BONE MARROW PATHOLOGY BARBARA J. BAIN MBBS, FRACP, FRCPath Reader in Diagnostic Haematology St Mary’s Hospital Campus of Imperial College School of Medicine, London and Honorary Consultant Haematologist St Mary’s Hospital, London DAVID M. CLARK MD, MRCP, FRCPath Consultant Histopathologist United Lincolnshire Hospitals NHS Trust Honorary Consultant Histopathologist University Hospital, Nottingham and Special Lecturer in Pathology University of Nottingham IRVIN A. LAMPERT MB, ChB, DCP, FRCPath Consultant Histopathologist Ealing Hospital, London Honorary Senior Lecturer, Hammersmith Hospital Campus of Imperial College School of Medicine and Honorary Consultant Histopathologist Hammersmith Hospital, London BRIDGET S. WILKINS DM, PhD, FRCPath Consultant Histopathologist Newcastle upon Tyne Hospitals NHS Trust and Honorary Senior Lecturer University of Newcastle THIRD EDITION © 1992, 1996, 2001 Blackwell Science Ltd Editorial Offices: 23 Ainslie Place, Edinburgh EH3 6AJ 350 Main Street, Malden Victoria 3053, Australia Other Editorial Offices: Blackwell Science KK MG Kodenmacho Building 7–10 Kodenmacho Nihombashi Chuo-ku, Tokyo 104, Japan Iowa State University Press A Blackwell Science Company 2121 S. State Avenue Ames, Iowa 50014-8300, USA The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the copyright owner. First published 1992 Second edition 1996 Third edition 2001 Set by Graphicraft Limited, Hong Kong The Blackwell Science logo is a trade mark of Blackwell Science Ltd, registered at the United Kingdom Trade Marks Registry DISTRIBUTORS Marston Book Services Ltd PO Box 269 Abingdon, Oxon OX14 4YN (Orders: Tel: 01235 465500 Fax: 01235 465555) USA Blackwell Science, Inc. Commerce Place 350 Main Street Malden, MA 02148-5018 (Orders: Tel: 800 759 6102 781 388 8250 Fax: 781 388 8255) Australia Blackwell Science Pty Ltd 54 University Street Carlton, Victoria 3053 (Orders: Tel: 3 9347 0300 Fax: 3 9347 5001) A catalogue record for this title is available from the British Library Library of Congress Cataloging-in-Publication Data Bone marrow pathology/Barbara J. Bain . . . [et al.].-3rd ed. p. cm. Rev. ed. of: Bone marrow pathology/ Barbara J. Bain, David M. Clark, Irvin A. Lampert. 2nd ed. 1996. Includes bibliographical references and index. 1 Bone marrow-histopathology. I Bain, Barbara J. II Bain, Barbara J. Bone marrow pathology. [DNLM: 1. Bone Marrow Diseasesa pathology. 2. Bone Marrowa pathology. WH 380 B7116 2001] RC645.7.B35 2001 616.4’107adc21 00-051929 For further information on Blackwell Science, visit our website: Printed and bound in Singapore by Fabulous Printers Pte Ltd QQQQD QQ Q 9600 Garsington Road, Oxford OX4 2DQQ, UK 54 University Street, Carlton MA 02148-5020, USA www.Blackwellpublishing.com 3 2006 ISBN 978-0-632-05578-4 ISBN 978-0-632-05578-4 CONTENTS Preface to the third edition, vi Acknowledgements, vii Abbreviations, viii 1 The normal bone marrow, 1 2 Special techniques applicable to bone marrow diagnosis, 51 3 Infection and reactive changes, 90 4 Acute myeloid leukaemia, the myelodysplastic syndromes and histiocytic neoplasms, 141 5 Chronic myeloproliferative and myeloproliferative/ myelodysplastic disorders, 191 6 Lymphoproliferative disorders, 231 7 Multiple myeloma and related disorders, 332 8 Disorders of erythropoiesis, granulopoiesis and thrombopoiesis, 360 9 Miscellaneous disorders, 391 10 Metastatic tumours, 430 11 Diseases of bone, 462 Appendix, 474 Index, 483 v In this book we have set out to provide a practical guide to bone marrow diagnosis, based on an inte- grated assessment of peripheral blood and bone marrow aspirate films, trephine biopsy sections and various supplementary investigations. We believe that a trephine biopsy specimen should not be ex- amined and interpreted in isolation. We have there- fore discussed the clinical context of bone marrow diagnosis and have given equal weight to cytolog- ical and histological features. Since bone marrow diagnosis is no longer based on