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World Health Orga nization Classifica tion of Tumours

Hamilton SR. Aartonen LA (Eds.) :

World Health Organization

Classification of Tumours ,
Patholog y and Genetics of Tumours

of the Digestive System (3rd edition) .

IARC Press: lyon 2000
ISBN 92 832 241 0 8

Eble J .N., Sauter G . Epstein J E.,

Sesterreon l.A . (Eds.) World Health
Organization Classification of
Tumours. Pathology and Genetics of

Tumours althe Urinary System and

Male Genital Organs (Jrd ed ition)
fARe Press : lyon 2004
ISBN 92 832 2415 9
Barnes L , Eveson J .W , Reichart P"
Sidransky 0 (Eds.): World Health

Organization Classification of
Tumours. Pathology and Genetics of
Head and Neck Tumours (3I"d edition) .
IARC Press : lyon 2005
ISBN 92 832 24 17 5

Organization Classification 01
Tumours. Patho logy and Genetics 01
Tumours of Soft Tissue and Bone
(3rd edition).
IARC Press : lyon 2002
ISBN 92 832 2413 2

Tavassoli F A .. Devilee P. (Eds .):

World Health Organization
Classification 01 Tumours .
Pathology and Genetics of Tumours
of the Breast and Female Genital
Organs (3rd edition).
IARC Press : lyon 2003
ISBN 92 832 2412 4

Travis wo., Brambilla E., Muller

Hermelink H.K ., Harris C .C. (Eds.):
World Health Organization
Classification 01 Tumours. Pathology
and Genetics of Tumours of lung
P1eu"a. Thyrrus and Heart (3I"d edi\lon),
IARC Press : lyon 2004
ISBN 92 832 2418 3

Delellis A.A., lloyd A.V, Heitz, P.U.,

Eng C . (Eds.): World Hea lth
Organization Classification of
TlJTlOUrs. Pathology and Genetics ot
TlJTlOUrs of Endocrine Organs (3rd
IARC Press : lyon 2004
ISBN 92 832 2416 7

Fletcher C.D.. Unni KK.,

Mertens F. (Eds,): World Health

leBoit P.E.. Burg G , Weedon D.,

Sarasm A . (Ed s.): World Health
Organization Classification of
Tumours. Pathology and Genetics of
Skin Tumou rs (3rd edition).
IA RC Press : lyon 2006
ISBN 92 832 2414 0

louis D.N" Ohgaki H ., WiesUer D.O.,

Cavenee WK (Ed s.) : World Health

Organization Classification of
Tumours . Tumours of the Central
Nervous System (4th edition ).
IARC, lyon 2007
ISBN 92 832 2430 2

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International Agency for Research on Cancer (IARC)

4th Edition

WHO Classification of Tumours of

Haematopoietic and Lymphoid Tissues
Edited by

Steven H. Swe rdlow

Elias Campo
Nancy Lee Harris
Elaine S. Jaffe
Stefano A. Pileri
Harald Stein
JOrgen Thiele
James W. Vardiman

Intern ational Agency for Resea rch on Cancer

Lyon , 2008

World Health Organization Classification of Tumours

Series Editors

Fred T. Bosman, M.D.

Elaine S. Jaffe. M.D.
Sunil R. Lakhani. M.D.
Hiroko Onqaki, Ph.D.

WHO Classification of Tumours of the Haematopoietic and Lymphoid Tissues


Sleven H. Swerdlow, M.D.

Elias Campo. M.D.
Nancy Lee Harris, M.D.
Elaine S. Jaffe , M D.
Stefano A. Pileri. M.D.
Harald Stein, M.D.
JOrg en Thiele, M.D.
James W. Vardi man, M.D.


Sebastien Antoni
Marlen Grassinger
Pascale Collard

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This volume was produced with support from the

Associazione S.P.E.S. Onlus, Bologna

Friends of Jose Carreras International Leukemia Foundation
Leukemia Clinical Research Foundation
MEDIC Foundation
National Cancer Institute, USA
National Institutes of Health Office of Rare Diseases, USA

University of Chicago Cancer Research Center

The WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues

presented in this book reflects the views of a Working Group
that convened for an Editorial and Consensus Conference at the
International Agency for Research on Cancer (fARC), Lyon
October 25-27. 2007.
Members of the Working Grou p are indicated
in the List of Contributors on pages 369-374.

Published by the International Agenc y for Research 00 Cancer (IARC),

150 cou rs Albert Thomas, 69372 Lyon ceoex 08, France

C International Agency for Research on Cancer, 2008

Distributed by
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The authors alone are responsible fOf the views expressed in this pubhcatlQfl.
The copyright of figures and charts remains with the authors
(see source 01 charts and photographs. page 376--379)

Format for bibliographic citations:

Swerdlow S.H., Campo E., Harris N,L., Jaffe E.S" Pileri S.A., Stein H" Thiele J , Vardiman J.w. (Eds.):
WHO Classification of Tumours of Haematopoietic and Lympho id Tissues,
IARC: Lyon 2008

IARC Ubrary Cataloguing in Publication Data

WHO Classific ation of Tumou rs of Haematopo ietic and Lymp hoid Tissues
Edited by Swerdlow S.H.. Campo E., Harris NL , Jaffe E.S. Piled SA, Stein H., Thiele J .. Vardiman JW.

1. Haematopoie hc System Neop lasms - genetics

2. Haematopoielic System Neop lasms - pathology

I. Swerdlow. Steven H.
ISBN 978-92-832-243 1-0

WHO Classifjcatioo
Summary table
Introduction to the classification of tumours of
haematopoietic and lymphoid tissues
Introduction and overview of the classification of
the myeloid neoplasms

2 Myeloproliferative neoplasms



Chronic myelogenous leukaemia. BCR-ABL 1 positive 32

Chronic neutrophilic leukaemia
PoIycythaemia vera
Primary myelofibrOsis

Chronic eosinophilic leukaemia. NOS

Cutaneous mastocytosis
Systemic mastocytosis
Masl cell leukaemia

Mast cell sarcoma

Extracutaneous mastocytoma
Myeloproliferative neoplasm, unc lassi fiable





3 Myeloid and lymphoid neoplasms with

eosinophilia and abnormalities of PDGFRA.



4 MyelodysplasticJmyeloproliferative neoplasms
Chronic mveiomonocync leukaemia
Atypical ctYonic myeloid leukaEmia. BCR-ABL 1 negative 80
Juvenile myelomonocytic leuk aemia
MyelodysplastiC/myeloproliferali ve neoplasm ,

5 Myelodysplastic syndromes
Myelodysplastic synd romes/n eo plasms , overview
Refractory cytope nia with unilineage dysplasia
Refractory anaemia with ring side rob lasts
Refractory cytopenia with multilineage dysplasia
Refractory anaemia with exc ess b lasts
Myelodysp lastic synd rome with isolated de l(5q)
Myelodysp lastic synd rome, uncrasslttabte
Childhood mye lodysp lastic synd rome
Refractory c ytopenia of c hild hood


6 Acute myeloid leukaemia (AML) and

related precursor neoplasms
AML with recurrent genet ic abn or malities
AML with t(8:21 )(q22:q22); RUNX1 -RUNX1T1
AML with inv( 16)( p 13.1q22) or
1(16:t6)(p 13.1;q22): CBFB-MYH 11
Acute orornveiocvnc leukaem ia with
t(15:17)(q22 :q 12): PML- RARA
AML with us.11)(p 22:q 23): MLLT3-MLL
AML with t(6:9)(p23 :q34); DEK-NU P2 14
AML with inv(3)( q2 1q26 .2) or t(3;3)( q2 1;q26.2);
AML (megakaryoblastic) with t( 1;22)(p13;q 13):

11 0
11 0
11 1
11 2

AML with mutated NPM 1

AMLwith mutated CEBPA
AML with myelo dysplas ia-related changes
Therapy -relate d myeloid neoplasms
Acu te myeloid leukaemia, NOS
AML with minimal diff erentiation
AML withOut matu ration
AML with maturabon
Acute myelomonocytic leukae mia
Acute monoblastic and monocytic leukaem ia
Acute erythroid leukaemia
Acu te megakaryoblastic leukaemia
Acute basophilic leukaemia
Acu te paomveosrs with myelofibros is
Myeloid sarcoma
Myeloid proli ferations related 10 Down synd rome
Transient abnOrmal myelopoiesis
Myeloid leukaemia associated with
Dc:rwn syndrome
Blastic plasmacytoid dendritic cell neoplasm

7 Acute leukaemiasof ambiguous lineage

Acute undlHerentiated leukaemia
Mixed phenotype acute leukaemia wilh
t(9;22)(q34;q 11.2): BCR-ABL 1
Mixed phenotype acute leukaemia with
t(v:11q 23): MLL rear ranged
Mixed phenotype acute leukaemia , B/myeloid, NOS
Mixed phenotype ac ute leukaemia , T/myeloid , NOS
Mixed phenoty pe acu te leukaemia, NOS rare
Other ambiguous lineage reukaerraes
Natura! killer (NK)-celilympho blastic
leukaemi a/lymphoma

15 1
t 55

8 Introduction and overview 01 the c lassification of

the lymphoid neoplasms

9 Precu rsor lymphoid neoplasms

B lymp hob lastic leukaemia/lymphoma, NOS
B lymphob lastic leukaemia/ lymphoma
with recu rrent gene tic abn orma lities
B lymphob lastic leukaem iallymphoma with
t(9 :22)(q 34;q 11.2): BCR-ABL 1
B lymp hoblastic leukaemia/ly mpho ma with
l(v:11q 23): ML L rearranged
B lympho blastic leukaemiall ymphom a with
t(12:2 1)(p1 3;q22 ): TEL-AMLl (ETV6--RUNX 1)
B lymphoblastic leukaemia/lymphoma with
hyperdi ploi dy
B lymphoblastic leukaemiallymphom a with
hypodiplOi dy (Hypodiploi d ALL)
B lymphoblastic leukaemiallymphoma with
t(5; 14)(q31;q32); IL3-IGH
B lymphoblastic leukaemiallymphoma with
t( 1;19) (q23:P13.3): E2A-PBX1( TCF3-PBXI)
T lymphoblastic leukaemiallymphoma



10 Mature B-ceUneoplasms
Chronic lymphocytic leukaemia Ismail
Iympt'locytic lymphoma :f
s-een prolyrTlhocytic leukaemia
Splenic B-cell marginal zone lymphoma
Hairy cell leukaemia
Splenic B-cell Iymphomalleukaemia, unclassiliable
Splenic diffuse red pulp small B-ceil lymphoma
Hairy cenleckaeme-....anent
lymphoplasmacytic lymphoma
Heavy chain diseases
Gamma heavy chain disease
Mu heavy chain disease
Alpha heavy chain disease
Plasma cell neoplasms
Monoc lonal gammop athy 01 undetermined
significance (MGUS)
Plasma ce ll myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Monoclonal immunoglobulin deposition diseases
Extranodat marginal zone lymphoma of mucosaassocia ted lymphoid tissue (MALT lymphoma)
Nodal marg inal zone lymphoma
Follicular lymphoma
Primary cutaneous follicle centre lymphoma
Mantle cell lymphoma
Diffuse large B-celllymphoma (DLBCl), NOS
T celilhi stiocyte-rich large B-ce ll lymphoma
Primary DlBCL of the CNS
Primary cutaneous DlBCl . leg type
EBV positive DLBCl of the elderly
DLBCL assoc iated with chronic inflammation
Lymphomatoid granulomatosis
Primary med iastinal (thymic) large B-celilymphoma
Intrav escurer large B-celi lymphoma
ALK positive large Been lymphoma
Plasmablastic lymphoma
large a-ceu lymphoma arising in HHV8-associated
multicent ric Castleman disease
Primary effusion lymphoma
Burkitllymp homa
B-cel1lymphoma, unclassiliab le, with features
intermediate between DLBCL and
B-ceillymphoma, unctessmebie. with features
intermediate between OLBCl and
clas sica l Hodgkin lymphoma
11 Mature T- and NK-cell neoplasms
r-cea prolymphocytic leukaemia
t- een large granular lymphocytic leukaemia
Chronic Iymphoproliferative disorder of NK cells
Aggressive NK cell leukaemia
Epstein-Barr virus (EBV) positive t-een
Iymphoprol ilerative diseases of ch ildhood
Systemic EBV+ t-een Iymphoproliferalive
disease of childhood
Hydroa vacclnrtorrne-uk e lymphoma
Adull T-ceil leukaemia/lymphoma
Extranodal NK/T-cell lymphoma. nasal type



Enteropathy -associated t-een lymphoma

Hepatosplenlc t -een lymphoma
Subcutaneous panniculitis-like t-een lymphoma
Mycosis fungoi des
Sezary syndrome
Primary cutaneous CD30 posi tive t-een
Iymphoprolilerative disorders
Primary cutaneous per ipheral t-een lymphoma s,
rare subtypes
Primary cutaneous garnna-della T-cen lymphoma
Primary cutaneous COB positive agg ressive
ep idermotrop ic cytotoxic T-celt lymphoma
Primary cutaneou s CD4 positive
small/medium T-cell lymphoma
Peripheral t-een lymphoma. NOS
Ang ioimmunoblastic t -een lymphoma
Anaplastic large cell lymphoma. AlK positive
Anapla stic large cell lymphoma . ALK negat ive








12 Hod gkin lymphoma

Nodular lymphocyte predominant Hodgkin Iymptuna
Classical Hodgk in lymp homa. introduction
Nodular sclerosis classical Hodgkin lymphoma
Mixed ce llularity classical Hodgkin lymphoma
Lymphoc yte-rich classical Hodgkin lymphoma
lymphocyte-depleted classical Hodgkin lymphoma

32 1


13 1rnmunode ficiency-assoc iated

Iymphoproliferative disorde rs
Lymp hoproliferative diseases associated with
primary immune disorders
Lymphomas associa ted with HIV infection
Post-nansotanttsmpnooronterauve disorders (PTlD) 343
Plasmacytic hyperp lasia and infectiousrroooo ocieose-uke PTlD
Polymorphic PTlO
Monomorph ic PTlO
Classical Hodgkin lymphoma type PTLO
Other iatrogenic immunodeficiency-assoc iated
Iymphoproliferative disorders
14 Histiocytic and dendritic cell neoplasms
Introd uction
Histiocyt ic sarcoma
Tumours der ived from langerhans cells
Langerhans cell histiocytosis
Langerhans ce ll sarcoma
Interdigitating dendrit ic cell sarcoma
Follicular de ndritic ce ll sarcoma
Other rare dendritic cell tumours
Disseminated juvenile xanthogranuloma

Clinical advi sory oorrrnittee
Source of Charts and photographs
Subject index
NOS, no! otherwise specifi ed



36 1




WHO Classification
4th Edition








WHO Classification of tumours of haematopoietic

and lymphoid tissues


Chronic myelogenous leukaemia ,

BCR-ABL 1 positive


Chronic neutrophilic leukaemia

996 3/3

Polycythaemia vera

995 0/3

Primary myelofibrosis

996 1/3

Essential thrombocythaemia


Chronic eosinophilic leukaemia, NOS

9964 /3


Cutaneous mastocytosis

9 74011

Systemic mastocytosis

9 74 1/3

Mast cell leukaemia

974 213

Mast cell sarcoma

974 0/3

Extracutaneous mastocytoma

974 0/1

Myeloproliferative neoplasm , unctassitlable

Refractory anaemia


Refractory neutropenia

999 1/3

Refractory thrombocytopenia


Refractory anaemia with ring sideroblasts


Refractory cytopenia with

multitineage dysplasia


Refractory anaemia with excess blasts


MyelodysplasUc syndrome
associated with isolated del(Sq)

Myelodysplasticsyndrome, uncJassifiable


Childhood myelodyspla suc syndrome

Refractory cytopenia of childhood






AML with recurr ent genetic abnormalities

AML with t(6 ;21)(q22;q2 2);



AML with inv(16)(pI 3.1q22 )

or t(16;16)(pI3.1;q2 2); CBFB-MYHl1


Acute promyelccytlc leukaemia

with t(15 ;17)(q22 ;qI2); PML-RARA


AML with t(9 ;11)(p22 ;q23); MLLT3-MLL


AML with 1(6;9)(p2 3;q34 ); DEK-NUP214



AML with inv( 3)(q2 1q26.2)

ort(3; 3)(q21;q 26.2); RPNI -EV/1


Chronic myetcmonocytic leukaemia


Atypical chronic myeloid leukaemia.

