Hematology and Coagulation (eBook)

A Comprehensive Review for Board Preparation, Certification and Clinical Practice

Amitava Dasgupta, Amer Wahed (Autoren)

eBook Download: PDF | EPUB

2015 | 1. Auflage
324 Seiten
Elsevier Science (Verlag)
978-0-12-800381-7 (ISBN)

Infos

Hematology and Coagulation is a clear and easy-to-read presentation of core topics and detailed case studies that illustrate the application of hematopathology knowledge to everyday patient care. In order to be successful, as well as to pass the American Board of Pathology examination, all pathology residents must have a good command of hematopathology, including the challenging topics of hematology and coagulation. Hematology and Coagulation meets this challenge head on. This basic primer offers practical examples of how things function in the hematopathology clinic as well as useful lists, sample questions, and a bullet-point format ideal for quick pre-board review. This book provides only the most clinically relevant examples designed to educate senior medical students, residents and fellows and 'refresh' the knowledge base, without overwhelming students, residents, and clinicians. - Takes a practical and easy-to-read approach to understanding hematology and coagulation at an appropriate level for both board preparation as well as a professional refresher course - Covers all important clinical information found in larger textbooks in a more succinct and easy-to-understand manner - Covers essential concepts in hematopathology in such a way that fellows and clinicians understand the methods without having to become specialists in the field

Amer Wahed is a graduate of Medicine, training initially in Internal Medicine at Royal Postgraduate Medical School, London, England. He subsequently trained in Anatomic and Clinical Pathology from the University of Texas-Houston Medical School. After working for several years in a private setting, he joined the Department of Pathology and Laboratory Medicine at the University of Texas-Houston Health Sciences Center. Currently he is an Assistant Professor of Pathology and Laboratory Medicine and Associate Director of Clinical Chemistry and Immunology at Memorial-Hermann Hospital at the Texas Medical Center. He is also the Associate Director of the Pathology Residency Program at the University of Texas-Houston Medical School. Dr. Wahed has a strong interest in teaching and is actively involved in the education of medical students, graduate students, residents, and fellows. He has been recognized for his teaching contributions through awards from his department, as well as the Office of the Dean. He is also active in mentoring pathology residents in research and has published multiple papers in peer-reviewed journals.

---

Hematology and Coagulation is a clear and easy-to-read presentation of core topics and detailed case studies that illustrate the application of hematopathology knowledge to everyday patient care. In order to be successful, as well as to pass the American Board of Pathology examination, all pathology residents must have a good command of hematopathology, including the challenging topics of hematology and coagulation. Hematology and Coagulation meets this challenge head on. This basic primer offers practical examples of how things function in the hematopathology clinic as well as useful lists, sample questions, and a bullet-point format ideal for quick pre-board review. This book provides only the most clinically relevant examples designed to educate senior medical students, residents and fellows and "e;refresh"e; the knowledge base, without overwhelming students, residents, and clinicians. - Takes a practical and easy-to-read approach to understanding hematology and coagulation at an appropriate level for both board preparation as well as a professional refresher course- Covers all important clinical information found in larger textbooks in a more succinct and easy-to-understand manner- Covers essential concepts in hematopathology in such a way that fellows and clinicians understand the methods without having to become specialists in the field

