology. The M:E ratio is 3:1. Myeloid and erythroid precursors are normal in number and mature fully. The myeloid precursors are mildly left-shifted. There are no excess blasts. Notable, there is an area of fibrosis, which appears to be associated with subcortical bone.
COMMENT: The bone marrow aspirate and biopsy reveal left-shifted myelogenesis and erythrogenesis. There is no relative increase in the number of promyelocytes or blasts. Since morphology is limited in distinguishing normal myelogenesis from residual disease, correlation with cytogenetic and/or molecular studies is recommended. DIAGNOSIS: BONE MARROW ASPIRATE, BIOPSY, AND PERIPHERAL BLOOD SMEAR MILDLY HYPERCELLULAR MARROW WITH LEFT-SHIFTED MYELOID AND ERYTHROID MATURATION (SEE COMMENT)
LABORATORY DATA:
WBC: HGB: HCT: MCV: PLT: RDW: ABS NEUT: ABS LYM:
6.4 K/uL 11.0 g/dL 34.0 % 74.2 fL 358 K/uL 14.5 % 3.92 K/uL 1.70 K/uL
Red blood cells are normochromic and range from microcytic to normocytic. There is occasional polychromasia. A few scattered teardrop forms are identified. Platelets are normal in number with occasional large and hypogranular forms. White blood cells are normal in number, with a normal absolute number of neutrophils. White blood cells are predominantly normal appearing segmented and band neutrophils, with fewer numbers of lymphocytes and monocytes.
BMA Report:
The bone marrow aspirate is adequate. Megakaryocytes are present in normal numbers with normal morphology. The M:E ratio is 2-3:1. Myeloid precursors are normal in number and are left-shifted without a relative increase in the number of promyelocytes or blasts. Erythroid precursors are present in normal numbers and are also mildly left-shifted. Iron stores are present within histiocytes, no ringed sideroblasts are identified.
The bone marrow biopsy is mildly hypercellular for age, approximately 70%. Megakaryocytes are present in normal numbers and morphology. The M:E ratio is 3:1. Myeloid and erythroid precursors are normal in number and mature fully. The myeloid precursors are mildly leftshifted. There are no excess blasts. Notable, there is an area of fibrosis, which appears to be associated with subcortical bone.
COMMENT: The bone marrow aspirate and biopsy reveal left-shifted myelogenesis and erythrogenesis. There is no relative increase in the number of promyelocytes or blasts. Since morphology is limited in distinguishing normal myelogenesis from residual disease, correlation with cytogenetic and/or molecular studies is recommended. DIAGNOSIS: BONE MARROW ASPIRATE, BIOPSY, AND PERIPHERAL BLOOD SMEAR MILDLY HYPERCELLULAR MARROW WITH LEFTSHIFTED MYELOID AND ERYTHROID MATURATION (SEE COMMENT)
SUMMARY
Scan at LPO Find spicule Evaluate cellularity Look for metastatic clumps (black ball) Estimate for megakaryocytes Determine presence or absence of predominance of one cell line (monotony) Scan for abnormal cells
SUMMARY
Scan under OIO Determine M:E (3- 4:1) Evaluate for orderly granulopoiesis Evaluate erythropoiesis
SUMMARY
Examine iron stain Determine amount of hemosiderin Look for ringed sideroblast (OIO) if stainable iron is increased