BCR-ABL 1 negative

AML (megakaryoblastic)
with t(I ;22)(p I 3;q I 3); RBMI5-MKLI



AML with mutated NPM1

986 1/3

Juvenile myelomonocytic leukaemia


AML wrlh mutated CEBPA


Myeloid and lymphoid neoplasms

with PD GFRA rearrangement
Myeloid neoplasms
with PDGFRB rearrangement
Myeloid and lymphoid neoplasms
with FGFR1 abnormalities


Myelodysplasticlmyeloproliferative neoplasm.
Refractory anaemia with ring sideroblasts
associated WIth marked thrombocytosis


Refractory cytopenia with unilineage dysplasia

WHO ctassrtceton

AML with myelodysplasia-related changes 969513

Therapy-re lated myeloid neoplasm s

99 6213

99 2013

Acute myeloid leukaemla",NOS


AML with minimal differentiation


AML without maturation


AML with maturation

9874 /3

Acute myelomonocytic leukaemia

9867 /3

Acute monob lastic and monocytic leukaemia 9891 /3

Acute erythroid leukaemia


Acute megakaryoblastic leukaemia

99 10/3

Acute basoph ilic leukaemia


Acute panmyelosis with myelofibrosis

9931 13

Myeloid sarcoma


Myeloid proliferations related to Down syndrome

Transient abnormal myelopoiesis


Myeloid leukaemia
associated with Down syndrome


Blastic plasmacytoid dendritic

cell neoplasm


B lymphoblastic leukaemia/lymphoma
with recurrent genetic abnormalities

B lymphoblastic leukaemiaflymphoma
with 1(9;22)(q 34;q l 1.2); BCR-ABU


B lymphoblastic leukaemiall ymphoma

with t(v;11q23); MLL rearranged


B lymphoblastic leukaemiall ymphoma

with 1( 12;21)(p13;q22); TEL-AMU


B lymphoblastic leukaemiallymphoma
w ith hyperdiploidy


B lymphoblastic leukaemiallymphoma
with hypod iploidy (hypod iploid ALL)


B lymphoblastic leukaemiallymphoma
with t(5;14 Xq31 ;q32 ); IL3-IGH


B lymphoblastic leukaemia/lymphoma with

t(1;19 )(q23 ;p13 .3); E2A-PBXl



T lymphoblastic leukaemia/lymphoma




Acute undifferentiated leukaemia

980 1/3

Mixed phenotype ac ute leukaemia

with t(9;22)(q3 4;q 11.2); BCR-ABL1


Mixed phenotype ac ute leukaemia,

B/myeloid, NO S


B-cell prolymphocytic leukaemia


Splenic Bccell marginal zone lymphoma


Hairy cell leukaemia


Splenic diffuse red pulp small B-cell lymphoma


Hairy eel/leukaemia-variant

959 1/3

Lymphoplasmacytic lymphoma


Natural killer (NK) cell lymphoblastic


waldenstrom macroglobulinemia
Heavy chain diseases


B lymphoblastic leukaemiaflymphoma
B lymphoblastic leukaemiall ymphoma, NO S


Splenic B-cell fymphomalleukaemia, unclassifiable 959 1/3

Mixed phenotype ac ute leuka em ia

with t{v;11q23); MLL rea rranged

Mixed phenotype ac ute leukaemia,

Tfmyeloid, NOS

Chronic lym phocytic leukaemia!

small lymphocytic lymphoma

98 11/3


Alpha heavy chain disease


Gamma heavy chain disease


Mu heavy cha in disease


Plasma cell myeloma


Solitary plasmacytoma of bone


Extraosseous plasmacytoma


WHO classification



Systemic EBV positive T-celllymphoproliferative

disease of childhood

Extranodal marginal zone lymphoma

of mucosa-associated lymphoid tissue
(MALT lymphoma)


Hydroa vaccin iforme-like lymp homa


Nodal marginal zone lymphom a


Adult T-cell ieukaemia/lymphoma



Extranodal NKIT cell lym phoma, nasal type

9719 /3


Enteropamy-associated T-cell lymphoma



Hepatosplenic T-cell lymp homa


Primary cutaneous follicle centre lym phoma


Mantle cell lymphoma


Subcutaneous panniculitis-like
T-cell lymphoma


Mycosis fungoides


Sezary syndrome


Paediatric nodal marginal zone lymphoma

Follicular lymphoma
Paediatric folliculaf lymphoma

Diffuse large B-eelllymphoma (OlBCl), NOS 968013

T-ceillhistiocyte rich large B-eelilymphorna


Primary DLBCl of the CNS


Primary cutaneous DlBCl. leg type


EBV positive OLBCL of the elderly


Ol BCl associated with chro nic inflammation 968013

l ymphomatoid granulomatosis

9766 /1

Intravascular large B-cell lymphoma


AlK positive large B-cell lym phoma


Plasmablastic lymphoma

973 5/3

l arge Bccell lymp homa arising in HHV8associated multicentric Castleman disease 9738/3
Primary effusio n lymphoma


Burkitt lymph oma

968 7/3

B-ceillym phom a, uncl assifiable, with feature s

intermediate between diffuse large g-ceu
968 0/3
lymph oma and Burkitt lymph oma
B-ceil lymph oma , unclassifiable, with feat ures
intermediate betwee n diffuse large 8-cell
lymphoma and classica l Hodgkin lymphoma 9596/3


j-cen prolymphocytic leukaemia


'f-celllarqe granular lym phocytic leukaemi a

983 1/3

Chronic Iymphoproliferative disorder of



Aggressive NK cell leukaemia




lymphomatoid papulosis


Primary cutaneous anaplastic large cell



Primary cutaneous qamma-delta

r -ceuivmpncma

Primary med iastinal (thym ic) large

B-celllym phoma


Primary cutaneous CD30 positive F-eel!

Iymphoproliferative disorders


Primary cutaneous COB positive aggressive

epidermotropic cytotoxic T-cefl lymphoma


Primary cutaneous CD4 positive smalVmedium

T-cell lymphoma


Peripheral Tccelllympboma, NOS


Angioimmunoblastic 'l-cetl Iyrnphoma


Anaplastic large cell lymp homa, ALK positive 97 14/3

Anaplastic large cell lymphoma, ALK negative


Nodular lymphocyte predomi nant
Hodgkin lymp homa


Classical Hodgkin lymp homa


Nodular sclerosis classical

Hodgkin lymphoma


l ymphocyte-rich classica l
Hodgkin lymphoma


Mixed cellularity classica l

Hodgkin lymphoma


l ymphocyte-depleted classical
Hodgkin lymphoma



Histiocytic sarcoma

9755 /3

l angerhans cell histiocytosis

975 1/3

langerhans cell sarcoma


Interdigitating dendritic cell sarcoma


Follicular dendritic cell sarcoma


Fibroblastic reticu lar cell tumour


Indeterminate dendritic cell tumour


Disseminated juvenile xanthogranuloma


Early lesi ons

P1asmacytic hyperplasia


Infectious mononucleosis-like PTLD

9971 /1

Polymorphic PTLO


Monomorphic PTlO (B- and TINK-cell types)'

Classical Hodgkin lym phoma type PTLO'"

NOS, not otherwise speci fied .

The italicized numbers are provi siona l cod es for the 4th
edition of lCD -D . While they are expected to be incorporated in the next ICD -O editi on , they currentty remain

subjectto changes.
The italicized histologi c type s are provisional enti ties , for
which the WHO Working Group fe ll the re was insufficient
evidence to recognize as distinct diseases at this time.
"These lesions are classi fied according to the leukaemia


lymphoma to which they correspond, and are assigned the

respective tCO-G code.

WHO classification


.. .

Introduction to the WHO classification

of tumours of-haernatopoletlc
and lymphoid tissues

NL Harris
E. Campo
E.S. Jaffe
SA Pileri

Why classify? Classification is the lan-

The WHO cl assification of tumours of the

classification , involvement of clinicians is

essential to ensure its usefulness and acceptance in daily practice 18971. At the lime
of publication of the WHO classi fication
(3rd edition), prop onents of other cla ssifications of haematologic neoplasms agreed
to use the new cl assification, thus ending
decad es of cont roversy over the classification of these tumo urs 147. 478 . t 89.
1B9A, 190, 673,7750 , 1344A. 18198 1,

haematopoietic an d lymphoid system is

based on the principles initially d efined in
the "Revised Europe an-Amer ican Classifica tion of Lymp hoid Neoplasms" (REAL).
from the Interna tiona l Lymphoma Stud y
Group (ILSG) 18981. In the WHO classification, these p rinciples have also been
appl ied to the class ification of myeloid
and his tiocy tic neoplasms, The gu id ing
prin cip le of the REAL and WHO cl assific ations is the attempt to define "real"
d iseases that c an be recognized by
pa tholo gi sts with availabl e techniques.
and that appear be distinct clinical entities . There are 3 important com ponents to
this p rocess First. recognizing tha t the
underlying c auses of these neo plasms
are often unknown and may vary, this approa ch to cl assifica tion uses all available
information - morpholog y, immunop henotype, genetic features, and cl inical features- to define diseases. The relative
impo rtance of eac h of these features
varies among diseases, d epend ing upon
the state of current knowledge, and there
is therefore no one "g old standard ," by
which all di seases are defined . Second.
rec ognizing that the com plexity 01 the
field makes it impossib le for a single
expert Of small g roup to be comptet ely
authoritative, and that broad agreement is
necessary if a classificati on is to be ac cep ted, this cta ssrncanon relies on bu ild ing a consensus among as many experts
as possible on the def inition and nomenclatu re of the diseases, We recognize that
com promise is essential in orde r to arrive
at a consensus, but bel ieve that the only
thing worse than an imperfect classification is multiple competing classifi cati ons .
Finally. wh ile patholog ists must take
pr imary respon sib ility for developing a

As indicated above , there is no one -gold

stand ard ," by which all diseases are
def ined in the WHO cl assific ation. Morpholog y is alway s important, and many
diseases have ch aracteristic or even diagnosti c morphologic featu res, Immunephe notype and genetic features are an
important part of the definition of tumours
of the naematopolettc and lymphoid
tissues , and the av ailability of this information makes arriving at conse nsus definitions easier now than it was when only
subjec tive morphologic criteria were
available . lrrmunophenotyping studies are
used in routine diagnosis in the vast
majority of haematolog ic mali gn ancies,
both to d etermine lineage in malig nant
processes and to dis tinguish be nig n lrom
ma lignant processes . Many disea ses
have a chara ct eristic immunophenotype.
such that one would hesitate to make the
diagnosis in the abse nce of the immunep henot yp e, while in others the immunoonenotvpe is only part of the diagnosis, In
some lymphoi d and in many myeloid ne0p lasms a speci fic genetic abnorma lity is
the key defining criterion, while etters lack
specific known genet ic ebnomantes.
Some g enetic abnormalities, while characteri stic of one dis ea se, are not specific
(such as MYC. CCND 1or BCl2 rearrangements or mutations in JAK2). and others
are prognostic factors in several diseases
(such as TP53 mutations or FLT3-ITO) ,
The inc lusion of jr munoohenotvoc leatures and genetic abnormalities to define
entities not only provides ob jective criteria
for disease recogni tion but has identified
antigens, genes or pathways that can be
targeted for therapy; the success of
rituxima b , an anti-CD20 molecule, in the

guage of medic ine: diseases must be

described , defin ed and named before the y

can be diagnosed , treated and stud ied .

A consensus on definition s and termin olog y is essent ial for both clinic al practice
and investigation . A cl assification should
contain diseases thai are clearly defin ed .
c linically d istinc tive . norKlVerlappi ng (mutually excllsive) and that together comprise
all known entities (collectively e xha ustive).

II should serve as a ba sis lor future investigation . and should be able to incorporate
new information as it becomes ava ilab le.
Classification has two aspects: clas s discovery - the proces s of identifying categories of diseases, and class pre diction
- the process of determining which cere-

gory an individual case belongs to. Pamerogi sts are critical to both processes .
The World Hea lth Org anizati on (WHO)
Classi fication of Tumours of the Haematopoietic and Lymp hOid Tissues (4th Edition ) was a coll aborative project of the
European Association for Haematopathology and the Society lor Hematopatholog y.
It is a revision and update of the 3rd Edition 11039 }. which was the first true
worldwide consensus c lassific ation of
baematoiocic malignancies. The update,
which began in 2006, had an a-me mbe r
steering committee composed of membe rs
of both societies, The Steering Comminee,
in a series of meetings and discussions,
agreed on a proposed list of diseases
and chapters and selec ted authors. with
input from both soc ieties. As with the
WHO 3fd ed ition 189 71. the advice of clin ical haematologists and oncologists was
obtained . in order to ensure that the classifica tion will be clinica lly useful. Two Clinic al Adv isory Committee s (CAG). one for
myeloid neoplasm s and other acut e
leukaemias and one for lym phoid neoplasms. were convened, The mee tings
were org anized aroun d a ser ies of
questions, inc luding disease definitions,
nomenclature, grading. and clinical relevance. The committ ees were able to
reach consensus on mos t of the questions po sed . and muc h of the inp ut of the

Introduction to the classification

committees was incorporated into the

class ification. Over 130 pa thologists and
haem ato logis ts from around the world
were involved in writing the chap ters. A
consensus meeting was held at the head quarters of the IARC in Lyon, France. to
make final d eci sions on the classi ficatio n
and the con tent of the book.

H. Stein
S.H. Swerdlow
J Thiele
J w. Vardiman

treatment of. B-cel! neoplasms, and 01

imatinib in the treatment of leukaemias associated with ABL 1 and oth re!lrrangements inv olving tryoene kinase genes are
testament to this approach. Finally. some
diseases require know ledge of clinical
features - age, nodal versus extranodal
presentanon. specific anatomic site . and
history 01 cytotoxic and other therapies
- to make the diagnosis. Most 01 the diseases described in the WHO classification
are considered to be distinct enti ties ;
howev er. some are not as clearly defined,
and these are listed as prov isional entities,
In addition . borderline categories ha....e
been created in this edition for cases that
do not c learly fit into one category, so that
well-de fined categories ca n be kept
homogeneous, and the borderline cases
can be stud ied further.
The WHO classification stratifiesneoplasms
primarily ac cording to lineag e: myeloid,
lymphoid, and histiocyticfdendritic c ell. A
normal c ounterpart is postulaled lor each
neoplasm. While the goal is to define the
lineag e of each neoplasm, lineage pla sticity may occur in precursor or imma ture
neoplasms, and has recently been identified in some mature haematotymphoid
neoplasms , In addition, genetic atooerreuues suc h as FGFR1, PDGFA and
PDGFB rearrangements may give rise to
neoplasms 01 either myel oid or lymphoid
lineage associated with eosinophilia ;
these disorders are now recognized as a
separate group. Precursor neoplasms
(acute myeloid reukaemes. lymphoblastic
Iymphomasfleukaemias, acute reukaerraas
01 amb iguo us lineag e, and blast ic p lasmacytoid de nd ritic ce ll neop lasm ) are
considered separately from mo re mature
neoplasms [myeloproliferative neoplasms
(MPN). myelodysplastic/myeloproliterative
neoplasms, myelodysplastic syndromes ,
mature (peripheral) B-cell and T/NK -cell
neoplasms, Hodgkin lymphoma. and hisIiocyteldeodritic-c ell neoplasms] . The mature myeloid neoplasms are stratified
according to the ir bi ologica l features
(myeIopl'oIiferative, with effective baereiopoiesis. ....ersus myelodysplastic , with ineffective neematcootesfs . as welt a s by
genetiC feature s). Within the mature lymphoid neop lasms , the diseases are listed
broadly ac cord ing to clinical presentation
(disseminated often leukaemi c, extran coat. indolent. aggressiv e). and to some
extent according to stage of differentiation
when this can be postulated: the

ord er of listing is in part arb itrary, and is

not an integral part of the cl assification.
The 4th ed ition of the WHO classification
inc orpo rates new information that has
emerged from basic and clinic al in....estrgat ions in the interva l since pu b lication of
the 3rd edition . It inc ludes new defining
criter ia for some disease s, as well as a
number of new entities. some def ined by
genetic criteria - particul arly among the
myeloid neoplasm s- and others by a
combination of morpholog y. immunoph eootype . and clinic al features. The frequent
application of immunophenotyping and
genetic stud ies to peripheral blood, bone
ma rrow, and lym ph node samp les has
also led to the de tection of small clonal
populations in asy mptomatic pe rsons .
These include small clones of cells with the
BCR-ABL 1 translocation seen in chronic
myelogenous leukaemia. small cl ones of
ce lls with BCL2-IGH rearrangement. and
small populat ions of c ells that have the
imm uoopheootype of chronic lymp hocytic
leukaemia (e l l ) or folli cu lar lymphoma
(mo noc lonal B lymphocytosis, follicular
lymphoma-in Situ , paediatric follicul ar hyperplas ia WIth monoclonal B c ells). In
man y case s. it is not clear whether these
represent earty involvement by a neoplasm,
a precursor iesoo. or an inconsequential
find ing. These situations have some
ana logies to the identification of small
monoclonal immunoglobulin components
in serum (monoclonal gammopathy of
unknown significance), The ch apters on
these neoplasms include recommendations for dea ling with these situations. The
rec omm end ations of international con sens us group s have bee n co nsidered.
with regard to criteria for the d iagnosis of
e ll, plasma cell myeloma, Waldenstr6m
macroglobulinemia, and new subtypes of
cutaneous lymphomas, as well as in the
development of new algorithms for the
diagnosis of MPN .

the WHO classification has produced a

new and exciting degree of cooperation
and conmunic ation among patholog ists
and oncologists from around the world .
which stould facilitate con tinued progress
in the understand ing and treatment of
haema totog ic manqnaocies . The mulliparameter approach to c lassification, with
an emphasis on defining real disease
entites. tha t has be en ad opted by the
WHO classification, has been shown in
inte rnational studi es 10 be reproducible:
the disea ses d efined are c linically disttnct iv e. and the uniform definitions and
terminology facilitate the interpretation of
clinical and translational stud ies 15 1, 791 .
In addition, accurate and precise classifi c ation of d isease entities has facilitated
the discovery of the genetic bas is of
my eloid and lymphoid neoplasms in the
ba sic science laboratory

A critic al feature of any class ification of

diseases is that it be periodically reviewed
and updated to incorpor ate new information. TheSocietyfor Haematopathology and
the European Association for Haematopathology now have a more than to-year
record of couebceaton and coo pe ration in
this effort. The societies are comm itted to
updating and revising the classification
as needed . with input lrom clinicians and
with the collaboration of the WHO . The
experience of developing and updating
Introdu ction to the cl assification


Introduction and Overview
of the Classification
of the Myeloid Neoplasms



Introduction and overview of the

classification of the myeloid neoplasms

J.w. Vardiman
A.D. Brunning
D.A . Arter
M.M.Le Beau

The WHO Classification of Tumours of the

Haematopoietic and Lymphoid Tissue s
(3rd edition) published in 200 1 reflected
a pa radigm shift in the approach to c lassification of myeloid neoplasms { 1039). For
the first time. genetic information was incor porated into diagnostic algorithms
provided lor the vario us en tities. The publicat ion was prefac ed with a comment
pred icti ng future revisions nec essitated
by rapidly eme rg ing gen el ic information.
The cu rrent revision is a commentary on
the significant ne w molecular insights mat
have bec ome avail abl e since the publication of the last ctass'ncauon .
The first entity described in this monograph . chronic myelogenous leukaemia
(CML) rema ins the prototype for the identification and c lassific atio n of myeloid
neoplasms This leukaemia is recognized

genetic features is used in an anerrctt c

define d isease entities , such as CML, that
are biolog ically homogeneous and clinically relevant - the same approach used
in the 3rd ed ition of the classification.
Altho ugh the previous scheme began to
open the door to including genetic abnormalities as c riteria to classi fy myeloid
neoplasms, this rev ision firmly acknow ledges that as in CML, recu rring ge netic
abno rmali ties provi de not onl y objec tive
c rite ria for recognition of speci fic entities
but also identification of abnormal gene
product s or pathways that are potent ial
targets for therapy. One example in this
revised sc heme is the addition of a new
subgroup of mye loid neoplasm s (Tabte
1.01) assoc iated with eos inoph ilia and
chromo somal ab normalities that involve
the oiateiet-oenved growth factor rece ptor

by its c linic al and morphologic features,

and its natural progression is charac terized by an inc rease in blasts of myeloid ,
lymphoid or m ixed myeloid/lymphoid
immunop henotype. It is always associated with the BCRABL 1 fusion gen e that
results in the production 01 an abnormal
protein tyros ine kinase (PTK) with enhance d enzyma tic ac tivity. This p rotein is
sut tcrentto ca use the leukaem ia and also
provides a targ et for prote in tyrosi ne
kinase inhibi tor (PTKI) the ra py tha t has
prolonge d the lives of thousands of pa tients with this often tatal illness {6 151.
This successful integ ratio n of cl inical ,
morphologi c and genetic information embodies the goal of the WHO classific ation
In th is revis ion . a combination of c linica l,
morpholog ic . imm uno phe noty pic and


Table 1.01 Themyeloid neoplasms' major sul:9'OUJlS and d\al;U::i tstic features at ~



eosinophilia and abriof
malilies of PDGFRA.

8M ctllularity

'10 MIrf'OW bluts

Usually increased.
often normalin ET

tbmaJ or sIighlIy
increased: <10% in
dI'onic phase


Normal or $IigM~
increased: <20% irl
cnronc phase


Nom1al or increased:







Relatively normal


relabYe/y normal,


A. Porwit
A . retten
C.D. Bloomfield
J. Thiele

.... """"

VanabIe; 008 or


IifIeage usually



j~t 5x10ir1.)






"""" .......




-,,- --_""


Usually oneormae


rrft'!lal cIyspIaSIa


eQPl in some cases

'l'Illh specific cybJeneIlc
abnorrnaIilies or in

some cases of






\IariabIe. WBC


more myeloid lineage




May Of may J'IOl be




Moy""Y ......

........ ........

or e"ect1ve



Mf)N, myeloproliferative neoplasms: MDS, myelod)'spla:slic syndromes; MDSlMf)N, myeIodysplasbcJmyeloprolifefalive neoplasms: AMl, ICIJIe myeloid leukaemia; ET, esseflIlaj
Ihfombocylhaemia, JMML. ju&nile myelomonocytic leukaemia, wec. wniIe bloocI e&II$.



Introduction and overview of the c lassif ication of the mye loid neoplasms

alpha (PDG FflA) Of platelet de rived growth

factor recep tor beta (PDGFRB) genes
-a subgroup defined larg er9 by genetic
events that lead to consti tutive act ivat ion
of the receptor tyrosine kinase, PDGFA,
and that respond to PTKI therapy {13 1,
466. 8121 . Similar examples are found
througho ut the classification in each
major subgroup, and inclu de not only
neoplasms assoc iated with rmcroscoprcally rec og niza ble chromosomal abnormalities but also with gene mutations
without a cytogenetic correlate as weu.
On the other hand . the importance 01
careful clinical, morphological and immunophenotypic characterization of each

myeloid neoplasm and coeretanoo with

the genetic findings cannot be over-

emphasized. The discovery of activating

JAK2 mutations has revolutionized the
approach to the diagnosis of the myeloproliferative neoplasms (MPN) 1163, 1044 ,
1186,12681. Yet JAK2mutatiQns are not
specific for any single clinical or morphologic MPN phenotype, and are also
reported in some cases 01 myelodysplastic syndromes (MDS), myeiooysplasnc/
myeloproliferative neoplasms (MDSlMPN)
and ac ute mye loid leu kaemia (AMl).
Thus, an integ rate d, multidisciplinary
approach is necessary for the classification
of myeloid neoplasms.
With so muc h yet 10 learn, there may be
some 'missteps" as trad itional approaches
to categorization are fused with more
rrcecuarfy-orentec clessifcaton schemes ,
Nevertheless, thi s revi sion of th e WHO
classification is an attempt by the authors,
editors and the c linic ians who served as
members of the Clinica l Advisory Committee (CAC ) to p rovide an "evidencebased" c lass ifica tion that ca n be used in
daily p ractic e for therap euti c deci sions
and yet pr ovide a flexib le framework for
integration of new data ,

Prerequisites for classification

ofmyeloid neoplasms by
WHO criteria
The WHO c lassification of myeloid neoplasms relies on the morphologic, cytochemical and immunophenotypic features
of the neop lastic cells to esta bl ish thei r
lineage and deg ree 01 ma turation and to
decide whether cellular p rolife ration is
q101ogica lly normal or dysplastic or
esecuve or ineffec tive . The classification

is based on cr iteria applied 10 initial specimen s obtained prior to any definitive therapy, includ ing growth lactor therapy, for the
myeloid neoplasm. The blast percentage in
the per ip her al b lood , bone ma rrow an d
other involved tissues remains of p ractica l
impo rtance to categorize myeloid neoplas ms and to judge their progression .
Cytogenetic and molecular genetic studies are requ ired at the time of d iag nosis
not only for recoq r nton 01 specific genetically d efined entities, but for establiShing
a baseline against which futu re studies
can be judged to assess disease progression. Beca use of the multidisciplinary
approach req uired to diagnose and classify myeloid neoplasms it is recomnended
thaI the various diagnostic studies be
correlated with the clinical findings and
reported in a single, integ rated report. If
a definitive classification cannot be
reached the report should indicate the
reasons why and provide guidelines for
additional studies that may clarify the
To obtain consistency, the following
guidelines are recommended for the evaluation of specimens when a myeloid neoplasm is suspected to be present. It is
assu me d tha t this evalua tion will be pe rformed with full knowled ge of the clinical
history and pertinent laboratory data.
Periphera l blood: A perip heral b lood (PB)
smea r sho uld be exa mined and co rrelate d with result s of a co mple te b loo d
c ount. Freshly mad e smea rs shou ld be
sta ined with May-Gnmwald -Giernsa or
Wright-G iemsa and examined for wh ite
bloo d ce ll (WBC) , red b lood ce ll (AB C)
and plate let abnormal ities It is impo rtant
to ascerta in that the smears are we llstained, Evaluation of neutrophil g ranularity
is imp ortant when a myelo id d isor der is
suspected; de signat ion of neut rophils as
abnormal b ased o n hypog ranular cytoplasm alo ne shoul d not be conside red
unless the stain is well-controlled . Manual
2OO-cell leukocyte di fferentials of PB
smea rs are recommended in patients with
a myeloid neoplasm when the WBC count
Bone manowaspirate: Bone marrow (BM)
as pi rate smears should also be stained
with May-G rQnwald-G iemsa or WrightGie msa for optimal visua lization of cytoplas mic g ranules and nuclear chromatin.
Because the WHO Classification relies on
percentages of blasts and other specific
Introduction and overview of the

11111111 111I 1111 1111 111111

F'S!. 1.01 Bone marrow tIeI:Me biopsy, Bone marfOW
b'ephinebiopsies should be alleast 1.5 em in length and
ollt<w1ed at right angles10 the cortical bone.
cells to categorize some eoutes. it is recommended that 500 nucleated BM cells
be counted on cellular aspirate smears in
an area as close to the particle and as
undiluted with blood as possible. Countll"lQ
from multiple smears may reduce sampling error due to irregular distribution of
cells. The cells to be counted include
blasts and promonocytes (see definition
below) . pronveocvtes. myelocytes, metamyelocytes, band neutrophils, segmented
neutrophils, eosiropnns. basophils, fTlQIlOcytes , lymphocytes. plasma cells , erythrOid
precursors and mas t cells. Megakaryocvtes. including dysplastic forms. are not
inc lude d. If a concomitant non-mye loid
neoplasm is present, such as p lasma ceu
myeloma, it is reasonable to exclude
tho se neo plastic cells from the coun t
used to evaluate the myeloid neop lasm. If
an aspirate ca nnot be obta ined du e to
fibrosis Of ce llular packing, touch preparatio ns of the b iop sy may yield valuable
c yto log ic informa tion, but d ifferential
co unts from touc h preparations may not
be repr esentative . The d ifferential co unts
obta ined from marrow aspi rate s should
be compared to an estimate of the p ropo rtions of cells o bserved in avai lab le
biop sy sections,
Bone marrow trephine biopsy: The contribut ion of adequate 8M bio psy sections in
the diagnosis of myeloi d neoplasms cannot be overstated. The tre phine biopsy
provides information rega rdin g overall
cellularity and the to pog raphy, propo rtion
and maturation of baematopolenc cells ,
and allows evalu ation of 8M stroma. The
biopsy also provid es material for immunohistochemical studies th at may have
diagnostic and prognostic importance. A
biopsy is essential whenever there is
myelofibrosis, and the classification of sore
entities , partiCularly MPN, relies heavily on
trephine sections, The specimen must be

ctassncauoo at the myeloid neoplasms


adeq uate, Iake n at rig ht angle from the

cortica l bone and at least 1.5 cm in length
to enable the evaluation of at least 10 partially preserved inter-trabecular areas. It
should be well-fixed, thinly sectioned at
3-4 micra, and stained with haematoxylin
and eosin and/o r a stain such as Giemsa
that allows lor detailed morphologic evaluation . A silver impreg nation method for
reticulin fibres is recommended and
marrow fibrosis graded according to the
European consensus scoring system
122141, A periodic acid-Schitt (PAS) stain
may aid in detection 01 megakaryocytes.
Immunohistoc hemical (IHe) study of the
biopsy is often indispensable in the eva luation of myeloid neoplasms and is discussed belOw,
Blas ts: The percentage of myeloid blasts
is important for dl8gnosis and ctasstcaton
of myeloid neoplasms , In the PB the blast
percentage should be derived from a
200-cell leukocyte differential and in the
8M from a 500-cell count of cellular 8 M
aspirate smears as described above . The
blast percentage derived 'rom the 8 M
aspirate should correlate With an estimate
of the blast percentage in the trephine
biop sy. although large foca l clusters or
sheets 01 blasts in the biopsy should be
regarded as possible disease progression.
Immunohistochemical staining of the BM
biopsy for CD34+ blasts often aids in the
correlation of aspirate and trephine biopsy
findings, although in some myeloid neoplasms the blasts do not express CD34 ,
Flow cytometry determination of blast
percentage should not be used as a substitute for visual inspection. The spec imen
for flow c ytometry is otten haemoouute.
and may be affected by a number of preanalytic variabl es. and as noted for the

biopsy. not all blasts express CD34 .

Myeloblas ts. monoblasts and megakary<>
blasts are included in the blast count.
Myeloblasts vary from slightly larger than
mature lymphocytes to the size of monocvtes or larger. with moderate to abundant dark blue to blue-grey cytoplasm.
The nuclei are round to oval with finely
granul ar chromatin and usually several
nucleoli. but in some nuclear irregularities
may be prominent. The cytoplasm may
contain a few azurophil granules (Fig 1,03),
Monob lasts are large cells with abundant
c ytoplasm that can be light grey to deeply
blue and may show pseudopod formation
(Fig 1.04 A. S). Their nuc lei are usually
round with deli cate , lacy chromatin and
one or more large prominent nucleoli.

They are usually strongly positive for n0nspecific esterase(NSE) but have no or only
weak myeloperoxidase (MPO) activity,
Promonocytes are considered as ' rroooblast equivalents " when the requisite percentage 01 blasts is tallied for the
diagnosis of acute monoblastic . acute
monoc ytic and acute myerorronocync
leukaemia. Promonoc vtes have a delicately convoluted. folded or grooved
nucleus with finely dispersed chromatin,
a small , indistinct or absent nucleolus,
and finely granulated cytoplasm (Fig 1.04
C, 0), Most promonocytes express NSE
and are likely to have MPO activ ity. The
distinct ion between mono brasts and
prornonocvte s is often difficu lt. but
because the two cell types are summated



Introduction and overview of the classification of the myeloid neoplasms

as rr onootasf s in making the diagnosis of

AML, the distinction between a monoblast
and promonocyte is not aly,.ogys critical.
On the other hand , distinguishin g promonocvtes from mo re matu re b ut abnormal leukaemic monocytes can also be
dilficult, but is critical, because the designation 01 a case as acu te monocytic or
acute myelomonocytic leukaemia versus
chronic myelomonocytic leukaemia olten
hinges on this distinclion . Abnormal
rrooocv tes have more clumped chromatin
than a p romonocyte, variably indented.
folded nucl ei and grey cytoplasm with
rrore abundant lilac -colored granules . Nucleoli are usually absent or indi stinct (Ftg
1.04 E.F). Abnormal monocytes are rot
consider ed as monoblast eouvaeots.
Megakaryoblasts are usually 01rreoen to
large size with a round , indented or
irregular nucleu s with finefy reticular
chromatin and one to three nucleoli. The
cytOplasm is basophiliC, usually agranular,
and may show cytoplasmic blebs (See
Chapter 6 on acute myeloid leukaemia,
NOS). Small dysplastic megakaryocytes
and micrornegal<.aryocyt es are not blasts.
Inacute promyelocytic leukaemia, the blast
equivalent is the abnormal promyelocyte .
Erythroid precursors (erythroblasts) are
rot included in the blast count except in
the rare instance of "pure" acute erythroid
leukaemia, in which case they are cons idered as blast equiva lents (See Chap ter 6
on acute myeloi d leukaemia, NOS).
Cytochemistry and other special steins:
Cytochemical stud ies are used to determine the lineage 01 blasts, althou gh in
some laboratories they have bee n supplanted by immun ologi c studies usin g
flow cytometry an d/or immunohistochem istry. They are usu ally perform ed on PB
and 8M aspirate smears but some can be
performed on sections 01 treph ine b iop sies or other tissues . Detec tion 01 MPO
indicates myeloid d ifferentia tion b ut its
absence does not exclude a myeloid lineage because early myelobl asts as well
asmonoblasts may lack MPO. The MPO
activity in rrweiobtasrs is usually granular
and etten concentrated in the Golgi region
whereas monobtasts. although usually
negative,may show line, scattered MPO+
granules, a pattern tha t becomes mo re
pronounced in prcmonocvtes . Erythroid
blasts, megakaryoblasts and Iymphoblasts
are MPO negat ive . Sudan Black B (SSBl
staining parallels M PO but is less speetc. Occ asional cases of lymphoblastic
leult.aemia exhibit SSB POSitiVIty, in which


Fig. 1.04 Monoblasts, promonocytes and abnormal mcnccytea from a case of acute monocytic laukaemia.
A, B Monoblastsarelarge with abundant cylOlJlasm that ma y contain a few vacuoles Of fine granules and have roullCl
nuclei withlacy chroma~n and one Of more variably prominent nucleoli. C, D Prornor.ocytes have more irregular ancl
delicately folded n~ withfine chroma~n, small indistinct nucleoli and finely granulated cytoplasm. E, F Abnormal
monocytes appear immature, yet have more condensed nuclear chroma tin, con'o'Q/uled Of fdded nuclai, and more
cylopIasmiC granulaboo (Courtesy of Or. J. Goasguen).

case light grey granules are seen rather

than the deeply black granules that characterize mverobrasts. The non-specific
este rases . u nap hthyl butyrate (ANB) and
(,( naphthyl acetate (ANA). show diffuse
cytoplasmic activity in monoblasts and
monocytes. Lymphoblasts may have foca l
punctate activity with NSE but neutrophils
are usually negative. Megakaryoblasts
and erythroid b lasts may have some multitocal. punctate ANA positivity, b ut it is
partia lly resistant to natrium ffuorid e (NaF)
inhibition whereas monocyte NSE is totally

inhibi ted by NaF, The combination of NSE

and the specific esterase , naph thol-ASDchloroaceta te esterase (CAE), which stains
primarily cells 01 the neutroph il lineage
and mast cells, permits ident ification of
monccvtes and immature and mature
neutroph ils simultaneously. Some cells ,
particularty in myeIornonocytic leukaemias,
may exhib it NSE and CAE simultaneously.
While norma l eosinoph ils lack CAE, it may
be expressed by neop lastic eosooohne.
CAE can be performed on tissue sections
as well as PB ()( marrow asp irate smears.

Introduction and overview 01 the ctass.tcanoo 01 the myeloid neoplasms


In acute erythroid leukaemia. a PAS stain

may be helpful in that the cytoplasm of
the leukaemic oroervmrobreate may show
large globules of PAS positivity. Wellcontrolled iron stains should always be
per formed on the 8M aspirate to detect
iroo stores. normal side roblasts and ring
side robrasts. the latter of which are defined as erythroid precursors with 5 or
more granules of iron encircling one-third
or more of the nuc leus.
Immunop henotype
Immunophenotypic analysis using either
multiparameter flow cytometry or IHe is

an essential tool in the cha racterization of

myeloid neoplasms. Differootiation antigens
that appear at various stages of haematooo'euc develo pment and in corresponding myeloid neoplasms are illustrated in
Fig . 1.05. and a thorough descriplion of
lineage assignment criteria is provided in
the chapters on mixed phenotype acute
leukaemia, The techn iques employed and
the antigens anafyzed may vary according to the myeloid neoplasm suspected
and the information required 10 best characterize it as well as by the tissue available. Although often important in the
diagnosis ol any haematoiogicaJ neoplasm.

immunophenotyping in myeloid neoplasms

is most com monly required in AML and in
determining the phe notype of blasts at
the lime of transfo rmation of MOS.
Mulliparameter flow cytometry is the
prefer red method of immuno phenotypic
analysis in AML due to the ability to analyze high numbers of cells in a relatively
short period of time with simultaneous
recording of information about severer
antigens for each individual cell. Usually.
rather extensive panels of monoclonal antibodies directed against leukocyte differentiation antigens are applied because

<--U II 7+

C U 1I7+

c m l 7-



C D.l6-

' fh+
C DJ6 -

CD l 6 -

CDIJ ~'-


C D235. -

C U,J. C O lJ5.prvQ')"lbn>bla. 1

b ....p bllk:
tory l b rub l.,.


toryl h ruh l 1

C U lM-

C I)l63+
C OU +

C IU J +
C D36-+
C I)6" +
HL-\ -DR +
C O ll b+
C D I 4+

C O}4...

C IU +
C D U'"

' r"",,::7:-:-~01 liLA-DR'"

C IU 3'"
C U34_

liLA -DR t-tl L -"-LO"--l,.

C U.\H++

C O l5-+-

COll ++

mon.. hl . ~1

p rumo"ucy'\'



C O Il 7 +1C ll1 J+
C D 33 +
C:0 6 5+
C D I5+/

C IH J d lm
C IU J +

C ))65+
C D I5 +
C U ll b+'_

C D 3.. +-+
C D .\N+-+

m nmx: yl f'

em sC lU J '"
C D6 5+
C U15+
C1U 5tlim

e m s-

Un _
C D J .....



C D3.. +
ClHM _
C D IlJ-.
C1 U 5 HA TI'O -R+


C UJ4+I.
C DJ M., _
C D61+
C I).&I+


C DJ8+
C 06 1+
C 04I +
C04 l +I

mtrocucuco and overview of lhe classification of the myeloid neoplasms

C U.14C O.\ II++

C I)6 I++
C I).& 1-+-+

C U"' l+

C DJ ....
IH...A-O R +
C O l lb++
C O l -t-t

the utility o f in,s:livid ual markers in identify-

ing commitme nt of leukaemic c ells into

the different haemat op oieti c tlneages is
limited Evaluation of exp ress ion patterns
of several antige ns, bo th membrane and
cytoplasmic, is necessary for lineage
assignment. to d etect mixed phenotype
acute leu kaemia, and 10 detect aberran t

phenotypes allowing lor follow-up of

minimal re sidua l d ise ase .