Inhalt

Front Cover 1
Hematology and Coagulation 4
Copyright Page 5
Dedication 6
Contents 8
Preface 18
1 Complete Blood Count and Peripheral Smear Examination 20
1.1 Introduction 20
1.2 Analysis of Various Parameters by Hematology Analyzers 20
1.2.1 RBC Count and Hemoglobin Measurement 22
1.2.2 Hematocrit, Red Blood Cell Distribution Width, Mean Corpuscular Volume, Mean Corpuscular Hemoglobin, and Mean Corpusc... 23
1.2.3 Reticulocyte Count 24
1.2.4 WBC Count and Differential 24
1.2.5 Platelet Count, Mean Platelet Volume, and Platelet Differential Width 24
1.3 Review of Peripheral Smear 25
1.3.1 Red Cell Variations and Inclusions 26
1.3.2 WBC Morphology 26
1.3.3 Platelets 27
1.4 Special Situations with CBC and Peripheral Smear Examination 29
1.4.1 Splenic Atrophy or Postsplenectomy 29
1.4.2 Microangiopathic Hemolysis 29
1.4.3 Leukoerythroblastic Blood Picture 29
1.4.4 Parasites, Microorganisms, and Nonhematopoietic Cells in the Peripheral Blood 30
1.4.5 Buffy Coat Preparation 31
Key Points 31
References 33
2 Bone Marrow Examination and Interpretation 34
2.1 Introduction 34
2.2 Fundamentals of Bone Marrow Examination 35
2.2.1 Dry Tap 36
2.2.2 Granulopoiesis 36
2.2.3 Erythropoiesis 37
2.2.4 Monopoiesis, Megakaryopoiesis, Thrombopoiesis, and Other Cells in Bone Marrow 38
2.3 Bone Marrow Examination Findings and Bone Marrow Failure 38
2.3.1 Disorders of Erythropoiesis, Granulopoiesis, and Thrombopoiesis 40
2.3.2 Infections 41
2.3.3 Granulomatous Changes 42
2.3.4 Storage Disorders 42
2.3.5 Metabolic Bone Diseases 43
2.3.6 Metastatic Tumors 43
2.3.7 Hemophagocytic Syndrome 43
2.3.8 Bone Marrow Necrosis/Infarction 43
2.3.9 Serous Atrophy 44
2.3.10 Bone Marrow Fibrosis 44
2.3.11 Reactive Lymphoid Aggregate 44
2.3.12 Bone Marrow Infiltration in Lymphoproliferative Disorders 44
2.3.13 Amyloidosis 45
Key Points 45
References 48
3 Red Blood Cell Disorders 50
3.1 Introduction 50
3.2 Anemia: Morphological and Etiological Classification 51
3.3 Common Causes of Anemia 51
3.3.1 Anemia Due to Blood Loss and Iron Deficiency Anemia 52
3.3.2 Lead Poisoning 53
3.3.3 Anemia of Chronic Disease 54
3.3.4 Sideroblastic Anemia 54
3.3.5 Megaloblastic Anemia 55
3.3.6 Bone Marrow Failure 55
3.3.7 Congenital Dyserythropoietic Anemia 57
3.4 Hemolytic Anemia 57
3.4.1 Hemolytic Anemia Due to Corpuscular Defects 58
3.4.2 Hemolytic Anemia Due to Membrane Defects 58
3.4.2.1 Hereditary Spherocytosis 58
3.4.2.2 Hereditary Elliptocytosis 59
3.4.2.3 Hereditary Pyropoikilocytosis 60
3.4.2.4 Hereditary Stomatocytosis 60
3.4.2.5 Rh Null Disease 60
3.4.2.6 Hemolytic Anemia Due to Enzyme Defects 60
3.4.2.7 Pyruvate Kinase Deficiency 61
3.4.2.8 Glucose-6-Phosphate Dehydrogenase Deficiency 61
3.4.2.9 Paroxysmal Nocturnal Hemoglobinuria 63
3.4.3 Hemolytic Anemias Due to Extracorpuscular Defects 64
3.5 Red Cell Poikilocytosis 65
3.6 Red Cell Inclusions 67
3.6.1 Malaria Parasites 68
Key Points 68
References 72
4 Hemoglobinopathies and Thalassemias 74
4.1 Introduction 74
4.2 Hemoglobin Structure and Synthesis 74
4.3 Introduction to Hemoglobinopathies 76
4.3.1 a-Thalassemia 77
4.3.2 ß-Thalassemia 79
4.3.3 d-Thalassemia 81
4.3.4 Sickle Cell Disease 81
4.3.5 Hereditary Persistence of Fetal Hemoglobin 83
4.4 Other Hemoglobin Variants 84
