Bone Marrow Findings In Patients Research Articles

Comprehensive morphologic characterization of bone marrow biopsy findings in a large cohort of patients with VEXAS syndrome: A single-institution longitudinal study of 111 bone marrow samples from 52 patients.

VEXAS syndrome is an adult-onset autoinflammatory disease caused by a somatic pathogenic mutation in the UBA1 (ubiquitin-like modifier activating enzyme 1) gene. Patients present with rheumatologic manifestations and cytopenias and may have an increased predisposition to myelodysplastic syndrome (MDS) and plasma cell neoplasms. Prior studies have reported on the peripheral blood and bone marrow findings in patients with VEXAS syndrome. Due to the protean clinical presentation and lack of specificity of morphologic features (eg, vacuoles in early erythroid and granulocytic precursors), an optimal screening methodology to identify these patients in a timely fashion is desirable. To further evaluate and describe the salient diagnostic morphologic features in VEXAS syndrome, we carried out a comprehensive study of the largest single-institution cohort to date. Diagnostic and follow-up bone marrow biopsy specimens from 52 male patients with molecularly identified VEXAS syndrome underwent central review. Cytopenias were common in all cases, primarily macrocytic anemia, monocytopenia, and thrombocytopenia. Bone marrow aspirate and biopsy were often hypercellular, with an increased myeloid/erythroid ratio, granulocytic hyperplasia with left shift, erythroid left shift, and megakaryocyte hyperplasia, which exhibited a range of striking morphologic findings. Distinctly vacuolated myeloid and erythroid precursors were seen in more than 95% of cases. Our data reveal potential novel diagnostic features, such as a high incidence of monocytopenia and distinct patterns of atypical megakaryopoiesis, that appear different from dysmegakaryopoiesis typically associated with MDS. In our experience, those findings are suggestive of VEXAS, in the appropriate clinical context.

Abnormal bone marrow findings in patients following treatment with chimeric antigen receptor-T cell therapy.

Bone marrow (BM) assessment after CAR-T cell immunotherapy infusion is not routinely performed to monitor adverse events such as cytopenias, hemophagocytic lymphohistiocytosis, or infections. Our institution has performed BM biopsies as part of CAR-T cell treatment protocols, encompassing pre- and post-treatment time points and during long-term follow-up. We conducted a systematic retrospective review of BM abnormalities observed in samples from 259 patients following CAR-T cell immunotherapy. We correlated BM pathology findings with mortality, relapse/residual disease, and laboratory values. At a median of 35.5 days post-CAR-T infusion, 25.5% showed severe marrow hypocellularity, and 6.2% showed serous atrophy, and peripheral blood cytopenias corroborated these observations. Marrow features associated with reduced disease burden post-CAR-T infusion include increased lymphocytes seen in 16 patients and an increase of macrophages or granulomatous response seen in 25 patients. However, a 100-day landmark analysis also showed increased marrow histiocytes were associated with lower survival (median OS 6.0 vs. 21.4 months, p = .026), as was grade 2-3 marrow reticulin (18 patients) (median OS 12.5 vs. 24.2 months, p = .034). These data represent the first systematic observations of BM changes in patients receiving CAR-T cell immunotherapy.

Bone marrow biopsy can be omitted in the diagnostic workup of CNS lymphoma of DLBCL origin: a population-based retrospective study in the PET-CT era

Currently, bone marrow (BM) biopsy (BMB) is recommended in the initial staging of patients with the presumed primary central nervous system (CNS) lymphoma (PCNSL). However, the added value of BMB in the era of positron emission tomography (PET-CT) has been challenged in other lymphoma subtypes. We analyzed BM findings in patients with biopsy-proven CNS lymphoma and a negative PET-CT scan for disease outside CNS. A comprehensive Danish population-based registry search was performed to identify all patients with CNS lymphoma of diffuse large B cell lymphoma (DLBCL) histology with available BMB results and staging PET-CT without systemic lymphoma. A total of 300 patients fulfilled the inclusion criteria. Of them, 16% had a previous history of lymphoma, while 84% were diagnosed with PCNSL. None of the patients had DLBCL in the BM. A minority (8.3%) had discordant BMB findings, mainly low-grade histologies that did not influence treatment choice in any case. In conclusion, the risk of overlooking concordant BM infiltration in patients with CNS lymphoma of DLBCL histology and negative PET-CT scan is negligible. As we did not find any patient with DLBCL in the BMB, our results suggest that BMB can be safely omitted in the diagnostic workup in patients with CNS lymphoma and a negative PET-CT.

