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Case 1

Stephan Dirnhofer and Andr Tichelli

History / Clinical findings


40-years old man, admitted for thoracic pain Diagnosis of classical Hodgkin lymphoma, nodular sclerosis, in a cervical lymph node Bone marrow biopsy for lymphoma staging

Blood counts
Parameter Hemoglobin MCV WBC Platelets Result 142 88 12.2 198 Reference 140-160 80-95 3.5-10.5 150-400 Units g/L fL x109/L x109/L

Peripheral blood

Cytology bone marrow

Indications for bone marrow examination


Investigation of peripheral blood abnormality - cytopenias, cytosis, abnormal cells Selected types of infectious diseases - Parvo-virus B19, Leishmaniosis, others Fever of unknown origin, unexplained splenomegalie, storage disease Staging and management of tumor patients - all lymphomas, childhood neoplasms, others Plasma cell dyscrasias incl. amyloidosis Systemic mast cell disease Monitoring of patients with leukemia - response to therapy, stem cell transplantation Miscellaneous - hps, effects of therapy, immunodeficiency, bone disorders

Strength of bone marrow biopsy


Assessment of:
cellularity, topographical distribution of hemopoesis and inter-relationships of cells
!

bone structure, blood vessels, stroma, lymphoid aggregates, iron content and degree of fibrosis or necrosis
!

focal processes (carcinoma, lymphoma, granuloma and other infiltrative processes)


!

bone marrow infiltration pattern for lymphomas, mast cell disease and others
!

Additional investigations (IHC, FISH, PCR)

Strength of bone marrow cytology


Individual cell morphology, dysplastic changes of the erythropoiesis and myelopoiesis, Auer rods in the blasts Particular forms of AML recognizable: Promyelocytic leukemia, AML with t(8;21), AML M4eo with t(16) or inv(16) Ringed sideroblasts for sideroachresia Material for flow-cytometry, cytogenetics and molecular genetics Rapidly available for analysis (1-2 hours)

Algorhytm for BM-biopsies


See the biopsy with a smear (and a hematologist) Systematic assessement of: Cellularity, Bone structure Topography and Maturation of all three cell lines Dysplasia, Blasts Lymphocytes, Plasma cells, other infiltrates Iron, Fibers Others: Granulomas, Mast cells, (Pseudo-)Gaucher cells... Final interpretation is an integrative diagnosis: a morphological diagnosis in combination with hemogramm, laboratory data, genetics and clinical findings

H&E

H&E

Gm

Final diagnosis
Normocellular, completely maturing bone marrow No evidence of Hodgkin Lymphoma

A normal bone marrow contains


1. No blast at all 2. Between 1-4% blasts 3. !5% blasts 4. No blasts but >5% CD35+ cells (exclusively endothelial cells) 5. Any number but always CD34negative

A normal bone marrow contains


1. No blast at all 2. Between 1-4% blasts 3. !5% blasts 4. No blasts but >5% CD35+ cells (exclusiveley endothelial cells) 5. Any number but always CD34negative

Among the following, what is the strength of marrow biopsy


1. Assess dysplasia of myelopoiesis 2. Assess ringed sideroblasts 3. Recognize Hodgkin infiltration 4. Point 3 and 5 5. Assess topographical distribution of the cells

Among the following, what is the strength of marrow biopsy


1. Assess dysplasia of myelopoiesis 2. Assess ringed sideroblasts 3. Recognize Hodgkin infiltration 4. Point 3 and 5 5. Assess topographical distribution of the cells

Among the following, what is the strength of marrow cytology


1. Assess diagnosis of acute promyelocytic leukemia 2. Assess fibrosis in CIMF 3. Recognize granulomas 4. Point 3 and 5 5. Recognize infiltration of carcinoma

Among the following, what is the strength of marrow cytology


1. Assess diagnosis of acute promyelocytic leukemia 2. Assess fibrosis in CIMF 3. Recognize granulomas 4. Point 3 and 5 5. Recognize infiltration of carcinoma

Take home messages


Use standardized diagnostic approach Consider clinical findings including blood counts and differentials Consider peripheral blood smear and aspirate Consider flow cytometry, genetics and stem cell cultures Integrate all data for final diagnosis

Well, ...it looks like you broke the Jamishidi-needle ...

Clinico-pathological cooperation is essential