4.5 Laboratory Investigation of Hemoglobinopathies 86
4.5.1 Gel Electrophoresis 87
4.5.2 High-Performance Liquid Chromatography 88
4.5.3 Capillary Electrophoresis 88
4.6 Diagnostic Tips for Thalassemias, Sickle Cell Disease, and Other Hemoglobinopathy 89
4.7 Apparent Hemoglobinopathy After Blood Transfusion 93
Key Points 95
References 98
5 Benign White Blood Cell and Platelet Disorders 100
5.1 Introduction 100
5.2 Hereditary Variation in White Blood Cell Morphology 101
5.3 Changes in White Cell Counts 102
5.3.1 Neutrophilia 102
5.3.2 Eosinophilia and Monocytosis 103
5.3.3 Basophilia 103
5.3.4 Neutropenia 104
5.3.5 Lymphocytosis and Infectious Mononucleosis 105
5.3.6 Lymphocytopenia 105
5.4 Platelet Disorders 106
5.4.1 Thrombocytopenias 106
5.4.2 Thrombocytosis 108
5.4.3 Thrombocytopathia 109
Key Points 109
References 111
6 Myeloid Neoplasms 112
6.1 Introduction 112
6.2 Classification of Myeloid Neoplasm 112
6.3 Myeloproliferative Neoplasm 113
6.3.1 Chronic Myelogenous Leukemia, BCR–ABL1+ 113
6.3.2 Chronic Neutrophilic Leukemia 115
6.3.3 Polycythemia Vera, Primary Myelofibrosis, and Essential Thrombocythemia 116
6.3.4 Chronic Eosinophilic Leukemia 116
6.3.5 Mastocytosis 117
6.4 Myeloid and Lymphoid Neoplasm Associated with Eosinophilia 118
6.5 Myelodysplastic/Myeloproliferative Neoplasms 119
6.6 Myelodysplastic Syndrome 119
6.6.1 Features of Dysplasia in Red Cells, Erythroid Precursors, Granulocytes, and Megakaryocytes 120
6.6.2 Arriving at a Diagnosis of MDS and Subclassifying MDS 121
6.6.3 Abnormal Localization of Immature Precursors 123
6.6.4 Cytogenetic Abnormalities Associated with MDS 123
6.6.5 Unusual Situations in MDS 124
6.7 Acute Leukemia 124
6.7.1 Blasts 125
6.7.2 Cytochemistry 125
6.7.3 Classification of AML and Diagnosis 125
6.7.4 AML and Flow Cytometry 128
6.7.5 Cytogenetics and AML 129
Key Points 129
References 134
7 Monoclonal Gammopathy and Its Detection 136
7.1 Introduction 136
7.2 Diagnostic Approach to Monoclonal Gammopathy Using Electrophoresis 137
7.2.1 Serum Protein Electrophoresis 137
7.2.2 Urine Electrophoresis 142
7.2.3 Immunofixation Studies 143
7.2.4 Capillary Zone Electrophoresis 144
7.2.5 Free Light-chain Assay 144
7.2.6 Paraprotein Interference in Clinical Laboratory Tests 145
7.3 Plasma Cell Neoplasm 145
7.3.1 Morphology of Plasma Cells in Myeloma 146
7.3.2 Immunophenotype of Neoplastic Plasma Cells 146
7.4 Cytogenetics in Myeloma Diagnosis 147
Key Points 147
References 150
8 Application of Flow Cytometry in the Diagnosis of Hematological Disorders 152
8.1 Introduction 152
8.2 Flow Cytometry and Mature B Cell Lymphoid Neoplasms 153
8.2.1 B Cell Markers 154
8.3 Flow Cytometry and Mature T and Natural Killer Cell Lymphoid Neoplasms 155
8.3.1 Detection of Clonal or Restricted Populations of T and NK Cells 156
8.4 Plasma Cell Dyscrasias 157
8.5 Flow Cytometry and Acute Leukemia 157
8.5.1 Flow Cytometry and Subtypes of Acute Myeloid Leukemia 158
8.6 Flow Cytometry and Myelodysplastic Syndrome 160
8.7 Flow Cytometry and Hematogones 161
Key Points 161
References 164
9 Cytogenetic Abnormalities and Hematologic Neoplasms 166
9.1 Introduction 166
9.2 Cytogenetic Abnormalities in Chronic Myeloid Leukemia 167
9.3 Cytogenetic Abnormalities in Myelodysplastic Syndrome 170
