Bone Marrow

Introductory lecture

Objectives
This lecture is designed to provide general knowledge of
hematopoiesis and bone marrow examination. By the
end of the learning, you should be able to:
Know the normal hematopoiesis
Assess the cellularity and M:E ratio
Recognize hematopoietic cells of different lineages and at
different maturation stages
Recognize abnormal cells
Recognize normal structures of the bone marrow
Recognize abnormality on the biopsy: leukemia, metastasis,
granuloma, fibrosis, dysplasia
Assess iron and fibrosis

H
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50-100 x
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50-100 x 10

Bone Marrow Works Really Hard! Production/day

Neutrophils

1x 109/kg)

Erythrocytes

150-200 x 109

(2x 10 /kg)

Platelets

150-200 x 109

(2x 10 /kg)

Bone Marrow Examination

Always in combination with:
Clinical history of the patient, indication?
Complete blood cell count, including platelet count and
reticulocyte count, should be performed on the day of the
marrow study
Peripheral Smear

Bone Marrow specimen includes:

BM core cellularity, architecture, M/E ratio etc

BM aspirate morphology, iron, cell count etc
BM touch prep if aspirate fails, may get some marrow
Special studies cytogenetics, flow cytometry etc

Examination of Marrow
Cellularity: the ratio of the volume of hematopoietic
cells to the total volume of the marrow space (cells
plus fat and other stromal elements)
Cellularity varies by age and location
Best evaluated on bx

Are all lineages present

Number of megakaryocytes
Distribution of cells
- Scan low power for abnormal patterns
Abnormal cells
Diff count

Bone marrow cellularity normally

decreases with age.
Cellularity decrease every year
after birth.
Very rough guideline:
Normal % = 100 age
Actually after 20 or 25 yd, the
decrease decreases, cellularity
reaches plateau, 40-70%, until
70 yd (<30%).
Some book says, after 6 yd,
cellularity is close to adult.
Also consider conditions like
osteoporosis, low cellularity not
equal to marrow hypoplasia

Diff count: the normal values vary from study to study, and
there is no unified reference range. Always consider pts info to
interpret the results. Blast count, M:E ratio are important for
most of the cases. Developmental alteration (maturation arrest
or left shift) be more carefully evaluated in certain cases.

Aspirate smear:
-Cellularity
-Diff count
-Morphology
- dysplasia, abnormal
cells, blasts

- iron

Morphology of erythroid series

Morphology of RBC Precursors

Pronormoblast , largest in the series,

with a large round nucleus, fine
chromatin and basophilic cytoplasm
(Wright-Giemsa)

Basophilic normoblasts with

chromatin condensation and
deeply basophilic cytoplasm

Polychromatophilic
normoblast with light
blue cytoplasm due to
accumulation of
hemoglobin

Othochromatic
normoblast with
pyknotic nucleus and
pink-gray cytoplasm

Reticulocyte
(polychromatophilic
erythrocyte) with pinkgray cytoplasm due to
residual RNA

Siderophage with associated normoblasts

(part of an erythroblastic island) in the bone
marrow

Morphology of Neutrophil Precursors

Myeloblast

Metamyelocyte

Promyelocyte

Band neutrophil

Myelocyte

Segmented neutrophil

Myeloblast:
15 m in diameter with a moderately
high N/C ratio;
a large oval to quadrangular nucleus;
very fine, uniform chromatin pattern;
delicate nuclear membrane; and two to
five nucleoli
The cytoplasm is pale, clear blue, and
without granules.

Promyelocyte:
slightly larger than the myeloblast.
The nuclear chromatin begins to
condense, and the nucleoli are less
obvious.
The cytoplasm is basophilic and is filled
by more and more azurophilic granules.

Myelocytes:
secondary granules in the
cytoplasm and show
condensation of nuclear
chromatin.
persistent primary granules are
seen in early myelocytes
(center-right) and are lost as
myelocytes mature.

Metamyelocytes:
nuclear indentation (<1/2
diameter) and increased
chromatin clumping

Band neutrophil:
Mature nucleus with clumped
chromatin but without segmentation

Segmented neutrophil:
Multiple nuclear lobes joined by
fine chromatin filaments

Morphology of Eosinophils

Eosinophil myelocyte with ovoid

Mature eosinophil with bilobed
nucleus and eosinophilic secondary nucleus and large eosinophilic
granules in the cytoplasm.
cytoplasmic granules. Mature
eosinophils express CD16 and
CD32.

Morphology of Basophils and mast cells

Mature basophil with large dark

red-purple basophilic granules
that partially obscure the
nucleus (usu. bilobed)

Bone marrow mast cell shows

numerous uniform purple
granules in the cytoplasm that
partially obscure the nucleus
(usu. nonlobated round)

Morphology of Monocytes

Promonocytes have fine

nuclear chromatin, often with
visible folds and basophilic
cytoplasm that may contain
vacuoles

Mature monocyte with an

indented nucleus, delicate
chromatin, basophilic cytoplasm
and fine azurophilic granules

Morphology of Megakaryocytes

Megakaryocyte with a large, lobated

nucleus and abundant granular
cytoplasm

Dwarf megakaryocyte with bilobed

nucleus and scant granular cytoplasm; a
few giant platelets are also seen. These
cells are most often associated with
myeloproliferative or myelodysplastic
disorders

*
#

Hematogones (*): larger than the average mature lymphocyte, have scant cytoplasm,
and a fine, soft chromatin texture. # myeloblast.

BM Iron stain
Perls Prussian blue:
Best performed on bone marrow
aspirate smears

Intracellular stores should be

evaluated, extracellular stores can
be confused with artifact
Most intracellular iron is in
macrophages, a small amount in
erythroblasts (sideroblasts)
Normally 20-50% of erythroblasts
are sideroblasts
Ringed sideroblasts are atypical,
with iron in mitochondria forming a
ring around nucleus

Perls Prussian Blue

Ring sideroblasts:
>5 granules
>1/3 of nucleus

BM biopsy:
- Cellularity, M:E
- Structure
- Distribution of cells
- Abnormal cells
- Fibrosis
- Megakaryocyte: num, morph

Periosteum

Cortical bone
Subcortical
hypocellular
region

Bony
trabeculae

Hematopoietic
tissue

M:E Ratio
Erythoid
Myeloid

Normal range
2:1 to 4:1

Myeloid Maturation
Normal: immature myeloid elements are
paratrabecular or perivascular.
Abnormal localization of immature precursors
(ALIP)- clusters of 5-8 myeloblasts/
promyelocytes in the central portion of the
marrow, away from vascular structures and
endosteal surface of the boney trabeculae
(WHO: 3 or more such foci is ALIP +, and is
associated with RAEB)

Normal localization of myeloid cells

paratrabecular

Blasts
Promyelocytes

perivasular

Neutrophilic myelocyte
Eosinophilic myelocyte
Endothelial cell

central

Neutrophil
Erythroid island

Bone Marrow Fibrosis

Reticulin Stain