Irrmunopheootypic analysis has a ce ntral

role in disting uishing be tween minimally
dllferentiated acut e myeloid leu kaemia
and acute lymphoblastic leukaemia, and
in CML between myeloid blast pha se
and lymphoid blas t phase. Among AM L
WIth recurrent genetic abnormalities , sev eral have characteristic phenotypes. These

patterns. described in the respective

sections, can help to plan molecular
genetIC {lluorescence in situ hybrid ization
(FISHlI and molecular inv estigation s in
individual patie nts, lm munophe notyp ic
features or the other AMl categor ies are
extremely heterog eneo us. probably due
to high genetic d iver sity. Although it has
been sugges ted that express ion of c ertam antiqens, such as CD?, COO, C Ol lb,
C014. CD56 and CD34 cou ld be associated with an adver se prognosis in AMl,
their independe nt prognostic value is still
controversial. Aberrant or unusual omorophenotypes have been found in at
least 75% of ca ses of AMl. These c an be
described as c ross-lineage antigen expression, matura tional as ync hronous
expression of antigens , antigen overexpression, and the red uction or abse nce of
antigen expressio n, Sim ilar aberra ncies
have also been reported in MDS as we ll.
and their presence ca n be used to sup port
the diagnosis in ear ly o r morpholog ica lly
ambiguous cases of MDS (See Chapter 5).
lm11unophenotyping by IHC on 8 M b iopsy
sections can be applied if ma rrow cell
suspensions are nol available for flow cytcmetry analysis. Antibodies reactive with
paraffin-embedded BM biopsy tissue are
available for many lineage-associated
markers (e,g. MPO.lysozyme, CD3, PAX:s,
C033, etc.). As noted previously, CD34
staining of the biop sy can fac ilitate the
detection of blasts and their distribution ,
provided the blasts expres s CD341 1650/.
For cases rich in megalob lastoid erythroblasts. immunohistolog y for glycophorin
or haemoglobin may be helpful in dist inguishing those cells from myeicotasts
(eg. in cases of RAEB or acute erythro1eI.Memia), and COOl or CD42 oflen aid


in the id entification of abnormal megaka rvoc ytes.

Genetic studi es
The WHO classi fication includes a numbe r of entities defined in part by scecmc
genetic abnormalities. including gene
rearrangemen ts due 10 chromosomal
nansrccarrons and to specific gene mutations. so de term ination of genet ic features
of the neoplastic cells must be performed
if possible. A complete cytogenetic ana lysis of 8M shou ld be perlormed at the time
of init ial eva luat ion to establish the cytogenetic profile, and at regu lar intervals
thereafter to detect evidence of genetic
evolution . Additional d iag nosti c genetic
studies should be guided by the diagnosis
suspected on clinica l, morpholog ic a nd
imTulophenotypi studies. In some cases,
reverse transc rip tase-pol ymerase c hain
reaction (AT-PCR) and/or FISH may detect gene rearrangements thai are present in low frequency and not observed in
the initial chromosomal ana lysis, in c ases
with var iants of typical cytogenetic
abnormalities, and in cases in which the
abnormality is cryptic , such as the
PDGFRA-FIP1L 1 fusion in myeloid neoplasms associated with eos inophilia, Depending on the abnormality, qu ant itative
PCR performe d at the time of diagnosis
may also p rovide a baseline against
whic h the response to therapy c an be
monitored . A num ber of gene mutations
d etect ed by gene sequencing, allelespe cific Pe A and othe r techniq ues have
em erge d as importa nt diagnostic and
prognostic ma rkers in all ca tegories of
mye loid neoplasm s, Mutat ion s of JAK2,
MPL , NRAS, NFl , PTPN 11, and KI T in
FLT3, RUNX1 and KIT, among others. in
AMl are impo rta nt for d iagnosis and
p rognosis. and some. particularly JAK2,
FLT3, NPM 1 an d CE8PA figure importantly in this revised classification . Furthermore , the role of gene over- and
unde r-expression as well as loss of hete rozygosity and copy number variants
detected by array-based approaches are
on ly now being recognized as impo rtant
abnormalities that may well influence
d iagnostic and prognostic models in the
near future 11531AI . Nevertheless,
m icroarray prof iling studies. alt hough
import ant in the research setting , have not
yet been tested in cl inic al practice .

Revised WHO classification of

myeloid neoplasms
Table 1,0 1 lists the major subgroup s of
myelold neop lasms and their characteristic
features at diagnosis. The nomenclature
for the myeloprolife rative entities has been
c hanged from "c hronic mye lopro liferat ive
diseases" to myeIoproIiferative neoplasms"
and the subgroup formerly designated as
"myelod ys pl as ticfm y e lo p ro li fe rati v e
dis eases" has been ch ang ed to
"myelod ysplasticJmyelo proliferative ne0prasms" to und erscore the ir neoplast ic
nature . Beside s the addition of the new
subgroup. "Myeloi d and lymp hoid ne0plasms with eosinophil ia and abnormalities
of PDGFRA, PDGFR8 and FGFRt , new
entities have been added and/or diagnost ic criteria updated with in each subgroup.
Myeloproliferative neoplasms (MPN)
The MPN (Table 1.02) are c lonal haeretcporenc stem cell d isorders Characterized
by pr oliferation of one or more of the
myel oid lineages (l.e. granulocytic , ery thro id . megakaryocytic and mast cell).
They are primarily neoplasms of ad ults
that peak in frequency in the 5th to 7th
decade, but some subtypes. parti cu larly
CM l and essential thrombocythaemia
(ET), are reported in children as well. The
inc id enc e of all sub types combined is
6-10/ 100,000 population annually {1053,
1059. 1060 f,
Initially. MPN is cha racterized by hypercellularity of the BM with effective
naematoporetc maturation and increased
numbers of gra nulocytes, red blood ce lls
and/o r plate lets in the PB. Splenomegaly
and hep atomeg aly a re co mmon and
caused by sequestration of excess b lood
cells or proliferation of abnormal raematopoietic cells, Despite an insidious onset
each MPN has the potential to undergo a
Table 1.02 ~live neoplasms (MPN).

ChrtncITl)9logenous 1Bukaen'ia, BCR-ABI. posibYe


Clwtlnic. neutrophilic leubeml8 (CNL)

~'o'efil (PV}

"""'" _ _ (PM~

ESSoElI'IUl ~ (ET)
Oworic eosnophic Ieukaer'ru. NOS lea NOS)


MyelqiltMaabYeneoplasm,loI'ldasslJable (UPN,U)

introouctco and overview of the ctassrncanon of the myek>id neoplasms




Myeloid neoplasms
with eosinoph ilia



JAK2 V617F, JAK exon 12


JAK2V617F, MPL W15 1UK


JAK2V617F, MPL W151 UK



Fig. ' .06 Myeloprololerative neoplasms (t.4PN)and oIhet myeloid neoplasms associated W11t1 mutaliOnlrearrangement of tyrosine kinase genes.

stepwise pr ogr ession that term inate s in

marrow failur e d ue to myelofib rosis , ineffective haemat opoi esis or Iransformalion
10 an acu te blast phase. Evid ence of ge netic evo lution usually heralds disease

progression as may increasing organamegaly, increasing or decreasing blood

counts , myelofi brosis and onset 01myelodysplasia. The finding of 10-19% b lasts
in the P8 Of 8M generally signi fies accelerated disease and 20% or more is
suHicient for a di ag nosis 01bla st pha se .


Rationale for tho diagnosis and

classification of MPN
In previous cl assification schemes the
detect ion of the Philadel phi a chromosome and/or BCR-ABL 1 fusion g ene was
used to coolirm the diagnosis of C Ml
wher eas the remaining MPN sub types
were diagnosed by their cli nical and
labo ratory features with relatively minor
contributions to the diagnosis from morph ologi c findings. A number of criteria
were required not only to distinguish

subtypes of MPN from each other but

from reacti ve granulocyt ic . erythroid andl
or megakaryocyt ic hyperplasia .
Revisions in the criteria for cla ssification
of MPN in the cu rrent scheme have been
influen ced by two fac tors - the recen t
discovery of gen etic abnorm alities involved in the pathogenesis of BCR-ABL 1
negative MPN and the wide r appreciation
that histologic features (megakaryocytic
morp hology and topograph y, marrow
stromal changes, id entific ation 01specific
cell lineages involved in the proliferation)
cor relate with clin ical features and c an be
used as criteria to identi fy MPN subtypes
{2 177. 22 16, 22221.
Mo st if not all MPN are assoc iated with
clona l abnormalities involving g enes that
encode c ytoplasmic or receptor PTKs.
The abnormalities described to da te
include transicc anons Of point mutations
of genes that result in abnormal, co nstitutively abnormal PTKs that activate signal
transdu cti on pathw ays leading to the
abnormal proliferation . In some c ases,

Introdu::tion and overview of the classi fication of the myeloid neoplasms

these genetic abnormalities. such as the

BCR-ABL1 fusion gene in CMl . are essocia ted with consistent clinical, laboratcry
and morp hologic find ing s that allow them
to be utilized as major criteria for classfication, whereas others provide proof that
the myeloid prolifera tion is neoplastic
rather than reactive.
Ac quired somat ic mutations of JAK2. at
chromosome 9p24. have been shown);)
playa p ivotal role in the pathogenesis d
many cases of BCR-ABL 1 negative MPH
11 04 4, 1163, 1186, 1287A , 12881. The
most comm on mutation , JAK2 V6 17F, results in a constitutively active cytoplasmic
JAK2 that activates signal transducer and
ac tivator of transcription (STAT), mitogen
activated p rotein kinase (MAPK) and
phospholidyllnositol a-kmase (P13K) sigo
naling pathways to prorote transforma1Ol
and proliferation of baemaroooenc pro.
g enitors (Fig. 1.07). The JAK2V617Fmutation is found In almost all patients wit~
polycythaemia vera (PV) and in n ear~
one-half of those with primary myelofil:Jrosis

(PfvlF) and wit~ esseotelmoroocvmaeraa

(ET), In the few PV patients wno lack the
JAK2 V6 17F, an acti vat ing JAK2exon 12
mutation may be fou nd , and in a small
proportion of cas es of PMF and ET, an activating mutation 0 1 MPL W5 15l or W5 15K
is seen. It is important 10 no te that JAK2
V617F is not specific for any MPN nor
does its absence exd ude MPN . Furthermore, it has been reported in some cases
of MDS/MPN, in rare cases of AMl, and
incombination w ith other well-defined genetic abnormalities such as the BCR-A8L 7
110641. Thus, diagnostic algorittvns for PIl,
ET and PMF have been altered to take the
mutationalstatus of JAK2 into account as
weN as 10outline the additional laboratory
and histo6ogic "ndi~JS required to reach
an accurate classification 01 c ases, regardless 01 whe ther the mu tation is or is
not present.
In addition to the changes in the cr iteria
lor N , ET and PMF, information reg ardi ng
abnormal PTK toncnon due to rearrangementsof the POGFRA, PDGFRBor FGFR1
genes in patients with myeloid neoplasms
associated with eosinop hilia led to reappraisaland new diag '1ostiC algorithms for
those syndromes as well (see below). The
appreciation 01 the role altered PTKs pla y
in the pathogenesis of C Ml, PV, ET and
PMF also argues lor the inclusion of similar chronic myelo id pronteranons related
10 PTK abnormalities under the MPN umbrella. Thus, systemic ma stocytosis, wh ich
has many features in common with other
MPN entities and is alm ost always associated with D816V mutation in the KIT
geneencoding the recep tor PTK, KIT, has
been added to this categ ory 121761 St ill,
tI"1e molecular pathogenesis of nearly half
of all cases of ET and PMF, of all cases of
chronic neutrophilic leukaemia and a
mm ber of myeloid neo plasms ass oc iated
with eosinophilia remai n unkn ow n . For
these reliance on cli nical, laboratory and
morphologic features is essenti al for
diagnosis and classification,

Stmnary 01major c hanges in the

classilication of MPN
I . The nomenclature , 'mveiopronte ranve
disease" has bee n changed to "myeloproliferative neoplasm "
2, Mastocytosishas been includ ed in the
MPN category
3 Some cases previously meeting th e
Cfllena for chronic eosinophilic leuka emia
(CEll may now be categorized as myeloid
(J ~ d neop lasms with eosinophilia

and ab normalities 01 PDGFRA. PDGFRB or

FGFR1 , If none of the se rearrangements
are d etec ted, and there is no BCR-ABL 7
fusio n gene , they should be ca tego rized
as GEL, not otherwise specified
4. The d iagnostic al go rithms for PV, ET
and PMF ha ve been substantially
c hanged to incl ude infor mation rega rd ing
JAK2 and similar ac tivat ing mutations as
well as pertinent histolog ic featu res 01 the
8M biopsy as d iag nostic Criteri a.
5. The threshold of the p latelet count for
the di ag nos is of ET has been lowered to
~4 5Ox 1 Q91l.
6. Crit er ia for CMl in accelerated phase
have been suggested w ith the caveat that
they have not been fully evaluated in the
era of PTKI therapy: studies 10 determine

their relevan ce are in progress and revisions may be necessary.

Myeloid and lymphoid neoplasms with
eosinophilia and abnormalitie s of


De termi ning the ca use of marked , persistent eosinophilia (~ 1 .5x1()9/l) in the
blood can be challengi ng and is sometimes cli nically urg ent beca use 01 the
potential damage to the heart, lungs , central nervous and other organ systems
caused by the eosinophilic infiltration and
release of cvtocnes. enzymes and other
proteins. The eoeoooous may be derived
from the neoplastic clone of a myeloid
neoplasm, such as GEL, GMl or AMl, or
lhey may be reactive due to abnormal








-- ----- -Activation of gene!o Important

in proliferation and survival


Fig. 1.07 MecRanism activatiOn aI JA1<2 kinase actMty by rn.rtaIiOns in the JAK2 Signalirg pathway. It. Cytokile
ligallds normaHy bind cytokine recepIors, .tlich results in JaI'llS ki\ase 2 (JAK2) pIlosphoryIatio, recruilmenI
\rcInsduc:er and actrvator allJansaipbon (Stal) signaling protelns and pIlospholyIation alld activatiOn of downstream
SigRaIing pathways ind\.I:lIng SIal ~ lactor&,lT\IlogefIlIdMlled proIeIn U1ase(MAPK) sigMWlg proteins , arIl
the phosphotidyinos 3-kinase (Pl3K)--Akt pathway B The JAK2 Vfi17F alld JAK2 ewn 121Tl11anl kilases bind
cytokine recepIors, are phosphorylated il the absence alligand and lead to ~ activation aI 0JwIn.
streamsignaing palhways. C Bycontrast, MPl. W515lA( rrUal'lllhiOi'~ recepb$ are able 10 phospI1Oi'y\ale
ri1-Iype JAK2lithe absence 01 hanbopoleIi., and red II tle aetwabon of signaling paltrways <townstream 01 IN<2.
Negative regulation 01 JAX2 sigNIng is nonnaIy medIaIed by suwessor of cytome s9laIilg (Socs) proWls, most
notably SOCSl alld SOCS3; recent dala i'ldic3Ie Ihalthe JAK2 V617F aIeIe night escape negatiYe IeectIacll by
SOCS3. Repro:U;:ed from {1287AI

Introduction and overview of the classification 01 the myeloid neoplasms


cytoki ne relea se from reactive or neoplastic r -ceus. In a numbe r of ca ses. no

underlying cause can be fOund and the
clonahty of the eos inophils ca nnot be
proven: these cases are app ropriately
termed "idiopathic hypereosinophilic ssndrome" (See Chapters 2 and 3).
Rationale for diagnosis and classification
of myeloid and lymphoid disorders with
eosinophilia and abnormalities of PDGFRA,
Since the last edition of the WHO c lassification it has been recog nized that many
cases of eosinophilia, incl udin g a substantial number conside red as "idiopathic"
are clonal myeloid neoplasms caused by
abnormalities in genes that encode the
alpha or beta chains 01 the receptor PTKs,
platelet derived growth factor receptor
(PDGFR) or fibrobl ast gro wth fac tor reo
ce ptor 1 (FGFR1), Rearrangements 01
PDGFRB at chromo some band 5q33 that
lead to constitutive activation of the beta
moiety of PDGFA were first recogni zed in
cases variably reported as CEL or chronic
myelomonocy tic leukaemia (CMML) with
eosinophilia 11 31 , 8 12. 20851. More recen tly the gen e that encodes the alpha
moiety of the PDGFR, PDG FRA, at chromosome b and 4q12. was found to be
involved in cryptic translocat ions in CEl
and in nearty one-half of cases reported
as idiopathic hypereosinophilic syndrome
14661 In addition , rearrangements of the
FGFR 1 tyrosine kinase gene have also
bee n implic ated in myeio oronteratrons
with prom inent eosinophilia 13, 13541.
However, the c linica l and morphologi c
presen tations associat ed with FGFR 1
rearrangement are variable, and include
not only presentation as a myeloproliferative neop lasm with eosinophilia, bul also
as AML and they may even present as, or
evolve to. precursor T or B lymphoblastic
leukaemia/lymphoma with prominent eosinophits Cases associated with PDGFRA
rearrangements can likewise present as
AMl or precursor t -een neoplasms 114691.

Tlb.. 1.03 Myeloid and lymphoid neoplasms W11t1

eosmphi lia ard abnormal~m ol POOFRA, POOFRB, or
Myeloid and lymphoid neoplasms with
PDGFRA real1"angement

Myeloid nooplasms with PDGFRB

Myeloid aoo IylTVIOid neoplasms wiltl
FGFRf abnormallbes

Although it might seem most efficient to

categorize these cases as CEl within
MPN, this would ignOfe cases WIth
PDGFRB abnormalities that present as
CMML as well as cases of FGFR1 and
PDGFRA rearrange ments that may even
have a lymphoid conoooenr. To accommod ate Ihese transiccatons. a new subgroup defined largely by the genetic
abno rma lities of PDGFRA, PDGFRB or
FGFR1 has been added (Table 1.03).
Detect ion of one of these abnormalities
places the case in this category, regardless at the morpholog ic classification.
Cases of myeloid neoplasms with
eosinophilia that lack all of these abnormalities and that meet the criteria for
CEL. NOS, in the MPN catecov should
be placed in that group.
neoplasms (MDSlMPN)
The MDS/M PN (Table 1.04) include clonal
myeloid neop lasms that at the time of initial presentation have some clinical, laborato ry or morphologic findi ng s that
support a diagnosis of MDS, and other
findings more consistent with MPN They
are usually cha racterized by bvpercenularity of the BM due to proliferation in one
or more of the myeloi d lineages . Frequently, the proliferation is effective in
some lineages with increased numbers of
circulating cells that may be morphologically and/or func tionally dysp lastic . Simultaneously, one or more 01 the other
lineages may exhi bit ineffective proliferation so that cytopenlate) may be present
as well. The blast percentage in the BM
and blood is always <20%, Although
hepatosplenom egaly is common, the clinical and labo ratory find ings vary and lie
along a continuum between those usually
associ ated with MDS or those usually
associated with MPN Patients with a welldefined MPN who develop dysplasia and
ineffective haematopoiesis as part of the
natu ral history of their disease or after
chemotherapy should not be placed in
this category. Rarely, some patients may
present in a transformed stage of an MPN
entity in which the chronic phase was not
reco gnized, and may have findin gs that
suggest that they belong to the MDS/MPN
gro up. In such cases, if c linical and laborato ry stud ies fail to reveal the nature of
the und erlying proce ss, the designation
of MDS/MPN, unc lassifiable may be ap
orcorare. Paneots wro have the BCRABL 1
fusion gene or rearrangements of PfX3FRA

nurooocuoo and overview 01 the classification of the myeloid neoplasms




cmnc myelomonocyllc leukaenU (CMMl)

Atypocal chrooiC myeloid leukae~ ,
BCR-ABLI negative (aCMl)
JIMIrIiIe myelomooocytic leukaemia (""' Ml)

