Bone Marrow Biopsy Examination Research Articles

Comprehensive Review of Mastocytosis From Pathophysiology to Management Strategies

Introduction: Mastocytosis is a rare hematologic neoplasm characterized by the abnormal proliferation and accumulation of mast cells in various tissues. Its clinical manifestations vary widely, ranging from cutaneous lesions to systemic involvement with potentially life-threatening symptoms. Understanding the pathophysiology, diagnosis, and management of mastocytosis is crucial for improving patient outcomes. 
 
 Aim of the Study: The aim of this study was to provide a comprehensive overview of mastocytosis, including its epidemiology, risk factors, pathophysiology, clinical manifestations, diagnostic approaches, and management strategies. By synthesizing current knowledge on mastocytosis, this study aims to enhance understanding of the disease and guide clinical practice. 
 
 Description of the State of Knowledge: Mastocytosis is classified into cutaneous and systemic forms, with various subtypes based on clinical and histopathological features. Diagnosis relies on a combination of clinical suspicion, serum tryptase levels, histological examination of bone marrow biopsies, and genetic testing. Management strategies include symptomatic treatment, avoidance of triggers, and targeted therapies such as monoclonal antibodies and tyrosine kinase inhibitors. Advanced forms may require cytoreductive therapy or allogeneic hematopoietic stem cell transplantation (alloHSCT). 
 
 Conclusions: Despite advancements in diagnosis and treatment, achieving lasting remission in mastocytosis remains challenging, especially in advanced cases. Further research into the molecular mechanisms underlying the disease and the development of novel therapeutic modalities are needed to improve patient outcomes and quality of life.

Factors affecting prognosis in myelodysplastic syndrome: an 11 years’ experience from a tertiary care center

Aims: Myelodysplastic syndrome (MDS) is a clonal bone marrow neoplasia characterized by morphological findings of dysplasia in hematopoietic cells, peripheral cytopenia(s), ineffective hematopoiesis, recurrent genetic abnormalities, and an increased risk of conversion to acute myeloid leukemia (AML). The International Prognostic Scoring System (IPSS) is the most commonly used prognostic classification system for MDS. Classification was made by a combination of morphology, cytopenia, and genetic studies. In this study, we aimed to examine the parameters that affect prognosis in MDS patients, show their effects on mortality, and evaluate their positive or negative effects on the course of the disease. Methods: Two hundred twenty-nine patients who applied to Erciyes University Faculty of Medicine, Department of Hematology, and were diagnosed with MDS according to WHO classification between 2010 and 2020 were included in this retrospective study. Age, gender, additional disease status, laboratory parameters, bone marrow biopsy materials, and genetic mutation analysis data were available. The bone marrow aspiration and biopsy examinations of each patient were evaluated and categorized according to the WHO classification. The prognosis was evaluated according to the data of the patients, survival-exitus, and survival after MDS-AML conversion. Risk scoring was analyzed with three different scoring systems (IPSS, WPSS, and R-IPSS). Results: Of the 229 MDS patients included in the study, 57% (131) were male. The mean age of the patients was 67 years. Age, MDS-AML conversion times, disease duration, cellularity, and pathology blast rate were found to be statistically significant between the groups (p<0.05). Leukocyte, neutrophil, platelet, hematocrit, lymphocyte, monocyte, CRP, erythropoietin, ferritin, and LDH data were found to be statistically significant regarding survival (p<0.05). Age, IPSS risk status 3, and W-PSS risk status 3 were found to be independent risk factors affecting survival. Conclusion: Age, IPSS high risk, and WPSS high risk status were found to be independent risk factors affecting survival. Although our study revealed important data in the analysis of MDS patients, single-center analysis of patients and retrospective analysis revealed the need for further studies.

Polycythemia Vera with Elevated Erythropoietin Level: A Review

According to the 2016 World Health Organization (WHO) recommendations, polycythemia vera (PV) should be suspected at hemoglobin levels of 16.5 gm/dl in males and 16 gm/dl in females. Depending on the underlying driving factor, polycythemia is classified to primary and secondary. Secondary polycythemia is driven by erythropoietin (EPO), which can be released due to hypoxemia, as seen in people living at high altitudes, those with chronic lung diseases, obstructive sleep apnea (OSA) and smoking. It can also be directly released by an underlying EPO secreting tumor, such as renal cell carcinoma. On the other hand, primary polycythemia or polycythemia vera (PV) is a myeloproliferative neoplasm (MPN) in which erythrocytosis is driven by an acquired activating mutation that increases sensitivity to EPO or causes EPO independent erythroid colony formation. Manifestations of PV include fatigue, excessive itching, abdominal pain, weight loss, and fever. However, the most critical complications of PV, which impact survival, are thrombotic complications such as stroke and venous thromboembolism and leukemic transformation. The risk for leukemic transformation in patients with PV is about 2-5% over 15 years and is more common in individuals older than 60. History and physical examination should focus on smoking history and signs and symptoms of cardiopulmonary diseases causing chronic or intermittent hypoxemia, as seen in OSA. On the other hand, findings of abdominal pain, early satiety, weight loss, erythromelalgia, and hepatosplenomegaly would be suggestive of PV. Laboratory workup classically starts with measuring EPO level which further directs workup toward PV or secondary polycythemia. If workup is suggestive of PV, the following steps would be testing for activating Janus Kinase 2 (JAK2) mutation (V617F), which has a sensitivity of 97% for PV, and bone marrow biopsy which shows hypercellularity with trilineage growth (panmyelosis) in cases of PV. EPO measurement constitutes an essential step in polycythemia workup. It is widely accepted that elevated EPO levels are associated with secondary polycythemia; and suppressed EPO level was considered a criterion to diagnose PV, according to the WHO 2016 diagnostic criteria for PV. We conducted a systematic review searching the entity of PV with elevated EPO to study the clinical significance and outcomes. Our search yielded 4 cases summarized in Table 1. The cases were of three males and one female, with a mean age of 50. Two of them were healthy, with two with comorbid diseases, and as seen in the table; only one was a smoker. The most common symptom was headache, followed by erythromelalgia. Thrombotic phenomena happened in a single case in the form of Budd Chiari syndrome. Hepatosplenomegaly was found in a single case, and splenomegaly was found in two cases. The mean Hb level was 20.2 gm/dl, and the mean EPO level was 213. EPO is a glycoprotein hormone that is mainly produced by the kidneys. However, it is also produced in small amounts in the liver, spleen, bone marrow, lungs, and brain. The primary regulator of EPO production is the partial pressure of oxygen (PaO2). Multiple case reports and case series suggested an association between PV with elevated EPO and Budd Chiari Syndrome. Thumures et al. described four patients that were diagnosed with Budd Chiari Syndrome with elevated red cell mass and were found to have elevated serum erythropoietin levels. PV was confirmed with JAK2 mutation assay and bone marrow biopsy examination. It is speculated that liver hypoxia with subsequent hepatocyte injury and necrosis caused by Budd Chiari Syndrome leads to EPO level elevation. Accordingly, we assume that patients with PV and elevated EPO have some degree of organ injury that results in the release of EPO into circulation. This highlights the importance of a systematic approach in medicine, where signs and symptoms remain the cornerstone in diagnosis and where lab tests should be taken in their appropriate clinical context. Thus, we recommend testing for JAK2 mutation in the proper clinical scenario regardless of the EPO levels. It still remains to be clarified whether there are any prognostic importance of the elevated EPO level in these patients and whether it would alter the management.

