Bone marrow histology in myelodysplastic syndromes. I. Histological findings in myelodysplastic syndromes and comparison with bone marrow smears

Nature or Nurture? Role of the Bone Marrow Microenvironment in the Genesis and Maintenance of Myelodysplastic Syndromes

Myelodysplastic syndrome (MDS) are clonal haematopoietic stem cell (HSC) disorders driven by a complex combination(s) of changes within the genome that result in heterogeneity in both clinical phenotype and disease outcomes. MDS is among the most common of the haematological cancers and its incidence markedly increases with age. Currently available treatments have limited success, with <5% of patients undergoing allogeneic HSC transplantation, a procedure that offers the only possible cure. Critical contributions of the bone marrow microenvironment to the MDS have recently been investigated. Although the better understanding of the underlying biology, particularly genetics of haematopoietic stem cells, has led to better disease and risk classification; however, the role that the bone marrow microenvironment plays in the development of MDS remains largely unclear. This review provides a comprehensive overview of the latest developments in understanding the aetiology of MDS, particularly focussing on understanding how HSCs and the surrounding immune/non-immune bone marrow niche interacts together.

[Correlation between Plasma D-dimer Count and Features of Non-small Cell Lung Cancer]

背景与目的

随着低剂量螺旋计算机断层扫描（computed tomography, CT）等筛查手段的普及，肺部小结节患者可以早期发现和治疗，但现有的检查手段对于肺小结节良恶性和肺癌淋巴结转移情况的预测均有一定局限性。本研究旨在分析术前血浆D-二聚体水平与非小细胞肺癌（non-small cell lung cancer, NSCLC）患者病理特征的相关性，从而探讨在早期肺癌患者术中进行常规系统性淋巴结清扫的必要性。

方法

回顾性分析567例肺部结节手术患者资料，使用Kruskal-Wallis检验、Spearman相关系数检测和绘制受试者操作特征曲线（receiver operator characteristic curve, ROC）等统计学方法分析患者术前D-二聚体水平与肺部结节良恶性、肺癌胸膜侵犯、肿瘤最大径、淋巴结转移情况等的相关性。

结果

术前D-二聚体的水平：肺癌患者显著高于肺部良性结节患者（P < 0.001）；肺癌伴淋巴结阳性患者显著高于淋巴结阴性患者（P < 0.001）；肺癌伴胸膜侵犯阳性患者显著高于胸膜侵犯阴性患者（P < 0.001）。肺癌患者的术前D-二聚体水平与淋巴结转移个数呈正相关（Spearman Correlation=0.264, P < 0.001），与肿瘤最大径呈正相关（Spearman Correlation=0.333, P < 0.001）。术前血浆D-二聚体水平对T1期NSCLC是否伴有淋巴结转移的最佳诊断指标为112.5 ng/mL。

结论

血浆D-二聚体水平对NSCLC患者的早期诊断、临床分期和预后判断有非常重要的临床意义，并且可以作为术中是否进行淋巴结清扫的参考指标之一。

Persistent injury-associated anemia and aging: Novel insights

BACKGROUND

Hypercatecholaminemia and bone marrow dysfunction have been implicated in the pathophysiology of persistent injury-associated anemia. The elderly may be more vulnerable to bone marrow dysfunction due to high basal and peak catecholamine levels and impaired hematopoietic progenitor growth. We hypothesized that aging would adversely affect persistent injury-associated anemia.

METHODS

Male Sprague-Dawley rats aged 8 to 9 weeks and F344-BN rats aged 25 months were randomized to naive controls, lung contusion plus hemorrhagic shock (LCHS), and LCHS plus daily chronic restraint stress (LCHS/CS). Urine norepinephrine was measured on Days 1 and 7. Mobilization of hematopoietic progenitor cells (HPCs), bone marrow colony-forming units-erythroid growth, and peripheral blood hemoglobin, mean corpuscular volume (MCV), and red cell distribution width (RDW) were assessed on Day 7 (*p < 0.05 young vs. aged counterpart by one-way analysis of variance).

RESULTS

Aged rats had higher norepinephrine levels at naive baseline (97* vs. 27 ng/mL) and 7 days following LCHS/CS when compared with young (359* vs. 127 ng/mL). Following LCHS/CS, HPC mobilization was greater among young rats when compared with aged (5.4 vs. 2.5%). Colony-forming units-erythroid growth was lower among aged animals for each group (naive: 47* vs. 65; LCHS: 40* vs. 50; LCHS/CS: 38* vs. 44 cells/plate). Aged naive rats had higher initial hemoglobin (15.2* vs. 14.3 g/dL) but lower MCV (48* vs. 59 fL/cell) and larger RDW at baseline and greater differences 7 days after LCHS/CS (MCV: 46* vs. 60 fL/cell; RDW: 17.4* vs. 16.3%).

CONCLUSIONS

Compared with young rats, aged rats had less HPC mobilization despite elevated basal and peak norepinephrine. Aged rats were disproportionately affected by impaired hematopoietic progenitor growth and an iron-restricted red blood cell phenotype at baseline, which persisted 7 days after injury. Further research is needed to assess how the clinical approach to persistent injury-associated anemia should differ for elderly trauma patients.

Myelodysplastic syndrome with myelofibrosis: myelodysplastic syndrome as a major primary disorder for acute myelofibrosis

Seven cases of myelodysplastic syndrome with myelofibrosis, which is defined using the following criteria: (1) pancytopenia with less than 5% blasts in the peripheral blood; (2) minimal or no splenomegaly; (3) myelofibrosis with cellular marrow; (4) absence of diffuse proliferation of blasts in the bone marrow; and (5) presence of myelodysplastic features of bone marrow or peripheral blood cells, are presented. They were in the range of 52-82 years old and consisted of 3 males and 4 females. Six out of 7 cases developed into acute leukaemia after 5 to 8 months from the onset and died from between 2 weeks to 8 months from the evolution to leukaemia. The type of leukaemia was acute myeloblastic in 3 patients, and acute myelo-megakaryoblastic in 3 patients. Another patient died of severe hepatic injury after 5 months from the onset of the disease. These findings revealed that the complication of myelofibrosis in the patients with myelodysplastic syndrome was an indicative sign of rapid progression to overt leukaemia or otherwise poor prognosis for survival. In addition myelodysplastic syndrome is thought to be major primary disorder for acute myelofibrosis. Myelodysplastic syndrome with myelofibrosis is closely associated with the neoplastic proliferation of megakaryoblasts in a considerable number of patients.