morphological fea- tures alone we have also, in this edition, discussed in considerable detail the role of immunopheno- typic, cytogenetic and molecular genetic analysis. We have dealt very fully with haematological disorders for which bone marrow examination is commonly performed. However, we have also sought to be as comprehensive as possible, includ- ing whatever information is available on uncom- mon and rare disorders so that the book will serve as a useful reference source. When possible, we have illustrated rare as well as common conditions and have cited the relevant scientific literature extensively. In this edition we have introduced a new section entitled ‘Problems and pitfalls’ which we believe will be of value. We have also expanded the descrip- tion of technical methods. We hope that haemato- logists and histopathologists will continue to find Bone Marrow Pathology a useful aid in their day-to- day practice and that trainees in these disciplines will find it indispensable. BJB, DMC, IAL, BSW December 2000 PREFACE TO THE THIRD EDITION vi We should like to thank our many friends and colleagues in North America, Europe, Africa, Asia and Australia who have provided illustrations or have permitted us to photograph microscopic slides from their personal collections. They are individu- ally acknowledged in the legends of specific figures. In addition we should like to thank our technical and medical colleagues in St Mary’s Hospital, Hammer- smith Hospital, Nottingham University Hospitals and Southampton University Hospitals for the direct and indirect help they have given us. This book is dedicated to Professor Emeritus David Galton who taught us and countless other haematologists and histopathologists for a great many years. Those who have worked with him have admired him both for his diagnostic skills and for his mindfulness of the individual patient. It is with much pleasure that we make this dedication to him. ACKNOWLEDGEMENTS vii aCML atypical CML AIDS acquired immune deficiency syndrome AILD angio-immunoblastic lymphadenopathy (with dysproteinaemia) ALCL anaplastic large cell lymphoma ALIP abnormal localization of immature precursors ALL acute lymphoblastic leukaemia AML acute myeloid leukaemia ATLL adult T-cell leukaemia/lymphoma ATRA all-trans retinoic acid BCL2 B-cell leukaemia/lymphoma 2 BCR breakpoint cluster region BFU-E erythroid burst-forming unit BM bone marrow B-PLL B-lineage prolymphocytic leukaemia CD cluster of differentiation CDA congenital dyserythropoietic anaemia CFU colony-forming unit CFU-GM granulocyte–monocyte CFU CFU-Meg megakaryocyte CFU CGL chronic granulocytic leukaemia CHAD cold haemagglutinin disease CLL chronic lymphocytic leukaemia CML chronic myeloid leukaemia CMML chronic myelomonocytic leukaemia CMV cytomegalovirus CT computerized tomography CyIg cytoplasmic immunoglobulin DIC disseminated intravascular coagulation DNA deoxyribonucleic acid EBER Epstein–Barr early RNA EBNA Epstein–Barr nuclear antigen EBV Epstein–Barr virus EDTA ethylene diamine tetra-acetic acid EGIL European Group for the Immunological Classification of Leukaemia EMA epithelial membrane antigen ESR erythrocyte sedimentation rate ET essential thrombocythaemia FAB French–American–British (co-operative group) FICTION fluorescent immunophenotyping and interphase cytogenetics FISH fluorescence in situ hybridization G-CSF granulocyte colony-stimulating factor GM-CSF granulocyte–macrophage colony- stimulating factor GMS Grocott’s methenamine silver (stain) GPI glycosyl phosphatidylinositol GVHD graft-versus-host disease H&E haematoxylin and eosin (stain) Hempas hereditary erythroid multinuclearity with positive acidified serum test HHV human herpesvirus HIV human immunodeficiency virus HLA human leucocyte antigen HTLV-I human T-cell lymphotropic virus I Ig immunoglobulin IGH immunoglobulin heavy chain (gene) IL interleukin ISH in situ hybridization JMML juvenile myelomonocytic leukaemia LDH lactate dehydrogenase