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Lee WH, Lin CC, Tsai CH, Tien FM, Lo MY, Tseng MH, Kuo YY, Yu SC, Liu MC, Yuan CT, Yang YT, Chuang MK, Ko BS, Tang JL, Sun HI, Chuang YK, Tien HF, Hou HA, Chou WC. Comparison of the 2022 world health organization classification and international consensus classification in myelodysplastic syndromes/neoplasms. Blood Cancer J 2024; 14:57. [PMID: 38594285 PMCID: PMC11004131 DOI: 10.1038/s41408-024-01031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Abstract
In 2022, two novel classification systems for myelodysplastic syndromes/neoplasms (MDS) have been proposed: the International Consensus Classification (ICC) and the 2022 World Health Organization (WHO-2022) classification. These two contemporary systems exhibit numerous shared features but also diverge significantly in terminology and the definition of new entities. Thus, we retrospectively validated the ICC and WHO-2022 classification and found that both systems promoted efficient segregation of this heterogeneous disease. After examining the distinction between the two systems, we showed that a peripheral blood blast percentage ≥ 5% indicates adverse survival. Identifying MDS/acute myeloid leukemia with MDS-related gene mutations or cytogenetic abnormalities helps differentiate survival outcomes. In MDS, not otherwise specified patients, those diagnosed with hypoplastic MDS and single lineage dysplasia displayed a trend of superior survival compared to other low-risk MDS patients. Furthermore, the impact of bone marrow fibrosis on survival was less pronounced within the ICC framework. Allogeneic transplantation appears to improve outcomes for patients diagnosed with MDS with excess blasts in the ICC. Therefore, we proposed an integrated system that may lead to the accurate diagnosis and advancement of future research for MDS. Prospective studies are warranted to validate this refined classification.
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Affiliation(s)
- Wan-Hsuan Lee
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chin Lin
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Hong Tsai
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Education and Research, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Feng-Ming Tien
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Min-Yen Lo
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Mei-Hsuan Tseng
- Tai-Chen Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Yuan-Yeh Kuo
- Tai-Chen Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Shan-Chi Yu
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chih Liu
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Tsu Yuan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pathology, National Taiwan University Hospital Cancer Center Branch, Taipei, Taiwan
| | - Yi-Tsung Yang
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Kai Chuang
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Sheng Ko
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Tai-Chen Cell Therapy Center, National Taiwan University, Taipei, Taiwan.
- Department of Hematological Oncology, National Taiwan University Cancer Center, Taipei, Taiwan.
| | - Jih-Luh Tang
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Hematological Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Hsun-I Sun
- Tai-Chen Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Yi-Kuang Chuang
- Tai-Chen Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Hwei-Fang Tien
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei, Taiwan
| | - Hsin-An Hou
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- General Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wen-Chien Chou
- Divisions of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Edahiro Y, Ochiai T, Hashimoto Y, Morishita S, Shirane S, Inano T, Furuya C, Koike M, Noguchi M, Usuki K, Shiratsuchi M, Nakajima K, Ohtsuka E, Tanaka H, Kawata E, Nakamae M, Ueda Y, Aota Y, Sugita Y, Ohara S, Yamasaki S, Asagoe K, Yoshida S, Yamanouchi J, Suzuki S, Kondo T, Kanisawa Y, Toyama K, Omura H, Mizuchi D, Sakamaki S, Ando M, Komatsu N. Clinical characteristics of Japanese patients with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis. Int J Hematol 2023:10.1007/s12185-023-03592-0. [PMID: 37058247 DOI: 10.1007/s12185-023-03592-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023]
Abstract
Myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) is a rare disease, which presents with features of myelodysplastic syndromes with ring sideroblasts and essential thrombocythemia, as well as anemia and marked thrombocytosis. SF3B1 and JAK2 mutations are often found in patients, and are associated with their specific clinical features. This study was a retrospective analysis of 34 Japanese patients with MDS/MPN-RS-T. Median age at diagnosis was 77 (range, 51-88) years, and patients had anemia (median hemoglobin: 9.0 g/dL) and thrombocytosis (median platelet count: 642 × 109/L). Median overall survival was 70 (95% confidence interval: 68-not applicable) months during the median follow-up period of 26 (range: 0-91) months. A JAK2V617F mutation was detected in 46.2% (n = 12) of analyzed patients (n = 26), while an SF3B1 mutation was detected in 87.5% (n = 7) of analyzed patients (n = 8). Like those with myelodysplastic syndromes or myeloproliferative neoplasms, patients often received erythropoiesis-stimulating agents and aspirin to improve anemia and prevent thrombosis. This study, which was the largest to describe the real-world characteristics of Japanese patients with MDS/MPN-RS-T, showed that the patients had similar characteristics to those in western countries.
