Bone marrow pathology. October 2013 BHS Educational Course

Transcription

1 Bone marrow pathology October 2013 BHS Educational Course

2 Technical aspects Interpretation of BMB

3 Introduction: technical aspects of histology Identification of a disease process or a diagnosis By tissue analysis Tissue preparation to allow microscopic evaluation Knowledge of normal histology and disease processes

4 BM biopsy: tissue preparation Fixation: buffered formalin, B5 fixative, (Bouin) Decalcification: New! acid decalcifiers: formic acid (1-2 days), rapid decalcifier (1 hour) chelating decalcifiers: EDTA (2-4 days) electrolysis: Sakura TDE TM 30 decalcifier system (1h ½) ultrasonic decalcification in EDTA: (2 hours) Embedding: paraffin, ( plastic methylmetacrylate)

5 Fixation for at least 6 hours Decalcification 90 min Overnight automated processing Embedding in paraffin cold plate

6 H&E immunohistochemistry microtome Hot plate

7 chromogen PRIMARY MOUSE ANTISERUM AG tissue

8 BMB Indications: diagnosis, staging, response to treatment & follow-up Intrinsic BM diseases MDS/AML MPD MDS/MPD Plasma cell proliferations Lymphomas Mast cell proliferation Infections (opportunistic infections in eg. HIV) Vitamin deficiencies Metastatic disease

9 The pathological report Representativity: length + composition of BMB Cellularity: estimation of % cells versus fat cells cave hypoplastic AML /MDS Hematopoietic cell types architecture / distribution maturation dysplastic features Other relevant information lymfoid infiltrates stroma, blood vessels,.. (eg amyloid) presence of granulomas fibrosis

10 Histologic Interpretation of BMB: morphology Pattern recognition: morphological important clues - Cellularity - Focal lesions - Fibrosis - Dysplasia - Disease specific clues Age and bone marrow cellularity Mean and 95% range in 177 cases of sudden death Anterior Iliac crest specimens decalcified and paraffin-embedded Hartsock et al. Am J Clin Pathol 1965; 43:

11 Quantification of bone marrow fibrosis 0 No reticulin fibres demonstrable 1 Occasional fine individual fibres and foci of a fine fibre network 2 Fine fibre network throughout most of the section; no coarse fibres 3 Diffuse fibre network with scattered thick coarse fibres but no mature collagen 4 Diffuse often coarse fibre network with areas of collagenization

12 Diagnostic clues Predominant cell type Necrosis Gelatinous transformation Granulomas Lymphoid infiltrates Blast count (CD34, CD117, )

13 Histologic Interpretation of BMB: immunohistochemistry Hematological marker: LCA Myeloid markers : MPO, CD15, CD34, CD68, CD117 Lymphocytic markers : CD3, CD5, CD20, CD10, CD21, CD23, CD30,CD138, kappa, lambda Erythroid marker: GlycophorinA Megakaryocytic marker : FVIII, LAT1, CD61

14 «the hypercellular marrow» Correlation with age Predominant cell type lymfoid lymphoma plasma cell myeloma myeloid MKC erythroid cells blasts panmyelosis: 3 series. Neoplastic vs reactive dysplasia N cells presence of disease related features: clustering, fibrosis,.

15 «the hypocellular marrow» Correlation with age Presence of dysplastic features? hypoplastic MDS Increase of blasts? hypoplastic AML Hypoplasia / aplasia: reactive lymphocytes and plasma cells

16 Pattern recognition The hypercellular marrow myeloid: MDS AML MDS/MPD MPD: CML- PRV leukemoid reaction lymphoid: reactive infiltrates, lymphoma plasmacells: MM mastcells: mastocytosis The hypocellular marrow aplasia MDS AML The fibrotic marrow (reticulin / collagen) MPD (IMF) AML(M7) - MDS/MPD- mastocytosis lymphoma metastatic carcinoma- auto-immune MF HIV myelopathy-

17 Pattern recognition The necrotic marrow ALL neuroblastoma- DIC/antiphospholipiden syndr medication or chemor/ effect - sickle cell anemia- GvHD- severe infections- The dysplastic marrow MDS HIV vit deficiencies BM regeneration chronic alcoholism heavy metals infections auto-immunity paraneoplastic The granulomatous marrow infections (viral-fungal-bacterial-toxo), Hodgkin and non-hodgkin lymphomas, CML, AML, ALL, MDS, carcinomas, drugs, autoimmune disorders, foreign bodies,.

18 Dysplasia/ dysmyelopoiesis Dysgranulopoiesis: INCOMPLETE MATURATION / LACK IN GRANULOCYTES (LEFT SHIFT) PRESENCE OF IMMATURE CELLS AWAY FROM THE BONEY TRABECULAE ABNORMALLY LOCATED IMMATURE PRECURSORS (ALIP) Dyserythropoiesis: ABSENCE OF MATURATION WITHIN THE ERYTHRON (SYNCHRONISATION) PREDOMINANTLY LATE STAGE MATURATION CELLS MITOTIC FIGURES MEGALOBLASTOID FEATURES (MAINLY IN RARS) Dysmegakaryopoiesis: SMALL MEGAKARYOCYTES HYPO OR HYPERLOBULATION OF THE NUCLEUS MONOLOBULAR MEGAKARYOCYTES OF ALL SIZES NO CLUSTERING OF MEGAKARYOCYTES NON-LOBULATED NUCLEI RING NUCLEI MULTIPLE NUCLEI NAKED NUCLEI