The Reticulin, Collagen, Osteosclerosis (RCO) Score Is Clinically and Prognostically Relevant in Patients with Secondary Myelofibrosis (SMF)

Introduction: Polycythemia vera (PV) and essential thrombocytemia retain an inherent risk for progression to secondary myelofibrosis (SMF; PPV- and PET-MF, respectively). Histopathological examination of bone marrow (BM) biopsy constitutes an essential step in SMF diagnosis and can show a variety of stromal changes, including reticulin fibrosis, collagen deposition, osteosclerosis, and microvascular proliferation. In 2017, Gianelli et al. ( Histopathol 2017;71:89) developed a comprehensive, prognostically informative score, named reticulin (MF), collagen (Co), osteosclerosis (Ost) score (RCOs), aimed at the histological evaluation of primary MF (PMF). Aims&Methods: This retrospective, single-center study aimed to validate the RCOs and explore its clinical, genetic and prognostic correlates in a cohort of patients (pts) with clinically and molecularly annotated SMF diagnosed according to the 2022 ICC criteria. The RCOs was assessed by two independent experienced histopathologists (U.G, R.S.), as previously described ( Histopathol 2017;71:89). Results: The study included 72 pts with a diagnosis of SMF: 28 (39%) PPV-MF and 44 (61%) PET-MF. Median age at diagnosis was 66 years (range 35-85), 44 (61%) were male. Histological analysis of BM stromal changes according to the RCO algorithm provided the following results (Fig. 1A): MF-0 n=0, MF-1 n=0, MF-2 n=35 (49%), and MF-3 n=37 (51%); Co-0 n=8 (11%), Co1 n=25 (35%), Co-2 n=22 (31%), and Co-3 n=17 (24%); Ost-0 n=25 (35%), Ost-1 n=25 (49%), Ost-2 n=7 (10%), and Ost-3 n=5 (7%). The corresponding figures for PPV- and PET-MF separately are reported in Fig. 1A. Overall, morphological features were homogeneously distributed with no significant differences between the two disease subtypes. The computation of the RCOs returned the following results: RCOs 0 n=0, RCOs 1 n=0, RCOs 2 n=6 (8%), RCOs 3 n=15 (21%), RCOs 4 n=10 (14%), RCOs 5 n=9 (13%), RCOs 6 n=14 (19%), RCOs 7 n=9 (13%), RCOs 8 n=5 (7%), and RCOs 9 n=4 (6%). Median RCOs was 5 (range, 2-9) for both PPV- and PET-MF. First, we investigated the correlations of the RCOs with distinct clinical and molecular characteristics in the whole SMF cohort. A higher RCOs was associated with lower hemoglobin value (Pearson's r, -0.3, P=.0173), lower platelet count (Pearson's r, -0.3, P=.0106), and higher LDH value (Pearson's r, 0.3, P=.0308). We found no significant correlations with regards to driver and other co-occurring mutations. Median overall survival (OS) was 71 months (95% CI 45-99), with no significant difference between the PPV- and PET-MF cohorts. In univariate Cox regression analysis, the RCOs directly correlated with the risk of death (HR 3.9, 95% CI 1.2-13.8, P=.0282). In multivariate analysis, the predictive relevance of the RCOs was independent of the MYSEC-PM stratification. By analyzing the single components of the RCOs, both the MF and Ost variables correlated with survival (respectively: HR 3.9, 95% CI 1-12.9, P=.0315; HR 2.2, 95% CI 1.1-4.7, P=.0337), unlike the Co variable. ROC analysis with death as endpoint identified 6 as the optimal cut-off value. Pts with RCOs >6 (n=32) had a significantly worst OS compared to pts with RCOs <6 (n=40), with median values of 42 vs 90 months (HR 2.5, 95% CI 1.3-5.2, P=.0097). ROC analysis separately in the PPV- and PET-MF cohorts returned 5 and 7, respectively. Due to the small study population, we opted to keep the two cohorts together and ascertained whether the integration of the dichotomous RCOs >/<6 (RCOs 6) improved the performance of the MYSEC-PM. To this end, we computed the C-index, Brier score, and time-dependent AUC to assess the prognostic performance of standard and RCOs 6-integrated MYSE-PM (Fig. 1 B). Overall, the combination of MYSEC-PM and RCOs 6 was remarkably superior in predicting death for all parameters and at all time points considered (24, 48, 72, and 96 months). Conclusions: The results of the current study indicate that the RCOs, although formerly developed for pts with PMF, is clinically and prognostically relevant in SMF. Most importantly, we showed that integrating the discrete RCOs 6 into the SMF-specific MYSEC-PM can significantly improve the predictive performance of the prognostic model.

