Diagnostic Hematology (LM358)

Dr. Mohammad A. Audeh

First semester
Dec 17th 2012
 Myelodysplastic syndromes

A group of disorders that are characterized by the clonal expansion

of hematopoietic stem cells in which maturation is abnormal
(dysplastic) and production is ineffective, resulting in many cells
being destroyed before they reach the systemic circulation.

ANEMIA, THROMBOCYTOPENIA, NEUTROPENIA

 Myelodysplastic syndromes
• A diseases of elderly (median age is ~ 70 years)
• BM is usually hypercellular, however it possibly be hypo-cellular or
partially fibrotic (etiology: exposure to ionizing radiation or cytotoxic
chemotherapy, usually with alkylating agents)
• Blasts may be increased but they do not exceed 20 % of ANC.
• Dysplasia may involve one or more hematopoietic lines of BM; if
dysplasia affects at least 10% of that line's cells in the bone marrow,
Note: Evidence for dysplasia may also be present on the peripheral
blood smear.
Myelodysplastic syndromes
 Dysplasia evidences: Erythroid
• Peripheral blood:
- Macrocytosis and anisocytosis,.
- Basophilic stippling, and Pappenheimer bodies.
- Poikilocytosis includes:
Target cells, acanthocytes,
elliptocytes, stomatocytes,
Schistocytes, and darcocytes.
 Dysplasia evidences: Erythroid
• Bone marrow:
- Nuclear abnormalities: budding, inter-nuclear bridging, abnormal
fine or dense chromatin multinucleated cells, karyorrhexis
(fragmentation), and megaloblastic changes (nucleus enlargment w/
less maturation).
- Cytoplasmic abnormalities: vacuolization and ringed sideroblasts,
which are erythroblasts that, on iron stain, contain ≥10 ferritin
granules encircling at least one-third of the nucleus.
 Morphological abnormalities: Erythroid
A B C D E

A. Dysplastic vacuolated pronormoblast.

B. Asymmetric bi-nucleation in mature erythroid.
C. Trinucleate mature erythroid.
D. Ringed siderocyte (iron stain).
E. Mature erythroid with “nuclear budding.”
 Dysplasia evidences: Granulocytic
• Peripheral blood:
- Neutropenia along with the presence of immature cells.
- hypersegmented neutrophils and Döhle bodies.
- Decreased or absent cytoplasmic granules.
- Hypolobulated nuclei (pseudo-Pelger-Hüet cells) which may have
dense chromatin clumping. (the presence of these on a blood smear
strongly suggests an underlying myelodysplastic syndrome).
- Eosinophils and basophils may have diminished granules and
decreased nuclear lobulation.
 Dysplasia evidences: Granulocytic
• Bone marrow:

- Similar abnormalities to these in PB.

- Small-sized granulocyte precursors, which may be present

centrally at abnormal location: a phenomenon called atypical

localization of immature precursors (ALIP) when at least three of such

foci occur in a bone marrow section.

 Morphological abnormalities: Granulocytic
A B C D E

A. Promyelocyte with dysplastic nucleus.

B. Hyposegmented neutrophil.
C. Hypersegmented neutrophil.
D. Hypogranular neutrophil.
E. Abnormal eosinobasophilic precursor.
 Dysplasia evidences: Megakaryocytic

• Peripheral blood:
- Thrombocytopenia,
- Giant platelets.
- Platelets with decreased or absent granules.
• Bone marrow:
- Dysplastic megakaryocytes are small (micromegakaryocytes), and
possess abnormal nuclei that are multiple and widely separated or
have decreased or absent lobulation.
 Morphological abnormalities: Megakaryocytic
A B C D E

A. Bizarre megakaryoblasts.

B - C. Unilobular micromegakaryocytes.

D - E. Megakaryocytes with separate nuclear lobulations.