A comprehensive analysis of cytopenias and bone marrow morphology in patients with a history of bariatric and metabolic surgery.

Following bariatric and metabolic surgery (BMS), patients may develop persistent cytopenia(s) despite adequate micronutrient levels. A comprehensive analysis of laboratory and hematopathologic findings in BMS patients with unexplained cytopenia(s) has not been previously described. We reviewed the clinical and laboratory data, bone marrow histology, and used ancillary testing to characterize patients with a history of BMS who had subsequent bone marrow biopsies due to unexplained cytopenia(s). All patients had anemia and 59% (23/39) had additional cytopenias. Myelodysplastic syndrome (MDS) and clonal cytopenia of unknown significance (CCUS) were diagnosed in 8% (3/39) and 10% (4/39), respectively. Remaining cases were classified as idiopathic cytopenia of unknown significance (ICUS) with anemia alone (ICUS-A) in 47% (15/32) or multiple cytopenias (ICUS-PAN) in 53% (17/32). Time since surgery, age, or amount of weight loss was not associated with a specific diagnosis. No patient was vitamin B12 or folate deficient. However, vitamin B6 and zinc were decreased in 47% (5/11) and 29% (9/29), respectively. Examination of bone marrow aspirates revealed slight erythroid dyspoiesis affecting <10% of precursors in 60% (9/15) ICUS-A and 59% (10/17) ICUS-PAN. Bone marrow findings in patients with unexplained cytopenia(s) after BMS are not specific in the majority of cases, and caution is advised when interpreting dyserythropoiesis. Levels of micronutrients and vitamins other than iron, folate and vitamin B12 are frequently disturbed in this patient cohort and warrant correction and close clinical follow-up.

Characteristic bone marrow findings in patients with UBA1 somatic mutations and VEXAS syndrome

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a newly characterized syndrome with underlying somatic UBA1 mutations in myeloid cells linking hematologic disease with autoinflammatory rheumatologic disorders. Hematologic abnormalities, particularly peripheral blood cytopenia(s) may prompt bone marrow evaluation in patients with known or unrecognized VEXAS syndrome. This review highlights key findings and diagnostic considerations encountered during bone marrow examination in patients with this disorder. Frequently reported hematologic changes include macrocytic anemia, cytoplasmic vacuoles in myeloid and erythroid precursors, marrow hypercellularity, and varying degrees of dysplasia. Myelodysplastic syndrome and plasma cell neoplasms have been diagnosed in patients with VEXAS syndrome. Macrophage activation syndrome and/or hemophagocytic lymphohistiocytosis and monoclonal B-cell lymphocytosis have also been reported. The bone marrow is a target organ in VEXAS syndrome. Heightened awareness of the bone marrow features and hematologic complications may aid in identifying individuals with VEXAS who may benefit from increased disease surveillance or alternative therapeutic strategies.

Are Peripheral Blood Counts Predictor of Bone Marrow Infiltration and Hypocellularity in Malignant Neoplasms?

To determine the association of peripheral blood counts (cytopenia and normal counts) with bone marrow findings in patients with malignant neoplasms. Descriptive study. Place and Duration of the Study: King Edward Medical University from 2017 to 2019. Patients having malignant diseases, of both gender and all ages, were included. Clinical data and results of bilateral bone marrow aspiration and biopsy were noted. Results were categorised as groups with bone marrow infiltration, normal morphology with normal cellularity and normal morphology with decreased cellularity. Results were analysed using SPSS V21 applying Chi-square test, keeping the confidence interval 95% and p-value of <0.05 as significant. A total of 157 patients were included (107 men, 50 women). The main categories of neoplasm included non-Hodgkin's lymphoma [93 (59.2%)] Hodgkin's lymphoma [31 (19.7%)], and solid organ malignancy [33 (21.0%]. Bone marrow infiltration was seen in 50 (31.8%) patients, normal morphology with decreased cellularity in 51 (32.5%) and normal morphology with normal cellularity in 56 (35.7%) patients. Cytopenias were seen in 88 (56.1%) patients (out of these 28 (31.8%) had bone marrow infiltrarion, 32 (36.4%) had decreased cellularity and 28 (31.8%) with normal cellularity). In 69 (43.9%) patients with normal CBC, 22 (31.9%) had infiltration, 19 (27.5%) had decreased cellularity and 28 (40.6%) had normal cellularity. No association of cytopenia with bone marrow results was obtained (p = 0.086). Bone marrow infiltration and hypocellularity are not reflected by peripheral blood counts. Therefore, bone marrow biopsy remains decisive in patients with malignant neoplasm for disease staging and selection of treatment options. Key Words: Peripheral blood counts, Bone marrow infiltration, malignant neoplasms, bone marrow hypocellularity.