9.4 Cytogenetic Abnormalities in Patients with Acute Myeloid Leukemia 173
9.5 Cytogenetic Abnormalities in Actute Lymphoblastic Leukemia 176
9.6 Cytogenetic Abnormalities in Multiple Myeloma 176
9.7 Cytogenetic Abnormalities in B and T Cell Lymphomas 177
9.7.1 CLL/SLL 177
9.7.2 Follicular Lymphoma 177
9.7.3 Mantle Cell Lymphoma 178
9.7.4 Marginal Zone Lymphoma 178
9.7.5 Diffuse Large B Cell Lymphoma 178
9.7.6 Burkitt Lymphoma 179
9.7.7 Anaplastic Large Cell Lymphoma 179
Key Points 179
References 183
10 Benign Lymph Nodes 184
10.1 Introduction 184
10.2 Reactive Lymphoid States 185
10.2.1 Viral Lymphadenopathy 186
10.2.2 Bacterial Infections and Lymphadenopathy 187
10.2.3 Toxoplasma gondii and Lymphadenopathy 187
10.2.4 Granulomatous Lymphadenopathy 188
10.2.5 Necrotizing Lymphadenopathy 189
10.2.6 Progressive Transformation of Germinal Centers 189
10.2.7 Regressive Changes in Germinal Centers 189
10.3 Specific Clinical Entities with Lymphadenopathy 190
10.3.1 Kikuchi–Fujimoto Disease 190
10.3.2 Kimura Disease 190
10.3.3 Kawasaki Disease 190
10.3.4 Dermatopathic Lymphadenitis 191
10.3.5 Lymphadenopathy in Autoimmune Diseases 191
10.3.6 Rosai–Dorfman Disease 191
10.3.7 Langerhans Cell Histiocytosis 192
10.3.8 Castleman Disease 192
Key Points 192
References 195
11 B Cell Lymphomas 196
11.1 Introduction 196
11.2 Follicular Lymphoma 196
11.2.1 Immunophenotyping in Follicular Lymphoma 198
11.2.2 Genetics of Follicular Lymphoma 198
11.3 Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma 199
11.3.1 Immunophenotyping for CLL/SLL 199
11.4 B Cell Prolymphocytic Leukemia 200
11.5 Mantle Cell Lymphoma 201
11.6 Marginal Zone B Cell Lymphoma 202
11.6.1 MALT Lymphoma 203
11.6.2 Splenic Marginal Zone Lymphoma 204
11.6.3 Nodal Marginal Zone Lymphoma 204
11.7 Burkitt Lymphoma 204
11.8 Lymphoblastic Leukemia/Lymphoblastic Lymphoma 205
11.9 Lymphoplasmacytic Lymphoma/Waldenström Macroglobulinemia 206
11.10 Diffuse Large B Cell Lymphoma 206
11.10.1 B Cell Lymphoma, Unclassifiable with Features Intermediate Between DLBCL and Burkitt Lymphoma (Gray Zone Lymphoma) 207
11.11 Hairy Cell Leukemia 208
11.11.1 Approach to the Diagnosis of Lymphoma 209
Key Points 210
References 215
12 T Cell and Natural Killer Cell Lymphomas 218
12.1 Introduction 218
12.2 Nodal T Cell Lymphomas 218
12.2.1 Angioimmunoblastic T Cell Lymphoma 219
12.2.2 Peripheral T Cell Lymphoma 219
12.2.3 Anaplastic Large Cell Lymphoma 220
12.3 Extranodal NK/T Cell Lymphomas 220
12.3.1 Extranodal NK/T Cell Lymphoma, Nasal Type 221
12.3.2 Enteropathy-associated T Cell Lymphoma 221
12.3.3 Hepatosplenic T Cell Lymphoma 221
12.3.4 Subcutaneous Panniculitis-like T Cell Lymphoma 222
12.4 Cutaneous T Cell Lymphoma 222
12.4.1 Mycosis Fungoides 222
12.4.2 Sézary Syndrome 223
12.4.3 Primary Cutaneous CD30+ T Cell Lymphoproliferative Disease 223
12.5 Leukemia/disseminated 223
12.5.1 T Cell Prolymphocytic Leukemia 224
12.5.2 T Cell Large Granular Lymphocyte Leukemia 224
12.5.3 Chronic Lymphoproliferative Disorders of NK Cells 224
12.5.4 Aggressive NK Cell Leukemia 224
12.5.5 Adult T Cell Leukemia/Lymphoma 225
Key Points 225
References 233
13 Hodgkin Lymphoma 234
13.1 Introduction 234
13.2 Overview of Hodgkin Lymphoma 234
13.3 Classification of Hodgkin Lymphoma 235