 Refractory anemia (RA)

• Accounts for about 5% to 10% of cases of MDS,

• The median survival is about 5 years, and acute leukemia eventuates
in approximately 5% of patients.
• Dysplasia occurs in the erythroid precursors alone, ranges from mild
to pronounced.
• On peripheral blood smear the red cells are normocytic or
macrocytic.
• Nonspecific cytogenetic abnormalities occur in about 25% of cases.
 Refractory Anemia with Ringed Sideroblasts
(RARS)

• Accounts for about 10% of cases of MDS.

• The median survival of about 6 years.

• Dysplasia occurs only in the erythroid line where at least 15% of the

red cell precursors are ringed sideroblasts.

• Cytogenetic abnormalities occur in <10% of cases.

Refractory Cytopenia with Multilineage Dysplasia
(RCMD)

• Accounts for about 25% of MDS, and the diagnosis requires

cytopenias and dysplastic changes in at least two lines. R
• RCMC and ringed sideroblasts (RCMD-RS) is a subtype where ringed
sideroblasts constitute >15% of the erythroid precursors,
• The median survival for both is about 3 years, and the risk of
leukemia is approximately 10%.
• Cytogenetic abnormalities occur in up to 50% of cases.
 Refractory Anemia with Excess Blasts (RAEB)
• Is characterized by a significant increase in the percentage of blasts,
but not sufficiently to meet the criteria for leukemia( i.e. <20%)
• Account for approximately 40% of cases of MDS.
• Approximately 33% to 50% of cases have cytogenetic abnormalities.
• RAEB subtype 1:
- 5 - 9% blasts in the bone marrow and <5% in the blood;.
- 25% of cases develop acute leukemia, with a median survival of 18
months
• RAEB subtype 2:
- has 10% to 19% blasts in the bone marrow and/or 5% to 19%
blasts in the blood.
- Auer rods may present
- 33% of cases develop acute leukemia, with a median survival of 10
months
 Myelodysplastic Syndrome, Unclassifiable
(MDS-U)
• MDS with a dysplasia that is restricted to either the neutrophil or
megakaryocytic lines.
• The criteria for the other MDSs are not met here.
• The median survival for patients, and the risk of developing leukemia
are uncertain.
Diagnostic Hematology (LM358)

Dr. Mohammad A. Audeh

First semester
Dec 17th , 2012
 Myeloproliferative disorders
• Chronic myeloproliferative diseases (CMPDs) are clonal disorders of
the hematopoietic stem cells
• CMPDs differ from MDS in that:
- BM dysplasia is absent
- Maturation is normal
- The production of cells is effective, causing elevated blood levels of
one or more cell lines
• MPDs include:
CML, polycythemia vera (PV), essential thrmobocythemia (ET) and
Idiopathic myelofibrosis (IM)
• A point mutation in the gene regulating Janus kinase-2 (JAK2V617F) is
common in PV, ET and IM
 Polycythemia vera (PV)
• Characterized by accelerated erythropoiesis that is not responsive to
erythropoietin and is not related to hypoxia.
• Molecular mechanisms are unknown, however, possible
mechanisms may include that erythroid precursors
- Have no dependence on EPO
- Be markedly hypersensitive to very small amounts of EPO
- Have reduced sensitivity to an inhibitory factor
• usually accompanied by increased platelets and granulocytes as
well.
 Polycythemia vera (PV)
• Clinical features:
•Typically arise from erythrocytosis, include dizziness, headache, visual
disturbances, and painful feet, sometimes associated with ischemia
and ulcerations.
• Erythrocytosis,