Clinico-hematological evaluation of pancytopenic adults in a tertiary care institution

Introduction: Pancytopenia is an important clinico-hematological entity encountered in our day-to-day clinical practice from a number of disease processes primarily and secondarily involving bone marrow. This study was carried out to evaluate bone marrow findings in patients with pancytopenia. Materials and Methods: This is a prospective cross sectional study carried out on 140 pancytopenia patients over the period of one and half years. Relevant clinical details were recorded, followed by screening of patients for routine blood investigations included a complete blood count, peripheral blood smear examination, reticulocyte count. Bone marrow aspiration was done in all cases and bone marrow biopsy performed whenever necessary and Perl’s Prussian blue stain for grading of bone marrow iron stores were done in all cases. Data analysed was compared with various studies published in literature. Results: The maximum cases of pancytopenia were in the age group of 31 to 40 years with male preponderance. Dimorphic anemia (49.3%) was found to be the most common etiology of pancytopenia followed by megaloblastic anemia (35%), iron deficiency anemia (5.7%). We encountered two cases of non-Hodgkin’s lymphoma and one case each of multiple myeloma, acute lymphoblastic leukemia, aplastic anemia and anemia of chronic disease. Most common clinical presentation was pallor followed by fatigue and fever. Conclusion: Present study concludes that basic primary hematological investigations along with bone marrow aspiration/trephine bone biopsy in the pancytopenia patients are helpful in understanding the disease process. This plays a key role in planning the further management. Keywords: Adults, Bone marrow, Dimorphic anemia, Megaloblastic anemia, Pancytopenia.

Bone Marrow Findings in Patients With Acute Promyelocytic Leukemia Treated With Arsenic Trioxide.

Increasingly, acute promyelocytic leukemia (APL) is treated with a combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). This study characterizes bone marrow findings after ATRA/ATO therapy. Bone marrow biopsies from 16 patients treated with ATRA/ATO and seven patients treated with ATRA/chemotherapy (CTX) for APL were evaluated. In ATRA/ATO cases, the marrow was likely to be hypercellular (79%) with a decreased myeloid:erythroid (M:E) ratio (88%), megaloblastoid maturation of erythroid precursors (100%), erythroid atypia (75%), and increased (88%) and atypical (75%) megakaryocytes. Significant myeloid atypia was only seen in extensive residual disease. The ATRA/CTX cases were less likely to be hypercellular (38%), have a M:E ratio of 1:1 or less (0%), exhibit significant erythroid atypia (0%), or have increased (0%) or atypical (38%) megakaryocytes. Bone marrow biopsies from patients treated with ATO have unusual but characteristic features. Despite variability in marrow findings, clinical outcomes were uniformly favorable.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal

Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia. A prospective observational study was conducted in Department of Pathology, Manipal College of Medical Sciences, Pokhara from January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia. Among 138 cases studied, patients' age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38 (27.5%) cases, followed by 26 (18.8%) cases of megaloblastic anemia and 19 (13.76%) cases of acute leukemia. Other findings included one case each of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma. This study highlights that pancytopenia is a common hematological problem and that the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management.

THU0406 Histological Findings of Spleen Affected by Adult Onset Still's Disease: an Analysis of 3 Cases

BackgroundDiagnosis of adult onset Still's disease (AOSD) is based on sets of several clinical and laboratory criteria, because no specific test is available. The differential diagnosis includes malignant lymphoma and...