LE lupus erythematosus LGL large granular lymphocyte LGLL large granular lymphocyte leukaemia LTC-IC long-term culture-initiating cell MALT mucosa-associated lymphoid tissue MBR major breakpoint region McAb monoclonal antibody MCR minor cluster region MDS myelodysplastic syndromes M:E myeloid : erythroid ratio MGG May–Grünwald–Giemsa (stain) ABBREVIATIONS viii ABBREVIATIONS ix MGUS monoclonal gammopathy of undetermined significance MIC morphologic, immunologic, cytogenetic (classification) MIC-M morphological, immunological, cytogenetic, molecular genetic (classification) MPD myeloproliferative disorder MPO myeloperoxidase mRNA messenger RNA NEC non-erythroid cells NHL non-Hodgkin’s lymphoma NK natural killer PAS periodic acid–Schiff (stain) PB peripheral blood PCR polymerase chain reaction Ph Philadelphia chromosome PLL prolymphocytic leukaemia PNET primitive neuro-ectodermal tumour PNH paroxysmal nocturnal haemoglobinuria POEMS polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes (syndrome) PRV polycythaemia rubra vera RA refractory anaemia RAEB refractory anaemia with excess of blasts RAEB-T refractory anaemia with excess of blasts in transformation RARS refractory anaemia with ring sideroblasts REAL Revised European–American Lymphoma (classification) RNA ribonucleic acid RT-PCR reverse transcriptase polymerase chain reaction SBB Sudan black B (stain) SD standard deviation SKY spectral karyotyping SLVL splenic lymphoma with villous lymphocytes SmIg surface membrane immunoglobulin TAR thrombocytopenia-absent radii (syndrome) TCR T-cell receptor TdT terminal deoxynucleotidyl transferase T-PLL T-lineage prolymphocytic leukaemia TRAP tartrate-resistant acid phosphatase WBC white blood cell (count) WHO World Health Organization ZN Ziehl–Neelsen may also be classified histologically on the basis of whether there are well-organized osteons in which a central Haversian canal is surrounded by concen- tric lamellae composed of parallel bundles of fibrils (lamellar bone) (Fig. 1.1) or, alternatively, whether the fibrils of the bone are in disorderly bundles (woven bone) (Fig. 1.2). The cortex is a solid layer of compact bone which gives the bone its strength. It is composed largely of lamellar bone but also contains some woven bone. The lamellar bone of the cortex consists of either well-organized Haversian systems or angular frag- ments of lamellar bone which occupy the spaces between the Haversian systems; in long bones there are also inner and outer circumferential lamellae. Extending inwards from the cortex is an anasto- mosing network of trabeculae which partition the medullary space (Fig. 1.3). The medullary bone is trabecular or cancellous bone; it contains lamellae but the structure is less highly organized than that of the cortex. Most of the cortical bone is covered on the external surface by periosteum which has an outer fibrous layer and an inner osteogenic layer. At articular surfaces, and more extensively in younger patients, bone fuses with cartilage rather than being covered by periosteum. The bony trabeculae and the inner surface of the cortex are lined by end- osteal cells including osteogenic cells (osteoblasts) and osteoclasts. Osteocytes are found within lacunae in bony trabeculae and in cortical bone. Although osteoblasts and osteoclasts share the surface of the bone trabeculae, they originate from different stem cells. Osteoblasts, and therefore osteocytes, are of mesenchymal origin, being derived from the same stem cell as chondrocytes and probably also stromal fibroblasts. Osteoclasts, however, are derived from a haemopoietic stem cell, being formed by fusion of cells of the monocyte lineage. ONE THE NORMAL BONE MARROW The distribution of haemopoietic marrow During extra-uterine life haemopoiesis is normally confined to the bone marrow. Bones are composed of cortex and medulla. The cortex is a strong layer of compact bone; the medulla is a honeycomb of cancellous bone, the interstices of which