hyperviscosity

Increased tendency for venous and arterial thromboses

(myocardial infarctions, strokes, and venous thromboses of the Legs)
 Polycythemia vera (PV)
• Laboratory findings:
Peripheral blood
- Increased red cell mass (>36mL/kg in men and >32 mL/kg in women)
- Hemoglobin levels of > 18.5 g/dL (Hct about 55.5) in men and >16.5
g/dL (Hct about 49.5) in women
- Leukocytosis in 70% of cases
- Thrombocytosis 80% of cases (400,000 - 1 milion/μL) with abnormal
platelet function
- Decreased erythropoietin
 Polycythemia vera (PV)
• Laboratory findings:
Peripheral blood
- Normal arterial oxygen saturation:
oxygen saturation ≥92% when the patient breathes room air
- Low serum erythropoietin level
Polycythemia vera (PV)
Polycythemia vera (PV)
 Polycythemia vera (PV)
• Laboratory findings:
Bone marrow
- Trilineage hyperplasisa: hyperplasia of the erythroid line is often
accompanied by increased megakaryocytes and granulocyte with
normal maturation
- Megakaryocytes may be large and hyperlobulated.
- Evidence of iron depletion as a result of excessive erythropoiesis
 Polycythemia vera (PV)
• PV may evolve into acute leukemia, myelodysplasia, or into a
“spent” or post-polycythemic phase
• The phase is characterized by anemia and other cytopenias caused
by ineffective erythropoiesis, marrow fibrosis, hypersplenism, and
extramedullary production of cells with shortened life spans.
• The blood smear shows leukoerythroblastosis (the presence of
nucleated red cells and cells in the granulocyte series that are more
immature than bands)
Polycythemia vera (PV)
 Essential thrombocythemia (ET)

A clonal stem cell disorder that is characterized by

striking thrombocytosis in PB and mature megakaryocytic
hyperplasia in BM
 ET: Clinical features

• Both thrombotic and bleeding episodes are possible .

• Thromboses usually involve the arteries, but venous occlusion also
can occur.
• The majority (approximately 1/3) of cases are asymptomatic
• if symptoms occur, they usually are related thrombosis e.g. dizziness,
headaches, visual disturbances and transient ischemic attacks.
• Erythromelalgia is a common finding, that is manifested by erythema,
burning pain, and warmth of the hands and feet that is exacerbated by
heat, or exercise and is relieved by elevation, cooling, and aspirin.
 ET: Clinical features

• Hemorrhage (increased bleeding tendecy) is less frequent.

• Most commonly involve from the upper respiratory and
gastrointestinal tracts.
• Hemorrhage etiology: is a result of an acquired von Willebrand
disease that is associated with marked thrombocytosis, in which the
large von Willebrand multimers adhere to platelets and are removed
from the circulation.
• If happen, splenomegaly and hepatomgaly (less frequently), usually
moderate and nonprogressive.
 ET: Diagnosis
• Many diseases, such as inflammatory reactions and other MPD, can
produce reactive thrombocytosis and show some common clinical
features, Therefore , the diagnosis of ET depends on the presence of
certain features and the exclusion of others.
• Sustained thrombocytosis (platelet count >600,000/μL )
• The most prominent finding on blood smear is the large number of
platelets, which vary considerably in size, ranging from small
to giant (diameter larger than an erythrocyte).
 ET: Diagnosis

• White cells are typically normal in number and appearance, as are

the erythrocytes, unless hemorrhage has led to iron-deficiency
anemia.
ET: Diagnosis
 ET: Diagnosis
• Characteristic bone marrow biopsy findings of increased large,
mature megakaryocytes which commonly form loose aggregates and
possess abundant cytoplasm with normal maturation and
along with deeply lobulated
nuclei.
 ET: Diagnosis
• Many diseases, such as inflammatory reactions and other MPD, can
produce reactive thrombocytosis and show some common clinical
features
>>> Therefore , the diagnosis of ET depends on the presence of
certain features and the exclusion of others.
• Sustained thrombocytosis (platelet count >600,000/μL.
• Characteristic bone marrow biopsy findings of increased large,
mature megakaryocytes.
 ET: Diagnosis
• No evidence of malignancy, inflammatory state (including infections),
or prior splenectomy that could explain the thrombocytosis;
• The absence of Philadelphia chromosome and BCR/ABL fusion gene

