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Common bone marrow aspirate sites:
Adults/kids: iliac crest, sternum, vertebral spines.

Babies: tibia
What type of needle used for:
Aspirate: 16 guage

Biopsy: 8 or 11 guage, with Jamshidi-stylet, cutting edge, and tapered end.
How much specimen is drawn in an aspirate?
1 ml
How do you determine which area of aspirate smear to use for evaluating cellularity/morpholog and counting the diff?
Near Particle; no fibrin, intact stells, good staining, not in the sinusoidal blood area.
What steps are taken to count the diff?
1. Estimate Megakaryocyte number
2. Look for abnormal cells
3. Count 200-1000 cells and calculate percentage of each.
How do you calculate the M:E ratio?
Quantify Myeloid;
Quantify Erythroid;

What are Myeloid cells?

What are Erythroid cells?

What are 4 reasons for doing a bone marrow exam?
1. Investigate nonresponsive anemia or pancytopenia
2. If blasts in peripheral blood
3. Investigate abnormal lymphs
4. To evaluate leukemic therapy and how well it worked
What are the referance ranges for bone marrow cells?
myeloid:erythroid Ratio = 3:1

-myeloid: mostly metas/myelos
-erythr: should see rubricytes
Why would an M:E ratio be increased?
Due to Myeloid hyperplasia or erythroid hypoplasia
Why would an M:E ratio be decreased?
Due to myeloid hypoplasia or erythroid hyperplasia.
What is the purpose of
-Prussian Blue stain?
-Silver stain?
Prussian: to evaluate bone marrow iron stores.

Silver: to evaluate reticulin.
What is the definition of a stem cell?
A stem cell has the capacity for continuous self-replication.
What factors affect the production and differentiation of cells?
CSFs - hematopoeitic growth factors.
What are 2 types of CSFs?
1. Pluripotent - affect the stem cell which is completely undifferentiated
2. Lineage-restricted - affects cells that have begun to differentiate.
What are the pluripotent growth factors?
Interleukin 1,3,6
What are the lineage-restricted growth factors?
What are the production sites of blood cells?
Medullary: bone marrow.

Extramedullary: liver, spleen, only during fetal development and BM disease.
A Pre-leukemia proliferation of an abnormal stem cell.
What is characteristic feature of ALL MDS cases?
Dyspoeisis and Progressive Cytopenia of at least one cell type.
What are some erythroid morphologic alterations seen in MDS?
-Megaloblastoid cells
-Pelgeroid cells
what are some general presenting features of myelodysplastic syndrome?
-Neutropenia - infection prone
-Thrombocytopenia - bleeding tendencies
What type of progression does MDS have?
Is the bone marrow infiltrated in MDS?
not totally; it has increased cellularity though.
How do you know MDS is not vitamin b12/folate deficiency if seeing megaloblastoid cells?
Doesn't respond to that therapy.
What types of inclusions are common to see in MDS?
-Basophilic stippling
-Howell Jollies
-Ringed sideroblasts *prussian*
What is nuclear bridging
When daughter cells of dividing progenitors are connected by their nuclei instead of cytoplasm.
What hemoglobin abnormalities can pop up in MDS?
-Acquired HbH
-Acquired HbF
What are 4 signs of dysgranulopoeisis seen in MDS?
1. Pelgeroid PMNs
2. Mixed eos/basos granules
3. Hypogranularity
4. Monocytosis unexplained
What is the name for the odd granulocytes in MDS?
Stoddmeister - looks like a monocyte b/c it is hypogranular but it's a pmn!
What are 4 metabolic abnormalities in grans in MDS?
1. Decreased myeloperoxidase
2. Decreased LAP
3. Defective chemotaxis
4. Decr. bacteriocidal activity
What are 4 thrombocytic abnormalities in MDS?
1. Giant platelets
2. Abnormal granulation
3. Circulating micromegakaryos
4. Hyperlobation/hypolobation
Because of MDS's abnormal thrombocytes, what results?
Abnormal bleeding disorders.
What are 4 chromosomal abnormalities associated with MDS?
1. 5q- (50-80%)
2. 5q-, +8, 20q- (advanced stg)
3. t(5:12) (assoc. w/ CMML)
4. -7 (assoc. w/ transit to AL)
Based on number of blasts, what distinguishes MDS for FAB? WHO?
FAB: Less than/equal to 30% of all nucleated cells are blasts.
WHO: less than/equal to 20%
What's the definition of "Myeloproliferative Disorder"?
-A clonal neoplastic disease of pluripotent hematopoeitic stem cells.
How does a Myeloproliferative disease differ from a reactive leukemoid rxtn?
Myeloprolif is monoclonal;
Leukemoid is polyclonal, in response to infectn/inflamm.
Which myeloprolif disorder especially causes splenomegaly?
IMF - Agnogenic myeloid metaplasia.
Which myeloprolif disorder is associated with Chromosomal abnormality? What is it?
CML - Philadelphia chromosome, t(9,22)
Which myeloprolif disorders do you see megakaryocytes in?
All of them.
What is Polycythemia by itself?
Increased RBCs only
What is Polycythemia vera?
PANmyelosis - increased RBCs, WBC, and Platelet count!!
What is a relative polycythemia?
A RELATIVE RBC increase due to decreased plasma volume
What 2 things can cause relative polycythemia?
What confirms Relative polycythemia?
1. Dehydration
2. Stress erythrocytosis.