Comparison of hypoplastic myelodysplastic syndrome (MDS) with normo-/hypercellular MDS by International Prognostic Scoring System, cytogenetic and genetic studies

The differences in clinical features and prognosis between hypoplastic myelodysplastic syndrome (h-MDS) and normo-/hypercellular MDS (NH-MDS) remain unsettled. In this study, the characteristics of 37 h-MDS patients and 152 NH-MDS patients were compared. Peripheral-blood white blood cell counts and bone marrow blast percentage were lower in h-MDS patients than in NH-MDS patients (P=0.012 and 0.016, respectively). Refractory anemia (RA) was predominant (56.8%) in h-MDS, whereas RA with excess of blast (RAEB) was most common (44.7%) in NH-MDS. Chromosomal abnormalities -7/7q- occurred less frequently in h-MDS patients than in NH-MDS patients (0 vs 18.3%, P=0.022). There was no significant difference in the prevalence of mutations of RAS, AML1, JAK2, PTPN11, FLT3/ITD, and hypermethylation of SOCS1 and SHP1 between these two groups. International Prognostic Scoring System (IPSS) was ideal for predicting prognoses in h-MDS patients (P=0.002). In low- or intermediate-1 (Int-1)-risk MDS patients, h-MDS patients had a superior survival than NH-MDS patients (P=0.01). In conclusion, distinct from NH-MDS, h-MDS patients have different patterns of hemogram, distribution of French-American-British subtypes, cytogenetic changes and prognoses. IPSS is applicable in h-MDS as in NH-MDS. In patients with low- or Int-1-risk MDS, h-MDS patients have a better prognosis than NH-MDS patients.

Marrow fibrosis as a risk factor for posttransplantation outcome in patients with advanced myelodysplastic syndrome or acute myeloid leukemia with multilineage dysplasia

Marrow fibrosis is considered a poor prognostic factor in patients with myelodysplastic syndrome (MDS). The affect of fibrosis on outcomes after hematopoietic cell transplantation (HCT) in patients with MDS has not been examined. We performed a retrospective analysis in 471 patients with MDS or acute myeloid leukemia with multilineage dysplasia arising from MDS, 113 with and 358 without marrow fibrosis, who received myeloablative allogeneic HCT. Post-HCT follow-up was 0.3-10 years (median, 3.6 years) for patients with, and 0.6-12 years (median, 5 years) for patients without fibrosis. Engraftment was significantly delayed in patients with fibrosis (hazard ratio [HR] = 0.4; P < .001). Overall, there were no significant differences in overall survival (OS), relapse-free survival (RFS), and nonrelapse mortality (NRM) between patients with and without fibrosis. However, among patients with advanced disease (int-2 or high-risk disease by the International Prognostic Scoring System), OS (P = .03), RFS (P = .04), and NRM (P = .04) were inferior when marrow fibrosis was present. Given that marrow fibrosis is a poor prognostic factor for patients with MDS, and that it does not appear to affect outcome of transplantation in patients with earlier-stage disease but has a negative impact on outcome for patients with advanced disease, patients with earlier-stage MDS and marrow fibrosis might be considered for HCT earlier than their disease stage would normally dictate.

Histological and cytogenetic characterization of bone marrow in relation to prognosis and diagnosis of myelodysplastic syndromes

Bone marrow (BM) histology of 102 myelodysplastic syndromes (MDS) patients was analyzed retrospectively. All the cases were reclassified according to the World Health Organization (WHO) classification. Karyotype study was conducted for all except one. Fifteen of the MDS cases were hypoplastic. The cellularity in bone marrow histology is sometimes ineffective in the differential diagnosis of MDS and aplastic anemia (AA). Nonetheless, a marked decrease in the number of megakaryocytes (average, 0.3/mm(2); range, 0-2/mm(2)) even in the hyperplastic foci of the marrow of AA was the most important histological feature differentiating AA from MDS, whereas the number of megakaryocytes increased in most MDS cases (44/mm(2); range, 1-240/mm(2)) and also in hypoplastic MDS (14/mm(2); range, 8-26/mm(2)). Hyperplastic marrow had a significantly high frequency of progress to acute myeloid leukemia (AML) and hypoplastic MDS had a lower rate of progress to AML. Severe myelofibrosis had a significantly poor prognosis. An increase in CD34-positive cells in MDS indicated a high rate of progress to AML. As for the patients with refractory cytopenia with multilineage dysplasia (RCMD; the new category under the WHO classification), the increased number of megakaryocytes was correlated with poor prognosis.

Accumulation of an intron-retained mRNA for granulocyte macrophage-colony stimulating factor receptor common beta chain in neutrophils of myelodysplastic syndromes

We recently identified a reduction in the neutrophil surface expression of common beta chain (beta c) of the receptor for granulocyte macrophage-colony stimulating factor (GM-CSF) in the patients with myelodysplastic syndromes (MDS). To determine the etiology of the impaired beta c expression, beta c mRNA from neutrophilic granulocytes of MDS patients and healthy controls was analyzed by a combination of direct reverse transcriptase-polymerase chain reaction-based single-strand conformational polymorphism and sequencing. Nine different beta c transcripts were detected, but none was specific for MDS. However, one of the transcripts (beta c79) containing a 79-base intron insertion between exons V and VI was significantly increased in MDS. This 27-kd isoform consisted of the beta c N-terminal 182 amino acids followed by a new 84-amino-acid sequence. beta c79 was overexpressed in all MDS subtypes. No genomic mutations were detected within the intron or at the intron/exon boundaries. The isoform is predominantly located in the cytoplasm by Western blot analysis and was unable to generate high-affinity binding sites or transduce a signal for proliferation when coexpressed with the receptor for human GM-CSF alpha chain. Our study suggests that the accumulation of the abnormal beta c transcripts with intron V retention results in the reduction in cell-surface expression of beta c observed in MDS.