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Affiliation(s)
- Yoko Edahiro
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan.
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan.
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Tomonori Ochiai
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoshinori Hashimoto
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Soji Morishita
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shuichi Shirane
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tadaaki Inano
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Chiho Furuya
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Michiaki Koike
- Department of Hematology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Kei Nakajima
- Department of Hematology/Oncology, University of Yamanashi, Kofu, Japan
| | - Eiichi Ohtsuka
- Department of Hematology, Oita Prefectural Hospital, Oita, Japan
| | - Hiroaki Tanaka
- Department of Hematology, Asahi General Hospital, Asahi, Japan
| | - Eri Kawata
- Department of Hematology, Matsushita Memorial Hospital, Moriguchi, Japan
| | - Mika Nakamae
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yasuo Aota
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Department of Internal Medicine, Kohsei Chuo General Hospital, Tokyo, Japan
| | - Yasumasa Sugita
- Department of Hematology, Oami Municipal Hospital, Oamishirasato, Japan
| | - Shin Ohara
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Kohsuke Asagoe
- Department of Hematology & Oncology, Shiga General Hospital, Moriyama, Japan
| | - Shuro Yoshida
- Department of Hematology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Japan
| | - Sayaka Suzuki
- Department of Hematology, Tottori University Hospital, Yonago, Japan
| | - Toshinori Kondo
- Department of Hematology, Kawasaki Medical School, Kurashiki, Japan
| | - Yuji Kanisawa
- Department of Hematology and Oncology, Oji General Hospital, Tomakomai, Japan
| | - Kohtaro Toyama
- Department of Hematology, Fujioka General Hospital, Fujioka, Japan
| | - Hiromi Omura
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Daisuke Mizuchi
- Department of Hematology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Sumio Sakamaki
- Department of Hematology, Hokuou Hospital, Sapporo, Japan
| | - Miki Ando
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, 2-1-1 Hongou, Bunkyo-Ku, Tokyo, Japan
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
- PharmaEssentia Japan KK, Tokyo, Japan
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Hypoplastic Myelodysplastic Syndromes: Just an Overlap Syndrome? Cancers (Basel) 2021; 13:cancers13010132. [PMID: 33401595 PMCID: PMC7795441 DOI: 10.3390/cancers13010132] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Hypoplastic myelodysplastic syndromes (hMDS) represent a diagnostic conundrum. They share morphologic and clinical features of both MDS (dysplasia, genetic lesions and cytopenias) and aplastic anemia (AA; i.e., hypocellularity and autoimmunity) and are not comprised in the last WHO classification. In this review we recapitulate the main clinical, pathogenic and therapeutic aspects of hypo-MDS and discuss why they deserve to be distinguished from normo/hypercellular MDS and AA. We conclude that hMDS may present in two phenotypes: one more proinflammatory and autoimmune, more similar to AA, responding to immunosuppression; and one MDS-like dominated by genetic lesions, suppression of immune surveillance, and tumor escape, more prone to leukemic evolution. Abstract Myelodysplasias with hypocellular bone marrow (hMDS) represent about 10–15% of MDS and are defined by reduced bone marrow cellularity (i.e., <25% or an inappropriately reduced cellularity for their age in young patients). Their diagnosis is still an object of debate and has not been clearly established in the recent WHO classification. Clinical and morphological overlaps with both normo/hypercellular MDS and aplastic anemia include cytopenias, the presence of marrow hypocellularity and dysplasia, and cytogenetic and molecular alterations. Activation of the immune system against the hematopoietic precursors, typical of aplastic anemia, is reckoned even in hMDS and may account for the response to immunosuppressive treatment. Finally, the hMDS outcome seems more favorable than that of normo/hypercellular MDS patients. In this review, we analyze the available literature on hMDS, focusing on clinical, immunological, and molecular features. We show that hMDS pathogenesis and clinical presentation are peculiar, albeit in-between aplastic anemia (AA) and normo/hypercellular MDS. Two different hMDS phenotypes may be encountered: one featured by inflammation and immune activation, with increased cytotoxic T cells, increased T and B regulatory cells, and better response to immunosuppression; and the other, resembling MDS, where T and B regulatory/suppressor cells prevail, leading to genetic clonal selection and an increased risk of leukemic evolution. The identification of the prevailing hMDS phenotype might assist treatment choice, inform prognosis, and suggest personalized monitoring.
