Laboratory Slides Book slides Description

 The bone marrow in PV is hypercellular, with hyperplasia of all elements:

Polycythemia Vera erythroid, granulocytic and megakaryocytic

 Although panmyelosis is characteristic, the morphologic findings and

clinical course vary depending on the stage of disease.

 The three stages include : Prepolycythemic, overt polycythemic amd

postpolycythemic myelofibrosis

 In the pre- and polycythemic stages, erythroid precursors predominate,

and the myeloid-to-erythroid ratio is less than 2:1.

 Erythroid maturation is normal. The granulocyte series also shows normal

maturation. Megakaryocytes are typically increased in number, are of
variable size and tend to cluster.

 In 90% of cases, marrow-stainable iron is decreased or absent.

 A mild to moderate increase in reticulin is common in the early stages. In

the later stage of postpolycythemic myelofibrosis, or the “spent phase,”
erythropoiesis decreases and the marrow becomes replaced by reticulin
and collagen fibrosis

 Late in the course, PCV often progresses to a spent phase characterized by

extensive marrow fibrosis that displaces hematopoietic cells. This is
An erythroid island showing dyserythropoiesis (B) and accompanied by increased extramedullary hematopoiesis in the spleen
CD117 positivity (C) but no expression of CD34 and liver, often leading to prominent organomegaly
(bone marrow)

 The marrow is hypercellular, but some residual fat is usually present.

 The increase in red cell progenitors is subtle and usually accompanied by

an increase in granulocytic precursors and megakaryocytes as well.

 At diagnosis, a moderate to marked increase in reticulin fibers is seen in

about 10% of marrows.

Bone marrow biopsy specimen in stable phase

polycythemia vera showing panmyelosis (hematoxylin
and eosin stain
 Polycythemia Vera  The peripheral blood often contains increased numbers of basophils and
abnormally large platelet

 The peripheral blood smear in the polycythemic phase reveals crowding of

RBCs, which are usually normochromic normocytic. Hypochromia and
microcytosis are seen if there is iron deficiency.

 Iron-deficiency anemia is common in PV, largely because storage iron is

diverted to the increased red cell mass or caused by phlebotomy or
gastrointestinal bleeding.

 In the later stages of PV, anemia develops and the peripheral blood smear
shows a leukoerythroblastic picture, poikilocytosis with teardrop-shaped
Peripheral blood film in stable phase polycythemia vera
RBCs.
with essentially normocytic, normochromic
erythrocytes
Acute Myelogenous Leukemia  Myeloblasts have delicate nuclear chromatin , 2-4 nuclei, and more
voluminous cytoplasm than lymphoblasts. Cytoplasm often contains fine,
peroxidase-positive azurophilic granules.

 Auer rods (yellow arrow), distinctive needle-like azurophilic granules, are

present in many cases; they are particularly numersous in AML with
t(15;17) (acute promyelocytic leukemia)

>25% myeloblasts

 Blood reveals leukocytosis, often exceeding 100,000 cells/mm3 which

Chronic Myelogenous Leukemia consists predominantly of neutrophils, band forms, metamyelocytes,
myelocytes, eosinophils, and basophils.
 Blasts usually make up less than 10% of the circulating cells. Platelets are
also usually increased, sometimes markedly.
 Pseudo pelger-huet Myelodysplastic Syndrome
cell This encompasses aspectrum of clonal-(neoplastic)-myeloid-disorder
marked by:
Spherocytes
− Ineffective- hematopoiesis(exaggerated marrow cell apoptosis)
? − Cytopenias-
− Qualitative- disorders of blood cells and their precursors–may have
defective cells
− Clonal-chromosomal-abnormalities
− Predilection to undergo clonal evolution to florid AML

 Pseudo-Pelger-Hüet cells, neutrophils with only two nuclear lobes

instead of the normal three to four, are observed at the top and
bottom of this field.
 Poikiloanisocytosis

Platelets

Eosinophils demonstrating abnormal lobation

Blast and monolobed neutrophil and hypogranulation
 - CLL is the most common leukemia in adults in the Western world
- The most common genetic anomalies are deletions of 13q14.3, 11q, and
Chronic Lymphocytic Leukemia
17p, and trisomy 12q
- Diagnostic requirement for CLL: absolute lymphocyte count >5000/mm 3
- Median age at diagnosis = 60 years

MORPHOLOGY
- Lymph nodes are diffusely effaced by an infiltrate of predominantly small
lymphocytes 6-12 um, with slightly irregular nuclei, condensed chromatin,
and scant cytoplasm
- Proliferation centers are pathognomonic

IMMUNOPHENOTYPE
- CD19, 20, 23, 5* (T-cell marker*)
Lymphoblastic leukemia/lymphoma
Low level expression of surface Ig (usually IgM, or IgM and IgD)proliferation
- Lymphoblasts have condensed nuclear
chromatin,
- Small nucleoli, and
- Scant agranular cytoplasm

This peripheral blood smear is flooded with
small lymphocytes with condensed chromatin
and scant cytoplasm.
A characteristic finding is the presence of
disrupted tumor cells – smudge cells (arrow).
A nucleated erythroid cell is present in the
lower left corner (box). Circulating nucleated red
cells could stem from premature release of
progenitors in the face of severe anemia, marrow
infiltration by tumor (leuko-erythroblastosis), or
both.
-Neoplastic lymphocytes are small but slightly larger than normal small
lymphocytes and show scant cytoplasm and round to slightly irregular nuclei
containing clumped chromatin (three arrows). Nucleoli are small to indistinct.
-A characteristic morphologic feature is the presence of “smudge” or “basket”
cells (two arrowheads) which are essentially neoplastic cells that got
“smudged” during slide preparation because of the fragile nature of these cells.
Compare the cell size of CLL cells with a single large granular lymphocyte
(curved arrow).