Analysis of Clinical Features, Prognostic Characteristics and Gene Mutations of the EB Subtype of Primary Myelodysplastic Syndrome Patients with Myelofibrosis

Objective ：This study aims to analyze the clinical features, prognostic characteristics and gene mutations of the primary myelodysplastic syndrome with myelofibrosis (MDS-MF) patients, to compare the differences and impact of MF on MDS-EB group and MDS-Non-EB group, ultimately to improve the cognition of MF on MDS-EB group. Methods ：From January 1, 2013 to February 1, 2020, 417 newly diagnosed primary MDS patients in the first affiliated hospital of Zhejiang University with bone marrow (BM) biopsy examination were included. They were divided into two groups (MDS-EB group and MDS-Non-EB group) according to 2016 WHO MDS classification.BM was reassessed on whether associated with fibrosis in grade MF0,1,2,3. (2005 European Myelofibrosis Network criteria). The clinical features, prognosis characteristics and gene alterations were analyzed between the MDS-EB group and MDS-Non-EB group retrospectively. Results ： ① MF was confirmed in 46.3％（193/417）cases of all the MDS patients, of which 66.3％（128/193）were MF-1 , 25.9％（50/193）were MF-2 and 7.8%(15/193) were MF-3 respectively. Compared with MDS-MF0 group, MDS-MF were significantly associated with worse OS(P=0.035) and worse PFS(p<0.001). ② There was 174 cases of MDS-EB and 243 cases of MDS-Non-EB. The proportion of MF in MDS-EB group was 54.0%(94/174) and significantly higher than in MDS-Non-EB group 40.7%（99/243）(p=0.010).The distribution of MF grade was also differently significant between the two groups(p=0.048). The clinical features analysis showed that there is higher level of C-reactive Protein (CRP), higher level of serum lactate dehydrogenase (LDH) and higher level of β2-microgram in the peripheral blood in the MF(MF1,2,3) group than in the MF0 group, regardless of whether it was in the EB group or the non-EB group. The difference was statistically significant (ALL p value<0.05). ③The impact of MF on MDS-EB patients and MDS-Non-EB patients has different significances concerning OS, PFS and t-AML. As far as the OS prognostic factor, no matter the comparison of MF0, 1,2,3 four groups, the comparison MF1,2,3 three groups, the comparison of MF0-1 with MF2-3, all showed that MF was an adverse prognostic factor in the EB-MF group (All p value <0.05), and it also showed the adverse impact related with the grade of MF, but none of any in the MDS-Non-EB group (All p value>0.05)(Figure1). Comes to the PFS, it showed the MF on MDS-Non-EB was an inferior factor when compared MF+(MF1,2,3) to MF-(MF0)(p=0.0097), but not between the comparison MF1,2,3 groups(p=0.96) and none of the MDS-EB groups（p=0.31 and 0.092 respectively）. The incidence of MF was related with a higher rate of t-AML not only in MDS-EB group but also in MDS-Non-EB group compared with MF0, no matter compared the MF+(MF1,2,3) with MF-(MF0) but also the comparison of MF0,1,2,3) (All P value < 0.001). ④ In the MDS-EB cohort, 66 patients in the MF-(MF-0) group completed Next-generation-sequencing (NGS) test, and 61 patients in the MF+ (MF1,2,3) group completed NGS testing. It seems that the incidence of gene mutation has no difference between the two groups. We conducted univariate COX regression analysis about the 30 genes (which were suggested in the NCCN guideline 2020) with OS, PFS and t-AML in the MDS-EB-MF cohort. The results showed that TP53, Nras, WT1 was related to the worse OS; U2AF1, Niras and TP53 was related to worse PFS and GATA2, IDH2, TP53, STAG2 was related to t-AML. Conclusion: MDS-MF has unique laboratory and clinical characteristics, act as an independent risk factor for shorter OS and worse PFS in the MDS-MF patients in our large cohort. In this study, we retrospectively analyzed 417 primary MDS cases in our hospital and analyzed the impact of MF on MDS-EB group and MDS-Non-EB group respectively. Our results showed the MF has a worse OS on the MDS-EB-MF group than the MDS-EB-MF0 group but no impact on MDS-Non-EB cohort. It was also consistent with the 5th edition of the WHO Classification of Haemato-lymphoid Tumors guidelines in which MDS-f was listed as a subtype concerning MDS with fibrosis concomitant with 5-19% blast cells in bone marrow or 2-19% blast cells in peripheral blood. The NGS sequencing showed TP53, Nras, WT1 was related to the worse OS; U2AF1, Niras and TP53 was related to worse PFS and GATA2, IDH2, TP53, STAG2 was related to t-AML.As far as we know, this is the first analysis of bone marrow fibrosis in MDS-EB patients. We need more research to help us understand the MDS-f subtype.

T Cell Selection Is Not Helpful for Therapeutic Efficacy of CART19 in Relapsed or Refractory B-ALL Patients with Peripheral Blood Leukemia Burden at Time of Apheresis