Blood volume studies.
What are the 2 forms of Absolute polycythemia?
1. secondary polycythemia
2. Polycythemia vera
What is 2' polycythm?
An increase in marrow erythroid precursors due to increased erythropoeitin.
What causes the increase in EPO in 2' polycyth?
What 2 mechanisms decrease the o2 supply to stim EPO productn?
1. Hypoxia -> 5 causes.
2. Disease state -> 5 causes
What 5 things cause hypoxia?
1. Cardiopulmonary dysfunction
2. Decreased blood volume
3. high altitude
4. Decreased Hb
5. Decreased O2 affinity
What 5 disease states cause hypoxia?
1. Renal ischemia
2. Renal artery stenosis
3. Renal casts
4. Hydronephrosis
5. Tumors on kidney/liver - produce EPO active substances.
What are major diffncs btwn 2' and 1' Polycythemia?
-Primary doesn't have increased EPO levels, 2' does.
-Primary has normal O2 saturatn, it is decreased in 2'.
-All cells are increased in 1', only RBCs in 2'.
What are similarities btwn 1' and 2' polycythemia?
-Both have increased RBC mass
What additional findings show up in polycyth vera and not 2'?
-Increased LAP
-Increased B12
What additional lab findings show up in progressed polycythemia vera?
PB: increases in young cells, dacrocytes, anemia, leukopenia and thrombocytopenia.
BM: increased myelofibrosis, reticulin/collagen fibers.
-Develops into ANLL.
What 3 major findings diagnosie polycythemia vera?
1. Splenomegaly
2. Increased cell mass
3. Normal O2 saturation
What 4 minor things can diagnose Polycythemia vera (if you have 2, plus 2 major)
1. Plt count over 450,000/uL
2. WBC count over 12,000/uL
3. Increased LAP
5. Increased B12
What causes the symptoms seen in polycythemia vera?
Sluggish blood - so many platelets, increased viscosity and blood volume.
How is polycythemia vera treated?
P32 + phlebotomy
Hydroxyurea to suppress myelos.
What can polycythemia vera turn into?
1. Idiopathic myelofibrosis
2. Idiopathic thrombocythemia
How can you best differentiate between a leukemoid and a chronic myeloprolif disorder?
1. Leukemoid has high LAP and limited young cell forms.
2. leukemia has LOW LAP, more immature forms, and unexplained baso/eosinophilia.
Between an acute and chronic leukemia, which has increased platelets? which has low plts?
Chronic has normal to increased.

Acute has low platelets.
What cell structure do Myeloperoxidase, SBB, NCE, and NSE all stain?
Primary granules - myeloblasts and beyond, except NSE which is monoblasts and beyond.
If NaF is negative after a positive NSE, what does it tell you?
It's definitely a monoblastic leukemia.
What does TdT stain?
the nuclei of lymphoblasts
What does PAS stain?
Glycogen in everything; useful in M6 b/c it stains the cytoplasms.
What are the key morphological characteristics of ALL?
No granules; No auer rods; Small sized cells; denser chromatin; small, fewer nucleoli.
What symptoms can be seen in all of the acute leukemias?
-Bleeding b/c of decr. platelets
-Anemia b/c of decr. RBCs
-Increased infections b/c of decreased PMNs.
What symptoms are characteristic of monocytic leukemia?
Hypertrophic gums and mucosal areas.
What symptom is characteristic of Tcell leukemias?
Mediastinal mass (thymic involvement)
What cytochemical stain is positive in Megakaryocytic leukemia?
Platelets = peroxidase positive.
What markers identify megakaryocytic leukemia?
CD41 and CD61
What are the Chronic lymphoproliferative disorders?
1. B-CLL (and prolymph transf)
2. T-CLL
3. Prolymphoctic leukemia
4. WDLL-Leukemic phase
5. Sezary
6. Hairy cell
7. Hodgkin's Disease
8. Plasma Cell Myeloma (mltpl)
9.Waldnstrom's Macrglblinemia
Describe the PB and BM findings for B-CLL:
PB: monomorphic lymphocytosis with smudge cells