MyekldysplastcIMyeloproliferative neoplasm,
undassdiable (MDSlMPN ,U)
Provisional entity: Refractory anaemia wittl Mrlg
sideroblasts and ltJramt>ocytasis (RARS-n
should not be categorized as MDS/MPN.
and in contras t to the criteria used in the
3rd edition of the WHO classification,
cases of CMML with PDGFRB rearrangements are also excluded
Rationale for diagnosis and classification
This diagnostic ca tegory was introduced
in the 3rd edition amidst controversy as to
wl1ether some entities, particularly CMML,
would be better categorized as either
MDS or MPN depend ing on the extent of
mye loprol iferation as evidenced by the
WBC cou nt. Some cases of CMML have
low neutroph il co unts and only modestly
elevated monocyte co unts and resemble
MDS clinically and morphologically
whereas others have markedly elevated
WBC counts and org anomegaly more in
keep ing with MPN. yet criteria that clearly
distinguish biologiCally relevant subtypes
of CMML remain to be defined .
To date, a lew cases of CMML and atypical chronic myeloid leukaemia, BCR-ABL1
neg ative (aCML) have been reported to
demonstrate JAK2mutations that characterize BCR-ABL 1 negative MPN, but the
prol iferative aspec ts of most cases of
MPD/MPN are related to aberrancies in
the AAS/MAPK signaling p athways. In juvenile myelQmonocytic leukaemia (JMML)
nearly 80% of patients demonstrate
mutually exclusive mutations 01 PTNPN1',
NRAS or KRAS, or NFl 11329. 2096,
21621. all of wl1ich encode signaling proteins in AAS dependent pathways, and
approximately 30- 40% of cases of CMML
and aCML exhibit NRAS mutations {1686,
231 1, 24171. In view of the lack of any
spec ific genetic abno rmality 10 suggest
that these entities should be relocat ed 10
another myeloid subgroup, they remainin
this "mixed" category which acknowledges
the overlap that may occ ur between MDS
and MPN. Casesof CMML with eosinophilia
associated with PfX3FRB rearrangements
are excluded , but rare cases of CMML

with eosinophilia that do not ex hib it such

rearrangements sho uld be cJassified in
this categOry
The most controverstat issue in the su bgroup at MDSIMPN is the provisional entity.
refractory anaemia with ring siderob lasts
and thrombocytosis (RAR5-T). The ma jority (SO- 60%) 01 cases of RARS-T studied
lor JAK2V6 17F carry this mut ation 1234.
354.762 , 1835. 1839. 1969,2081,2139.
23581. This has prompted the notion that
RARS-T should be moved to the MPN
group of myeloid neoplasms. whereas
othershave argued thaI RARS-T is not an
entity at all but merely one of the better
recogniZed MPN entities, such as PMF or
ET. i'l which genetic evolution has led to a
dysplastic teanse. ring sideroblasls 11966.
2139. 23581. In a few cases reported.
hl:1Never. the cells of patients with RARS-T.
when studied by in vitro cul ture techniques, have growth characteristic more
in keeping with MOS than MPN 1234,
18351. An additional question is hOw to
clearly distinguish RAR5- T from RARS, in
which moderately elevated pla telet
counts are etten repo rted . This question
is morepressing in view of the revised c riteria for RARS-T that lowers the p latele t
threshold from ~x lrJl/L to ~450x 1rPlL,
in parallel with the revised threshold lor
Ef It is important to note that the d iagnostic criteria for RARS-T include not only
the Iinding of an elevated platelet coun t in
conjunction with anaem ia and ring elderoblasts in the 8 M, but al so mo rp hologicallyabnormal megakaryoc ytes similar to
those of ET or PMF. Only a few pat ient s
with RARS and plate let counts in the
450,500x W 9/L rang e have be en studi ed
for JAK2 mutat ions and in mo st with
platelet counts in the lower rang es no mutations have been found . Neverth ele ss,
more stud ies are need ed , and we rec ommend to test for JAK2 mutation s in patents who have RARS and pl atelet counts
above the normal range . The sum of current information reg arding RAR5-T argu es
for its continued placemen t in the
MDS/MPN category. but in view of the
debate regar ding its precise definition
and nature, it is best reg arded as a
'provisional entity" until more data are
lastly. classification of myeloid neoplasms
that carry an isolated isochromosome t 7q
and that have less than 20% bl asts in the
P8 or BM may prove difficult. Some authOrs suggesl this cytogenetic defect
defines a unique disorder characterized

by mixed MOS and MPN features associated with pro minent pseuoo-Percer-Hoet
anomaly of me neutroot urs. low 8M blast
count, and a rap id ly p rog ressive clinical
course. Most c ases rep or ted have a
prominent monoc ytic component and
meet the c riteria lor CMML, b ut in some,
the PB monocyte coun t may not reach the
low er threshold fo r that dia gnosis 1708,
14371 In cases that do not fu" ill the c riteria
lor CMML or another well de fined myeloid
category. desig nation as MOSIMPN. unclassifiable. with isolated isochromosome
17q abnormality, is most ap propriate.

$urTmary of major changes in MDSIMPN

1. Some cases of CMML with eosinophilia
are relocated to the category, "Myeloid
neoplasms with PDGFRB rearrangement"
2 . The c ategory, "Atypical CML" has been
renamed as Atypical C ML . BCR-ABL 1
negative" to emphasize this disease is not
merely a va riant of BCR-ABL 1 positive
3 . RAR$-T remains as a provisional enlity,
classified as MDS/MPN . uncrassiuabre .
until furthe r data clarifies its approp riate
designation. The crite ria for its recognition
have been modified. The platelet threshold has been lowered to ~ 45Ox 1rPll, and
meg akaryoc yte s w ith morp hology simil ar
to those seen in ETor PMF must be present
Myeladysplastic synd romes (MOS)
These disorders , usually characterized by
the simultaneous prolifer ation and apo ptests of baematopoienc cells that lead to a
normal or nvoerceuurar BM bi op sy and
PB c ytopenia(s), remain among the most
c halleng ing of the myeloid neop lasms for
p rope r d iagn osis and class ification , The
general fea tures of MOS, as well as
specific gu ide lines fo r diagnosis and
c lassific ation are outlined in Chapter 5.
An impo rtant add ition to the MOS ca tego ry (Table 1.05) is the provision al entity,
refractory c ytopenia of c hild hood (RCG),
This categ ory is reserved for c hildre n with
MOS who have <2% b lasts in their PB and
<5% in their 8M and pe rsistent cvtopenia(s) with d ysp lasia , In contrast to MDS
with ref rac tor y cvtc oentee in eo utts. the
majority of cases of ACC have hypoc ellular
8M bio psy specimens, and the d istinction
from acqui red apl astic anaemia and
inherited BM fai lure syn dromes is often
c hallengin g 117841,
An issue appro priate 10 menton at this
point is the cntene used for ctassmcatco
of myeloid neoplasms in which more lhan

50% of the BM ce lls are erythroid precutan d for which ac ute eryt hroid
leukaemia is co nsidered a po ssible dia gnosis. In such cas es. if blasts acc ount for
fewer than 20% of WBC in the PB and 01
all nucleated 8 M cells, and for less than
20% of the non-erythroid c ells in the BM
(lym phocytes, plasma c ells, etc. are also
excluded in this latter calculation), the
case is considered as MOS. In this scenario. there is lac k of consens us among
mem ber s of the WHO committee as to
whether the MOS should then be classified according to !he b last perceotace of
all nucleated 8 M cells or according 10the
blast percentage of all non-erythroid BM
cells. but the majority recommend s that
the MOS be classified using the blast percentage of all marrow nucleated cells.
Many cases of refractory anaemia with
ring sioerobrests as well as refrac tory
anaemia have marked eryth roid proliferation and using the b last percentage of the
non-erythroid cells lo r classification of
such cases might c ause these to be
placed in an unnecessarily high-risk category. On the other hand , if there is
severe multiline age dysplasia, very bizarre
erythroid morphology. and/o r minimal or
no maturation to segmented neut roobus.
and the btast percentage of total 8 M cells
is not sufficienl to place the c ase into a
hig h-g rade MOS c ategory, the case
shoul d be flag ged tor clin ical co rrelation
an d discussion, with ca refu l follow- up
(Tab le 1.06 ). More stud ies are needed
however to cla rify this controversial issue.


Acute myeloid leukaemia (AML)

AML is a d isease resul ting from the c lonal
expansion of my eloid blasts in the PB,
8M , or othe r tissue, It is a heterogeneou s
di sease c linically, mo rphologicall y and
ge neti cally and may involve only one or
Tabl. 1.05 Myelodysplastcsyndromes,
Reffacto!y ~nia wlltlll1 iWleage dysfllas48
Reffa<:byanaemia (RA)
Refracloty neutropenia (RN)
Refradcry ltuQmbocytopenia (RT)
Re!fadclry allaemia with ri1gSiderObIasts (RARS)
Relractory cytlpenia with ITIJlblineage dysplasia
Refractory all8e/l'M8 wiII1 excess bIasls (ME B)
MyelodyspIa$llc syncWmewilI1 iSOIatecI dfll(Sq)
Myelodysplllsbc syndrcIme. undas.sJliable (J.I>S.U)

C*hood ~ syrw:lrome
Pn:MsicnaI nty Refra:t:ry ~ ~ d*hlod

Introduction and overview of me classification 01 the myelOId neoplasms


... . -

Table 1.06 PMSib1e d~ when erythroid precursors ~50'10 of bone marrow nucleatedcells.

- -_."""""-

% Erythroid ~

Blocdhnarrow findirlgl.

0ltIer f1odlng&


~ blasts in blood or

Case meets alteria lor

AMLwith my8lOdysplasia

AML With fl'lyelodyspIaSia

related changes

of all nucleatedmarrow

inmatln IJyIIwid

Few lit'{ myeIclt:Qsts

""""" ..., """'"



' 50'

blasts <m d II


<20% blasts in blood,

blasts <20% of all

"""'"' """""-

related changes


Miwnall <Wly




... """""

Blasts <20% 01 all


~roid' cells

PIn 8I)tWIlid IeWemia

MDS: classifyMDS

acx:oroing 10 number of
blasts in blood and blasts
as pen:entIge d II

"""""" """""-

Erythroid precursors , lymphoid cells andplasmacens aresubtracledfrom a" nlJdeatedmarrowcells to calDJlate

the"noo-erythroid eels" in thebone marrow.

all myeloid lineages. Worldw ide the incidence is app roximately 2.5-3 cases per
100,000 popu lation per year, and is
reportedly highest in Australia. Western
Europe and the United States. The median age at diagnosis is 65 years, with a
slight male predominance in most c ountries. In Children less than 15 years of age,
AML com prises 15- 20% of all c ases of
acute leukaemia, with a peak incidence in
the first 3-4 years of lite 1559A, 2463AI.
The requisite blast perce ntage for a diag
rosrs of AML is 20% or more mveiobtasts
and/or monoblastslpromonocytes and/or
meg akaryo blasts in the P8 or BM. The di agnosis of myeloid sarcoma is synonymous with AML rega rdless of the numb er
of blasts in the PB or BM, unless the
patient has a prior history of MPN
or MDS/MPN, in wh ich c ase myeloid
sarcoma is evidence of acute transformation . The d iagnosis of AML can also
be mad e when the blast percentage in
the PB and/or BM is less than 20% if
there is an associated t(8;21XQ22;Q22),
inv(16)(p 13.1Q22), t(16:16XP13.1;Q22) or
t(15;17)(Q22:q 12) chromoso mal abnormality, and in some c ases of acute erythroid IeuI<aemia when eryttvoid precursors
ac count for more than SO% of the BM
ce lls and blasts account for more
than 20% of the non-erythroid marrow
ce lls (See Chapter on acute myeloid
leukaemia, NOS).
Although the diagnosis of AML using the
above guidelines is ope rationally useful to
indica te an unde rlying defec t in myeloid

IntroductIOn and

matur ation, the d iagnosis doe s not necessar ily translate into a mandate to treat
the pa tient for AML; c linical factors. including the pace of prog ression of the
dise ase, most atways be taken into consloerenon when deciding therapy.
Rationa le for the WHO diagnosis and
classification of AML
The 3rd edition 01 the WHO ctassrncatoo
ushered in the era of formal incorporati on
of gene tic abnormalities in the diagnostic
algor ithms for the diagnosis of AML. The
abnormalities included were mainly ch romosomal transiocenoee involVing transcription fac tors and associated with
charac teristic cl inical , morpholog ic and
immunophenotypic features Ihat formed
a clinico-pathologic-genelic entity. As
know ledge regarding leukaemogenes is
has increased, so has the acceptance
that the genetic abnormal ities leading to
leukaemia are not only heterogeneous,
but complex, and multiple aber rations
often coo perate in a multistep proce ss to
initiate the co mple te leukaemia phenotyp e. Expe rimental evide nce suggests
mat in many ca ses, although rearrangement of genes such as RUNX1, CBFB or
RARA that enc ode transcncuon factors
impair myeloid differentiation, a sec ond
genetic abnormality is necessa ry to promote proliferation or survival of the neoplastic clone (Fig . 1.08) 11135A I. Often.
the additional abnormalities are mutations
01genes such as FLT30 r KITthat encode
proteins that act ivate signal transduct ion

overvIew of the ctassuceuoo of the myeloid neoplasms

pathways to promote proliferation/survival

A similar multistep process is also evident
in AMl that evolves from MDS or that has
myelodyspl asia-related features, often
characterized by loss of genetic material
and haploinsufliciency of gene s. Within
the last few years, genetic mutations have
also been identilied in cytog enetically
normal AML 115321. Sane of the rrutations,
such as those of CEBPA and perhaps
NPM1 invdve transcriplion faclors. whereas
erne-e. including those of FlT.J and
NRASIKRAS. affect signal transduction.
Not only have these mutations led to an
unde rstand ing of leukaemoc enests in
c ytogenetic ally normal AML, bul they
have proved to be powe rful prog nostic
factors 115321. In summary, genetic abnormalit ies in AML eluci date the pathogenesis of the neoplasm, provide the
most reliable prognoslic information, and
will likely lead 10 dev elopment of more
successful targeled therapy.
One of the challenges in this revision has
been how to incorporate important and/or
recently acquired genetic information into
a classific ation scheme of AMl and yel
adhere to tile WHO principle of defining
horoogeneOuS, biologically relevant entities
based not only on gene tic studies or their
prognostic value, but also on clinic al,
morpho logic and/or immu nophenotypic
studies . This was particular ly prob lematic
for the most frequent and progn ostically
impo rtant mutat ions in c ytogenetically
normal AML, mut ated FLT3 , NPM 1 and
CEBPA. They have few or variably consistent mor phologic, irrwnunophenotypic
and clinical features reported to dale , and
the mutation s are not mutuall y exc lusive.
For the most par t, the framework coostructec in the 3rd edition proved flexible
enough to incor porate the new entities
propo sed by membe rs of the WHO c0mrmttee and the CAC (Table 107). The entities initially described in the subgroup
AML with recurring genetic ab normalnee' remain with only minor mod ifications
(Table 1.07) and three more entities, characterized by chromosomal transtocatioos
associated with fairly unilorm morphologica l and cl inic al features have been
added . Cases with muta ted NPMl and
CEBPA are added to the same subg roup
as ' provisional entities' ind icating that
more study is needed 10 lully characterize
and estab lish them as unique entities
Although mutated FLT3 is not includ ed as
a separa te entity because it is found to be
associated with a number of other entities,

Class I mutations

Class II mutations


MLL fusions

Proliferation and/or
survival advantage; not
affecting differentiation

its siqrsbcance should not be uoderestmated, and it is essential that it be tested

for in all cytog enetically normal patients,
including those who demonstrate NPM 1
and CEBPA mutations.
Modifications have been made in the
subgroup previously ter med "AM L wi th
multilineage ovsprasta." Initially, it was
envisioned that this g rou p would encompass biologically unique AML charac terized by MD$ -like fea tures, in cl ud ing
unfavourable cytogenetics, a higher lnc toence of ove rex pressfon 01 multidrug
resistance gfycoprotein (AS CS 1 or M DR-1)
and an unfavou rable respo nse to therapy.
Dysplasia in ~50 % of ce lls in tw o or m or e
heematop oienc lineag es w as used as a
universally-ap plic ab le surrogate m arker
for the myelodysp las ia- re late d featu res .
Although the c linical sig nificance of th is
grOl.lp has been verified in so me stud ies ,
it has been d isputed in othe rs in w hic h
multivariate anal ysis showed tha t m ultilin eage dyspla sia had no independent significance in predi c ting clinical outcome
wen cytogenetic findings were mc orporated in tne analysis 169, 869, 2356,
24651. Accordingly, in this revision, this
group has been renamed as "A ML with
myelodyspl asia- related changes," Patientsmay be assigned 10this ca tegory if
they evolve Irom previously documented
MOS. have specific myelodysplasiarelated cytogenetic abnormalities. or lastly,
if they exhibit mo rphologic mu ltilineage
dysplasia as def ined above. Pat ients in
Ianer group with a normal karyotype

to their g enetic a bno rm alities, but until

more data are available, we recommend
thai such c ases be classi fied as AM L with
m yelodysplasia-related c hanges (multilineage dysplasia) with the muta tional status
of the gene appended,
Therapy-related myeloid neoplasms (t-AMLJ

tMDS and t-AMlIt-MDSlMPN) remain in

the revised classificatio n as a distinct
subgroup. How ever, most patients who
develop therapy-related neoplasms have

Impaired haematopoietic
differentiation and
HqUent .poptos~


should be evalu ated for FLT3, NPM I and

CEBPA rnutanons. Cu rrently, however, the
clinical significance of a mutalion of one
or more of these genes in the setting of
mo rpholog ic multilineage dysplasia is not
clear. Future studies may well prove that
such cases are better classifie d according

received therapy with both alkylating

agents as well as with topo isomerase II
inhibitors, so that a division according to
the type of the rapy is usually not pr actical
and not recommended in this revision. It
has been argued that 90% or more 01
cases with I-AMLIt-MDS or t-AMl/t-MDSI
MPN have c ytog enetic abnormalities
similar to those seen in A ML with recurrent genetic abnormalities or AML with
myelodyspiasia-relaled features and could
be assigned to those categories. However,
except for patients w ith t-AML who have
inv(16Xp 13.1q22), t(16;16XP13.1;q22)or
t(15 :17Xq22;q 12), in most reported series
those w ith therapy-rel ated myeloid neop lasm s have a significantly wor se c lin ical
outcome Ihan the ir de novo counte rp arts
with the same genetic abnormalities 136,