Abstract Introduction: We have demonstrated peripheral blood (PB) blasts negatively affected chimeric antigen receptor T cells targeting CD19 (CART19) production and the clinical efficacy of CART19 therapy in patients (pts) with refractory/relapsed B cell acute lymphoblastic leukemia (r/r B-ALL) (published in Molecular Therapy: Methods & Clinical Development ,2021). Whether sorting T cells before activation might be helpful for ex-vivo CART19 quality and in-vivo treatment efficacy requires further investigation. Here, we retrospectively analyzed 40 pts with or without upfront T cell purification to evaluate these indexes. Patients and Methods: From July 2021 to June 2023, 40 r/r B-ALL with PB blasts at time of apheresis experienced CART19 therapy. After leukapheresis, all pts' PBMCs were isolated using lymphocyte separation liquid. 30 pts didn't perform T cells selection (group 1) and 10 pts performed T cells selection (group 2). All of cells were activated with CD3 and CD28 antibodies for 24h, then transduced with the lentivirus encoding anti-CD19-CD3zeta-4-1BB CAR and cultured for 5-6 days in serum-free media containing IL2, IL7, IL15, IL21. The baseline characteristics, including age, sex, previous therapy period, blasts in BM, EMD distribution, complex chromosome aberration, poor fusion genes and gene mutations, did not differ between the two groups (Table 1). Cell viability, expanding fold, percentage of CD3 +T and CD3 + CD8 +T cells, transfection efficiency, B cells were all examined pre CART19 infusion. All pts received cyclophosphamide 250 mg/m2/d X 3d, and fludarabine 30 mg/m2/d X 3d, followed by CART19 infusion with a median number of 9.7(0.17-60) X10 5cells/kg in group 1 and 10 (4-16.3) X10 5cells/kg in group 2 ( P=0.99). PB and BM blasts was determined by flow cytometry (FCM). All pts underwent bone marrow (BM) biopsy examination and FCM studies on day 15 or day 30 to determine the response and remission status. Results: At time of apheresis, group 1 and group 2 had a median leukemia cell of 18% (2%-71%) and 19.4% (7%-54.4%) in PB ( P=0.5), respectively. In group 1 and group 2, the median percent of CD3 +T and CD3 + CD8 +T cells were 97.7% (70% - 99.5%) vs. 97.7% (94.8%-99.2%) ( P=0.46) and 66% (24.3% - 88.3%) vs. 64.2% (28% - 84.4%) ( P=0.45), respectively. The median cell viability, transfection efficiency and cell expanding fold in the final products was 82.9%（44.4%-92.2%) vs. 88.6%（76.4%-95.2%）( P=0.09), 31.4%（3.1%-65.5%) vs. 23.6% (12.4%-35.5%) ( P=0.08) and 3.18-fold（0.24-13.6) vs. 2.32-fold（0.48-8.13) ( P=0.83), respectively. Both of normal B and leukemia cells were undetectable pre CART19 infusion in two groups. After CART19 infusion, the median peak CART19/ lymphocyte cells, expanding fold and absolute CART19 count in vivo was 45% (0-79.4%) vs. 57.9% (0-75%) ( P=0.86), 16.7-fold (0-397.3) vs.13.2-fold (0-406)( P=0.96) and 229 (0-4810) X10 6/L blood vs. 242 (0-3220) X10 6/L blood ( P=0.83) in two groups, respectively. In group 1, 28/30 cases were evaluable and 25/28 (89.3%) obtained complete remission (CR)/ incomplete count recovery CR (CRi) and 24/28 (85.7%) obtained minimal residual disease (MRD) - CR. 1/2 patient unevaluable died from pneumonia due to severe and persisted neutropenia. One no-responder was infused at <1 X10 5 cells/kg and his culture failed to expand in vivo, and the other no-responder was infused at 1.16 X10 5 cells/kg (with TEL-AML1 positive). In group 2, 8/10 cases were evaluable and 6/8 (75%) obtained CR/CRi with all MRD - CR (75%). The two non-responders had no detectable CART19 in PB after infusion for one month. Results were shown in Table2. Conclusion: We have demonstrated pts with PB blasts without sorting T cells had poorer ex-vivo CART19 quality and in-vivo treatment efficacy compared to pts without PB blasts (published). Sorting T cells before activation is expected to remove the adverse culture conditions in the system. However, in the present study, upfront T cell purification didn't improve ex vivo cell characteristics and in vivo cell dynamics in r/r B-ALL pts with PB blasts, showing that the negative influence of PB blasts at the time of apheresis could not be reversed by upfront T cell purification. Therefore, leukemia burden in PB is suggested to be reduced before leukapheresis. Absolutely, one of the limitations of our study is that a relatively small number of products was evaluated, and larger samples need to be included to further demonstrated.

A Comprehensive Study of Etiology and Pathogenesis in Hemophagocytic Lymphohistiocytosis

Background: Hemophagocytic syndrome, or hemophagocytic lymphohistiocytosis (HLH), is a rare yet life-threatening hyperinflammatory disorder marked by excessive immune cell activation. This study aims to delineate diverse etiological triggers of HPS and enhance comprehension of its pathogenesis through meticulous analysis of an afflicted cohort. Methods: Conducted within the Hematopathology Section of the Department of Pathology, this retrospective cum prospective observational study involved 64 meticulously selected patients meeting inclusion criteria. Referral for Bone Marrow Aspiration and Biopsy examinations was the basis for patient inclusion, with approval from the Institutional Ethics Committee. Results: The average age of the 64 patients ranged from 10 months to 85 years (mean: 41.5±19.74 years). Males exhibited a predominant presence (65.6% vs. 34.4% females). 82.2% of patients displayed haemophagocytosis solely on bone marrow aspirate, while 17.2% manifested haemophagocytosis in both aspirate and biopsy. Secondary HLH predominated (96.9%), with a minor proportion of primary HLH cases (3.1%). Infections were identified in 68.8% of cases, with viral infection as the prominent etiology (20.3%), followed by typhoid (12.5%), hepatitis C (9.4%), sepsis (7.8%), and tuberculosis (7.8%). Conclusion: This study's amalgamated findings of hematopathological insights and etiological understanding enhance comprehension of HLH, fostering clinical awareness and driving the pursuit of advanced therapeutic approaches. Keywords: Bone marrow, hemophagocytic lymphohistiocytosis (HLH), hyperferritinemia, primary HLH, secondary HLH

Clinical value of 18F-FDG PET/CT to predict MYCN gene, chromosome 1p36 and 11q status in pediatric neuroblastoma and ganglioneuroblastoma.

To explore the value of 18F-2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET)/computed tomography(CT) in MYCN gene and chromosome 1p36 and 11 statuses in newly diagnosed pediatric NB(neuroblastoma) and GNB(ganglioneuroblastoma). We retrospectively analyzed newly diagnosed patients with 48 NB and 12 with GNB in our hospital. The data obtained from the clinical medical records included age, sex, pathologic type, and laboratory parameters such as lactate dehydrogenase (LDH), neuron-specific enolase (NSE) and the status of MYCN gene and chromosome 1p36 and 11q. The bone conditions were also obtained in the examination of bone marrow biopsy. Primary tumors were manually segmented to measure the maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), tumor volume(MTV) and total lesion glycolysis(TLG) and the maximal length of the lesion in the axial image(LEGmax). The differences in bone marrow involvement and lymph node metastases in patients with chromosome 11q deletions were statistically significant (all p < 0.05). Chromosome 11q deletion was an independent factor affecting bone marrow involvement (OR=17.796, p=0.011). The levels of NSE, LDH, LEGmax and SUVmax, SUVmean, MTV, TLG all predicted MYCN gene amplification (all p < 0.05). The levels of LDH, LEGmax and MTV, TLG all predicted deletions in chromosomes 1p36 (all p < 0.05), while NSE, SUVmax and SUVmean did not (all p > 005). The LDH levels, LEGmax, MTV and TLG can effectively predict the status of the MYCN oncogene and chromosome 1p36 in pediatric neuroblastoma and ganglioneuroblastoma. Those patients with chromosome 11q deletions are more likely to develop bone marrow involvement and lymph node metastases, showing a worse progression-free survival.