Clinical and morphological features of paediatric myelodysplastic syndromes: a review of 34 cases

BACKGROUND

The clinical and morphological spectrum of myelodysplastic syndromes (MDS) during childhood has not yet been completely documented. We herein present the clinical features and morphological data from peripheral blood (PB), bone marrow aspirates (BMA) and bone marrow biopsies (BMB) of a series of paediatric MDS patients, with particular emphasis on their specific morphological characteristics and their diverse underlying genetic background.

PATIENTS AND METHODS

Thirty-four patients with MDS (median age 8.45 y) were consecutively diagnosed and treated during a period of 15 y (1988-2002). Diagnosis was based on clinical manifestations, morphology of PB, BMA and BMB, and cytogenetic analysis of BM cells. Clonogenic methylcellulose cell cultures were performed in 23/34 patients. Patients were categorized into group A [26 primary/de novo MDS, i.e. refractory anaemia (RA) 18, RA with excess of blasts (RAEB) 2, RAEB in transformation (RAEB-t) 6] and group B (8 secondary MDS, i.e. RA 4, RAEB 1, RAEB-t 3). Treatment options varied according to protocols active during the period of the study and the availability of a suitable BM donor. Survival probabilities were estimated using the Kaplan-Meier method.

RESULTS

Dysplastic features of the erythroid, myeloid and megakaryocytic lineage were detected at BMA in 85%, 50% and 90% of the patients, respectively, while decreased cellularity was found at BMB in 21/34 patients (60%). RA patients of group A presented at BMB significant hypocellularity (14/18) as a prominent finding due to decrease of the myeloid (13/18 patients) and/or the megakaryocytic (14/18 patients) lineage. Hypocellularity in RA was accompanied by dysplasia of the erythroid (17/18 patients) and megakaryocytic (16/18 patients) lineage, the presence of abnormal localization of immature precursors (ALIP, 8/18 patients), fibrosis (5/18) and stromal changes (11/18). Chromosomal aberrations were revealed in 17/34 patients, of which monosomy 7 was present in seven. Cell cultures demonstrated abnormal myeloid and/or erythroid in vitro clonal growth pattern in all the examined patients. An associated disorder or inherited disease, was identified in 14/26 patients (54%) with primary MDS. Cumulative survival of group A patients was 44.2% (RA 66.6%, RAEB/RAEBt 14.6%; p = 0.001), and of the whole group 42.4%, at 14 y.

CONCLUSIONS

Hypocellularity of significant degree is a constant and prominent feature among paediatric MDS, especially those with RA. A large variety of associated disorders underlies the clinical appearance of paediatric MDS, reflecting their marked heterogeneity. RA represents the prominent subtype during childhood (69% in this study), and it appears to have the best prognosis, while prognosis of RAEB/RAEBt remains extremely poor.

Acute panmyelosis with myelofibrosis

Acute panmyelosis with myelofibrosis (APMF) is an ill-defined disorder that may either evolve as a clonal hematopoietic condition or as a sequel of toxic exposure to the bone marrow (BM). Therefore, controversy and discussion continues as to whether APMF may be considered as a hyperfibrotic (de novo) myelodysplastic syndrome (MDS), as acute myeloid leukemia (AML) or as a severe toxic myelopathy with accompanying myelofibrosis. In this context scant knowledge exists about BM findings, but especially evolution of this disorder according to sequential examinations. Clinically patients present with pancytopenia, a very few blasts in the peripheral blood and no or little splenomegaly. Initially BM histopathology is characterized by different degrees of reticulin-collagen fibrosis and wide ranges of cellularity with a prominent left-shifted and often macrocytic erythropoiesis associated with a reduction and maturation defects of the neutrophil series. Most conspicuous are abnormalities of the megakaryocytes including loose clustering, dislocation towards the endosteal border and appearance of atypical microforms with compact nuclei. Moreover, besides myelofibrosis in a number of patients the interstitial compartment displays a remarkable inflammatory reaction with lymphoid nodules, abundant iron-laden macrophages, perivascular plasmacytosis and increase in microvessels. Repeatedly performed BM biopsies reveal an accumulation of dispersed or clustered CD34+ and lysozyme-expressing blasts in keeping with the insidious transformation into acute leukemia. Prognosis is unfavorable with a median survival of less than 1 year. In conclusion, APMF has to be regarded as a condition that shows considerable overlappings with primary hyperfibrotic MDS, AML and toxic myelopathy (secondary MDS) with accompanying myelofibrosis and therefore can not be considered as a definite clinical entity.

Pathogenesis, classification, and treatment of myelodysplastic syndromes (MDS)

Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal myeloid disorders characterized by morphologic dysplasia in one or more cell lineages. Dysplasia in MDS is associated with insufficient production of blood cells and consecutive cytopenia(s). The natural course and prognosis of MDS vary among patients and depend on genetic defects that occur during clonal evolution. In a significant group of patients (roughly 30%) progression to secondary leukemia is observed. These patients appear to have a grave prognosis. The treatment of patients with MDS has to be adjusted to the individual situation and age in each case. In many patients, control of blast cell production by palliative cytoreduction, continuous support with red blood cells, as well as other supportive measures, seem appropriate. In other patients, however, curative therapy (chemotherapy, stem cell transplantation) should be considered. The final decision to offer curative therapy must be based on many different factors including age and the overall situation of the patient. Recently established scoring systems aimed at predicting survival and evolution of leukemia in MDS may be helpful in this regard.