Bone Marrow Biopsy Findings in Patients with Hepatitis C Infection

AbstractAbstract 4840Patients with hepatitis C often present with cytopenias - thrombocytopenia, neutropenia and less commonly anemia. Hypersplenism may contribute to cytopenias but effects on the bone marrow due to the hepatitis C infection also likely play a role in its pathogenesis. Hepatitis C infection predisposes to development of lymphomas as well. The bone marrow findings in patients with hepatitis C infection are not well described and to our knowledge there has only been one peer reviewed study published till date.In order to elucidate this further, we conducted a retrospective review of bone marrow biopsies performed at our institution on patients with known hepatitis C infection.Between years 1999 and 2010, 56 adults (36 male and 20 female) patient with hepatitis C underwent bone marrow biopsies. The indications for bone marrow biopsy included evaluation or staging of lymphoma or myeloma (24 patients) OR investigation of cytopenias (32 patients). None of the patients were on treatment for Hepatitis C at the time of the bone marrow biopsy.Of the 24 patients with lymphoma/myeloma, 11 showed bone marrow involvement, while 10 patients had benign lymphocyte aggregates in the marrow. 9 out of 24 patients had a hypercellular marrow and 8 had a hypocellular marrow. Mild to moderate megaloblastic change in the erythrocyte series was seen in 5 patients and dyserythropoiesis in 2. Hyperplasia of megakaryocytes was seen in 11/24 and 6/24 showed atypical megakaryocytes with focal clustering in 7/24. Reticulin fibrosis was noted in 7 patients. Iron stores were increased in 13/24 with decreased sideroblasts in 15/24 patients.Review of the 32 patients who had the bone marrow biopsy done for cytopenias showed 16 were hypocellular and 9 were hypercellular while 4 patients had variable cellularity. Mild to moderate megaloblastic change in the erythrocyte series was seen in 12/32 and dyserythropoiesis in 11/32. Granulocytic hypoplasia was seen in 14/32. Benign lymphoid aggregates were noted in 20 patients. Hyperplasia in the megakaryocytes was seen in 8 while 11 had decreased megakaryocytes. Atypical megakaryocytes were noted in 10/32 with clustering seen in 4 patients. Reticulin fibrosis was noted in 13 patients. Iron stores were increased in 16/32 and sideroblasts were decreased in 13/32. Frank hemophagocytosis was observed in 5 patients. Of these 32 patients, 4 were HIV positive. Myelodysplastic syndrome was diagnosed in 2/32, AML and Hemophagocytic lymphohistiocytosis in one each. Conclusions:Bone marrow biopsies are usually performed in patients with Hepatitis C to investigate cytopenias and for diagnosis or staging lymphoma or myeloma. Even without lymphoma involving the marrow, a substantial number of patients have benign lymphocyte infiltrates seen in the marrow. Marrow hypocellularity is common. Megaloblastic change in the erythroid series, dyserythropoiesis, atypical megakaryocytes and reticulin fibrosis can be seen in a substantial minority of the patients which contribute to cytopenias. Disclosures:No relevant conflicts of interest to declare.

Evaluation of bone marrow in patients with pancytopenia

Background: Pancytopenia is a common hematological finding resulting from varieties of disease processes that require evaluation of bone marrow. This study was carried out to evaluate bone marrow findings in patients presenting with pancytopenia.Materials and Method: This was a prospective cross sectional study carried out to identify the causes of pancytopenia based on bone marrow examination. Bone marrow examinations were performed in 503 cases for different indications over a period of one year.Results: One hundred and two (20.27%) cases fulfilled the criteria of pancytopenia. Trephine biopsy was possible only in 48 cases. In 75% cases aspiration findings were similar to biopsy. Mean age of patients was 38.8 years. Maximum number of cases was seen in age group of 15-30 years. Hypoplastic anemia was the commonest cause followed by hematological malignancies, megaloblastic anemia, leishmaniasis and Gaucher disease. Bone marrow examination alone was able to establish the diagnosis in 76.5% cases. In rest marrow findings were nonspecific and in 4.9% cases findings were normal.Conclusion: Bone marrow aspiration coupled with trephine biopsy can diagnose majority but not all the cases of pancytopenia. Hypoplastic anemia, hematological malignancies and megaloblastic anemia are the commonest causes of pancytopenia. Maximum diagnostic yield can be achieved by correlation with clinical findings, peripheral blood findings and with other laboratory and radiological parameters.Journal of Pathology of Nepal (2012) Vol. 2, 265-271DOI: http://dx.doi.org/10.3126/jpn.v2i4.6875