CLL cell is only slightly larger than a red blood cell and shows clumped
chromatin, sometimes likened to a “soccer ball.”
 Myelofibrosis

Primary Myelofibrosis (Peripheral Blood Smear). The hallmark of primary

myelofibrosis is the development of obliterative marrow fibrosis. The
replacement of the marrow by fibrosis suppresses bone marrow
hematopoiesis, leading to cytopenias and extensive neoplastic extramedullary
hematopoiesis. Extramedullary hematopoiesis causes red cell precursors to be
demonstrated on the peripheral smear.

Primary Myelofibrosis (Peripheral Blood Smear).

Two nucleated eryhtroid precursors and several
teardrop-shaped red cells (dacrocytes) are
evident. Immature myeloid cells were present in
other fields. An identical picture can be seen in
other diseases producing marrow distortion and
metamyelocyte
fibrosis.

Primary Myelofibrosis (Peripheral Blood Smear). Extramedullary hematopoiesis

results to the presence of red cell precursors in the blood; red blood cells of
varying sizes and morphology are typically demonstrated (anisopoikilocytosis);
especially noted are the teardrop-shaped red cells ( dacrocytes).

Chronic Myelofibrosis (Peripheral Blood Smear).

This is the blood smear of a 67-year old female
with pancytopenia, a markedly enlarged spleen,
and extramedullary hematopoiesis. She is found
to have a JAK-2 mutation. The diagnosis in this
case is chronic myelofibrosis. The teardrop-
shaped red cells and normoblast in this blood
smear are indicative of a fibrotic marrow.
 Neutrophil Maturation Series
The earliest recognizable myeloid cell is the
myeloblast (10-20m dia) with a large round to oval
nucleus. There is fine diffuse immature chromatin
(without clumping) and a prominant nucleolus.
The cytoplasm is basophilic without granules.
Although one may see a small golgi area adjacent
to the nucleus, granules are not usually visible by
light microscopy. One should not see blast cells in
the peripheral blood.
The promyelocyte (10-20m) is slightly larger than a
blast. Its nucleus, although similar to a myeloblast
shows slight chromatin condensation and less
prominent nucleoli. The cytoplasm contains
striking azurophilic granules or primary granules.
These granules contain myeloperoxidase, acid
phosphatase, and esterase enzymes. Normally no
promyelocytes are seen in the peripheral blood.
At the point in development when secondary
granules can be recognized, the cell becomes a
myelocyte
Myelocytes (10-18m) are slightly smaller than
promyelocytes and have eccentric round-oval
nuclei, often flattened along one side. The
chromatin is fine, but shows evidence of
condensation. Nucleoli may be seen in early stages
but not in the late myelocyte. Primary azurophilic
granules are still present, but secondary granules
predominate. Secondary granules (neut, eos, or
baso) first appear adjacent to the nucleus. In
neutrophils this is the "dawn" of neutrophilia.
Myelocytes are not normally found in the
peripheral blood.
Metamyelocytes (10-18m) are slightly smaller than
myelocytes. They have kidney shaped indented
nuclei and relatively dense chromatin, especially
along the nuclear membrane. The cytoplasm is
faintly pink with almost no blue background.
Numerous secondary granules (neutro, eos, or
baso) clearly outnumber primary granules. Zero to
one percent of the peripheral blood white cells
may be metamyelocytes (juveniles).
Bands, slightly smaller than juveniles, are marked
by a U-shaped or deeply indented nucleus.
Opposite sides or lobes are of roughly equal size or
diameter. There is no nuclear constriction > than
1/2 the lobe diameter. The chromatin is heavily
clumped and secondary or specific granules either
neutrophilic or basophilic predominate.
Normal band counts vary but are usually in the
range of 0-6%.
Segmented (segs) or polymorphonuclear (PMN)
leukocytes (average 14 m dia) are distinguished by
definite lobation with thin thread-like filaments of
chromatin joining the 2-5 lobes. The chromatin of
the segmented neutrophil is coarsely clumped and
the cytoplasm is pink due to large numbers of
secondary granules.
In practice when examining peripheral blood,
neutrophils are the only leukocytes to be divided
into myelocyte, juvenile, band, and PMN stages.
Eosinophils and basophils of all stages are lumped
together in most instances.
Normally approximately 45-75% of the peripheral
blood white cells are segmented neutrophils.
Erythrocyte Maturation Series