13.3.1 Nodular Lymphocyte Predominant Hodgkin Lymphoma 236
13.3.2 Classical Hodgkin Lymphoma 236
13.4 Immunostains for Diagnosis of Hodgkin Lymphoma 238
13.5 Staging of Hodgkin Lymphoma 240
Key Points 240
References 242
14 Lymphoproliferative Disorders Associated with Immune Deficiencies and Histiocytic and Dendritic Cell Neoplasms 244
14.1 Introduction 244
14.2 Lymphoproliferative Disorders Associated with Immune Deficiency 244
14.2.1 Lymphoproliferative Disorders Associated with Primary Immune Deficiency 245
14.2.2 Lymphoproliferative Disorders Associated with HIV Infection 245
14.2.3 Post-transplant Lymphoproliferative Disorders 245
14.3 Histiocytic and Dendritic Cell Neoplasms 246
14.3.1 Histiocytic Sarcoma 246
14.3.2 Dendritic Cell Neoplasms 246
14.3.2.1 Follicular Dendritic Cell Sarcoma 246
14.3.2.2 Interdigitating Dendritic Cell Sarcoma 247
14.3.2.3 Langerhans Cell Histiocytosis and Langerhans Cell Sarcoma 247
Key Points 248
References 249
15 Essentials of Coagulation 250
15.1 Introduction 250
15.2 Normal Hemostasis 250
15.2.1 Platelets and Platelet Events 251
15.3 Thrombocytopenia and Thrombocytopathia 253
15.3.1 Hereditary Thrombocytopenias 254
15.3.2 Idiopathic Thrombocytopenic Purpura 255
15.3.3 Heparin-induced Thrombocytopenia 255
15.4 Tests for Platelet Function 256
15.4.1 Thromboelastography 260
15.4.2 Platelet Mapping 263
15.5 Secondary Hemostasis 264
15.6 Tests for Secondary Hemostasis 265
15.6.1 Factor Assays 269
15.6.2 Von Willebrand Disease 270
15.6.3 Diagnosis of Various Types of Von Willebrand Disease 272
15.7 Antiplatelets and Anticoagulants 273
Key Points 275
References 279
16 Thrombophilias and Their Detection 282
16.1 Introduction 282
16.2 Thrombophilia: Inherited Versus Acquired 282
16.3 Factor V Leiden 283
16.3.1 Activated Protein C Resistance Test 284
16.4 Prothrombin Gene Mutation 285
16.5 Protein C Deficiency 285
16.6 Protein S Deficiency 287
16.6.1 Assays for Protein C and Protein S 288
16.7 Antithrombin III Deficiency 289
16.8 Hyperhomocysteinemia 289
16.9 Increased Factor VIII Activity 290
16.10 Acquired Causes of Thrombophilia 291
16.10.1 Lupus Anticoagulant and Anticardiolipin Antibodies 291
Key Points 292
References 294
17 Sources of Errors in Hematology and Coagulation 296
17.1 Introduction 296
17.2 Errors in Routine Hematology Testing 297
17.2.1 Errors in Hemoglobin Measurement and RBC Count 297
17.2.2 Errors in MCV and Related Measurements 297
17.2.3 Errors in WBC Counts and WBC Differential Counts 299
17.2.4 Errors in Platelet Count 300
17.3 Errors in Specific Hematology Testing 301
17.3.1 Cold Agglutinins 301
17.3.2 Cryoglobulins 302
17.3.3 Pseudothrombocytopenia 302
17.3.4 Spurious Leukocytosis 303
17.3.5 False-positive Osmotic Fragility Test 304
17.4 Errors in Coagulation Testing 304
17.4.1 Errors in PT and aPTT Measurements 304
17.4.2 Errors in Thrombin Time Measurement 305
17.4.2.1 Incorrectly Filled Tubes 305
17.4.2.2 Dilution or Contamination with Anticoagulants 306
17.4.2.3 Traumatic Phlebotomy 306
17.4.2.4 Fibrinolysis Products and Rheumatoid Factor 307
17.4.3 Platelet Aggregation Testing with Lipemic, Hemolyzed, or Thrombocytopenic Samples 307
17.4.4 Challenges in Anticoagulants and Lupus Anticoagulant Tests 308
Key Points 309
References 311
Index 314