19 Left shifted granulopoiesis

20 MEGALOBLASTOID RED SERIES

21 DYSMEGAKARYPOIESIS

22 ABNORMALLY LOCATED IMMATURE PRECURSORS OR ALIP VERY SMALL, ROUND TO OVAL CELLS OCCURRING AS SINGLE CELLS OR IN SMALL CLUSTERS AWAY FROM THE BONEY TRABECULAE HAVING ALMOST NO CYTOPLASM THIN BUT WELL DEMARCATED NUCLEAR MEMBRANE FINE NUCLEAR CHROMATINE AND SMALL BUT INCONSPICUOUS NUCLEOLUS TO BE COMPARED WITH MYELOBLASTS RESIDING ALONG BONE TRABECULAE MOSTLY CD34 POSITIVE

23 ALIP CD34

24 Myeloproliferative features High cellularity (100% in CML) Fibrosis (in IMF) Clustering of MKC (PV, ET, IMF) Small MKC in CML Very large MKC (PV, ET, IMF)

25 Identification of blasts «round» immature cells Dd blasts versus precursors CD34 (CD117) Other markers: CD68, MPO

26 Carcinomas Staging

27 Staging & Follow-up Lymphomas: Hodgkin & non-hodgkin lymphomas

28 What does the clinician expect from the pathologist? 1) is the BM infiltrated by lymphoma? 2) what is the (sub)type of lymphoma? 3) additional information on hematopoiesis, stromal alterations, therapy-effect,

29 Bone marrow involvement by lymphoma Often focal involvement Ideally bilateral iliac crest BM biopsy Ideally step sections of BM biopsy Sometimes extensive fibrosis Some lymphomas can easily be missed by cytology and flow, due to the low number of neoplastic cells (e.g. Hodgkin, THRBCL)

30 Advantages of bone marrow biopsy: overall assessment of neoplastic infiltration: Pattern of involvement - extent of involvement - morphology/cytology of neoplastic cells May give diagnostic or prognostic clues Overall assessment of hematopoiesis and stromal component: bone marrow fibrosis, necrosis, T-cell infiltration after treatment for FL with Rituximab, mast cells in LPL, erythrocyte extravasation in HCL, Immunohistochemistry a reliable identification of the subtype of lymphoma can be made in a significant number of cases

31 Disadvantages of BM biopsy IHC: some antibodies (e.g. CD103, CD25) do not work on paraffin embedded material Kappa/lambda: difficult to detect clonality in B-cells, easy for plasma cells

32 Pattern of involvement by lymphoma: Focal non-trabecular Focal trabecular Diffuse interstitial Diffuse solid Intrasinusoidal/intravascular

33 Bone marrow involvement by B-cell lymphoma NHL type Incidence Pattern B-ALL/LBL 40-60% Patchy, interstitial CLL/ SLL 45-75% Nodular, non-paratrabecular LPL 75-90% Vaguely nodular, non-paratrabecular MCL 50-80% Nodular, para + non-paratrabecular FL 40-70% paratrabecular Splenic MZL ~100% Nodular, non-paratrabecular and intrasinusoidal (usually focal and in combination with other infiltration patterns) DLBCL 8-35% Nodular, diffuse THRBCL 0-62% Nodular, diffuse Intravascular BCL 10-20% intrasinusoidal Burkitt 20-35% Interstitial (diffuse) Hairy cell leukemia ~100% Interstitial diffuse

34 Diagnostic bone marrow biopsy: Reticulin stain Large paratrabecular infiltrate CD20 CD10 Diagnosis: follicular lymphoma

35 Hairy cell leukemia Diffuse interstitial infiltration pattern hairy cells: pale cytoplasm Reticulin fibrosis, extravasated rbc Associated hematopoietic alterations -Hyperplastic (megaloblastoid) RCS -Dysplastic MKC -Hypoplastic myelopoiesis

36 Erythroid hyperplasia Extravasated RBC

37 CD20 Interstitial hairy cells

38 Diagnostic bone marrow biopsy CD20 CD20 Diagnosis: DLBCL

39 Diagnostic bone marrow biopsy CD15 CD30 Diagnosis: classical HL

40 Pitfalls Hematogones vs ALL/BL Reactive vs neoplastic infiltrates Therapy effect: post-rituximab T-cell infiltrates

41 Cytologic/Morphologic assessment Discordant morphology: most often DLBCL in LN, small B-cell infiltration in BM Transformation: Richter transformation in CLL, transformation to DLBCL Morphological variant: MCL, blastoid variant

42 Fibrosis in lymphoproliferative diseases Any lymphoproliferation from benign lymphocytic aggregates to replacement of the BM in CLL- is accompanied by varying degrees of increase in reticulin fibers, particularly within nodules, when present. Current Diagnostic pathology 1997:4:36-44 Most frequently: Hairy cell leukemia Multiple myeloma Classical Hodgkin s lymphoma DLBCL THRBCL Cave: underestimation of BM infiltration on aspirate and flow or even discordant results with bone marrow biopsy

43 In conclusion: bone marrow examination Indication: diagnosis, staging, response to treatment & follow-up Material: BM aspiration smears, core biopsy (min length 2cm), touch imprints, clot sections and PB smears Methods: cytology, histology, immunohistochemistry, flow cytometry, karyotyping, (F)ISH, PCR Ideally: combined approach BM involvement in NHL: increased diagnostic sensitivity by combination of immunocytology, cytomorphology and trephine histology Br J Haematol 1992

44 References Guidelines for subtyping small B-cell lymphomas in bone marrow biopsies. Henrique, Achten, Maes et al. Virchows Arch, 1999, 435: Bone marrow manifestations of infections and systemic diseases observed in the bone marrow trephine biopsy. Diebold, Molina, Camilleri-Broët et al. Histopathology 2000, 37: The bone marrow trephine biopsy: a review of normal histology. Brown, Gatter. Histopathology 1993,22: Hodgkin and non-hodgkin lymphoma involving bone marrow. Viswanatha, Foucar. Seminars in diagnostic pathology, 2003,20: