Bone Marrow Diagnosis (eBook)

An Illustrated Guide

Kevin Gatter, David Brown (Autoren)

eBook Download: EPUB

2014 | 3. Auflage
232 Seiten
Wiley-Blackwell (Verlag)
978-1-118-95204-7 (ISBN)

Infos

Bone Marrow Diagnosis is an essential resource for all those who need to report bone marrow trephine biopsies. The text will be succinct and concentrates on the core information necessary to make an accurate diagnosis. Each diagnostic entity will be accompanied by high quality images which show typical and more unusual examples of histological features.
Each section will be comprehensively revised by an international team of authors. Over 900 high quality colour images will accompany each diagnostic entity. There will be coverage of cytology in sections relating to myeloid dysplasias and acute leukaemias, as well as incorporating new WHO classification of lymphomas and leukaemias.

The digitally photographed and remastered images in this new edition will be of the highest quality, put onto disk directly from the microscope in digital format and reproduced in print form. The text will give comparisons of the common methods of sample collection, fixation and staining, and a clear description of how to examine a trephine section. It will cover the disorders of bone marrow, discussing the clinical features, histopathology of bone marrow and diagnostic problems of each condition. Chapters close with a summary of key points. The consistent approach to describing each condition makes this a valuable reference tool for the trainee and practicing histopathologists, pathologists and haematologists.

Autor

Kevin C Gatter, Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, Oxford, UKKevin Gatter is Professor of Pathology and Head of the Nuffield Department of Clinical Laboratory Sciences at the John Radcliffe Hospital. He has published textbooks on bone marrow diagnosis, skin lymphoma and lymphoma classification. His research interests include lymphoma diagnosis, medical informatics and angiogenesis in malignancy. He is honorary director of the ICRF Tumour Pathology Unit and Honorary Consultant in Pathology at the John Radcliffe Hospital.

Inhalt

Preface to the third edition vi

Preface to the first edition vii

1 Introduction 1

2 The normal bone marrow 4

3 Infections including human immunodeficiency virus 18

4 Anaemias and aplasias 32

5 The myelodysplastic syndromes 42

6 Myeloproliferative neoplasms 49

7 Acute leukaemia 69

8 Lymphomas: an overview 89

9 Precursor B and T lymphoblastic leukaemia (acute lymphoblastic leukaemia) and lymphoblastic lymphoma 101

10 Mature B cell neoplasms 108

11 Mature T and NK cell neoplasms 161

12 Hodgkin lymphoma 179

13 Metastatic disease 188

14 Bone stroma and miscellaneous changes 196

15 Technical considerations 209

Index 215

Textauszug

CHAPTER 1
Introduction

During the late 1950s, McFarland and Dameshek introduced an acceptable means of obtaining bone marrow core biopsies.1 This advance made it possible for the histopathologist to diagnose a wide range of haematopathological disorders including the leukaemias, lymphoproliferative and myeloproliferative disease, myelodysplasia, metastases and reactive disorders.

Most biopsies are taken from the posterior superior iliac spine. Ideally in an adult the core of tissue should be at least 1 cm in length. This often raises the question: ‘But what is the minimum you need?’ There is no standard answer. Although half a crushed marrow space full of carcinoma is diagnostic, in most cases a good rule of thumb is a minimum of five complete marrow spaces for most haematological diagnoses. An aspirate is usually taken from the same site before the biopsy is removed (but from a different needle track, or the biopsy may be a haemorrhagic mess). The haematologist will usually make about 10 smear preparations from the marrow particles that have been aspirated and either discard or send the remainder for histology. We find it useful to have both of these types of specimen since there are occasions when only an aspirate is available, in which case it is then important to have built up experience examining aspirate preparations for which trephines have been available for comparison.

The trephine biopsy has a number of advantages over the aspirate specimen. The most important is to enable examination of the topographical distribution of the cellular constituents of the marrow, their relationships to the bony trabeculae and an assessment of marrow cellularity. Furthermore, in diseases which produce fibrosis, e.g. Hodgkin lymphoma or myeloproliferative disorders, an aspirate often fails to produce an adequate diagnostic sample (‘a dry tap’).

Close liaison with haematologists is important since it makes the reporting of trephine biopsies easier and ensures that misdiagnoses are kept to a minimum. Many if not most authorities recommend reporting of the trephine biopsy alongside the aspirate, either by yourself or with the haematologist. However, this does not seem to be common practice and, as workloads and specialist referrals rise, will inevitably decline. You can report safely most trephines on their own provided you know your limitations and keep a good dialogue open with your clinicians. Multidisciplinary team meetings are also invaluable, allowing for a review of all malignant haematological diagnoses and discussion of diagnostically difficult cases. The authors appreciate that many trainee histopathologists who see only occasional trephine biopsies find it difficult to observe any order, even in a normal marrow, and often give up on this subspecialty as being ‘too difficult’. Our advice is to persist and spend time initially on examining as many normal/reactive marrows as possible.

There has been debate involving the embedding medium for bone marrow biopsies. There are essentially two schools of thought: those who believe that the biopsies should be embedded in plastic and those who believe paraffin embedding with decalcification to be superior. The reason for this divergence is related to the nature of the biopsy itself, which consists of both hard tissue (i.e. bone) and soft tissue (i.e. marrow and fat). In order to cut intact sections one can either make the biopsy material uniformly soft (by decalcification) or uniformly hard (by resin embedding).