Myelodysplastic syndromes, chronic myeloproliferative diseases, and myelodysplastic/myeloproliferative diseases

This article reviews the major diagnostic criteria for the myelodysplastic syndromes, chronic myeloproliferative diseases, and myelodysplastic/myeloproliferative diseases. Perhaps the most important message this article intends to convey is that the proper diagnosis and classification of myelodysplastic syndromes, chronic myeloproliferative diseases, and myelodysplastic/myeloproliferative diseases requires a multidisciplinary approach that correlates morphologic findings with clinical, genetic, and other laboratory information. Thus, the pathologist is central to the diagnosis of these disorders. Not only do pathologists have the morphologic skills to interpret peripheral blood and bone marrow aspirate smears and bone marrow biopsy specimens properly, but they often are responsible for interpretation of flow-cytometry and molecular genetic data as well. Pathologists are therefore in the best position to determine whether all the individual pieces of data fit together for the diagnosis under consideration. An additional important theme in the paper is that "well-prepared" blood and bone marrow aspirate smears and "adequate, well-processsed" bone marrow biopsy specimens are essential for the diagnosis. In the author's opinion, inadequate specimens usually account for most of the difficulties encountered in the proper diagnosis of these diseases. It is hoped that when an excellent specimen is available, the guidelines contained in this article may provide the pathologist with assistance in arriving at the most appropriate diagnosis.

Disordered hematopoiesis and myelodysplasia in the elderly

Normal hematopoiesis constitutes the process of producing diverse, differentiated blood cell types in a manner related to physiological requirement. During aging, modulation of hematopoiesis becomes disordered, impairing the ability of older people to respond appropriately to the physiological demand for blood cell replacement triggered by stimuli such as blood loss or cytoreductive chemotherapy. This may contribute to the increase in the prevalence of anemia that is observed during aging. In addition, various age-related events, such as genomic mutations secondary to oxidative stress and impaired regulation of cytokine production, may contribute to or cause the emergence of abnormal clones of hematopoietic cells. Therefore, normal hematopoiesis is disrupted, and the hematopoietic system is populated with cells that are quantitatively and functionally deficient and are also subject to leukemic transformation. These defects in the production and maturation of the various differentiated blood cells are referred to as myelodysplastic syndromes. These syndromes are so tightly associated with aging that they are considered to be geriatric disorders; they can lead to anemia, neutropenia, and thrombocytopenia and to the development of acute nonlymphoblastic leukemia. Dysregulation of mechanisms controlling hematopoiesis is therefore an important characteristic of the hematopoietic system in the elderly, but the response of progenitor cells to humoral stimulators is preserved and accounts for the effectiveness of recombinant hematopoietic growth factors used as emerging treatment modalities for hematopoietic disorders in the elderly.

A practical, comprehensive classification for pediatric myelodysplastic syndromes: the CCC system

PURPOSE

Pediatric myelodysplastic syndromes (MDS) are biologically diverse. The French-American-British (FAB) classification of adult forms of MDS is not always applicable because many pediatric patients do not fit into any of the categories. To circumvent the FAB schema and other flawed formats, the authors developed a practical classification system for childhood MDS.

PATIENTS AND METHODS

The authors analyzed 40 children with MDS diagnosed in Toronto between 1988 and 1998 to test the utility of the classification. Children were classified according to three main features: category, cytology, and cytogenetics.

RESULTS

Using this system the authors were able to classify all 40 patients; about half could not be classified by FAB. Patients could also be longitudinally classified by serial analysis to show progression of disease. Juvenile myelomonocytic leukemia was excluded because of its known myeloproliferative pathogenesis. Chronic myelomonocytic leukemia, which almost never occurs in children, was also omitted. Also excluded were other chronic myeloproliferative disorders and any cytopenias without malignant potential.

CONCLUSIONS

Based on these data, the CCC system appears to have prognostic potential; children with advanced class and cytogenetic abnormalities had a poorer outcome. The authors urge international adoption of this system for uniformity in clinical practice and reporting purposes.

A practical, comprehensive classification for pediatric myelodysplastic syndromes: the CCC system

PURPOSE

Pediatric myelodysplastic syndromes (MDS) are biologically diverse. The French-American-British (FAB) classification of adult forms of MDS is not always applicable because many pediatric patients do not fit into any of the categories. To circumvent the FAB schema and other flawed formats, the authors developed a practical classification system for childhood MDS.

PATIENTS AND METHODS

The authors analyzed 40 children with MDS diagnosed in Toronto between 1988 and 1998 to test the utility of the classification. Children were classified according to three main features: category, cytology, and cytogenetics.

RESULTS

Using this system the authors were able to classify all 40 patients; about half could not be unclassified by FAB. Patients could also be longitudinally classified by serial analysis to show progression of disease. Juvenile myelomonocytic leukemia was excluded because of its known myeloproliferative pathogenesis. Chronic myelomonocytic leukemia, which almost never occurs in children, was also omitted. Also excluded were other chronic myeloproliferative disorders and any cytopenias without malignant potential.

CONCLUSIONS

Based on these data, the CCC system appears to have prognostic potential; children with advanced class and cytogenetic abnormalities had a poorer outcome. The authors urge international adoption of this system for uniformity in clinical practice and reporting purposes.

Incidence of nucleoli in erythroblasts in patients suffering from refractory anemia of myelodysplastic syndrome

Nucleoli of erythroblasts have been studied in patients suffering from refractory anemia (RA) of myelodysplastic syndrome (MDS) and in control patients without a disturbed erythropoiesis in order to provide information on the incidence of nucleoli and micronucleoli in these cells. Nucleoli in erythroblasts were visualized by a simple cytochemical procedure for the demonstration of RNA which facilitated the visualization not only large nucleoli but also micronucleoli in advanced stages of the erythroblastic maturation. In control patients nucleoli were detected in all stages of erythroblastic development. In patients suffering from RA of MDS, a relatively large population of polychromatic and orthochromatic erythroblasts was characterized by a loss of nucleoli accompanied by the decreased incidence of micronucleoli characteristic of these cells. In contrast to control patients, in patients suffering from RA of MDS the number of nucleoli expressed by the values of the nucleolar coefficient of erythroblasts was smaller, particularly in both the early and terminal stages of erythroblastic development. Thus in patients with RA of MDS both the abnormal loss of nucleoli and decreased number of nucleoli in erythroblasts apparently represent and reflect a further abnormality of disturbed erythropoiesis.

