Bone marrow pathology Educational course, Belgian Society of Hematology 18 Nov 2017 Dr. J. Somja, CHU Sart Tilman, Liège, [email protected] Learning objectives When ? Bone Why ? marrow What ? examination How ? I. When ? Indications for BM examination Indications for BM examination • Haematological abnormalities that cannot be explained by available clinical and laboratory data. • A good indication is essential for an accurate diagnosis • 3 main indications : – Diagnostic purposes – Staging for malignant diseases – Monitoring Riley et al., JCLA, 2004 II. What? What specimens to collect ? (Bone marrow Particle clot) BONE MARROW Bone marrow aspirate Bacteriology Bone marrow trephine biopsy if necessary Smear Preparation + Heparin +EDTA Heparin FFPE 2-10 days Molecular Morpho, IHC, Flow biology Cytogenetics FISH, (clonal cytometr (clonal days-weeks expansion, NGS) y expansion, Karyotyping (hours) NGS, …) BM biopsy MGG Cyto- FISH Days-Weeks FISH cytology chemistr If necessary touch imprint (hours) y (hours) (days) (hours) Usefull if dry tap BM aspirate or trephine biopsy ? BM ASPIRATE BM BIOPSY • Quick results • Complete assessement of • Fine cytological detail cellularity and architecture • Enumeration of marrow • More sensitive for focal cellular elements lesions • Wider cytochemical stains • Allows grading of fibrosis can be used • Use of IHC • Ideal for flow cytometry, • Useful for assessment of cytogenetics/molecular AA, metastasis, some studies infections BM aspirate or trephine biopsy ? A thorough bone marrow examination includes both BM aspiration and trephine biopsy. – MDS: BM aspirate >>> BM biopsy – MPN: BM aspirate = BM biopsy – MPN/MDS BM aspirate > BM biopsy – AML: BM aspirate >>> BM biopsy – NHL: BM aspirate << BM biopsy – HL: BM aspirate <<< BM biopsy – MM: BM aspirate < BM biopsy – Carcinoma: BM aspirate << BM biopsy III. How? How to collect these specimens ? 1. Anatomic sites 2. Collection procedure 3. Adequacy Anatomic sites • Crest of the posterior superior iliac spine – Preferred site • Sternum – Experienced operator – Only marrow aspiration ! – Not in MM • Anterior superior iliac spine – Rarely performed • Anterior tibial plateau – Very young children Riley et al., JCLA, 2004 Collection procedure BM aspirate adequacy • Adequate aspirate – 6-12 slides – Bone marrow particles ! – Not crushed – Not too thick – Not clotted – Allow to dry quickly – Dry tapes represent 2-7% of the cases – If an adequate aspirate has not been possible, considerations should be given to preparing touch imprints of the core biopsy prior to placing it in fixative BM Aspirate smears Riley et al., JCLA, 2004 Touch imprints of the core biopsy Riley et al., JCLA, 2004 Touch imprints of the core biopsy Be gentle, be delicate ! Do NOT CRUSH ! Riley et al., JCLA, 2004 Collection procedure BM trephine biopsy adequacy • 11-gauge needle AT LEAST • If osteopenic, a 8-gauge needle allows the collection of an intact core biopsy with minimal crush artifact • 13-gauge biopsy needle for paediatric patients • Adequate core biopsy, – At least 1.6 cm to 2 cm long • Prior to fixation • Exclusive of cortical bone, cartilage, or periosteum • Free of crush artifact or interstitial hemorrhage or fragmentation Riley et al., JCLA, 2004 I. Why? Understanding of the BM examination reports Shemes like this should not have any secrets … BM trephine : Generalities Jaffe, Hematopathology, second edition, 2017 Erythropoïesis Granulopoïesis Courtesy of Pr. Tassin and Dr. Keutgens Jaffe, Hematopathology, second edition, 2017 Mégacaryocytes Other? • Monocytes • Macrophages • Plasma cells • Lymphoid cells • Mast cells • Oestoclasts • Bone • Iron • … Courtesy of Pr. Tassin and Dr. Keutgens Jaffe, Hematopathology, second edition, 2017 Immunohistochemistry • Erythroid: GlycophorinA, LMO2, CD71 • Myeloid: MPO • Megacaryocytes: CD61, Factor VIII • Blasts: CD34, CD117, CD33 – CD34+ cells are rare in normal marrow – CD34 does not equal blast • not all blasts are CD34+ • not all CD34+ cells are blasts – Not all AML’s are CD34+ – CD34 is not lineage specific • Mastocytes: Tryptase, CD117, CD25, CD2 • Plasma cells: CD138, IgKappa, IgLambda • Lymphocytes: CD20, CD3, CD30, … • … Cellularity 100-age = expected cellularity for age Severe AA is characterized by a markedly hypocellular bone marrow (<25% of normal for age or 25 to 50% of normal with <30% hematopoietic cells) accompanied by two of the following: granulocytes <0.5 × 109/L; platelets <20 × 109/L; or corrected reticulocyte count <1% Riley et al., JCLA, 2009 Jaffe, Hematopathology, second edition, 2017 Bone marrow (neoplastic) pathology WHO 2016 Myeloid Neoplasms WHO 2016 Myeloid Neoplasms 1. Myeloproliferative neoplasms • Clonal hematopoietic disorders • Characterized by proliferation of cells of one or more