Bone marrow findings in patients with autoimmune liver diseases

We have recently reported quantitative and qualitative differences of the bone marrow (BM) hematopoietic progenitor cells in autoimmune hepatitis type-1 (AIH-1) and primary biliary cirrhosis (PBC). In order to better investigate the possible involvement of BM in these diseases, we studied the morphological abnormalities of BM aspirates in the same patients with AIH-1 and PBC. BM smears from 13 AIH-1 and 13 PBC patients were investigated. BM from 12 patients with cirrhosis of non-autoimmune etiology and eight healthy individuals served as pathological (PC) and healthy controls (HC). Erythroid, granulocyte and platelet precursors were variably altered. Polychromatic normoblasts and immature megakayocytes were higher in AIH-1 (11.9 +/- 2.9 and 16.2 +/- 16.9, respectively) and PBC (10.2 +/- 3.6 and 17.3 +/- 20.2, respectively) compared to PC (7 +/- 2 and 2.3 +/- 6.0, respectively) and HC (7.9 +/- 1.6 and 0 +/- 0, respectively) (P = 0.0001 and P = 0.006). In AIH-1, immature megakaryocytes were significantly higher in patients receiving immunosuppression (25.71 +/- 17.66 vs 5.00 +/- 5.48; P < 0.02) and were associated negatively with laboratory markers of disease activity. BM plasmacytosis was observed more frequently in AIH-1 compared to PBC and PC. BM monocytosis was found in all patients with AIH-1, PBC and PC whereas approximately half of the patients with autoimmune liver diseases and all PC had BM lymphocytosis. BM monocytosis and lymphocytosis are commonly found in AIH-1 and PBC patients irrespective of the presence of cirrhosis or the use of immunosuppression. BM plasmacytosis appears to be a distinct finding in some AIH-1 patients, as similar findings were observed in only one PBC and one PC, whereas BM immature megakaryocytes characterize both AIH-1 and PBC. Whether BM is a target organ in AIH-1 and PBC needs further investigation.

Spectrum of bone marrow findings in patients with angioimmunoblastic T‐cell lymphoma

Bone marrow (BM) biopsy is often performed early in the evaluation of patients with angioimmunoblastic T-cell lymphoma (AITL), and may be the first diagnostic tissue sample; yet the BM histopathology associated with this disease has not been well described. In this study, BM specimens from 13 patients with AITL were reviewed. Seven (54%) were involved by AITL, which was characterised by paratrabecular and interstitial polymorphous infiltrates containing cytologically atypical lymphocytes, histiocytes and eosinophils. The neoplastic cells were positive for CD10 and CXCL13 by immunohistochemistry in a subset of cases. As in lymph nodes, the lymphomatous infiltrate in some BMs contained numerous small or scattered large B cells, resembling either benign lymphoid aggregates or T cell rich large B cell lymphoma, respectively. Secondary haematological changes were frequent and presented independent of BM involvement by AITL; these included trilineage haematopoietic hyperplasia and plasmacytosis. When BM biopsy preceded the diagnosis of AITL, these secondary changes were misinterpreted as chronic myeloproliferative disease (n = 2), or plasma cell dyscrasia (n = 2). In two cases, these changes obscured the presence of BM involvement by AITL. The spectrum of BM findings in AITL patients is important to recognise for early and accurate diagnosis in this disease.

Bone marrow findings in patients with adult Still's disease

Objective: Peripheral neutrophilia is one of characteristic laboratory findings in patients with adult Still's disease (ASD). We performed this study to identify the bone marrow findings in patients ASD.Methods: We examined 12 bone marrow biopsy specimens from patients with ASD.Results: The most frequent finding was granulocyte hyperplasia (12/12, 100%) and hypercellularity was observed in 75.0% (8/12) of patients. Plasmacytosis was present in 8.3% (1/12) of specimens. Histiocytosis and reactive hemophagocytosis were found in 25.0% (4/12) and in 16.7% (2/12) respectively.Conclusion: Our results show that bone marrow granulocyte hyperplasia is the main possible mechanism for peripheral neutrophilia and that histiocytic activation is a not infrequent bone marrow findings in patients with ASD.