Table 1.07 Acutemyeloid leukaemia andrelatedmyeloidneoplasms,

Atutt myeloidIeukaemi,with recurrent gtllllIlIt Ibnormalitles
AMLwith ~8;2 1 )(Q22:Q22): RUNXt-RUNXm
AML with inv{16)(p13.1q22} c. \(16:16Kpl3.1:q22); CBFB-MYHIt
APl with \(15;17)(q22:Q12); PML-RARA
AMLwitht(9:11){p22:q23}: MLLT3-MLL
AMl with t(6:9)(p23;Q34): OEK-NUP214
AMl with inv(3KQ21Q26.2) ort(3:3J(Q21;q26,2); RPN1EVl l
AML (megakeryoblastic)with 1(1;22)(p13; q13): RBMI5-MKL 1
Provisional entity:AMl with mutated NPM1
Provisional entity: AML with mutated CEBPA
Acutemyeloid leukaemia with mye!ody,plilil-related changes
Therapy-related myeloid neoplil5m,
Acutemyeloid leukaemia, no! otherwl$l spec;lrted
AMLwith minimal diffe!lll1tialiorl
AML without maturation
AMLwith mallJ"aUon
Acute m~ leukaemia
Acute roonoblasticJmooocytic Ieukaemla
Acute ~ IeukaelBas
PIse erythroid leukaemia
EIythroleukaemia, 8I')1hroidfmyeloid
Acute megakaryoblas.lic Ieukaetnia
Acute basophl1ic Ieukaen'Ha
Acute panmyeIosis with myebfibrosis
Myeloid sarcoma
Myeloid proliferations related to Down syndrome
Transaent abnormal myelopoiesis
Myeloid leukaemia ISSOCiaIed with Down syndrome
Blastic plil5maC}'loid dendritic u1llll1oplalms

Introduction and overview of lhe classification 01 the myeloid neoplasms


227 , 1886~ 2034 , 204 1}, suggesting some

biological differences between the two
groups. Fur thermore, the stu dy of therapy-related neoplasms may provide valuable insig ht into the pat hogenesis of de
novo d isea se by p rov id ing c lues as to
wh y a few pat ients de ve lop leukae mia
wher eas most p atients treated with the
same therapy do not. Therefore, patients
with therapy- related neoplasms should be
de sig nated as suc h, but the specific c ytogenetic abnorma lity shou ld also be
listed, for example, "therapy-related AML
with s,11}(p22;q23)".
Acute myeloid leukaem ia , not otherwise
specified, encompasses those cases that
do not fu lfil the spec ific criteria of any of
the othe r entities. This g roup accounts for
only 25-30% of a ll AM L that are not assigned to one of the mo re specific ca tegories. As more genetic subgroups are
iden tified , the num ber of pa tients that fall
into the AMl , NOS c ateg ories w ill cantmoe to diminish . Of note is that infor mation used to characterize the subgroups
within this c atego ry, suc h as epidemic-logic or clinical out come , is oft en ba sed
on older stud ies tha t inc lud ed patients
now assigned to d ifferent diagnostic ca teg or ies. and may not be reliable. Althou g h the p roposal to collapse th is
category into fewer subgroups has bee n
made. the notion that some of these may
yet be found to be associated with spec ific genetic or b iologic abnormalities
argued to maintain this category.
Myeloid sarcoma, an extramedullary
tumour mass consisting of myeloid blasts,
is inc lud ed in the classifica tion as a d istinc t pa tholog ic entity. How ever, wh en
mye loid sa rco ma occu rs de novo, the
d iagnosis is eq uiva lent to a d iagnosis of
AML . and fu rthe r evaluation , including
genetic analysis, is necessary to determine the approp riate cl assific atio n of the
leukaemia 117421. When the PB and BM
is concurrently involved by AMl. mese tissues may be used for ana lysis and furthe r


classification . However, when the myeloid

sarco ma precedes ev idence of PB or BM
invotvement. the irrvnunophenotype should
be ascertained by flow cytometry and/or
irrvnunohi stoc hemistry, and the genotype
determined by cytogenetic analysis, or in
the absence of fresh nssue. by FISH o r
molecular ana lysis for recurrent g enetic
abnormalities. Myeloid sarcoma may also
be the initial ind ic atio n 01 relap se in a
pat ient previously d iagnosed With AM L or
may indicate disease progression to a
blast phase in pat ients with a pr ior d iagnosis of MDS, MDS/MPN o r MPN.
Lastly, the unique featu res of Down synd rome- related myeloid neoplasms has
been rec og nized in a separate listing that
incl udes transient abnormal myelopo iesis
and mye lo id leukaemias (MDS/A ML )
assoc iate d with Down synd rome.

Summary of major changes In AML

1. AML with recurrent genetic abnorma lities,
a ) AML w ith t(8;2 1)(q22;q22), AMl w ith
inv( 16}(p 13 .1q 22 ) or I( 16; 16}(p 13. 1;q 22),
and APL with t(15;17}(q22 ;q 12) are considered as AM L regard less of bla st count;
for all othe rs, b lasts 2:20% of P8 or of all
nucleated BM ce lls are req uired .
b) In API... with1( 15;17)(Q22;q12); FM..-R.AR4,
varia nt RARA uenslocaucos with other
partner ge nes are recognized separately ;
not all hav e typica l APl featu res a nd
some have ATRA resistance .
c ) The termer cat egory, AM L with 11q23
(MLL) abnormalities has been re-defined
as -AML with 1(9;11)(p22;q23); MLLT3-MLL".
Balanced transtocanons other than that
involving MLLT3 should be specified in
the di agn osis. Ot her abn or malities of
MLL , such as partial tande m du p licatio n of
MLL should not be placed in this categ ory.
d) Three new cytogenetically delined entities are ad ded : AML with t(6;9)(p23;q23);
DEK-NUP214, AML with inv(3)(q21q26.2)
or t(3;3)(q21 ;q26 .2); RPN1-EV/1; and AMl
(megakaryoblaslic) with t(1 ;22)(p 13;q 13) ;
RBM15-MKL t.

Introduction and ove rview of the classification of the myeloid neo plasms

e) Two p rovi siona l ent ities are added:

AML with mutated NPM1 and AMl with
mutated CEBPA. Although not included
as a distinc t entity, examination lor mutations of FLT3 is slron gly rec orrwnended in
all cytogenetically normal AM L.
2 . AM L with mye lodysplasia-related
changes .
a) Name changed from AML with rru llilineage dysp lasia".
b ) Cases of AML are assig ned to this categ ory if 1) they have a previous history of
MDS and have evol ved to AML , 2) they
have a myelodysp las ia-related cytogenetic abnormality, or 3) if ;<:50% 01cells in
two or more myeloid lineages are dysplastic ,
3. Therapy -related myeloid neoplasms.
Cases are no longer subcategorized as
"alkyl ating agent related " o r ' tccoisomerase tl-intubttor related " or "other",
4. AM L, NOS.
a) Some c ases previously assigne d to the
subcategory of AMl. NOS as acute erythroid leukaemia may be re-classihed as
AML with myelodysplasia-related changeS.
b ) Cases previously ca tegorized as AML
NOS. acute megakaryoblastic leukaemia
should be placed in the appro priate
ge netic category il they are associa ted
With inv(3)( q2 1q26 .2) or t(3:3)(q21 ;q26.2);
RPN1-EVlf, or AM L (megakaryoblastic)
with t(1;22)(p 13;q 13); RBM15-MKL 1.1JcM'n
synd rome related cases are excluded
from this ca tego ry as well .
5 . Myeloid proli ferations related to Down
New ca tegory to inc or porate trans ient
abno rmal mye lopoies is as we ll as myeloid
leukaemia that is Down synd rome related
MDS related to Down syndrome is conside red biolog ically identical to AML
related to Down syndrome.


Chronic myelogenous leukaemia,

BCR-ABL 1 pos it ive


Chronic myelogenous leukaemia (CMl)

is a myeloproliferative neoplasm thai
originates in an abnormal plur ipotent
bone marrow (8 M) stem cell and is consistently associated with the BCR-ABL1
fusion gene located in the Philadelphia
(Ph) chromosome {154. 1455 . 1607, 18841.
Although the in.tial major finding is neu trophilic leW<ocytosis, the BCR-ABL 1 is found
in all myeloid lineages as well as in some
lymphOid cells and endothelial cells . The
natural history 01 untreated CML is bi- or
tripha sic : an initial indolent ch ronic phase
(CP) is followed by an accelerated phase
(AP), a b last phase (BP) or both.

ICD-O code


(WBC) count performed at the time of a

routine med ic al exa mination is found to
be abnormal 1486 . 755, 1942/. Common
findi ngs at p resentation inc lude fatigue.
wei ght loss, nig ht sweats, splenomegaly
and anaemia 1486. 19421. Atypical presentations include marked thrombocytosis
unaccompanied by a significantly elevated
WBC count as well as initial presentation
in BP without a previously detectable C P
134 ,486. 17301. In the absence of curative
treatment most patients progress from CP
to BP either suddenly or through a transitcoat AP. although some die in AP without
progression. The transformed phases are
generally accompanied by worsened performance status and by symptoms related
to severe anaemia, throm bocytope nia or
marked sp lenic enla rgement 17551.

J W _Vard iman
J ,V. Melo
M . Bacc arani
J . Thiele

for less than 5% of the marrow cells in CP

and 10% or more indicates disease progression 14821- Erythro id precu rsors vary
but erythroid islan ds are usually reduced
in number and size {222 11 . The megakaryocytes of CML are smaller than normal
and have hypolobated nuclei ("dwarf
megakaryocytes"). Althou gh they may be
normal or slightly decreased in number.
40-50% of patients exhib it moderate 10
extensive megakaryocytic proliferation
1296.775,22 15.222 1). The initial biopsy

Ch ronic gr anulocytic leukaemia ; ch ronic
myeloid leukaemia

Epid emiology
CM L has a wo rldwi de annual inci dence of
1- 2 cases per 100 ,000 po pul ation. The

disease can occur at any age, but the

median age at diagnosis is in the 5th and
6th de cades of life There is a slight male
oreoorno ance 1755, 1053 , 1826 1.
Factors p red isposing to CML are unknown.
Rad iation exp osure has been implica ted
in some c ases 1226, 4791. There do es not
appear to be an inherited di sp osition.
Sites of Involvement
In CP, the leukaemic
are minimally
invasive and the proliferat ion is la rg ely
confined to naerocoieuc tissues, primarily b lood . BM an d sple en although the
liver may be infiltrated as well . In BP, extramedullary tissues, including lymph nodes,
skin and soft tissues may show infiltration
by blasts 1486,1029,15341.


Clinical featu res

Most patients are diagnosed in CP which
usually has an insidious onset. Nearly
20-40% of patients are asymptomatic and
are diagnosed when a white blood cell


Myelop",lile"tive neoplasms

Chronic phase (CP)
In CP the peri pheral blood (PB) shows
leukocytosis (12-1 000x 1()lI1L. median
- 1OQx1CPIL) d ue to neutrop hils in different
stages of maturation wit h peaks in the
pe rcent of mye locyt es and seg mented
neutrophils 1486, 755, 1164, 1942, 20671 .
There is no significant dysplasia 11 89 ,
2458 }. Blasts usua lly account tor less than
2% of the wac 1189, 206 7l. Ab solute
basoph ilia is invariab ly pr esent and
eosinop hilia is common (2067l. Ab solut e
monocytosis may be p resent but the frac tion of rnonocvtes is usua lly <3% (189 1.
except in rare c ases assoc iated with the
p 190 BCA -A8 L 1 tsoto rm. in whi ch case
monoc ytosis is nearly always present and
con fusion with c hronic myelom onocytic
leukaemia is possib le 114581 The platelet
co unt usually rang es tram normal to
gre ater than 1000 x1()91L and thrombocytopeni a is uncommon 119421. The 8 M cellular ity is incr eased due to g ranulocytic
proliferation with a maturation pattern similar to that in the blood 1486, 1534 1. In
biopsy sections the paratrabecutar Cuff of
imma ture neutrophile is often 5- 10 cells
thick in contrast to the normal 2-3 cell
layer and 1he mallie neutroph~s are situated
in the intert rabecutar areas. Eosinophils
may be prominent. Blasts usually account

F""i-2.o1 CML. ctvoricphase. A ~ blood SlTlllit"

showing Ieukocy1osis and neu1rophiIic eels at varyI1g
stages d malnIKn 8asqJIiIia is ~ ttl dyspIasiI
iii ~ B Bone marrow biopsy $I'lOw$marked hypeIc:eIIuIanty due to granulocytic prolderabon. C The
megaka/yOC)1es in CMl are c:harac:leilsbcaly ~
ItIan ~ megakaryocyIes.

stoNs moderate to marked reticulin fibrosis

in approximately 30% 0 1 cases wh ich
often correlates with inc reased numbers
01 megakaryocytes, larger spleen size
and reportedly. a worse p rognosis 1293 ,
540, 1217.2215. 222 11. Pseudo-Gaucher
cells and sea-blue histiocytes are commooly observed secondary to inc rease d
cell turnover and are de rived 'rom the
neoplastic clone 135. 22271. More than
80% of patients have sign ifican tly redu ced
or no iron-laden macrop hag es 120451.
In CP the spleen is enl arge d du e to
inliltration of the red pulp co rds by g ranulocytes in differe nt mat uration sta ges ,
A similar infiltrate may be seen in the
hepatic sinusoids and port al areas.
Disease progressionltra nsformed
phases in CMt
The recognition of di sea se prog ression
from CP to the transfo rmed stages of AP
and BP is impo rtant for prog nosis and
treatment, but the c linica l and mor phologic boundaries between the se stag es
olten overlap and the parameters used to
identify them have va ried among di fferent
investigators [118, 293, 481 , 482, 829 ,
1100.194 11 . Furthermore, there are only
scant data relevant to d isease pr ogre ssion in the era 01 protein kinase inhibitor
(PTKI) therapy. Bone ma rrow c hanges
following short and long term PTKI trea tment have been extensively stu died
showing a reduction 01 g ranulocytic eelkJlaflly. normalization of megakaryopoiesis,
regression of fibrosis and inc rease in
eccctosis associated with decrease in
proIilerative act ivity 122191.

Acce lerated phase (AP)

In the 3ld ed ition of the WHO Classifica tion
110391, it was suggested that the d iagnosis
of AP could be made if any of the follOwing
paramete rs were present: 1) persistent or
inc reasing WBC (> 10x1()9!L) and /or pers istent or increasing splenomegaly
unres ponsive to the rapy, 2) persistent
mrontocvrose [> 1000xlcYlL) uncontrolled
by therapy, 3) pe rsistent thrombocytopen ia

100xl()9!L ) unrelated to therapy, 4)

clonal cytogenetic evolution oc curring
afte r the initial diagnostic karyotype. 5)
20% or more basophils in the per ipheral
biooo . and 6) 10-19% myeloblasts in the
blood or 8M. Criteria 1- 4 are more likely
10 be ass oc iated with transition from CP
to AP, whereas c riteria 5 and 6 more
frequently indicate a transition between
AP and SP. Although modifications to

Fig. 2.04 CUL dVonicphase, "Pseudo-GaiI:: eels in CML.. A Pseucb-Gauchef cells In COITIllOl'Ily obsenoed i'l
the marTOW aspIate$ aI pabents WIth CML. B They Ina)' also be ~ as loamy or strialed eels in ITIlI"I'OW
biopsy sedions. TheseI'listo:)"es are seaJndary " increased celllm::Ner. <We del'ived from the neopIaslic dln and
easily ~ from the &mal rnagakaryoc:yte tt-" rn8f9I").

Chronic myelogenous leukaemia. BCR-ABL I positive


Fi9. 2.05 Splenomegaly 11 CML A The gross appearara of Itle spleen is solid and uniIonnIy deep red, although areas of inlartt IlI8)' appear as IlghIer aIloured regions, 8 TIll
red pljp disbibubon of!tie infiltrate usually (XIll1lfesse5 alldobhlefates lhe while pulp. C The leukaemiC cells are present in!he SInuses as wei asin!he spleniccools of lhe red pulp.

these criteria have been suggested and

different criteria proposed by others
[4821. it is recommended tha t the paramete rs liste d abo ve sti ll be conside red as
evide nce of d isease pr ogression. Whether
they or other parameters, such as drug
resistance, necessarily ind ica te shortened
survival times or imminent blast nanetorma hon is not c lear in view of the efficacy
of current trea tment strategies, and more
studies are needed to accurately identify
criteria for AP in the face of PTKI therapy.
Often in AP the BM is hypercellular and
myelodysplasia is seen 11534, 24581. The
increase in myeloid lineage blasts may be
readily appreciated with stains for CD34
performed on the biopsy 116501. large
clusters or sheets of small , abnormal
megakaryocytes associated with marked
reticu lin or COllagen fibrosis are commonly


Myeloproliferative neoplasms

observed and may be considered as

pres umptive evidence of AP. although
these find ing s are almost always associated with one or more of the othe r c riteria
listed ab ove 1289, 293,15341. The find ing
of lymphoblasts in the blood or ma rrow is
unusual in AP and should raise concern
for lymphoblastic BP 15571.

cases the blasts are Iymphoblasts 1557.

1138. 1558, 1706. 1913,24541. In BP the
blas t lineage may be ob vious morpho logic ally bu t often the b lasts are p rimitive or

heterogeneous and cytochemical and

immunophenotypic analysis is recommended.
If accumulations of bl asts occupy focal

but significant areas of the 8M , e.q. an

Blast phase (BP)
The BP may be d iagnosed when 1) blasts
equal or are greater than 20% of the PB
WBC or of the nucleated cells 01 the BM,
or 2) when there is an extramedullary
blast proliferation. In approximately 70%
of cases. the blast lineage is myeloid and
may inc lude neutrophilic . eosinophilic. besophilic . monocytic, megakaryocytic or
erythroid blasts or any combination thefeof.
whereas in approxi ma tely 20-30% of

entire intenrabecular region, a presump-

tive dtaqrosrs of BP is warranted , even if

the remainder of the 8M biopsy shows CP
12891. Immunohistochemical studies lor
CD34 andlOf terminal deoxynucleotidyl
transferase (TdT) may help in distinguishing such foci of blasts in BP from the loci

01 promyelocytes and myelocytes thal

often are prominent in paratrabecutar and
perivascular regions during CPo
Extramedullary blast proliferations most

v- --

0 0


c:orrvnonly present in the sk in. lym ph

node, spleen. bone or central nervous
system, but can occur anywhere, and may
be 01 myeloid or lymphoid lineage 110291.