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Outcome of allogeneic hematopoietic stem cell transplantation for hypoplastic myelodysplastic syndrome. Int J Hematol 2020; 112:825-834. [PMID: 32803698 DOI: 10.1007/s12185-020-02969-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
The prognosis of patients with hypoplastic myelodysplastic syndrome (hMDS) after receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains unclear. This study aimed to evaluate the outcomes of patients with hMDS after allo-HSCT. Between September 2013 and October 2019, a total of 20 consecutive patients with hMDS and 1 patient with clonal cytopenia of undermined significance (CCUS) who underwent allo-HSCT, which included procedures with 9 matched sibling donors, 2 matched unrelated donors, 4 mismatched unrelated donors and 6 haploidentical donors, were enrolled in this study. The median time for myeloid engraftment was 11 days (range 9-17 days), and that for platelet engraftment was 10 days (range 7-17 days). The cumulative incidence (CI) of myeloid and platelet recovery was 95.2 ± 6.0% and 90.5 ± 7.3%, respectively. The CI rates were 40.0 ± 11.3% for grades II-III acute graft-versus-host disease (GVHD), 36.8 ± 11.5% for chronic GVHD and 23.8 ± 9.6% for nonrelapse mortality. No patients experienced relapse. Sixteen surviving patients were followed up for a median of 1113 days (range 110-2305 days), and the overall survival and relapse-free survival rates were both 72.7 ± 10.6%. This limited retrospective analysis suggests that patients with hMDS had a favorable survival after allo-HSCT.
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Clinical, histopathological and molecular characterization of hypoplastic myelodysplastic syndrome. Leukemia 2019; 33:2495-2505. [PMID: 30940907 DOI: 10.1038/s41375-019-0457-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/22/2019] [Accepted: 03/14/2019] [Indexed: 11/08/2022]
Abstract
Diagnostic criteria for hypoplastic myelodysplasic syndrome (h-MDS) have not been clearly established, making the differential diagnosis from other bone marrow failure syndromes (BMF) challenging. In this study, we aimed to delineate clinical, histopathological, and molecular features of h-MDS, based on a large and well-annotated cohort of patients with bone marrow (BM) hypocellularity. The study included 534 consecutive adult patients with hypocellular BM (278 h-MDS and 136 aplastic anemia), and 727 with normo- or hypercellular MDS (n-MDS). Comparison of clinical features of patients with h-MDS as defined by BM cellularity ≤25% (n = 204) or reduced age-adjusted cellularity (n = 74) did not reveal significant differences. We developed a diagnostic score to discriminate h-MDS from non-malignant BMF based on histological and cytological variables with the highest specificity for MDS (h-score). The information from chromosomal abnormalities and somatic mutation patterns was then integrated into a cyto-histological/genetic score (hg-score). This score was able to segregate two groups of h-MDS with a significantly different risk of blast progression (P < 0.001). The integration of cyto-histological and genetic features in adult patients with hypocellular BM facilitated segregation into two distinct groups, one with clinical and genetic features highly consistent with myeloid neoplasm, and one with features more consistent with non-malignant BMF.