Textauszug

Chapter 2

Bone Marrow Examination and Interpretation

This chapter discusses the review of bone marrow slides, their interpretation, and common bone marrow findings in non-leukemia and non-lymphoma cases, including infections, storage disorders, and granulomatous diseases. Bone marrow examination is also important in the diagnosis of multiple myeloma.

Keywords

Bone marrow; multiple myeloma; leukemia; lymphoma; storage disorders

Contents

2.1 Introduction 15

2.2 Fundamentals of Bone Marrow Examination 16

2.2.1 Dry Tap 17

2.2.2 Granulopoiesis 17

2.2.3 Erythropoiesis 18

2.2.4 Monopoiesis, Megakaryopoiesis, Thrombopoiesis, and Other Cells in Bone Marrow 19

2.3 Bone Marrow Examination Findings and Bone Marrow Failure 19

2.3.1 Disorders of Erythropoiesis, Granulopoiesis, and Thrombopoiesis 21

2.3.2 Infections 22

2.3.3 Granulomatous Changes 23

2.3.4 Storage Disorders 23

2.3.5 Metabolic Bone Diseases 24

2.3.6 Metastatic Tumors 24

2.3.7 Hemophagocytic Syndrome 24

2.3.8 Bone Marrow Necrosis/Infarction 24

2.3.9 Serous Atrophy 25

2.3.10 Bone Marrow Fibrosis 25

2.3.11 Reactive Lymphoid Aggregate 25

2.3.12 Bone Marrow Infiltration in Lymphoproliferative Disorders 25

2.3.13 Amyloidosis 26

Key Points 26

References 29

2.1 Introduction

Complete blood count (CBC), examination of peripheral blood smear, and other routine laboratory tests may not provide enough information for unambiguous diagnosis of hematological or nonhematological disease in certain patients. For these patients, direct microscopic examination of the bone marrow is required for a proper diagnosis. The bone marrow, which is disseminated within the intertrabecular and medullary spaces of bone, is a complex organ with dynamic hematopoietic and immunological functions. The role of bone marrow in hematopoiesis was first described by Neumann in 1868; since then, methods for bone marrow procedures have undergone many improvements. Following the development of newer techniques and equipment, bone marrow aspiration and bone marrow biopsy have become important medical procedures for diagnosis of hematological malignancies and other diseases and also for follow-up evaluation of patients undergoing chemotherapy, bone marrow transplantation, and other forms of therapy [1]. Bone marrow trephine biopsy should be carried out by a trained health care professional, and bone marrow aspirate should be collected during the same procedure. Because a diagnostic specimen is a small representation of the total marrow, it is important that material be adequate and representative of the entire marrow. The specimen must also be of high technical quality. Cytochemical analysis and various other diagnostic procedures can be performed on the liquid bone marrow aspirate, and bone marrow biopsy material can be stained using immunoperoxidase and other stains. The recent development of bone marrow biopsy needles with specially sharpened cutting edges and core-securing devices has reduced the discomfort of the procedure and improved the quality of the specimen obtained [2]. Today, bone marrow examination is considered an important and effective way to diagnose and evaluate primary hematological and metastatic neoplasm as well as nonhematological disorders [3]. Common indications for performing bone marrow examination are listed in Box 2.1.

Box 2.1

Common Indications for Bone Marrow Examination

Diagnosis of Diseases

 Acute or chronic unexplained anemia including hypoplastic or aplastic anemia

 Differentiating megaloblastic anemia from normoblastic maturation

 Unexplained leukopenia

 Unexplained thrombocytopenia, pancytopenia

 Myelodysplastic syndrome

 Myeloproliferative disease

 Plasma cell dyscrasia

 Hodgkin and non-Hodgkin lymphoma

 Suspected leukemia

 Disseminated granulomatous disease

 Primary amyloidosis

 Metabolic bone disease

 Suspected multiple myeloma

 Suspected storage diseases (e.g., Gaucher’s disease)

 Fever of unknown origin

 Confirmation of normal marrow in a potential allogeneic donor

Follow-Up of Medical Treatment

 Chemotherapy/bone marrow transplant follow-up

 Treatment of isolated cytopenia

2.2 Fundamentals of Bone Marrow Examination

Prior to a bone marrow examination, the relevant history of the patient, CBC, and the report from the peripheral blood smear examination must be reviewed [4]. During a routine bone marrow examination, slides obtained from the aspirate, slides from the clot sections, slides from the trephine biopsy, touch preparation slides obtained from the trephine biopsy, and iron strains must be carefully examined for proper interpretation of results. Occasionally, examination of a well-prepared aspirate slide, core biopsy specimen, and iron strain by a well-trained professional may be adequate for arriving at a diagnosis [1]. However, additional tests, such as flow cytometry and cytogenetics studies, may be needed in other cases. Additional steps that may be performed during bone marrow examination are listed in Box 2.2.