of the myeloid lineages; erythroid, granulocytic, or megakaryocytic • Initially, the proliferation in the bone marrow is effective and associated with maturation of the neoplastic cells • Leads to increased numbers of mature granulocytes, red blood cells (RBCs), and platelets in the peripheral blood • Splenomegaly and hepatomegaly are common and caused by the sequestration of excess blood cells, extramedullary hematopoiesis or both in these organs. Chronic Myeloid Leukaemia, BCR-ABL1+ • Blood findings – Leukocytosis – Plts N or ↗ – Often anaemia – Spectrum of maturing granulocytes with a « myelocyte bulge » – Blasts usually <2% if WBC – Absolute basophilia – No significant dysplasia • BM findings – Hypercellularity – Increased M:E ratio – Blasts usually <5%, always <10% – Widening of maturing granulocytes with myelocyte bulge but no dysplasia – Megs N or ↗ in number, with « dwarf » morphology – Reticulin fibers N to moderately increased • Genetics – 100% have Phi chromosome or BCR-ABL1 fusion gene Courtesy of Pr. Tassin and Dr. Keutgens Jaffe, 2017 Jaffe, 2017 Jaffe, 2017 Jaffe, 2017 Jaffe, 2017 Essential Thrombocytaemia From major mixed to the 4th to minor Jaffe, 2017 Jaffe, 2017 Possible cause of Thrombocytosis • Secondary – Infection – Inflammation and AI diseases – Blood loss, hemorrhage – Chronic iron deficiency – Post-splenectomy – Hyposplenism – Trauma (brain injury) – Post-surgical procedures – Neoplasms (Non-hemato and non-myeloid hemato) – BM regeneration, rebound, following chemotherapy • Myeloid neoplasm related – MPN – CML, BCR-ABL1+ – PV – ET – AML with t(3;3)(q21.3;q26.2) or inv(3)(q21.3q26.2) – MDS with isolated del(5q) abnormaly – MDS/MPN-RS-T Polycythaemia Vera Was >18.5 g/dL Was >16.5 g/dL From minor to major criteria Endogenous erythroid colony formation in vitro Jaffe, 2017 Jaffe, 2017 Jaffe, 2017 Primary Myelofibrosis Jaffe, 2017 Diagnostic criteria of distinctive value regarding WHO-defined ET (left) versus early- prefibrotic stage of PMF (right), including standardized morphologic features (Table 1 contains more details), allowing the generation of characteristic histologic BM patterns Jürgen Thiele et al. Blood 2011;117:5710-5718 ©2011 by American Society of Hematology Jaffe, 2017 Jaffe, 2017 Jaffe, 2017 Bone marrow fibrosis European consensus on grading bone marrow fibrosis and assessment of cellularity. J.Thiele et al. Haematologica 2005; 90:1128-1132 Standard grading Bauermeister 1971; Manoharan et al. 1979 Jaffe, 2017 2. Myelodysplastic syndromes Definition • Sustained unexplained anemia, neutropenia or thrombocyopenia (Hb<10g/dL; Abs. Neutrophil count <1.8 x109 or platelets <100 x109/L) • And at least one of the following – Dysplastic morphology in erythroid cells, granulocytes or megacaryocytes, affecting at least 10% of the cells of at least one of these lineages – Acquired conal MDS-associated cytogenetic abnormality in hematopoïetic cells and absence of de novo AML-defining cytogenetic abnormalities t(15;17), inv (16)/t(16;16) or t(8;21) – Increased blasts (at least 5% of marrow cells) not attributable to exogenous GF administration or transient marrow recovery Acquired conal MDS-associated cytogenetic abnormality Del(20q), +8 and –Y abnormalities, although common findings in MDS, are not considered MDS defining and cannot in isolation be used to make a diagnosis of MDS Dysplastic Erythropoeisis • Nuclear – Nuclear budding – Internuclear bridgking – Karyorrhexis – Multinuclearity – Nuclear hyperlobation – Megaloblastic changes • Cytoplasmic – Ring sideroblasts – Vacuolisation – PAS positivity Jaffe, Hematopathology, 2017 Cantù Rajnoldi et al., Ann Hematol, 2005 Ring Sideroblasts • 3 types of sideroblasts – Type 1 : <5 siderotic granules • Reactive ring sideroblasts – Type 2 :>5 siderotic granules but no perinuclear – distribution Alcohol (plasma cell iron) – Type 3 : Ring sideroblasts : 5 or more perinuclear – Zinc granules in a perinuclear distribution, surrounding the nucleus or at least 1/3 of the nuclear – Pyridoxine deficiency circonference – Drugs (isoniazid, cycloserine) • MPN and MDS/MPN – PMF, ET – MDS/MPN-RS-T • Hereditary – Hereditary sideroblastic anaemia Mufti et al., Haematologica, 2008 Dysplastic Myelopoiesis • Small or unusually large size • Nuclear hypolobation (pseudo-Pelger-Huët; pelgeroid) • Irregular hypersegmentation • Decreased granules; agranularity • Pseudo-Chédiak-Higashi granules • Auer rods Jaffe, Hematopathology, 2017 Cantù Rajnoldi et al., Ann Hematol, 2005 Dysplastic Megacaryotes • Micromegacaryocytes • Nuclear hypolobulation • Multinucleation – Normal megacaryocytes are uninucleate with lobulated nuclei Jaffe, Hematopathology, 2017 Cantù Rajnoldi et al., Ann Hematol, 2005 Hasserjian, XIII EBMWG , 2017 MDS : Pitfalls Non-MDS conditions associated