form the medullary cavity and contain the bone mar- row. Bone marrow is either red marrow contain- ing haemopoietic cells or yellow marrow which is largely adipose tissue. The distribution of haemopoietic marrow is dependent on age. In the neonate virtually the entire bone marrow cavity is fully occupied by proliferating haemopoietic cells; haemopoiesis occurs even in the phalanges. As the child ages, haemopoietic marrow contracts cen- tripetally, being replaced by fatty marrow. By early adult life haemopoietic marrow is largely confined to the skull, vertebrae, ribs, clavicles, sternum, pelvis and the proximal half of the humeri and femora; however, there is considerable variation between individuals as to the distribution of haemopoietic marrow [1]. In response to demand, the volume of the marrow cavity occupied by haemopoietic tissue expands. The organization of the bone marrow Bone The cortex and the medulla differ functionally as well as histologically. Bone may be classified in two ways. Classification may be made on the basis of the macroscopic appearance into: (i) compact or dense bone with only small interstices that are not visible macroscopically; and (ii) cancellous (or trabecular) bone with large, readily visible interstices. Bone 1 The cells that give rise to bone-forming cells are designated osteoprogenitor cells; they are flattened, spindle-shaped cells which are capable of develop- ing into either osteoblasts or chondrocytes, depend- ing on micro-environmental factors. Osteoblasts synthesize glycosaminoglycans of the bone matrix and also the collagenous fibres which are embedded in the matrix, thus forming osteoid or non-calcified bone; subsequently mineralization occurs. Bone undergoes constant remodelling. In adult life, remodelling of the bone takes place particularly in the subcortical regions. Osteoblasts add a new layer of bone to trabeculae (apposition), while osteoclasts resorb other areas of the bone; up to 25% of the trabecular surface may be covered by osteoid. The osteoclasts which are resorbing bone lie in shallow hollows, known as Howship’s lacunae, created by the process of resorption, while osteoblasts are seen in rows on the surface of trabecular bone or on the surface of a layer of osteoid. As new bone is laid down, osteoblasts become immured in bone and are converted into osteocytes. The bone that replaces 2 CHAPTER ONE Fig. 1.1 BM trephine biopsy section showing normal bone structure; the trabeculae are composed of lamellar bone. Paraffin-embedded, reticulin stain ×188. Fig. 1.2 BM trephine biopsy section showing woven bone (pale pink; without lamellae) in a hypocellular but otherwise unremarkable bone marrow. Paraffin-embedded, H&E ×188. THE NORMAL BONE MARROW 3 osteoid is woven bone which, in turn, is remodelled to form lamellar bone. The difference between the two can be easily appreciated by microscopy using polarized light. The organized fibrillar structure of lamellar bone, with bundles of parallel fibrils run- ning in different directions in successive lamellae, gives rise to alternating light and dark layers when viewed under polarized light. Trephine biopsies from children may contain cartilage as well as bone and endochondrial bone formation may be observed (Figs 1.4 and 1.5). Transition from resting cartilage to proliferating and hypertrophic cartilage can be observed, followed by a zone of calcifying cartilage, invading vessels and bone. Mature cartilage can also be seen in trephine biopsy specimens from adults (Fig. 1.6). Other connective tissue elements The haemopoietic cells of the bone marrow are embedded in a connective tissue stroma which occupies the intertrabecular spaces of the medulla. Fig. 1.3 BM trephine biopsy section showing normal bone structure; there are anastomosing bony trabeculae. Paraffin- embedded, H&E ×48. Fig. 1.4 BM trephine biopsy section from a child showing endochondrial ossification in an island of cartilage. Paraffin- embedded, H&E ×188.