Box 2.2

Additional Steps That May Be Performed as Part of a Bone Marrow Examination

 Immunophenotyping by flow cytometry (performed on the aspirate specimen)

 Immunophenotyping by immunohistochemistry (performed on the biopsy or clot section slides)

 Special stains—for example, acid fast bacilli (AFB), Grocott’s methenamine silver (GMS), reticulin, trichrome, Wright–Giemsa stain, Prussian blue stain

 Cytogenetic studies

 Molecular studies—for example, polymerase chain reaction (PCR), fluorescence in situ hybridization (FISH)

 Electron microscopy

The aspirate slides are typically used to assess morphology by performing a differential count and thus obtaining the myeloid:erythroid (M:E) ratio. If the aspirate lacks particulates or is unsatisfactory, morphology may be assessed from the touch prep slides.

The architecture of the bone marrow is best assessed from the trephine biopsy slides. Infiltrates (e.g., granulomas, lymphomatous infiltrates, and metastatic tumors), if any, and their distribution can also be assessed from the biopsy slides. The cellularity of the bone marrow is usually assessed from the biopsy slides. In addition, reticulin or collagen fibrosis is also assessed from the biopsy slides. Bone marrow stroma and the bone itself are assessed from the biopsy slides. In the absence of a good trephine biopsy specimen, the slides from the clot section may be used as an alternate means of assessment.

2.2.1 Dry Tap

Causes of dry tap while performing a bone marrow procedure include the following:

 Faulty technique

 Packed marrow (e.g., with leukemia)

 Fibrotic marrow (e.g., myelofibrosis)

 Hairy cell leukemia.

In cases of dry tap, one must improvise to obtain the greatest possible amount of information. One way of achieving this is to obtain two trephine biopsies and to submit the first for flow cytometry and the other for cytogenetic studies. Good touch preps from the second biopsy should provide adequate morphological and architectural information.

2.2.2 Granulopoiesis

Granulopoiesis involves maturation of myeloblasts into mature polymorphonuclear neutrophils, basophils, and eosinophils. The steps include the transformation of myeloblasts to promyelocytes to myelocytes to metamyelocytes to bands to mature granulocytes.

Myeloblasts are large cells with a high nuclear to cytoplasmic (N:C) ratio, moderately blue cytoplasm (less blue than the cytoplasm of an erythroblast), and prominent nucleoli. Promyelocytes are larger cells compared to myeloblasts and have prominent nucleoli, a Golgi hof, and granules. These granules are primary granules and appear reddish-purple. The promyelocytes of the three granulocytic lineages cannot be differentiated by routine light microscopy. Myelocytes no longer have nucleoli but continue to have granules. However, these granules are secondary and specific granules. Thus, cells of the three granulocytic lineages can now be distinguished. Myeloblasts, promyelocytes, and myelocytes are all capable of cell division. Metamyelocytes have indented nuclei and cannot undergo cell division. The nucleus of bands is “U” shaped. Granulopoiesis in a normal marrow is seen adjacent to the bony trabecular surface (as a layer two or three cells thick) and to arterioles.

The following is one approach to the accurate...

Produkt-Details

• Erscheint lt. Verlag: 21.1.2015
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Hämatologie
• Themenwelt: Studium ► 1. Studienabschnitt (Vorklinik) ► Physiologie
• Themenwelt: Naturwissenschaften ► Biologie ► Biochemie
• Themenwelt: Naturwissenschaften ► Biologie ► Humanbiologie
• Themenwelt: Naturwissenschaften ► Physik / Astronomie ► Angewandte Physik
• ISBN-10: 0-12-800381-2 / 0128003812
• ISBN-13: 978-0-12-800381-7 / 9780128003817