The oeutrophils in CP have markedly

decreased neutroph~ alkaline phosphatase
{16401. In myeloid BP the blas ts may have
strong. weak or 00 myetoperoxidase
activity but express antigens associated
withgranulocytic, monocytic , megakaryoblastic and/or erythroid differentiation. In
the majority of c ases the myeloid b lasts
will express one or more lymp ho id an tigens as well {557. 1138 , 1558 , 19 13 1.
Mos1 cases of lymphoblastic BP are precursor B in origin but cases of T lym phoblastic origi n also oc cur p 138 , 1558 ,
19131. In lymphoblastic BP, one or more
myeloid antigens are co-expressed on the
nphoblasts in the majority of c ases, Ap proximately 25% of BP cases fulfill c riteria
for mixed phenotype acute leukaemia
(MPAL) 1557. 1138. 1558, 19 131, but these
are considered as exa mp les 01 BP and
are different from de novo MPAL,
At diagnosis. 90-95% of cases of CM L
have lt1e characteristic t(9 ;22)(q 34 :q 11,2)
reciprocal translocation tha t resu lts in the
Ph chromosome [der (22q)] 11607. 18841.
This translocation fuses sequences of the
BCR gene on ch romosome 22 with
regions of the ABL 1 gene from c hrom osome 9 11541. The remaining cases either
have variant trens'ocauons that involve a
third or even a fourth chromosome in
addition to ch romo somes 9 and 22 . or
neve a cryptic translocation of 9q34 and
22<;11.2that canno t be identified by reotile cytogenetic ana lys is. In suc h cases,
'tie BCR-ABL 1 fusion gene is present and
Cl be detect ed by FISH analysis . AT-PCR
Of Southern blot tec hniques 114541. The

site of the breakpoint in the BGR gene

may influence the phenotype of the e nsease 11454) . In CML, the breakpoint in
BGR is a lmost always in the major breakpoint cluster region M ~8C R . spanning
exons 12-16, (previously known as b1-b5)
and an abnormallusion protein, p2 10. is
formed wh ich has increased tyrosine
kinase activity {1454 1. Rarely, the breakpoint in the eGR gene occurs in the
1J-8CA reg ion , spanning exons 17-20
(p reviou sly known as C1-C4 ) and a larger
fusion prote in, p230, is encoded . Patien ts
with this fusion may demonstrate prominent
neutrophilic maturation and/orconspicUClUS
throm bocytosis {1454 , 1685 1. Although
breaks in the minor breakpoint region,
m-BCR (BCR exons 1-2) lead s 10 a
shorter fus ion p rotein (pl90) an d is most
freq ue ntly associ ated with Ph positive

ALL , small amounts of the p190 transcript

can be detected in >90% of patients
with classical p210 CML as well, due to
alternative splicing of the OCR gene 11907,
23061 . However, this breakpoint may also
be seen in rare cases of CML that are d istinctive for having increased numbers of
monocytes and thuscan resemble chronic
myelomonocytic leukaemia 114581.
The enhanced tyrosine kinase activity of
BCRABL 1 is responsible for coosntunve
activation of several signal transduc tion
pathways 15391. This resu lts in the
leukaemic phenotype of CM L ce lls which
encompasses deregulated proliferation ,
red uced adherence to the 8M stroma and
defective apoptotic response to mutagenic st imuli . The understand ing of the
abnorma l signaling in CML cells led to
the design and synthesis of small

F"tg. 2.08 0r.I... myeloid bla ~ ptlase. A ~ l:tlodofl pllientWllh myeIoidbllst phase . Tht ma;onty oftle "'*
l:tlod oats<n blasts. B.C Sheetsof ~ in' " bin! ITWTtM bqIsy. D Myeloperolidase del8cllId Imu'oo
tvmchei,U1. pIWng ee myetoid lineage of hi blasl P'~lIlul.

Chronic myelogenous leukaemia, BCR-ABL 1positive


A Penphetal blood smear. 8 Bone malTOW biopsy C Mam:lw aspirate smear.

Fig. 2.10 0Al.. myeloid bIasI phase , in 8Ile~ site . A,8 l~ node biopsy obtained from iI pabent with a tIiStor'y 01 CML lor 3 ~_ The lymph node d1iteclln is
Iatgely eIIaoad by a proIrfefatlon 01 medir.Jmkllarge Sized cells. C l~ im~ confirms the myeloid lineage ollhe blasts,

molecules that target the tyrosine kina se

ac tivity of BCR -AB L 1, of which imatinib
was Ihe first to be successfully used to
treat CML 1616, 6 171. lmatinib competes
wi th ATP lor b ind ing to me BCR-ABL 1
kinase domain thus preventing phosphorylation of tyrosine resid ues on its substrates, Interruption of the oncogenic
sig nal in this way is very effective for control of the d isease , particularly when used
early in CPo However, the eme rg ence of
sub-c lones of leukaemic prog enitor c ells

with point rrutations that prevent the bnding

0 1 the inhibilOf to the kinase domain of
BCR-ABL 1 can lead to d rug resistance,
p articularly in AP and BP 11103. 23731.
The second generation compounds nilotmib and d asatinib can circumvent this
form of d rug failure in the case of most but
not all kinase domain mutations assoc iated
with imatinib resistance 11103, 2373} .
The mol ecu lar ba sis of d isease tran sformation is still large ly unknown . Progression
is usua lly associated w ith clo nal evolu tion

1657, 1487, 14881, and at the time of

transformation 10AP or BP, 80% of patients

demonstrate cytogenetic changes in additlOO to the Ph ch romosome, such as an
extra Ph, . 8, . 19 , or i(17q). Genes shown
to be altered in the transformed staqes include TP53, RB1, MYC, p1 f7'"""" {CDKN2Aj,
RAS, AML 1 and EVil , but their role in lhe
transformati on , if any, is currently unknown
1821 , 1455 , 14871- The recent introduction
of gen ome -wide expression profiling by
mrc roarray tech nolog y has started to reo
vea l othe r cand idate genes assoc iated
with the ad vanc ed stages , and has also
revealed similar gene expression patterns
betwee n AP and BP, suggesting that the
genetic even ts lead ing to transformation
in AP and BP occur in late CP or early AP
11608, 1624 , 18031.
Postu lated celt

of origin

It is curren tly accepted that CML-CP

originates from a plu ripotent 8M stem eel.
However. disease progression may originate in more corrvn itted precursors lhan
previously supposed, as myeloid BP has
Fig. 2.11 Fluorescence il SItu hybAckzalion (FISH) with dual color and dual fusion probe on a normal metaphase eel
(A) 8Ild metaphase preparaOOn (8) from a patient witht(9-,Z2)(q34;q11 .2~ AWal alia' anddual fusion InInsloc:aIion probe
is used (VysisR corporatlon). The ABL I and BCR probes are labeled with SpectrumOrange and SpectrumGreen
respecIJYeIy. In J'lOfmllI eels (A) two orange Signals represenbng the ABL 1 gene al 9q3.4 and two green SIgnals representing the BCR at 22(111.2are &hown. In the pall&nl's CMl cells (8) one orange (J'lOfmllI 9q34), onegreen (normal
22q11.2) andtwo orangeJgteen(yelOw) signals, repl"esenOOg derivative 9q3.4 and 22q11 ,2, respedively, are detected.


Mye loproliferative neoplasms

been repor ted to involve the g ranulOcytemac rop hage prog enitor pool rather than
the naerroooletc stem cell pool 114741.
Whether the same applies to lymphoid BP
is not know n,


AlP-bind ing com etitors

\m t?9;22)(q34 ;q11.2)



rig. 2.1 2 ... SC1lemabc representabDn of !he U:9:22) chromosomallranslocabon, me fusion mRNA ~ encoded by !he BCR..-&.1 tl)trid gene geoeqted in !he 22q. or

F'IlIacletiIlia (PIli chi OliiOJmll , and hi nnslated BCR-ABL1 kl5ion protOO, ...nose oncogenic ptqlllrties I'e/y pl'lIl'IiIdy' on ts conslllUOVely actrvaled tyrosne U1ase en:xlded bytie
s..:~ I ISH1)domain i'llicatedby ltle red Orde. Some of It1e oltlef ~ UlcWlaI don'IaI'S CQ'1tnlluted by tie BCR andABLl pcnons oIlhe Oi iCClPi oceifl n sI'lowfl.
These n 1Ile dMnensaliOn domain (00): Vl n wtlich is !tie allloptlosphoryllion s<1e crucial lor binding to 008-2; the ptIospho-Ser and -Thr SH-binding dorr'I<Wl; a region
turdogaIs tI Rho guarlIdne ru:Ieoticle exet.ange laclots (Rho-GE.F): ee ABll regoJa1o"y SH3 and SH2 domains; Y412 as !he map Slt8 r:I ~ wiltlillhe StU
IrNse dcrnarI; ru::i8ar kx:att:alitw, J9IaIs (tt.S) and lhe DNA- and adn-I:imng danains.. B Mectllnsm 01 adIion 01 acR-A8I..l \yrtliW1e kNse ~ 'M1ereas h physdogicaI
tning rJATP III its poDelllbn BCR-ABLllO phosphorylate seIeded tyrosWle residues onrts SI.tIslrales (left <iagam). a synlheIicATP rrmc such lIS inalinlb fits t1ls
Iiaopm),lluliXles nol prOYide Ihe esseoIiaI phosphate ~ lO be transfem!d k11he SI.tIslraIe Thedownstream d1aIn 01 reactions is lhenhaAed because,lfII'iltI irs tyrosines i'llhe
~ form. ee subslrate does not assume the necessary ronJoonabon 10erlSlH associabon WIlh itS efleclor.


~ and predictive factors

Based on historical data prior to any

effective therapy, median survival times in
CML ranged bet ween 2-3 years {7671_
With conventional c hem othe rapy (bus ulfan, Hydroxycarbami de) me dian survival

was about 4 years, but progression to AP

and BP was only slightly delayed w ith 10year overall survival (OS) less than 10%
1767, 1948, 2022). Interfe ron-u -based
regimes delayed prog res sion signilicarttly, with median survival of approximately 6 years and to-yea r OS of - 25%
1115l. With allogenic stem ceutransotant.
1O-year OS ranges between 10 and 70%,
depending on d isease phase, patien t age

and donor ty pe 1116 , 828, 20221. Thre e

pr ognosl ic models ba sed on baseline
pr ognostic variables including age ,
spleen size, p late let count , the percentage of mveiobrasts in PB as well as the
percentage of basophils and eosinopnns
in the PB allowed the c alc ulation of rela tive risk, hence of the life expectancy, of
patients treated with conventional chemotherap y an d inte rferon 1905, 1101 , 2044 1
and w ith im atinib { 116, 6 15), b ut not those
treated wi th all ogene ic stem ce ll tra nsp lant. Som e stud ies have show n that the
p redictive va lues of these models can be
fur ther improved by the inclusion of morphologic parameters, particularl y the

pres ence or abse nce of m ye lofib rosis

1292 , 293, 12 17, 12 181. Pretra nsplant
myelof ibrosis ha s been reported to be
associat ed wit h a delayed or failure of
naematoooenc reconstitution 1293, 22071.
How ever, in the current era of PTKI
therapy, the most important prognosti c
ind icator is the response to treatment at
the haematologic , cytogenet ic and molecular level 1116/ Cu rrently the comple te
cytogenetic response rate to ima tin ib is
70-90%, with a 5-year progression free
survival and OS between 80 -95% 1116,


Chrooc myelogenous leu kaemia, BCR-A BL 1 po sitive


Chronic neutrophilic leukaemia

B.J . Bain

RD. Bru nning

JW. Vardiman
J . Thiele

Chronic neutrophilic leuk aemia (CNL) is a

rare myeloproliferative disease . cha racterized by susta ined peripheral bloOd (PB)
neut rop hilia. bone marrow (8M) hypercellulanty d ue to neutrophilic granu locyte proliferation. and hepatosplenomegaly. There

is no Philadelphia (Ph) chromosome or

BCRABL 11usion gene, The diagnosis reo
quires exc lusion of reac tive neutrophil ia

and other myeloproliferative neoplasms,

ICD.Q cod e


Epidem iolog y
The true incidence 01 CNL is unknown ,

but only about 150 cases have been

reported. In one study 01 660 cases of
chronic leu kaemias of myeloid origin. not

a singlecase 01 CNL was observed 120031.

CNL gene rally affects olde r adults. but
has also been reported in adolescents
1909, 2474, 2504}. The sex distflbulion is
nearly equal 1231 . 640, 2474, 25041.

The cause of CNL is not known. In up to
20% of reported c ases, the neutrophilia
wa s associated with an und er ly ing neoplasm , most usua lly multiple my e loma
1355, 58 4, 20761. To dale, no cases of
CNL as sociated with myeloma have been
rep orted in wh ich a clonal c hromosomal
abnormal ity o r evid enc e of cronauty by
molecular tec hniques has been co nvinc ingly d emons trated in the neutroonns
120771. II is thus likely that most cases of
CNL associated w ith mye lom a are not
autonomous prolif erations of the neuuophi ls , but are secondary to abnorma l
cvtokme release from the neoplastic
plasma cells or othe r cells regulated by
the plasma cell population . The same
may be true of C NL associated with other
neoplasms. However, it should be noted
that evolution to acute myeloid leukaemia
(A ML) occurred in one pat ien t with CNL
associated with multip le my eloma {5841 .
Sites of involvement
The PB and BM are always involved, and
the splee n and liver usually show leukaemic

Myeloprol iferat ive neoplasms


. :t

Fig. 2.13 Ovtnc newophIc ~ _ A The neutrophiia dIatac:IeristIc oIltie ~ t*:xx1 il CNL B The. .
granUatiolllXlr!JTllldy obset'o'ed. Reproduced from Anastasi and ~ (3SAJ. C The bone rnatfOW asprDt SI!W
der!lcmIrates neutrophil proWerabOn from myebcytes to ~ forms 'Mlh toO: granu/abOn, 1M no olIW"
s9'ificant abnormaibes. D The bone marrow biopsy specimen is hyperceWar, showing a markedly eIevMld
myeIoicI:erylM:lid ratio WI!h increased IIJrmers of nNrophk, partK:tarly maturesegmented bms.

infil trates 12257. 2474 . 2504 1. How ever,

any tissue may be infiltrated by the rectrophils 12257 , 2474, 25041.
Clinical features
The most constant c linical feature reported
is sp lenome ga ly. whi c h may be symptomatic . Hep atomeg aly is usu ally present
as we lt 12474 , 2504 1 A history of b leed ing
from mu cocutaneous surfaces or from the
gastrointestinal tract is reported in 25-30%
of patients 1909, 25041. Gout and pruri tus
are other possi ble symptoms 12504 1.


The PB smear shows neu trophilia w ith a

wh ite b lood celt count ~25x l ()9/L.. The
neutrop hils are usuatty segmented, b ut
there may be a substantial increase in
band for ms as we lt. In almost alt cases,
neutrophil precursors (pn::rnyeIocytes, myeiocytes. metemyetocytes) account for
fewe r than 5% of Ihe white cells, but oc casionally, they may account f()( ~p to 10%
1231 ,640 , 909 , 2474. 25041. Myeloblasts

are almost never observed in the blood

The neutrophils often ap pear toxic . with
abnorma l, coa rse granules, but they may
also a ppear normal. Neutrop hil dysplasia
is not present. Red blood ce ll and platelet
morphology is usually normal. The 8M
b iop sy shows hypercel lular ity w ith neutrophilic p roliferat ion. The myeloid:e rythroid rat io may reac h 20 : 1 or greate r
Myelo blasts and p rom yeiocytes are not
inc reased in percentag e at the time 01 diagnosis, but the percent of mvelocvtee
and mature neutrophils is inc reased. Erythroid and megakaryocytic prol ifera tion
may also occur 1231, 24741. Sig nific ant
dysplasia is not present in any 01 the cell
lineages and, if found , another diag nosis.
such as atypical chronic myel oid
leukaemia . should be considered (See
Chapter 4). Retic ulin fibros is is uncommon 1231, 640 , 2474, 25041. In view of the
reported frequency of CNL in association
with multip le myeloma, the BM should be
examined for evi dence of a pl asma ceu
neoplasm 1355, 584, 2076, 20771. If plasma

cell abnormalities are p resent, clona lity 01

the neutrophil lineage should be supported by c ytog enetic or molecular tec hniques
be fore
diagnosis of CNL. Splenomegaly and
hepatomegaly result from tissue inliltration
by the neutrop hils. In the spleen , the infiltrate is mainly confined 10 the red pulp; in
!he liver. the sinusoids, portal areas or
both, may be infutrated 12474, 25041.

The neutrophil alkaline phosphatase score
IS usually norma l or inc reased. but no
OCher cvtocoencarabl"l()(mahty has been


Table 2.01 Diagnostc criteria lor chronic neu troph~ iC Ieu ~aemia.
Peripheral blood leukocytosis, wac <:25xW/L
5e9meflted neutrophils andband folms Bftl >80% of wtlite bloodceas
ImmatlKEl granu~es (promyelocytes, myebcytes, metamyelocytes) <10%ofwtllte bloodcells
Myeiotllasts<1 %of I't11ite blood cells


HyperceftlJar bone matTllW biopsy

Neutrophilicvanuloc)1es increased II'l pen;enlage andnumber
Myeloblasts <5% 01 rWeated IT\CIl'ltI'IIf' cetIs
NeutmplVliC maluration paneronormal
Megaka ~ normal or left shifted



No ideflt! caJ5e lorptrysioIogic neutrophika or. if presanl, denw:lnslration 01 donaIiIy ofmyeloid eels
by cytogenelic or molllo.I* studies
Noinfecbous or J1lIarnmaIory JlItlC8SS

NoPtlitadelphia cMlmo5ome or BCR-ABL 1 Mlon gene




No ~ of polyc'y1tlaenia vera. pti'Tlaty A'I)'elofibmsis or essential ~


Noevidence 01 a myebcIysplaSllC ~ or a myeIodyspIasIicImyeloproleraliw neop(asms

No gtafUcqtc dysplasia
No myelodysplaslic changes II'l olher myeloid hages
MonocyIes <hl O"IL

1909. 2504 1.

CytogenetIC studies are ooemat in nearly

00% 01 patients. In the remaining patients,
clonal karyotypic abnormalities may
include +8, +9 . +2 1, del(2Oq ), del (1 1q)
andde~12pl l 566. 640 , 736, 1415, 24661.
Clonal cytogenetic abnormalilies may
appear during the cou rse of the disease .
There is noPh chromosome Of BCR-ABL 1
fusion gene. A vana nt of chronic myelogenous leukaemia, BCRABL 1 positive
(CML) has been repo rted that demonstratesperipheral blOOd neutrophil ia stmilar to that seen in CNL 1168 51. In such
cases, a variant BCR-ABL1 fusion protein ,
p230, is found. Cases with this molec ular
variant of the BCRABL 1 fusion gene
should be considered as CMl , not CNL.
Occasional patients with a JAK2 rnutation
have been reported [1083, 14351and this
bassometimes been homozygous 110831.
Ccrnplete cytogenetic remission with imatnib was reported in a patient with CNl

No_.. . .

and 1(15; 19)(q13:P13.3), suggesling the

possibility of an unident ified fusion gene
in some cases 1433 J.
Postulated cell of origi n
Cell of origin is unknown. It is most likely
a BM stem cell with limited lineage ooten tiaI 1736, 2466 1.
Prognosis and predictive fac tors
Although generally regarded as a slowly
prog ressiv e disord er, the survival of
pa tients wi th CNl is variable , ran gin g

from 6 months 10 more than 20 years.

Usually the neutrophilia is p rog ressive.
and anaemia and thrombocytopenia may
ensue. The development of myelodysplastic
features may signal a translor mation of
the disease to AML, which has been reported in some patients 1909, 2504 1. It is
not clear whether the transformation was
relate d to previous cytotoxic therapy in
the cases rep orted.