Unfortunately, decalcification inevitably produces some tissue distortion and plastic embedding limits the range of immunohistochemical studies. The debate over which is superior continues, with vociferous advocates on either side.2–6 The advantages and disadvantages of each approach are summarized in Table 1.1.

Table 1.1  Comparison of the relative advantages and disadvantages of paraffin and plastic embedding of bone marrow trephine biopsies.

	Paraffin embedding	Resin/plastic embedding

Advantages

Widespread antigen preservation allows immunohistochemical studies Pathologists are familiar with sections cut from paraffin-embedded material

Superb cytological detail available from the very thin sections obtained by this technique

Disadvantages

Loss of some histochemical reactivity within the granules of the granulocyte and mast cell series, e.g. Leder stain. This loss is directly proportional to the strength of the acid used in decalcification Some inevitable tissue distortion is produced by decalcification

Loss of some immunoreactivity A separate technique is required solely for bone marrow biopsies Pathologists are unfamiliar with resin-embedded sections and their associated artefacts, e.g. the basophilic hue indicative of erythroid histogenesis is lost in resin-embedded sections

We believe that, with a little extra care, it is possible to provide sections, from paraffin-embedded trephines, which meet the practical requirements of the diagnostic haematologist.7

Just as there has been division among pathologists regarding the best embedding medium, so too has there been debate over the most appropriate general stain. This inevitably involves an element of personal preference. The well-established place of the H&E stain in general diagnostic pathology has assured it of much support as the primary stain in bone marrow histology. We believe that a good Giemsa stain provides more information than its H&E counterpart, e.g. in identifying cell lineage, the detection of fibrosis and the estimation of iron stores. A good Giemsa stain requires fastidious technical preparation (see Chapter 15). The results are worth the initial perseverance required by both the technical staff and the pathologist to become familiar with it. When indicated, we include a reticulin stain in our bone marrow set.

Reasons for Performing Bone Marrow Biopsies

The majority of bone marrow biopsies are performed for the following reasons.8

1. Dry tap. The commonest diagnoses are:
   • fibrosis (Hodgkin lymphoma, metastatic cancer, primary myelofibrosis);
   • hairy cell leukaemia;
   • extreme hypercellularity (‘packed marrow’) such as may be seen in cases of leukaemia and lymphoma.
2. Assessment of cellularity:
   • extent of infiltration by leukaemia, lymphoma and myeloma;
   • amount of residual marrow;
   • assessment of marrow post chemotherapy and after engraftment;
   • investigation of cytopenias.
3. Identification of focal disease:
   • metastatic cancer, lymphomas, granulomas.
4. Lymphoma staging.
5. Assessment of HIV and its opportunistic infections.

How to Examine a Trephine Section

It is important to have an organized approach to the examination of bone marrow sections in order not to miss diagnostic features. One possible scheme is based on an assessment of cellularity, topography, morphology and accessory structures, as illustrated in Tables 1.2–1.5 with a selection of some common pathological conditions.

Tables 1.2–1.5   A scheme for assessing the bone marrow trephine with some common pathological conditions as examples.

Table 1.2

Assessment of cellularity

Hypocellular

Aplastic anaemia Hairy cell leukaemia Acute myeloid leukaemia

Normocellular

Be aware of subtle infiltrates such as myeloma

Hypercellular

Homogeneous

Non-Hodgkin lymphoma Acute leukaemias

Heterogeneous

Reactive Myeloproliferative neoplasia Myelodysplasias Metastatic cancer Small cell tumours of childhood

Table 1.3

Topography (distribution) of cellular elements

Are all cell types present? Are any particular cells present in abnormal numbers?     e.g. increased granulocytes in chronic granulocytic leukaemia     Prominent mast cells in Waldenström's macroglobulinaemia Normal cellular distribution Granulocytes     Paratrabecular, peri-arterial Erythroid     Intertrabecular Megakaryocytes     Intertrabecular and peri-sinusoidal Common abnormal patterns Myelodysplasia/myeloproliferation     Paratrabecular erythroid and megakaryocytic colonies     Megakaryocytic clustering Non-Hodgkin lymphoma     Follicular lymphoma has a paratrabecular pattern     CLL is usually diffuse or nodular

Table 1.4

Assessment of cell morphology

Atypia     Abnormal megakaryocytes in myeloproliferation     and myelodysplasia Maturation abnormalities     Maturation arrest, e.g. drug induced     Asynchronous maturation in...

Produkt-Details

• Erscheint lt. Verlag: 10.11.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Endokrinologie
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Anamnese / Körperliche Untersuchung
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Pathologie
• Schlagworte: Approach • biopsies • Bone marrow • Chapters • clear • Collection • Common • comparisons • comprehensively • Core • Description • Essential • information necessary • Medical Science • Medizin • Methods • Pathologie • Pathologists • Pathology • provides • Range • resource • Sample • section • succinct • trephine • whilst
• ISBN-10: 1-118-95204-9 / 1118952049
• ISBN-13: 978-1-118-95204-7 / 9781118952047