Bone marrow changes in heart transplant recipients with peripheral cytopenia

BACKGROUND

We analyzed bone marrow changes in heart transplant recipients who develop peripheral cytopenia and underwent bone marrow biopsy (BMB). We correlated the changes in bone marrow with survival, acute and chronic rejection, infections, and malignancy.

METHODS

The test group was constituted of 64 heart transplant recipients with peripheral cytopenia, in whom 82 BMBs were performed to assess marrow quantitative (cellularity, erythropoiesis, myelopoiesis, megakaryopoiesis, fibrosis, and blast cells) and qualitative (dyserythropoiesis, dysmyelopoiesis, and dysmegakaryopoiesis) changes. The control series was constituted of 217 matchable transplant recipients without cytopenia. Statistical analysis was aimed at assessing whether: (1) cytopenia is an independent risk factor for survival; (2) acute rejection, chronic rejection, infections, and malignancy predict cytopenia; (3) the degree in BMB change allows further stratification of the risk of death; and (4) characteristics and distribution of BMB lesions vary in patients with and without acute and chronic rejection, infections, and malignancy.

RESULTS

In the test group, BMB specimens showed reduced cellularity in 68% of patients and dysplastic changes of a mild degree affecting all three marrow lines (erythropoietic in 88%, myelopoietic in 43%, and megakaryopoietic in 79%). At statistical analysis, peripheral cytopenia was an independent risk factor for survival, and malignancy proved to be a risk factor for cytopenia. Of BMB specimen changes, only dysmegakaryopoiesis showed a trend as a negative risk factor for survival. Acute rejection was associated with a high score of erythropoiesis, infections with a low score of dysmegakaryopoiesis, and malignancy with a high score of cellularity.

CONCLUSIONS

Peripheral cytopenia is an independent risk factor for survival in heart transplant recipients. Different marrow changes correlate with transplantation-related complications, i.e., acute rejection, infection, and malignancy.

Myelodysplastic syndrome: a search for minimal diagnostic criteria

We have evaluated dyshemopoietic features in bone marrow (BM) samples obtained from healthy people aged over 50 without peripheral blood (PB) cytopenia patients and compared them with MDS patients. Control group displayed BM features of dyserythropoiesis and dysgranulopoiesis in up to 15 and 27% of the considered cell elements (P90) respectively, overlapping in part with MDS patients. Interobserver agreement in dyshemopoietic features was highest for BM blast cell and pathological sideroblast counts. An algorithm based on BM blast cell and pathological sideroblast counts that has been verified on 613 patients from different Spanish centers may be of help to improve reproducibility in Myelodysplastic syndrome (MDS) diagnosis.

Bcl-2 expression by myeloid precursors in myelodysplastic syndromes: relation to disease progression

RATIONALE AND METHODS

the bcl-2 oncogene blocks apoptosis in various cell types and is expressed by normal myeloid precursors, declining with maturation. To investigate whether bcl-2 plays a role in the increase of myeloblasts in myelodysplastic syndromes (MDS) and their progression to acute myeloid leukemia (AML), we studied bcl-2 expression in initial (pre-therapy) bone marrow biopsies from MDS at early (refractory anemia, RA, with or without ring sideroblasts) and advanced stages (RA with excess blasts, and in transformation). Sequential biopsies were also studied to evaluate the effect of time or disease progression, including evolution to AML, or therapy with granulocyte colony stimulating factor (G-CSF). Early myeloid precursors (EMPs), predominantly myeloblasts, were identified in paraffin sections after immunostaining; bcl-2-positive EMPs were enumerated as a percentage of all EMPs (Bcl-2%), and by their absolute frequency per x 900 microscopic field (Bcl-2 index).

FINDINGS

in initial biopsies, the Bcl-2% and Bcl-2 index in early MDS (9.9+/-2.6 and 1.4+/-0.6, respectively; mean+/-S.E.) were significantly lower than in advanced MDS (26.4+/-3.6, 4.6+/-1.4), but similar to controls (8.1+/-0.3 and 0.8+/-0.1). The Bcl-2% and Bcl-2 index in three patients with AML evolved from MDS (57.4+/-17.9 and 85.1+/-62.4) were similar to values for seven patients with de novo AML (63.0+/-10.0, 98.4+/-29.8) and significantly higher than values for other groups. Bcl-2% showed relative increments with time or disease progression (range, 21-273%; 11 of 18 sequential biopsies from six of ten MDS patients), which was not clearly altered by G-CSF therapy (four of six patients with, two of four patients without treatment).

CONCLUSIONS

bcl-2 expression by EMPs (in both proportion and absolute number) correlated with initial MDS stage, progressed over time independent of G-CSF therapy, and was associated with evolution to AML. These data provide support for the hypothesis that MDS progression is related to accumulation of immature myeloid cells with increased bcl-2 expression and decreased apoptosis.

Myelodysplastic syndromes (MDS): prognostic factors and scoring systems

OBJECTIVE

To evaluate the score systems of Cassano and Sanz and suggest a new one.

DESIGN

Case series.

LOCATION

Teaching hospitals: EPM UNIFESP and Faculdade de Medicina de Botucatu.

PARTICIPANTS

59 patients diagnosed from 1979 to 1992.

INTERVENTION

Evaluation of clinical-laboratorial data.

MEASUREMENT

Statistical comparison, uni and multivariate analysis and actuarial survival curves.

