Sgpath Case01 Dir

8/13/2019 Sgpath Case01 Dir

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Case 1

Stephan Dirnhofer and Andr Tichelli

40-years old man, admitted for thoracic pain

Diagnosis of classical Hodgkin lymphoma, nodular

sclerosis, in a cervical lymph node

Bone marrow biopsy for lymphoma staging

History / Clinical findings


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Blood counts

x109/L150-400198198Platelets

x109/L3.5-10.512.212.2WBC

fL80-958888MCV

g/L140-160142142Hemoglobin

UnitsReferenceResultParameter

Peripheral blood


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Cytology bone marrow

Indications

for bone marrow examination Investigation of peripheral blood abnormality

- cytopenias, cytosis, abnormal cells

Selected types of infectious diseases- Parvo-virus B19, Leishmaniosis, others

Fever of unknown origin, unexplained splenomegalie, storage disease

Staging and management of tumor patients- all lymphomas, childhood neoplasms, others

Plasma cell dyscrasias incl. amyloidosis

Systemic mast cell disease

Monitoring of patients with leukemia

- response to therapy, stem cell transplantation Miscellaneous

- hps, effectsof therapy, immunodeficiency, bone disorders


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Strength of bone marrow biopsy

Assessment of:! cellularity, topographical distribution of hemopoesis

and inter-relationships of cells

! bone structure, blood vessels, stroma, lymphoid

aggregates, iron content and degree of fibrosis or

necrosis

! focal processes (carcinoma, lymphoma, granuloma

and other infiltrative processes)! bone marrow infiltration pattern for lymphomas,

mast cell disease and others

Additional investigations (IHC, FISH, PCR)

Strength of bone marrow cytology

Individual cell morphology, dysplastic changes of the

erythropoiesis and myelopoiesis, Auer rods in the blasts

Particular forms of AML recognizable: Promyelocyticleukemia, AML with t(8;21), AML M4eo with t(16) or

inv(16)

Ringed sideroblasts for sideroachresia

Material for flow-cytometry, cytogenetics and molecular

genetics

Rapidly available for analysis (1-2 hours)


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Algorhytm for BM-biopsies

See the biopsy with a smear (and a hematologist)

Systematic assessement of:

Cellularity, Bone structure

Topography and Maturation of all three cell lines

Dysplasia, Blasts

Lymphocytes, Plasma cells, other infiltrates

Iron, Fibers

Others: Granulomas, Mast cells, (Pseudo-)Gaucher cells...

Final interpretation is an integrative diagnosis: a morphological

diagnosis in combination with hemogramm, laboratory data,

genetics and clinical findings


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H&E

H&E


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Gm

Final diagnosis

Normocellular, completely maturing

bone marrow

No evidence of Hodgkin Lymphoma


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A normal bone marrow contains

1. No blast at all

2. Between 1-4% blasts

3. !5% blasts

4. No blasts but >5% CD35+ cells

(exclusively endothelial cells)

5. Any number but always CD34-

negative

A normal bone marrow contains

1. No blast at all

2. Between 1-4% blasts3. !5% blasts

4. No blasts but >5% CD35+ cells

(exclusiveley endothelial cells)

5. Any number but always CD34-

negative


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Among the following, what is

the strength of marrow biopsy

1. Assess dysplasia of myelopoiesis

2. Assess ringed sideroblasts

3. Recognize Hodgkin infiltration

4. Point 3 and 5

5. Assess topographical distribution ofthe cells

Among the following, what is

the strength of marrow biopsy

1. Assess dysplasia of myelopoiesis

2. Assess ringed sideroblasts

3. Recognize Hodgkin infiltration

4. Point 3 and 5

5. Assess topographical distribution of

the cells


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Among the following, what is the

strength of marrow cytology

1. Assess diagnosis of acute

promyelocytic leukemia

2. Assess fibrosis in CIMF

3. Recognize granulomas

4. Point 3 and 55. Recognize infiltration of carcinoma

Among the following, what is the

strength of marrow cytology

1. Assess diagnosis of acute

promyelocytic leukemia2. Assess fibrosis in CIMF

3. Recognize granulomas

4. Point 3 and 5

5. Recognize infiltration of carcinoma


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Take home messages

Use standardized diagnostic approach Consider clinical findings including blood

counts and differentials

Consider peripheral blood smear and

aspirate

Consider flow cytometry, genetics and

stem cell cultures

Integrate all data for final diagnosis

Well, ...it looks like

you broke the

Jamishidi-needle

...

Clinico-pathological cooperation is essential

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Sgpath Case01 Dir