>>>> the exclusion of CML

• The absent or mild reticulin fibrosis and no collagen fibrosis in the
bone marrow >>> the exclusion idiopathic myelofibrosis .
• The absence of a myelodysplastic evidences >>>> the exclusion of
MDS .
• The presence of a normal Hct and MCV as well as stainable marrow
 Idiopathic myelofibrosis (IM)

• Also called myelofibrosis (or myeloid metaplasia) with myeloid

metaplasia
• IM is characterized by the clonal proliferation of megakaryocytes
and granulocytic precursors in the bone marrow, accompanied by
reactive, marrow fibrosis thought to be secondary to local release of
fibrogenic growth factors.
• Replacement of the marrow by fibrosis leads to extramedullary
hematopoiesis, which is most common in the spleen and liver, but can
also affect many other sites, such as lymph nodes, lung, and pleura.
 IM: Classification
• Primary
 Abnormal multi-lineage stem cell
 Abnormal myeloid cells
 Release of fibroblastic growth factors
 Stimulation of fibroblasts
• Secondary
 Reaction of megakaryocytes to abnormal conditions (infections,
metastatic carcinoma, toxic chemicals, lymphoma or leukemia)
 release of fibroblastic growth factors
 stimulation of fibroblasts
Idiopathic myelofibrosis (IM)
 Idiopathic myelofibrosis (IM)

• The disease is progressive with a pre-fibrotic phase, which is

commonly asymptomatic and is characterized by a hypercellularity of

BM and minimal or no fibrosis.

• During the fibrotic phase, marked increase in reticulin fibers and

collagen deposition occurs

• In the last sclerotic phase, development of trabecular bone and focal

fatty involution of bone marrow occurs (severe form)

IM: Diagnosis
 IM: Clinical features
• During pre-fibrotic phase, most patients are asymptomatic
• Symptoms typically occur from anemia, hypermetabolism (resulting
from high cell turnover), splenomegaly, or thrombocytopenia .
• Anemia can lead to complaints of fatigue, dyspnea, weakness, and
palpitations.
• Hypermetabolism may cause weight loss, fever, sweats, or problems
associated with hyperuricemia including gout or renal stones
• Splenomegaly can produce left upper quadrant discomfort, a
sensation of early satiety from compression of the stomach, or
diarrhea from pressure on the bowels.
 IM: Clinical features

• Thrombocytopenia may cause cutaneous hemorrhage

• Extramedullary hematopoiesis in the skin produces erythematous or

purplish nodules, papules, and plaques.

• Extramedullary hematopoiesis at other locations, may cause

symptoms ranging from organ enlargement, bleeding, fluid formation,

or compression of adjacent normal structures.

 IM: Diagnosis
• Peripheral blood
- Decreased red cell with dacryocytes
- WBC < 30 x 109/L with mild left shift
- Eos. and Basos may be increased.
- Leukoerythroblastic picture: immature neutrophils and nucleated
red cells in peripheral blood) is a reflection of a space occupying
lesion in the marrow.
- Platelets are increased, normal or decreased with
myeloproliferative platelets (bizzare and non-functional plt.)
- Circulating dwarf megakaryocytes.
IM: Diagnosis
IM: Diagnosis

Dacrocytosis
 IM: Diagnosis
• Peripheral blood

- Platelets are increased, normal or decreased with

myeloproliferative platelets (bizzare and non-functional plt.)

- Circulating dwarf megakaryocytes:

megakaryoblasts do not undergo endomitosis or they stop

endomitosis at a very early ploidy level. They then go on to form

cytoplasmic granules.
IM: Diagnosis

Myeloproliferative Platelet
 IM: Diagnosis

Dwarf megakaryocyte
 IM: Diagnosis
• Peripheral blood

- Sinusoidal hyperplasia and hyper-vascularity.

- Marrow fibrosis may be minimal to affecting over 1/3 of the

marrow.

- Pronounced proliferation of abnormal megakaryocytes in clusters

(often with hyperchromatic nuclei)

IM: Diagnosis