RESULTS

Cassano's system divided the patients into high and low risk (p = 0.0966) while Sanz's gave high, intermediate and low risk (p = 0.0108). The univariate analysis showed hemoglobin, WBC count, E/M ratio, liver size and blast percentage in BM as statistically significant. The multivariate analysis showed blast percentage in BM (p = 0.004) and Hb (p = 0.050) as significant. Our system, considering the multivariate analysis data, divided the patients into high, intermediate and low risk (p = 0.0038).

CONCLUSIONS

Sanz's system was more functional than Cassano's, while ours showed predictive survival value and ease of use in clinical practice.

Epidemiological characteristics of myelodysplastic syndrome in a well-defined French population

Data on myelodysplastic syndromes (MDS) are seldom collected by cancer registries and unbiased findings from population-based studies remain rare. We report detailed information on MDS in a well-defined French population in the period 1980-1990. The crude incidence rate was 3.2 per 100000 per year and no significant change in incidence was noted in the study period. The sex ratio was 1.9 and the male predominance was present in all age groups. We observed a rise in incidence after 60 years of age but no significant change in incidence of MDS as a whole was observed over the period studied. Refractory anaemia with excess of blasts (RAEB) was the most frequent subtype. Overall 5 year transformation rate of MDS was 31% (+/- 4%) but it was 100% in RAEB in transformation. The observed 5 year survival rate was 23% +/- 3% and the corresponding corrected rate was 33%. The prognosis of RAEB in transformation was worse than the prognosis of other subtypes (P < 0.01). Discrepancies with epidemiological data from other European countries are discussed.

Hypocellular myelodysplastic syndromes (MDS): new proposals

To determine whether hypocellular MDS differs from normo/hypercellular MDS, we attempted to identify hypocellular MDS cases either by correcting the bone marrow (BM) cellularity by age (28 patients) or by using a single arbitrary value of BM cellularity (25 patients) and compared these two groups of hypocellular cases to the normo/hypercellular MDS cases (72 patients). 18 patients were common to both hypocellular groups. Patients with hypocellular MDS in both of these selected groups have similar features with regard to age and sex distribution, peripheral blood and bone marrow parameters, FAB subtypes, karyotypes, leukaemic transformation, and survival. However, the median age of patients in < 30% BM cellularity group was higher than those patients in the age-corrected group (69 years v 62 years). The selection of < 30% cellularity excluded 10 cases in the age group < 70 years but included another seven patients in the age group of > 70 years. However, correction of BM cellularity by age revealed that those included patients (selected for < 30% cellularity) who had normocellular BM by their age. Therefore we recommend the age-correcting grouping to ensure comparable series for comparison, for response to treatment, and survival. Finally, BM cellularity does not appear to be an important factor on prognosis in MDS, because patients with hypocellular MDS in both selected groups have similar prognosis to those with normo/hypercellular MDS patients.

Myelodysplasia. The clinical spectrum of 51 patients

BACKGROUND

Over a 15 year period, the authors followed 51 male patients with myelodysplastic syndromes whose clinical findings, laboratory data, and evolution demonstrated a wide spectrum of disease.

METHODS

The following characteristics were assessed: age at diagnosis, risk factors, clinical presentation, laboratory features, category of myelodysplasia, leukemic conversion, and overall survival.

RESULTS

The clinical manifestations included hemolytic episodes in two patients, antibody-mediated thrombopenia in one, marked marrow fibrosis in two; thrombocytosis in three, and simultaneous lymphoproliferative disorders in two. There were 21 patients whose marrow was either normo- or hypocellular. Six patients presented with single cytopenia but not anemia. There were six instances of overlapping of the French-American-British classification. Eighteen patients progressed to acute leukemia and 1 to chronic myelomonocytic leukemia.

CONCLUSIONS

These observations indicate that patients with myelodysplastic syndromes may have single cytopenia without anemia that progresses to acute leukemia and may, rarely, evolve into chronic myelomonocytic leukemia. The clinical aspects of these syndromes may include autoimmune phenomena and myeloproliferative features.

FAB classification of myelodysplastic syndromes: merits and controversies

Guidelines for the definition and diagnosis of myelodysplasia were set out by the French-American-British Cooperative group (FAB), and the resulting framework has greatly helped the now very large number of workers in many scientific disciplines who are actively investigating the myelodysplastic syndromes (MDS). Most patients with MDS can be readily classified into clinically relevant subgroups by correlation of clinical findings with the findings from well-prepared peripheral blood and bone marrow specimens. However, there are several areas where the standard morphological features are insensitive, but integration of these parameters with histology and cytogenetic and molecular techniques may help us in understanding this fascinating disease.

c-mpl expression in hematologic disorders

The c-mpl gene encodes a member of the hematopoietic cytokine receptor superfamily. This gene was discovered through the study of a murine retrovirus which induces an acute myeloproliferative syndrome in mice. MPLV (for myeloproliferative leukemia virus) has transduced a truncated and constitutively activated form of the c-mpl receptor chain. The c-mpl ligand is unknown, but recent data indicate that it could specifically regulate thrombocytopoiesis. This review focuses on the expression of the c-mpl gene in a large series of human hematopoietic pathologies by Northern blot analysis. Barely detectable transcript levels were detected in normal bone marrow (BM) and in BM samples from chronic myeloproliferative disorders, plasmocytoma, Burkitt lymphoma or acute lymphoid leukemia. In contrast, high levels of c-mpl expression were detected in 45% of acute myeloid leukemia (AML). No correlation was found between c-mpl expression and the French-American-British classification subtype of AML. However c-mpl expression correlated with CD34 expression, and unfavorable cytogenetic abnormalities, defining a subgroup of AML with a low rate of complete remission. In myelodysplasia, c-mpl expression was elevated in 44% of chronic myelomonocytic leukemia (CMML), 42% of refractory anemia with excess myeloblasts (RAEB), and RAEB in transformation to acute leukemia (RAEBt), but not in refractory anemia (RA) and RA with ringed sideroblasts (RARS). In CMML, there was no correlation between c-mpl expression and any prognostic factor tested, nor with the course of the disease. The biologic significance of c-mpl expression in RAEB and RAEBt is probably different.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone marrow cellularity in myeloid stem cell disorders: impact of age correction