Patterns of bone marrow infiltration in lymphomas- A retrospective descriptive analysis from a tertiary care centre in Southern India

Bone marrow biopsy (BMB) examination is the gold standard for staging of lymphoma which is interpreted along with other clinical, laboratory and radiological investigations. This study aimed to evaluate the various patterns of BMB infiltration by lymphomas which include Hodgkin and Non Hodgkin lymphoma and the usefulness of BMB compared to bone marrow aspiration (BMA). : In a period of three years, there were 212 cases which showed lymphoma infiltration in bone marrow. We assessed the peripheral blood smear (PBS), BMA and BMB slides and concordance between each was evaluated. BMB slides were assessed for the pattern of involvement. The most frequent subtype was chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) (21.70%) followed by Hodgkin lymphoma (HL)(12.73%)and follicular lymphoma (FL)(11.32%). Predominant pattern of infiltration showed by CLL/SLL cases was mixed pattern, by FL was paratrabecular pattern, mantle cell lymphoma(MCL) showed either diffuse or nodular, diffuse large B cell lymphoma (DLBCL) and Burkitt lymphoma(BL) showed predominantly diffuse pattern. Hairy cell leukemia (HCL) and peripheral T cell lymphoma (PTCL) showed an interstitial pattern. In HL, the pattern was usually focal nodular however diffuse involvement was seen in a few. Of the 212 cases, 50.94% cases had atypical lymphocytes or lymphocytosis in PBS and 81.14% cases showed infiltration in BMA. Atypical lymphoid cells may not be present at times in peripheral blood or bone marrow aspirate in spite of infiltration in the bone marrow. Different lymphomas show characteristic patterns of marrow involvement.

Morphological Spectrum of Bone Marrow Changes in Patients of Chronic Kidney Disease: A Cross-sectional Study

Introduction: Bone marrow investigations are crucial for Chronic Kidney Disease (CKD) patients with anaemia because they monitor iron stores and reveal morphological abnormalities. In the context of CKD, the examination of bone marrow plays a crucial role in assessing iron levels in individuals with anaemia, as well as providing valuable insights into the specific morphological alterations that occur in CKD patients. Aim: To determine the bone marrow changes and bone marrow iron storage in the patients with CKD; and to study the association between haematological parameters and different CKD stages. Materials and Methods: This cross-sectional study design enrolled 50 CKD patients in the Department of Pathology at MLB Medical College, Jhansi, Uttar Pradesh, India from December 2021 to November 2022. Each patient underwent bone marrow biopsy examination. The Medonic-M Series, an automated haematological analyser, performed the Complete Blood Count (CBC) with red cell indices. Perl’s staining and the Gale Grading Systems were used for assessing iron storage. Descriptive analysis employed frequency and proportions for categorical variables, while mean and Standard Deviation (SD) were used for continuous variables. One-way ANOVA was used to compare differences between variables. Data was collected, compiled, tabulated, entered into a Microsoft Excel sheet, and analysed using Statistical Package for the Social Sciences (SPSS) version 23.0. Results: The study included 50 cases, with the majority of patients being in their fifth and sixth decades of life. Of the total cases, 28 (56%) were males and 22 (44%) were females. Most patients were in Stage-V CKD (N=28, 56%), followed by Stage-III (N=16, 32%), and Stage-IV (N=6, 12%). Among the haematological variables, the difference in Haemoglobin (Hb) was statistically significant (p-value=0.001) in all CKD stages. Iron absorption was found to be normal in 58% (n=29) of patients and increased in 32.00% (n=16) of cases. A total of 26 (52%) out of 50 CKD patients had normocellular bone marrow biopsy and bone marrow smears. Conclusion: Bone marrow examination is undervalued but may be beneficial for CKD patients with anaemia, erythropoietin resistance, thrombocytopenia, or pancytopenia. This method should be considered in centres, whenever possible.

Analysis of Clinical Features, Prognostic Characteristics and Gene Mutations of Primary Myelodysplastic Syndrome Patients with Myelofibrosis

Objective ：This study aims to analyze the clinical features, prognostic characteristics and gene mutations of the primary myelodysplastic syndrome with myelofibrosis (MDS-MF) patients, ultimately to improve the cognition of MDS-MF. Methods ：From January 1, 2013 to February 1, 2020, 417 newly diagnosed primary MDS patients in the first affiliated hospital of Zhejiang University with bone marrow (BM) biopsy examination were included. They were divided into two groups according to whether BM associated with fibrosis (2005 European Myelofibrosis Network criteria), the MDS-MF group(MF grades 1-3）and the MDS without MF group (MDS-MF0).The clinical features, prognosis characteristics and gene alterations were analyzed between the two groups retrospectively. Results ： ① MF was confirmed in 46.3％（193/417）cases of all the MDS patients, of which 66.3％（128/193）were MF-1 , 25.9％（50/193）were MF-2 and 7.8%(15/193) were MF-3 respectively. The proportion of MDS-EB in MDS-MF group was 48.2%(93/193) and significantly higher than in MDS-MF0 group 35.7%（80/224）,the difference had statistical significance(P=0.008). However, the occurrence of MF does not differ among the MDS subtypes according to the 2016 WHO classification (P=0.342). ② The clinical features of the two groups had statistically significant differences in the higher number of BM blast cells(P=0.006), higher prevalence of death (P=0.031), higher rate of Leukemic transformation (P<0.001), higher level of serum lactate dehydrogenase (LDH) in the peripheral blood (p<0.001), higher level of β2-microgram in the peripheral blood(p=0.003) and higher level of C-reactive Protein (CRP) in the peripheral blood (P=0.004) in the MDS-MF group than in the MDS-MF0 group. The number of WBC, Hb, PLT and Ferritin at the first diagnosed in our hospital were no difference compared the two groups (All P>0.05). The sex, Age and the IPSS-R score(IPSS-R >3.5 v ≤3.5) were no difference in the two groups (ALL P>0.05). ③Compared with MDS-MF0 group, MDS-MF were significantly associated with worse OS(P=0.035) and worse PFS(p<0.001). The median overall survival was 13.20(0.07-90.70) months in MDS-MF group, and was 23.77(0.53-98.97) months in MDS-MF0 group respectively. Subgroup analysis showed that both OS and PFS of either the MDS-MF1-2 group or the MDS-MF 3 group were also significantly worse than those of the MDS-MF0 group（P＝0.013 and <0.001 respectively）. ④Among all the patients ,337 were finished Next-generation-sequencing (NGS) test, sequencing errors and all known or possible single-nucleotide polymorphisms were excluded. The number of mutations (>2) was more frequently in the MDS-MF, the difference had statical significance(P=0.030). The RNA splicing was more frequently in the MDS-MF than the MDS without MF, the difference also had statical difference(P=0.025). The ratio of U2AF1 mutation occurred in MDS-MF group higher than MDS-MF0 group, the difference had statical significance (P=0.027). There was totally 14.2% (48/337) patients with the mutation of U2AF1, of which 19.7%（29/147) in MDS-MF group and 10.0%（19/190) in MDS-MF0 group. Conclusion: MDS-MF has unique laboratory and clinical characteristics. MF is an independent risk factor for shorter overall survival (OS) and worse progression-free survival (PFS) in primary MDS. Evaluation of MF is very significant for prognosis judgment in primary MDS. The U2AF1 mutation may be a biomarker related to the occurrence and poor prognosis of MDS-MF. However, the mechanism of U2AF1 in MDS-MF patient needs to be further explored. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