Failure to Engraft after Bone Marrow Transplantation: Bone Marrow Morphologic Findings

Few studies have explored bone marrow findings in patients with graft failure or delayed engraftment after bone marrow transplantation (BMT). The authors retrospectively identified 4 patients of 165 transplant recipients who underwent bone marrow examination after BMT because peripheral blood counts had not recovered to expected levels. All patients were women who were 21- to 49-years old (mean 37 years). Three patients underwent autologous BMT; the fourth received peripheral stem cell infusion. Transplants were performed for treatment of Hodgkin's disease, breast carcinoma, and follicular small cleaved cell lymphoma. Three patients received GM-CSF after marrow infusion. The time between transplant and biopsy ranged from 19 to 40 days (mean 22 days). White cell counts ranged from 0.1 to 0.6 x 10(9)/L, hematocrits from .25 to .41, and platelet counts from 10 x 10(9)/L to 39 x 10(9)/L. Aspirate smears were markedly hypocellular in all cases, and markedly hypocellular, and all contained histiocytes with foamy eosinophilic cytoplasm diffusely throughout the biopsy. Acid-fast and Gomori's methenamine-silver (GMS) stains were negative. Serous fat atrophy and marrow fibrosis were not seen. Delayed engraftment after BMT may be associated with a profuse histiocytic proliferation similar to that seen in immunodeficiency, some hematologic disorders, and storage diseases.

Peripheral blood and bone marrow findings in patients with acquired immune deficiency syndrome

In 4 years (1984-1987), 183 bone marrow examinations were performed on 155 human immunodeficiency virus (HIV) antibody positive patients. One hundred and fifty three had category IV AIDS. One-third of the marrows yielded specific information. This included opportunistic infection, in particular Mycobacterium Avium Intracellulare Complex (MAI) (24%), malignancy (4%), consistent with ITP (9%) and iron deficiency (1%). In the remaining two thirds of the bone marrows the most frequent non-specific abnormalities were dyserythropoiesis, erythroid hypoplasia, reticuloendothelial iron block, granulomas, lymphoid aggregates, plasmacytosis and histiocytosis. Common peripheral blood findings were anemia, lymphopenia, anisocytosis, rouleaux and atypical lymphocytes. Peripheral blood and bone marrow examinations on 16 patients on AZT are included. These patients have more pronounced blood and bone marrow abnormalities. The causes of these abnormalities are multifactorial and include low T4 levels, severe viral and other infections and therapy with marrow toxic drugs.

THE BLOOD AND BONE MARROW IN PATIENTS WITH CIRRHOSIS OF THE LIVER

Abstract The peripheral blood and bone marrow findings in patients with cirrhosis of the liver have been analyzed on the basis of a review of the literature and the authors’ study of 25 patients with diagnoses verified by biopsy of the liver. The principal blood findings are macrocytic or normocytic anemia with normal or elevated mean corpuscular hemoglobin values, lymphopenia and thrombocytopenia in the majority of cases. Anemia may be independent of bleeding, and the severity of anemia or macrocytosis does not appear to be related to the severity of the liver lesion. The consistent change in the bone marrow is extension of the marrow organ so that active hematopoiesis is found in the shafts of the long bones. Regardless of the presence or absence of bleeding or anemia, the marrow of the sternum is of normal or increased cellularity, with normal or increased erythrocytogenesis and megakaryocytogenesis in most cases. Hypocellularity of the marrow is an unusual finding, even in patients with advanced liver lesions. Macronormoblastic erythropoiesis is seen in patients with macrocytic anemia, but megaloblastic erythropoiesis dces not result from cirrhosis of the liver. The presence of peripheral cytopenias (anemia and thrombocytopenia) in spite of normal or increased formation of erythroblasts and megakaryocytes in the marrow is suggestive of hypersplenism in patients with hepatic cirrhosis. In patients with chronic hemorrhage the blood and bone marrow pictures are those of iron deficiency anemia, although other changes such as lymphopenia and thrombocytopenia tend to persist. The combined peripheral blood and sternal marrow examination is often of value in establishing the diagnosis of cirrhosis of the liver.