We have reviewed the initial diagnostic bone marrow aspirate and biopsy specimens performed on the same date on 92 patients with acute myeloid leukaemia (AML), 100 patients with myelodysplastic syndrome (MDS), 24 patients with chronic granulocytic leukaemia (CGL), 19 patients with polycythemia vera (PV) and essential thrombocythemia (ET). An excellent assessment of cellularity by aspirate and biopsy was found. The estimation of BM cellularity for each group was utilized with and without age adjustment based on normal marrow biopsies. Without correcting the BM cellularity for age it was observed that the median BM cellularity was > 50% in AML, CGL, PV and ET. In contrast, the median BM cellularity was estimated at 40% for MDS. In the age group 70 years and beyond the median BM cellularity was not changed in CGL, PV and ET, and only slightly decreased (35%) in MDS. However, a trend from hypercellularity to normocellularity was observed in patients with AML in this age group. By utilizing anatomic comparisons with normal age the corrected data disclosed that all patients with CGL, PV and ET, 63% of patients with AML and only 35% of patients with MDS had hypercellular BM according to their age, while only two patients with AML and seven patients with MDS were found to be truly hypocellular by age. The optimal cut-off value for definition of hypocellular AML and hypocellular MDS, and differences between MDS and other myeloid stem cell disorders in terms of BM cellularity have been discussed.

CD34 immunohistochemistry of bone marrow biopsies: prognostic significance in primary myelodysplastic syndromes

Bone marrow (BM) biopsies from 58 patients with primary myelodysplastic syndrome (MDS) were studied using QBEND10, a monoclonal antibody that recognizes the human progenitor CD34 antigen in routine aldehyde-fixed paraffin-embedded samples. FAB subtypes were RA (5 patients), RARS (9 patients), RAEB (20 patients), RAEBt (11 patients), CMML (3 patients). In addition, 10 MDS patients whose BM biopsies revealed heavy reticulum fibrosis were included. Neither the percentage of CD34+ cells nor the number of CD34+ aggregates (defined as clusters of 3 or more cells) correlated with the presence and morphology of abnormal localizations of immature precursors (ALIP). When all patients were considered, median survival was 69 months in those with less, and 25 months in patients with more than 1% CD34+ cells (P < 0.05). Median survival was 15 months in patients with CD34+ aggregates and 41 months in those without aggregates (P = 0.0017). When RAEB patients were considered median survival was 41 months in those with less than 1%, and 29 months in those with more than 1% CD34+ cells; the 4-year survival chance was 45% in the former and 18.3% in the latter group. Therefore, CD34 positivity of more than 1% identifies a subset of RAEB patients with shorter life expectancy. In addition, leukemic transformation was observed in 11 of 35 patients (31%) with no CD34 aggregates, but in 14 of 23 patients (60%) with aggregates (P < 0.05). CD34 immunostaining, which can be easily performed on routinely prepared BM biopsies, was found to be a powerful prognostic tool for predicting survival and outcome in MDS.

Trisomy 14, deletion 20q and t(3;3) (q21;q26) in a case of myelodysplastic syndrome with myelofibrosis

We describe a patient with trilineage myelodysplasia and hyperplastic megakaryopoiesis associated with significant myelofibrosis at diagnosis, who developed acute myeloid leukaemia two months afterwards. The clinical and pathological features were consistent with a myelodysplasia/myelofibrosis syndrome with leukemic transformation. Cytogenetic investigation showed trisomy 14, del(20q) and t(3;3) (q21;q26). These findings are of possible significance in the understanding of the association between myelodysplasia and myelofibrosis.

Haemopoietic regrowth after chemotherapy for acute leukaemia: an immunohistochemical study of bone marrow trephine biopsy specimens

AIM

To analyse haemopoietic regrowth and residual disease in bone marrow trephine biopsy specimens after treatment for acute leukaemia, using immunohistochemical staining.

METHODS

Biopsy specimens before and after treatment were studied from patients diagnosed as having acute myeloid or lymphoblastic leukaemia. Specimens after treatment encompassed periods from two to 56 weeks from the start of treatment. Routine haematoxylin and eosin and Giemsa stained sections were evaluated in association with immunostained preparations. A panel of antibodies was used, which reacts with epitopes showing restricted expression dependent on the lineage or maturation stage of cells. Results were evaluated in the light of clinical, peripheral blood, and marrow aspirate findings.

RESULTS

The speed and sequence of regrowth of haemopoietic cells were more variable than expected. Immunostaining highlighted features of dysplasia after treatment and in some cases assisted detection of residual or relapsed leukaemia. Peripheral blood and aspirate cell counts reflected accurately the amount of regrowth, but not the dysplasia, seen in biopsy samples. Delayed regrowth was associated with complex individual factors.

CONCLUSIONS

Morphological and immunohistochemical study of trephine biopsy specimens from patients treated for acute leukaemia provides information complementary to that obtained from peripheral blood and aspirated marrow. Variation in the timing and sequence of regrowth is highlighted. Immunostaining can aid in the detection of relapse or minimal residual leukaemia. The clinical relevance of dysplastic changes in biopsy specimens after treatment is uncertain, but such changes may persist for long periods.

Collagenase digestion of bone marrow trephine biopsy specimens: an important adjunct to haematological diagnosis when marrow aspiration fails

Failure to obtain sufficient material from marrow aspiration (dry tap) posed a diagnostic problem in two patients with pancytopenia. By using collagenase digestion of the trephine biopsy specimen, a precise diagnosis was reached. This technique is very useful because it permits flow cytometric and immunocytochemical analyses of cell suspensions obtained after collagenase digestion of the trephine biopsy specimen core. Acute leukaemia presenting with a dry tap can therefore be accurately immunophenotyped. The technique is easy to perform and merits wider use.