BM: slow infiltration of the same.
Describe the PB and BM findings for T-CLL
PB:lymphocytosis with large granular lymphs

BM: rapid infiltration of the same, as well as dissemination to the skin and CNS.
Describe the PB and BM findings for Prolymphocytic leukemia
PB and BM are filled with prolymphocytes.
Describe the PB and BM findings for WDLL-Leukemic phase:
It looks like CLL.
Describe the PB and BM findings for Sezary syndrome:
Convulted nuclei with pearl necklace vacuoles
Describe the PB and BM findings for Hairy cell leukemia
Big lymphocytes with hairy cytoplasm.
Describe the PB and BM findings for Hodgkin's Disease
BM = Reed-Sternberg cells.
Describe the PB and BM findings for Plasma Cell (multiple) myeloma:
PB: rouleaux

BM: nests of plasma cells
Describe the PB and BM findings for Waldenstrom's macroglobulinemia:
PB: rouleaux

BM: lymphocytosis, plasmacytoid and plasma cells.
What clinical symptoms and lab test results are seen in CLL-B?
Hypogammaglobulinemia, AIHA, autoimmune thrombocytopenia, and it is a long-term disease.
What clinical symptoms and lab test results are seen in CLL-T?
HYPERgammaglobulinemia, it is a short term disease.
What clinical symptoms and lab test results are seen in Prolymphocytic leukemia?
Marked splenomegally - very rapid progression after diagnosis, short-term.
What clinical symptoms and lab test results are seen in Sezary?
What clinical symptoms and lab test results are seen in Hairy cell leukemia?
Splenomegaly, Reticulin in the Bone Marrow
What clinical symptoms and lab test results are seen in Plasma cell myeloma?
IgG or IgA increase - bone pain and breaks, Bence Jones proteiurea, clonal excess of kappa or lambda.
What tests are done for Plasma cell myeloma?
-Serum protein electrophoresis
-Quantitative Ig
What clinical symptoms and lab test results are seen in Waldenstrom's?
IgM; tested in same way as plasma cell myeloma, look for clonal excess of kappa/lambda light chains.
Which has it; Waldenstrom or MM?
-Lytic bone lesions
-Renal failure
-Length of survival
Organ: Waldenstrom's
Hypervisc: Waldenstrom's
Bones: MM
Renal: MM
Better survival: Waldenstrom's
What is the TRAP stain?
Tartrate Resistant Acid Phosphatase
How does the TRAP stainwork?
Only hairy cells don't lose their ability to stain for acid phosphatase in presence of tartrate - they resist it!
What is the definition of LYMPHOMA?
Malignancy of the lymph nodes
How do you differentiate between Hodgkin's and Non-hodgkin's lymphoma?
Hodgkin's: lymph node involvement follows lymphatics. Abnormal cells are Reed-sternberg, can find in BM.
NHL: lymphnode involvmnt has no set pattern; abnormal lymphs can be found in BM and PB.
In what disorders does extramedullary hematopoeisis occur?
Chronic myeloproliferatives.
Which FAB AMLs are "AML not otherwise categorized"?
M0, M1, M5, M7
Which FAB AMLs are "AML w/ recurrent cytogenetic abnormalities?"
M2, M3, M4eos
Which FAB AMLs are "AML with Multilineage Dysplasia"?
M4, M6
Which FAB AMLs are "AML Therapy related"?
Any secondary leukemia.
What chromosomal abnormality is associated with:
M2? M3? M3eos? M4?
M2: t(8;21)
M3: t(15,17)
M3eos: t(16:16),inv16
M4: t(9:11)
M5a: t(9:11) M5b: t(8,16)
What age popultation is assoc w/
CLL: some kids, more older folks
ALL: children
CML: mid-aged to elderly
AML: older folks

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