S3445 Microscopic Enteritis: A Rare Manifestation of T-cell Promyelocytic Leukemia

Introduction: An abnormal infiltration of intraepithelial lymphocytes in the intestinal mucosa is described as microscopic enteritis (ME). ME is a heterogeneous condition that can be found in, but not limited to, celiac disease, autoimmune disorders, food protein intolerance, parasitic infections, and NSAID use. Thus, an obvious cause of ME is difficult to elucidate and requires thorough work up. We report a case of a patient who was found to have ME thought to be secondary to infiltrative T-cell promyelocytic leukemia (T-PLL). Case Description/Methods: A 68-year-old male with a history of type II diabetes and hyperlipidemia presented with intermittent fever, abdominal pain, nausea, and emesis. He was found to have small bowel obstruction with severe enteritis of 3/4 of the small bowel (distal jejunum to the ileocecal valve). He had a small bowel resection with pathology revealing necrotizing lymphocytic enteritis. Bidirectional endoscopy revealed mild colonic, ileal and duodenal edema with biopsies revealing increased intraepithelial lymphocytes. He was empirically treated with intravenous methylprednisolone with resolution of fevers. He was discharged home with a follow up with gastroenterology for ME and with hematology for persistent leukocytosis. He continued to have recurrent fevers with persistent lymphocytic leukocytosis (14,200 WBC/microliter). Infectious (acid fast bacteria, fungi, cytomegalovirus, adenovirus, syphilis) and rheumatologic diagnostics were unrevealing. He underwent bone marrow biopsy and peripheral blood examination with immunostains, flow cytometry, and cytogenetic studies and was found to have clonal T-cell receptor gamma gene rearrangement concerning for T-PLL. He was treated with alemtuzumab; however developed worsening disease and disseminating opportunistic infections (cytomegalovirus and aspergillosis). He passed away shortly after his diagnosis. Discussion: ME is a challenging diagnosis as its etiology can be difficult to elucidate. Prompt, timely evaluation should be prioritized to improve outcomes. T-PLL is a rare leukemia due to abnormal growth of T-lymphocytes and typically presents with leukocytosis, weight loss, and infection; however, gastrointestinal symptoms may be a presenting symptom.

Using deep learning for quantification of cellularity and cell lineages in bone marrow biopsies and comparison to normal age-related variation

Cellularity estimation forms an important aspect of the visual examination of bone marrow biopsies. In clinical practice, cellularity is estimated by eye under a microscope, which is rapid, but subjective and subject to inter- and intraobserver variability. In addition, there is little consensus in the literature on the normal variation of cellularity with age. Digital image analysis may be used for more objective quantification of cellularity. As such, we developed a deep neural network for the segmentation of six major cell and tissue types in digitized bone marrow trephine biopsies. Using this segmentation, we calculated the overall bone marrow cellularity in a series of biopsies from 130 patients across a wide age range. Using intraclass correlation coefficients (ICC), we measured the agreement between the quantification by the neural network and visual estimation by two pathologists and compared it to baseline human performance. We also examined the age-related changes of cellularity and cell lineages in bone marrow and compared our results to those found in the literature. The network was capable of accurate segmentation (average accuracy and dice score of 0.95 and 0.76, respectively). There was good neural network-pathologist agreement on cellularity measurements (ICC=0.78, 95% CI 0.58-0.85). We found a statistically significant downward trend for cellularity, myelopoiesis and megakaryocytes with age in our cohort. The mean cellularity began at approximately 50% in the third decade of life and then decreased ±2% per decade to 40% in the seventh and eighth decade, but the normal range was very wide (30-70%).

Intussusception in a child with Acute Lymphoblastic Leukemia: a remarkable presentation with literature review \u2013 a case report

BackgroundGastrointestinal complications are not uncommon in patients of Acute Leukemia. Intussusception as a complication in leukemia, although described, is exceedingly rare. Also, it is usually seen after chemotherapy and not as a part of the native disease process. This case report aims to highlight such a rare association which warrants clinical and pathological attention.Case presentationA 14 year old male presented with an acute abdomen. Initial routine investigations revealed a deranged blood picture. On further examination of bone marrow aspirate, biopsy and detailed immunohistochemical studies a diagnosis of B-Acute Lymphoblastic Leukemia (B-ALL) was made. Concurrent ultrasound of the abdomen to find a cause for severe abdominal pain revealed an Ileo-colic intussusception. The patient was started on steroids; however he succumbed to his illness after two days, before surgery could be attempted.ConclusionRare presentations of relatively common diseases are a hurdle for timely and effective medical intervention. Although a rare condition in itself in leukemic patients, the occurrence of Intussusception in this particular patient, especially when no chemotherapy was initiated, is a very rare event. This case report was made to add to the relatively scarce literature available on this particular association. As it is a surgically treatable condition and since delay in diagnosis may lead to poorer prognosis, possibility of co-existence of ALL and intussusception should be borne in mind by all treating physicians and hematopathologists for effective patient care.