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Additional prognostic impact of the percentage of erythroid cells in the bone marrow of patients with myelodysplastic syndromes. Leuk Res 2019; 77:8-13. [PMID: 30605856 DOI: 10.1016/j.leukres.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/22/2018] [Accepted: 12/27/2018] [Indexed: 11/23/2022]
Abstract
In patients with myelodysplastic syndromes (MDS) the impact of the percentage of erythroid precursors in the bone marrow has been the subject of considerable debate, especially with regard to prognosis. We examined the prognostic impact of the percentage of erythroid cells in the bone marrow (bmery) in 2453 primary untreated MDS patients in a retrospective multi-center analysis. Bmery were quantified in bone marrow smears at the time of diagnosis and were correlated with overall survival (OS) and AML evolution. We identified three distinct risk categories: "< = 10% bmery" (poor), "11-25 or >45% bmery" (intermediate), and "26-45% bmery" (good) with distinct OS of 23, 40 and 48 months, respectively. The percentage of bmery showed prognostic significance concerning OS (Dxy = 0.08, p < 0.001) and AML-free survival (Dxy = 0.15, p < 0.001). Considering the IPSS-R by stratification, the Dxy were 0.09 for survival, and 0.18 for transformation (p < 0.001). Added to the IPSS-R, bmery enhances the prognostic power for both survival (Dxy = 0.39) and time to AML (Dxy = 0.59). Survival and time to AML differ in MDS according to the percentage of bmery. The best outcome was found in those who had normal or near normal bmery counts. Moreover, adding bmery as differentiating feature to the IPSS-R may enhance its prognostic significance.
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Shingai N, Harada Y, Iizuka H, Ogata Y, Doki N, Ohashi K, Hagihara M, Komatsu N, Harada H. Impact of splicing factor mutations on clinical features in patients with myelodysplastic syndromes. Int J Hematol 2018; 108:598-606. [DOI: 10.1007/s12185-018-2551-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 12/15/2022]
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Tohyama K. Present status and perspective of laboratory hematology in Japan: On the standardization of blood cell morphology including myelodysplasia: On behalf of the Japanese Society for Laboratory Hematology. Int J Lab Hematol 2018; 40 Suppl 1:120-125. [PMID: 29741254 DOI: 10.1111/ijlh.12819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 02/07/2018] [Indexed: 11/30/2022]
Abstract
The Japanese Society for Laboratory Hematology (JSLH) was launched in 2000 and has been developed by a mutual collaboration of hematologists, medical technologists, and the companies involved in hematological laboratory testing. The aim of JSLH is the progress and development of laboratory hematology by academic conferences, periodic publication of academic journal, training and education (in the meeting, the journal, or the website), promotion of the standardization of laboratory hematology, and certification of the laboratory hematology specialists. Among 3 specialized committees organized for the standardization of laboratory hematology, the standardization committee on blood cell morphology has been dealing with the various projects on peripheral/bone marrow blood cells and normal/abnormal morphology. Another independent organization, the Japanese National Research Group on idiopathic bone marrow failure syndromes (BMF), has raised the importance of the dysplasia of myelodysplastic syndromes (MDS) and has been conducting the prospective registration, central review, and follow-up study of MDS. This group recently proposed the grading system for diagnostic accuracy of MDS, and the detailed procedure of morphological diagnosis of MDS is presented in the specialized color atlas with typical photographs of various dysplasia. JSLH has also approved the grading system for diagnostic accuracy of MDS and adopted this standardized diagnostic system to the educational item for certification of the laboratory hematology specialists, aiming at a nationwidely expanding morphological evaluation of myelodysplasia. Further and significant progress in the standardization of blood cell morphology will be expected in Japan through the activity of JSLH.
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Affiliation(s)
- K Tohyama
- Department of Laboratory Medicine, Kawasaki Medical School, Kurashiki-City, Okayama, Japan
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