Clinical and cytogenetic significance of myelodysplastic syndromes with disease evolution

We performed a retrospective study of 83 patients with myelodysplastic syndrome (MDS) to clarify the clinical and cytogenetic implications of disease evolution. Twenty-three patients showed disease progression; six of the 11 patients whose disease evolved within 100 days showed complex cytogenetic aberrations and most of them died within 300 days. Of the patients who survived more than 300 days, those with high bone marrow (BM) blast percentages experienced significant disease progression, but we noted no cytogenetic indicators for disease evolution at the later phase. Sixty percent of patients showing karyotypic evolution without disease evolution had deletion-type chromosome changes. The most frequent anomaly in patients with disease evolution who survived more than 300 days was an additional numerical change, whereas patients with disease evolution who survived less than 300 days showed karyotypic instability. It was difficult to predict disease progression for patients whose disease evolved more than 300 days after diagnosis, but in some patients the presence of additional numerical changes was related to disease progression. The cutoff level of early disease evolution was 100 days after diagnosis, and most patients with complex abnormalities survived less than 300 days with or without disease evolution.

The bone marrow trephine biopsy: a review of normal histology

Bone marrow trephine biopsies are becoming increasingly common in routine surgical pathology. Familiarity with normal marrow histology plays an important part in understanding and interpreting marrow pathology. The aim of this article is to describe the histological features of normal human bone marrow, in particular those features which are relevant to the diagnostic pathologist. The advantages and disadvantages of different technical aspects, such as choice of embedding material and type of stain, are discussed. The use of immunochemistry in identifying different cell types within the marrow is illustrated.

Hypoplastic myelodysplastic syndrome: incidence, morphology, cytogenetics, and prognosis

The present study, based upon the retrospective evaluation of 352 patients with primary myelodysplastic syndrome (pMDS), revealed hypoplastic MDS in 42 patients (11.9%). Median age is similar in hypo- and normo-/hypercellular MDS (72.6 versus 70.7 versus 72.4 years). Hypoplastic MDS occurred significantly more often in women compared with normo- and hypercellular MDS. Sequential biopsies were performed in 14 patients, showing a persistence of hypoplasia over a period of up to 43 months. The proportion of patients showing mesenchymal reaction, especially an increase of mast cells, was significantly higher in hypoplastic MDS, whereas dysplastic features of hematopoiesis occurred less frequently and were of lower grade in comparison to normo-/hyperplastic MDS. Among the subgroup with hypoplastic bone marrow, the classification according to FAB criteria revealed 28 patients with RA (66.7%), three with RARS (7.1%), and eight with RAEB (19.0%), as well as one patient each with RAEB-T and CMMol (2.4% each), and one case which had to be reckoned among the category of unclassifiable MDS (2.4%). Median survival was 21.8 months for hypoplastic MDS, 26.9 months for normoplastic MDS, and 14.2 months for hyperplastic MDS. During follow-up, 14 patients (33%) with hypoplastic MDS developed acute nonlymphatic leukemia. Although not a constant finding, karyotype abnormalities involving particularly chromosome 7 seem to be associated with hypoplastic MDS. The results confirm the existence of a hypoplastic variant of MDS which seems to more frequently affect female patients, and which requires bone marrow biopsy for its accurate diagnosis.

Myelodysplastic syndrome: diagnostic implications of cytochemical and immunocytochemical studies

Cytochemical and immunocytochemical studies were performed on bone marrow aspirates from 96 cases of primary myelodysplastic syndrome (MDS), 11 cases of secondary MDS, 22 cases of non-MDS hematologic disorders, and 10 cases of nondiagnostic, apparently normal marrow specimens to determine the practicality and utility of these stains for diagnosing MDS. Cytochemical studies included iron stain, periodic acid-Schiff (PAS), peroxidase, butyrate esterase, chloroacetate esterase, and double esterase stains. Immunocytochemical staining was done with monoclonal antibody HP1-1D, which recognizes the glycoprotein IIb/IIIa complex in megakaryocytes. The iron stain remained most helpful in identifying abnormal ringed sideroblasts, a feature of dyserythropoiesis, and thus in supporting the diagnosis of MDS. The PAS stain was helpful, if positive, in identifying patients with MDS; however, when it was negative, this stain did not help distinguish MDS from non-MDS hematologic disorders. The immunocytochemical stain with HP1-1D monoclonal antibody was also helpful in identifying atypical micromegakaryocytes, indicative of dysmegakaryopoiesis. Other cytochemical abnormalities were infrequently observed and were less specific for the diagnosis of MDS. The combination of two stains--for example, PAS and iron stain or PAS and double esterase--was helpful, however, in excluding MDS, inasmuch as neither the miscellaneous nor the control group stained positively with these combinations.

Reticulocyte count with maturation fractions in pancytopenic evaluation by a fully automated counter

Using a fully automated reticulocyte counter, the roles of the reticulocyte count with maturation in pancytopenia were evaluated. Different groups of pancytopenia including aplastic anemia, infiltrative marrow disorder, hypersplenism, and megaloblastic anemia were recruited. All patients had bone marrow examinations for morphological diagnosis and reticulocyte evaluation using an automated counter. The roles of these parameters were then analyzed statistically in the differential evaluation among these conditions. The following subjects were studied: 292 normal subjects, 67 cases of aplastic anemia, 69 cases of marrow infiltration by different malignancies, 35 cases of hypersplenism, and 13 cases of megaloblastic anemia. The results showed that the absolute reticulocyte counts were lowest in the groups of aplastic anemia and megaloblastic anemia and highest in hypersplenism. Both showed significant differences from the infiltrative groups. The maturation fractions were most immature in the group of marrow infiltration and are significantly different from the other groups. It was concluded that the highest absolute reticulocyte count (> 0.09 10(12)/L) obtained in pancytopenic patients suggests it to be a case of hypersplenism. The lowest counts (< 0.03 10(12)/L) with lowest immature fractions (< 10%) suggest the groups of aplastic or megaloblastic anemias. The highest immature fractions (> 30%) with a nearly normal reticulocyte count favor the group of marrow infiltration.