Ascites in A Patient with Hairy Cell Leukaemia and Carcinoma of Breast: A Diagnostic Challenge

Hairy cell leukaemia (HCL) is a rare indolent B-cell lymphoproliferative disorder. We report a diagnostic challenge in detecting the cause of ascites, which is a rare, unique manifestation of HCL. A 72-year-old lady presented with 1-month-history of pain in left upper abdomen and loss of weight. There was hepatomegaly, splenomegaly, bilateral inguinal lymphadenopathy, anaemia, and lymphocytosis. She was diagnosed as HCL, based on morphology, immunophenotyping of peripheral blood and bone marrow biopsy examination. In 2009, she was diagnosed as carcinoma of breast when she presented with a mass in left breast; and she received treatment. For HCL, she received intermittent chemotherapy (Chlorambucil+Prednisolone). Her HCL was stable until 2018 when she presented with recurrent ascites which needed frequent, regular peritoneal paracentesis. Since she had HCL and carcinoma of breast, determining the aetiology of ascites was challenging. Possible causes of her ascites included metastatic carcinoma of breast, HCL, cirrhosis of liver with portal hypertension and peritoneal tuberculosis. Cytology of peritoneal fluid showed mature-looking lymphocytes but no malignant cells. Interestingly, flow cytometry analysis of peritoneal fluid showed the presence of clonal B cell population with lambda light chain restriction. Therefore, it was concluded that her ascites was a manifestation of HCL. A few months later, she succumbed to septicaemia. Impact of ascites on disease course of HCL included rapid disease progression, poor prognosis and shortened survival. We highlight the important role of immunophenotyping in addition to cytomorphology to guide us in confirming the aetiology of ascites in a patient with haematological and solid organ malignancies.

A Retrospective Study of 67 Inflammatory Waldenström’s Macroglobulinemia

Introduction Waldenström's macroglobulinemia (WM) is an indolent lymphoma with medullary infiltration by a lymphoplasmacytic clone associated with an immunoglobulin M paraprotein. Some patients diagnosed with WM present a concomitant inflammatory syndrome: increased C-reactive protein (CRP) levels, fever, recurrent night sweats, anorexia. These patients were usually referred as inflammatory WM despite no definition has been established. Here, we describe clinical and biological characteristics of inflammatory WM patients, response to treatment, survival and discuss pathogenesis hypotheses. Methods In this descriptive retrospective study, we included WM patients followed at Saint-Louis hospital between 2007 and 2019 with WM diagnosis fulfilling the World Health Organization's criteria, with medullary infiltration proven by bone marrow biopsy or aspiration examination and monoclonal M paraprotein, associated with a biological inflammatory syndrome with or without clinical inflammatory signs. Inflammatory WM diagnosis was retained in the absence of differential diagnoses for the inflammatory syndrome such as cancer, infection, autoimmune or inflammatory diseases, using complete blood workup, PET and body scanner. Results Two-hundred and forty-two patients were included: 67 of inflammatory phenotype (28%), 166 non-inflammatory (68%) and 9 with inflammatory syndrome of unknown origin (4%). Describing inflammatory WM, diagnoses were made between 1985 and 2018, 50% after 2007. At treatment initiation, median age was 69 years (range 45-94), monoclonal IgM median value was 24.9 g/L (4.8-77.3) (Table 1). Median CRP was 40.5mg/L (IQR 23.8-64.8). CRP was correlated with fibrinogen (r =0.53, 95% confidence interval (CI) 0.18-0.76, p=0.006) and inversely correlated with albuminemia (r=-0.65, CI -0.82- -0.39, p &amp;lt; 0.001). Mean medullary infiltration was 50%. Three of 35 patients with avalaible karyotype had 6q deletion. Only 12 patients had medullary molecular analysis: 9 of them harboured MyD88 L265P mutation, 2 p53 mutations and none CXCR4 WHIM mutation. Five cryoglobulin tests were positive, Coombs test positive for 3 patients and anti-MAG antibodies positive for 2. Indications for front-line therapy were cytopenias in 44 patients (88%), inflammatory syndrome for 20 (40%), systemic symptoms in 15 (30%), tumoral syndrome in 10 (20%) and hyperviscosity syndrome in 3 (6%). Sixty-two patients were treated, at front-line 60% received rituximab-based therapy and 39% monotherapy. Overall response rate was 84%. Inflammatory and hematological response were statistically correlated (OR 13.8, CI 2.07-74.6, p = 0.005). Median follow-up was 12.6 years (IQR 7.0-22.8). Median progression-free survival (PFS) after front-line therapy was 32 months and estimated PFS was 68% (CI 55-78) at 10 months, 59% (CI 46-70) at 20 months and 30% (CI 19-42) at 5 years. Overall survival (OS) for inflammatory and non-inflammatory WM patients were not significantly different (median OS 14.0 and 16.4 years, respectively, c2 0,14, p=0,71, Figure 1). At 5 years, estimated OS was 85% (CI 71-93) inflammatory patients and 84% (CI 75-90) for non-inflammatory, at 10 years 66% (CI 48-79) and 70% (CI 58-79). Three patients were secondarily diagnosed with diffuse large B-cell lymphoma (DLBCL). Conclusions We reported 67 WM patients with inflammatory phenotypes, representing a third of WM patients in our cohort. Compared with literature, their clinical and biological characteristics do not differ from non-inflammatory WM patients, as well as response to treatment and PFS. There is no excess of transformation into DLBCL. Our inflammatory and non-inflammatory cohorts show no difference in terms of OS. Inflammatory response is strongly correlated with hematological response. Non-decrease of CRP level during treatment and increase of CRP during follow-up in inflammatory WM patients should be a warning sign for refractory disease or relapse. Further studies are needed to better delineate this sub-group of patients and explore its pathogenesis. Studying medullary cytokinic environment, WM cells, tumoral microenvironment and M paraprotein contributions could elucidate the underlying pathophysiological mechanisms involved. Disclosures Thieblemont: Roche, Hospita: Research Funding; Roche, Amgen, Kyte Gilead, Celgene, Abbvie, Novartis, Cellectis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support; Cellectis: Speakers Bureau.

Analysis of clinical features, gene mutation, and prognostic characteristics in de novo acute myeloid leukemia patients with myelofibrosis

目的探讨初诊急性髓系白血病（AML）合并骨髓纤维化（MF）患者的基因突变、临床及预后特征。方法2016年1月1日至2020年2月1日河南省人民医院收治的初诊并同时行骨髓活组织检查的103例AML患者纳入研究，根据WHO（2016）骨髓纤维化分级标准将患者分为AML伴MF组（MF-1～3）与AML不伴MF组（MF-0），并对两组患者的临床特征、基因突变、疗效和预后进行回顾性比较。结果①103例患者中AML伴MF组46例（44.7％），其中MF-1 39例（84.8％），MF-2/3 7例（15.2％）；AML不伴MF组57例（55.3％）。和AML不伴MF组相比，AML伴MF组中位WBC显著增高［11.205（0.69～191.82）×109/L对4.64（0.18～95.10）×109/L，P＝0.024］；外周血出现有核红细胞的比例明显增高（43.5％对24.6％，χ2＝4.119，P＝0.042）；FAB分型：4例AML-M0患者均在AML伴MF组，而AML不伴MF组AML-M2所占比例更高（P＝0.014）。②AML伴MF组患者FLT3-ITD及NPM1基因突变率更高（15.2％对1.8％，P＝0.021；26.1％对10.5％，P＝0.039），而CEBPA基因突变率明显低于AML不伴MF组（2.2％对17.5％，P＝0.029）。③AML伴MF组完全缓解（CR）率显著低于AML不伴MF组（69.7％对93.2％，χ2＝7.412，P＝0.006）。多因素分析显示MF，尤其是纤维化程度是影响初诊AML患者CR的独立危险因素。④AML伴MF组3年总生存（OS）率明显低于AML不伴MF组（20.5％对72.2％，χ2＝4.032，P＝0.045）；亚组分析显示MF-1和MF-2/3两组患者的OS率、无进展生存（PFS）率显著低于AML不伴MF组（P＝0.001）。Cox多因素分析显示MF，尤其是MF-2/3是影响初诊AML患者OS和PFS的独立危险因素（P值分别为0.021和0.044）。结论AML合并MF患者具有较为独特的实验室及临床特征；MF是影响AML患者CR、OS和PFS的独立预后不良指标，MF的评估对初诊AML的疗效和预后判断具有重要意义。

Severe Anemia in a Patient With Mild T Cell Hypofunction Infected With Parvovirus B19

Severe Anemia in a Patient With Mild T Cell Hypofunction Infected With Parvovirus B19

Diagnosis and Prognosis Value of Bone Marrow Aspirate Detection for the Bone Marrow Involvement in Non-Hodgkin's Lymphoma Patients

To compare and evaluate the sensitivity, specificity, and prognostic value of various assays for bone marrow involvement in patients with non-Hodgkin's lymphoma (NHL). A total of 351 patients with NHL who underwent concurrent bone marrow biopsy in Third Hospital of Peking University from January 2013 to November 2017 were selected. Bone marrow biopsy (BMB), flow cytometry (FCM), gene rearrangement detection, and bone marrow morphology examination were performed for evaluation of bone marrow involvement. Bone marrow biopsy was used as the gold standard, the sensitivity and specificity of FCM, gene rearrangement and bone marrow morphology of bone marrow aspirate were analyzed, and their ROC curves were drawn. In the survival analysis of 77 patients with NHL, the overall survival (OS) time, progression-free survival (PFS) time, and complete remission rate (CRR) were counted. The survival of patients in the FCM positive group, the gene rearrangement positive group, the positive control group (BMB positive group) and the negative control group were compared. The detection rate of flow cytometry and gene rearrangement of bone marrow aspirate both were higher than that of bone marrow biopsy and bone marrow morphological examination, showing better diagnostic efficacy. The sensitivity of the combined method of flow cytometry and gene rearrangement was 82.5%, while the specificity was 90% and the AUC was 0.863. The gene rearrangement detection of bone marrow aspirate possessed the role suggesting the poor prognosis for NHL patients. The 3-year survival rate of patients in the gene rearrangement-positive group (RG group) was lower than that of patients in the no-bone involvement group (All negative group) (P＜0.05). Although the survival curve of patient in RG group was not significantly different from that of patients in All negative group (P＜0.1), it still showed a poor prognosis for NHL patients. And the significance of predicting death risk was reflected in Cox regression model (P＜0.05). There was no statistical difference in the prognosis of patients in the FCM-positive group (FCM group). In the bone marrow aspirate tests, flow cytometry and gene rearrangement detection have good diagnostic efficiency, and gene rearrangement can suggest the prognosis of patients. The combined detection efficacy of two methods is better.

Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature.

Currently, one of the most useful prognostic indicators in Ewing sarcomas (ES) is the presence of metastatic disease at diagnosis. According to various clinical guidelines, the assessment of bone marrow (BM) metastases, using light microscopy examination of bone marrow aspirates and biopsies (BMAB) is mandatory. However, the prognostic value of BM positivity is discussed controversially. Therefore, the primary aim of this study was to retrospectively review BM samples from patients with ES. This retrospective single centre study included 31 patients that were newly diagnosed with ES between 2000 and 2014. Twenty-seven patients had skeletal ES and in 4 patients the tumour was localized in the soft tissue only. Metastases at diagnosis were present in 5 out of 31 patients. BM samples were morphologically and immunohistochemically searched and screened for the presence or absence of BM metastases. Furthermore, in 15 of the 31 patients BM samples were still available and were reanalysed, using nested-polymerase chain reaction. All BM samples of our 31 ES patients, including the 5 metastatic patients, were, morphologically and immunohistochemically tested negative for tumour cell appearance. The nested-PCR results were also negative in all of our 15 retested patients, including two patients with metastatic disease. Based on our results and on the contradictory results reported in the literature we recommend a re-evaluation of the necessity and the prognostic value of BMAB in the initial staging process of newly diagnosed ES patients.