Chronic neutrophrlic leukaemia


Polycythaemia vera

Poiycvtbaemra vera (PV) is a chronic
myeloproliferative neoplasm (MPN) characterized by increased red blood cell
production independent of the mechanisms
that normally regu late erythropoiesis.
Virtually all pat ients carry the somatic
ga in-ol-lunction mutation 01 lhe Janus 2
kinase gene, JAK2 V617F or anothe r
functionally similar JAK2 mutation thai
results in proliferation not only 01 the
erythroid lineage but of the granulocytes
and megakaryocytes as well , t.e "panmyelosi s". Three phase s 01 PV may
be recognized : (1) a prOdromal, prepo lycythaemic phase c harac terized by
borderline to only mild erythrocytosis; (2)
an overt poIycythaemic phase. associated
with a significantly increased red cell mass ;
and (3 ) a "spent" or post-oo'vcvtnaemic
myelofibrosis phase (post-Pv MF) in
which cvtooeruas. including anaemia . are

associated with ineffective haematobone marrow (8M) fibrosis. extramedullary haematoooesrs (EMH) . and
hypersplenism, The natural progression
of PV also includes a low incidence of
evolution to a myelodysplastic/preleukaemic phase and/or to acute leukaemia
(AML). All causes of secondary eryth rocytosis, inheritab le po lycythaemia and
othe r MPN mus t be excluded. The d iagnosis requires integration of c linica l, laboratory and 8M histolog ica l features as
outlined in Tab le 2,02 .

J. Thiele
H ,M , Kvasnicka
A TeHeri
G , 8irgegard

Evolution _

....21 Idl!!!9-U-


- - - - - - - Transformation
Post -polycythaemc
myeIokl metaplasia
(post-PV MF)


. - -_ _ 20 %


L.._ < 10 %

definite increase In
red cell mass

Post-PV MF WIth
biasbc transformation


Tennin.J1 sage

Fig. 2.14 SdJematic presentabOn of ee 8YOIuliOn of 1hedisease process ., ~ vera.




Polycythaemia rubr a vera,

Epidem iology
The reported annual incidence of PV
increases with advanced age and varies
from 0.710 2.6 per 100 000 inhabitants in
Europe and North America. but is much
Iavver in Japan 110591. Most reports indicate
a slig ht male predominance, with the M :F
ratio rang ing from 1- 2:1 ISO. 1389 1. The
median age at d iag nosis is 60 years . and
p atients you ng er than 20 years old are
only rarely reported 117001.


Myeloproliferative neoplasms

Etiolog y
The underlying cause is unknown in most
cases. A genetic predisposition has been
reported in some famil ies 11778 , 20321.
Ionizing rad iation and occupational
expo sure to toxins have been suggested
as po ssib le causes in occasional pa tients

Sites of involv eme nt

The blood and 8M are the major sites 01
involvement, but the spleen and fiver are
also affected and are the major sites of
EMH in the later stages, However, any
organ can be damaged as a result
of the vascular co nsequences of the
increased red cel l mass .

Table 2,02 Diagnosticcriteria lor poI~emia vera (PV). Diagnosis requires the presence 01 bottl major criteria and
onemM criteriOn or \he presence of the firstmajor cri tel'\orl togeth&r with two minor criteria.

t. Haemoglobin >18.5gJdL., men, 16,5g!<ll

in 'Io'OfT'l8l1 orother evidence of eceeseo red cell voll,lTlEl'

2. Preserce of JAK2 V617F or otnerfunctionaly slnVlar mutiltion sudl as JAKZe_on 12 rl'lI.ltalion

Minor criteria

t . Bone marrow biopsy shoWing hypercellularily lor ageWIth lJirIeage growttl (panmyelosis) wiltl prrITWIefll
erytIvoid, granulocytic aodmegakaryocytJc proMerabon

2. serum erylhl'ClPClie'n levelbelowthe reIerenc:e range lor normal

3. EI'IOOgenous eryttvoid colony Iormabon II'l VItto
Haemoglobin Of haematoall >99th pertentile of rneIIlod-speofJ reference range lor age. sex, albtude of
resideool a hael,qJobiI. >11 gill. 10 men. 15 Wdl in women assoaaled WIth a doI:menled iIfld sustaned
Mease of alleasl 2 gldL from an indMdual's baseline value Il\al tarl nol be attnbuted 10 correctlOn 01 irOn
defDency, or lll&vated red c:eI f'lIa$$ >25% llbove mun normal predicIer:l value

Clinical features
The major symptoms of PV are related to
hypertension or vascular abnormalities
causedby the increased red cell mass, In
nearly 20% of patients an episode of
venous or arterial thrombosis, such as
deep vein thrombosis, myocardial ischaemia or stroke, is documented in the
medical history lSOI and may be the first
manifestation of Pl/lSO, 197, 1389.20711.
Mesenteric, portal or splenic vein thrombosis and the Budd-Chiari syndrome
should always lead to coosideration of PI/
asanIJlderlying cause and may precede
the onset 01 an overt polycythaemic
phase ISO, 2701. Headache, dizziness.
visual disturbances and paraesmeses
are major complaints, and pruntus. erythromelalgia and gout ere also common.
In the full-blown polycythaemic stage
physical findings usually include plethora
and palpable splenomegaly in 70% and
hepatomegaly in 40% 01 patients 11445,

Clinical laboratory studies that aid in
confirmation 01 the diagnosis of PV
include subnormal erythropoietin (EPO)
levels [223. 15271. endogenous erythroid
c:oklny (EEC) formation 15951. and oetectoo
at the JAK2 V617F or functionally similar
mutations, e.q. JAK2exon 12 mutations

Fig. 2.15 F'dycylhaemiaveta, ~stage. A I.WcIy hyperc:eWa' bone If\ilIJOIIWsI'oIro'rIga ~01

large megakaryocytes in ee bone mafI'OW secUon. B Many large ld gianttlyperIobuIated ( ET~ ke) megakyotytes
in a pa\leIIl dilic:ally mrrickJng ET, because 01 a platelettxUlt in excess 0I 10D0xlO'1t- Note ee my dIy inaeased
~ lnf ef)'tt"ropoiesi (panmyelosis), beUerdlImDl ostraIed by ~ esterase f9ClCtiOrL

the morphological findings are of sufficienl

specificity to allow distinction of PV from
secondary poIycythaemla as well as other
subtypes of MPN 122031,

Pre-polycythaem ic phase and

overt poIycythaemia
Generally, in the pre-polycythaemic and
polycythaemic phases of PV the major
features in the peripheral blood (Pal and
8 M are attributable to effective proliferalion
in the erythroid , granulocytic and megakaryocytic lineages, Le. there is pannweosrs.
The PB shows a mild to overt excess of

normochrcmie, normocytic red blood cells.

If iron deficiency due to bleeding is present. the red cells may be hypOchromic
and microcytic. Neutroptufia and rarely
basophilia may be present. Occasional
irrmature granulocytes may be detectable
in the overt polycyttlaemic phase, but circulating blas ts are generally not observed ,
Because of prominent thrombocytosis, up
to 15% of cases of early phase PV
may clinically mimic essential thronbocvthaerma (Ell 122101 but such cases
eventually evolve into an overtly polycvmaemc stage 11047, 2007, 22101.

11 981,2168. 21771.
Occasionally. patients may present with
clinical symptoms suggestive of PV b ut
WIth a haemoglobin level and/or red cell
volume not sufficiently e levated to substantiate the d iagnosis. Such patients
may be in the pre-oo'vcvtbaemrc phase,
wtlich was previously refe rred to by some
authors as "latent PV' or as ' p ure id iopathic erythrocytosis" 1197,1559, 1715,
1697,2224), The detection of a sub normal
EPO level, a JAK2V617F or funct ionally
similar mutation andlor abnormal EEC
lcmaton. in combination with the typ ical
morphologic features described below,
will allow the diagnosis of this phase of
PV; these features are not found in
secondary or spurious polycythaemia.
The ore-ooivcvtnaemc phase may be
expected to become overtly poIycythaemic
at a later time.

The morphological lind lngs in BM biopsy
specimens at patients with PV must always be correlated with other clinical and
taboratory fmd ings in order to firmly establish the diagnosis 121771. However,
eYen n the earty pre-po/ycyttlaemi stage
PoIycythaemia vera


FIg. 2.11 AcuteIeukaen'ilWl poIycyth8emia WlflI . Blood

a pabenl M1h. ~ Ilist:Iy of PII.
The patient had been treated with a/kyIabng agents
!bing !he poIycyIhaemic stage. The blasts
C013. C033. C0117 alld C03-f. and had a compleJ
karyotype. COf1SISlenl wrIh Il'lerapy-related aalte myeloid
~ from



Bone marrow cellular ity has been reported

to range from 35-100%, with a median
cellularity of about 80% [641 1, but c haracteristically the BM biopsy is hyperceuular for the pa tient's age. A finding that is
especially noteworthy is increased ce llularity in the subcortical marrow space, an
area which is nor mally nyooceuurar (775 ,
2203] Panmyelosis accounts for the inc reased ce llularity b ut an increase in the
numbe rs of e ryth roid pr ecursors and of
meg akary oc ytes is often most promin ent
{641, 775, 22031. Erythropoiesis is normobl astic, and granulopoiesis is mor p holog ica lly no rmal. The pe rcentage of
myeloblas ts is not increased. Mega karyocvtes are increased in number. particularly in cases with an excess of platelets,
and display characteristic morphological
abnormalities, such as hyperlobated
nuclei, even in the early phase of the
disease , The presence 01 the panmyelosis, which although less prominent in the
pre-poivcvtnaenc than in the overt polycythaemic phase, is nevertheless detectable and helps to distinguish early PV
from ET, whi ch it may otherwise resemble
clinically 1221 01 As in the pre-pdycythaefr
phase, megakaryocytes seen in the
poIycythaemic stag e 01 PV are clearly
di st inguishable from those seen in ET.

MyeloproliferatIve neoplasms

They typically tend to lo rm loose c lusters

or to lie close to the bone trabeculae, and
often show a significant degree 01 pleomorphism with a mixture of different sizes .
The major ity of the megakaryocytes
exhibit normally folded or deeply lobulated
nuclei, and usually lack significant cytologica l abnormalit ies, alt hough a minori ty
show bul bous nucle i and othe r nuclear
ab norma lities, pa rticularly when assoc iate d with a minor incr ease in ret icu lin
{22 111. When taking the c ha racte ristic
histological pattern of PV into account,
d iscr imination of PV from ET and PMF as

well as the distinction from reactive erythrocytosis and thrombocytosis is feasible

{2211 , 22221. Reticulin stains will show a
normal reticulin libre network in about
80% 01 patients . but the remainder display
inc reased reticulin and even borderline 10
mild collagen fib rosis {297 , 641 , 775,
1189,221 1] de pen d ing on the stage 01
disease at first dia gnosis, Reactive nodular
lymp hoid agg regates are found in up to
20% of cases {22031. Sta ina ble iron is
lack ing in the 8M as p irate and biopsy
specimens in mo re than 95% of the cases

1641, 22221 .

Tabl.2.03 Diagooslicaileria fOf postiJOlycythaemic myelofibrosis (posl-PV MF )

Required criteria
1. Documentation ofa previous diagnosis of'MiQ.defined PV

Bone mallOlll1ibl"os4s grade 2-3 (000-3 $C8Ie) orgr-ade 3-4 (000- 4 scale)

Additional criteria (2 art rtquiredj

Anaemia' Of sustained km of ei1hef pl1Iebotomy r~ the abseoce of ~ therapy)orcytoreduc:M
lrealmenl requilKnent b~s


Leukoel)1hroblaslic penpheral blood picbQ


Incteasll1g spIenornegllIy defIOlld as .rther aninaeasein palpable SPleoomegaIy of >S an from baseIint
ldistanee from the left costal marg.n) Of Iht 1pp&afaflC8 of newly palpable spleoomegaly

Development of >1 of 3 consblulional symploms: >1 0%weighlloss i'l61'1'lC11'1\tts, iWJhI sweats.

unexplained Ie'o'eI' (>31.S C)

"Spent phase"and postpolycythaemic

myelofibrosis (oost-Pv MF)
During the later phases of PV, e rythropoiesis progressively decreases. As a
consequence, the red blood cell mass
normalizes and then decreases, and the
spleen further enlarges. Usually these
Changes are accompanied by corresponding 8M aneranons 1641 . 20711. The most
common pattern of disease progression
is posf-Pv MF accompanied by myeloid
metaplasia which is characterized by a
Ieukoerythroblastic PB smear, poikilocy'
ioss wil h teard rop-shaped red blood
cells. and splenomegaly due to EMH , as
defined in Table 203 {143A). The morphological hallmark of th is slage of the
disease is overt reticulin aOO collagen
fbrosisofthe BM 1641 . 775 , 2203, 22221,
The CelkJarity varies in this terminal stage.
tu: h'y1:loceIIular specimens are coreroo.
CUsters of megakaryocytes, olten with
hyperchromatic and very dysmorphic
nuclei, are prominent Eryth ropoiesis and
granulopoiesis are decreased in amount.
and are sometimes foun d . along with
megakaryocytes, lying within dila ted marrcw srcsocs 12203 1. Osteosclerosis may
also occur 164 1, 775 1, The splenic enlargement is a consequence of EMH ,
....nich is characterized by the presence of
erythroid. granu locylic and megakaryccvnc elements in the splenic sinuses
and cords of Billrot h. An increase in the
number of immature cells may be observed in these stages, butme finding of
) 10% blasts in the PB or 8 M or the pre sence of signific ant my e lodysp lasia is
unusual, and mosl likely sig nals tran sformation to an acce lerated phase and/or a
myelodysplastic synd rome (MD S), Cases
inwhich 20% or more blasts are found are
AML 11701, 2071, 2203, 2222).


No abnormal phenotype has been reo

The mosf frequent genetic ab normality in
PV is the somatic qam-ot-tuncnon mut atoo JAK2 V617F. Altho ug h il occurs in
>95%of patients with PV, it is not specific
and is found in other MPN as well. but in


Fig. 2.19 ~ Ylll'a, ~ rnyelofbosis (pos&-PV MF) and"lbd metaplasia ,

specinen. The splenic enlarvement in the ~ ptIase isdue IlIMlIy b eJb"ameOJlary Ilaema!DpoIesis
!hat Cll:X:ln II1 It1e splenic sftlses , as wei 11$Iibrosis.-.d lll1trapmenl d platelets and tIaernalopoieli eels II1lhe splenic

iower freq uencvltea. 1044 ,1 186 , 12881.
The mutation occurs in a haematopoielic
stem cell , and is found in all of the
myeloid lineages. Hence cells that utilize
JAK2 kinase in the intr acellular signaling
path way may be hyp ersen sitive to g rowth
fa ct ors a nd other cvtokmes. inc lud ing
EPO . A fun ct ionally similar mutat io n in
exon 12 of JAK2 has also been reported
11981/. so that virtually all patient s with PV
have a JAK2 aber ration , St ill, no ge ne tic
defect enti rely specif ic to PV has been
ide ntified . At diagnosis, c yto ge ne tic
ab normal ities are detectab le in ab out
20% of pa t ients. The mo st c ommon
rec urring abnormalities inc lude +8, +9,
del(20Q), de l( 13q) and de l{9p) : sometimes +8 and +9 are found tog ether 142,
2394/. There is no Philade lphi a c hromosome or BCR-ABL 1 fusi on g ene . The se
c hromosomal ab normalities are seen with
increasi ng frequency with d isea se progression and in near ly 80-90% of those
w ith post-PV MF 1421, Almost 100 % o f
those wh o develop MDS or AMl have
cyt ogenetic abnormalities. inclu ding those
commonly o bserved in the rapy-related
MD S and AMl (See Chapter 6 ).

Postulated cell of ori gi n

Heemetopoteuc stem cel l.
Prog nosi s and pred ictive fact ors
With currently available treatment, median
survival li mes > 10 ye ars are commonly
repor ted {SO, 1215 , 1548,2071/ . although
controversy persists about the risk factors
other than olde r age {1215, 1389, 17021 .
Most p atients d ie from thrombosis or
haemorrhage , but up to 20% succumb to
myelodysplasia or acute mye loid leukaemia
ISO, 1389, 207 11,
The factors tha t p red ict the risk of thrombo sis or haemorrhage are not well
d efined 11389, 1700,20711, The incid ence
of MDS and ac ute leukaemic transformation is only 2-3% in patients who hav e not
been treated with cy totoxic agents , but
increases to 10% or more follow ing
ce rtai n types of c hemot hera py {704 ,
1389 , 1548 , 170 1, 1702 1_

PoIycythaemlCl vera


Primary myelofibrosis

J . Thiele
H M . Kvasnicka
A. Tefferi
G. Barosi
A. Orazi
JW. Vardi man

ICD-O code

Primary myelofibrosis (PMF) 11464 1 is a
clonal myeloproliferative neoplasm (MPN)
characterized by a proliferation of predominantly megakaryocytes and granulocytes in the bone marrow (8M) that in fully
developed d isease is associated with
reactive deposition of fibrous connec tive
tissue and with extramedul lary haematopoiesis (EM H) . There is a step wise evolution from an initial prefibrotic phase
121771 cha rac terized b y a hypercell ular
BM wit h absent or minimal reticulin fibrosis
to a fibrotic phase with marked reticulin

9961 /3

Chronic idiopathic myelofibros is (CIMF);
Agnogenic myeloid metaplasia (A MM);
Myelofib rosiS/scl erosis with myeloid metaplasia (MMM) ; Id iopathic myelofibrosis .

or collagen ubrosrs in lhe 8M and often

The overt fibrotic pha se is estimated to
oc cur at 0.5- 1,5 per 100 000 persons per
year {1060,21671. It occur s most C()fTV'TK)ll1y
in the sixth 10 seventh decade of life, and
both sexes are nearty equally affected
121671. Children are rarely affected 136n

osteosclerosis. This fibrot ic stage of PMF

is characterized by ieukoervtbrobiastosis
in the booo witll teardrop-shaped red cel ls.
and by hepatome galy and sp lenomegaly
(Tabl e 2,0 4 ).

Exposure to benzene or ionizing radi ation
has been documented in some cases
{5881 Rare familial c ases of 8 M fibrosis

Table 2.114 Diagnos1ic crilefialor primary myelofibrosis: <iagnosis requires meeting all 3 mator and2 miroof crileria

MaiOI' eritltria
t . Presence d

~ ........... 1

atypiI", usuaIylaXllTlpalied byllitlerreIla*l inlier a:tagen ~


nile absenat d sig1Icat /W)Jin Iibrosi:s, tle ~ chat'gesIl'LISI be llCClJI'llliDed by a'l 1lcJeaged
bone ITI8fTOWcelIularrty characlenzlld by granuIol:yIic pn:jferabDn and often deaea:Sed erythn;lpooesis
~ e. p!VftlroIic ceItEr-pllase disease ).

2. Not meeting WHO Criteria lor poIy<:ythaemia~. BCRABLt+ chronic myeIogeoous leukaemia'.
myelodysplaslic syndrome'.fJ( other myejoid neoplasms

in yo ung chil d ren have been reported

How often this represents an MPN is ~
known. but at least some cases appear 10
represent an autoscmal recessive imented
families with a
oondilioo 118731 In
somewhat later age of onset . the leal1.Xes
havebeen consistent withan MPN, suggesting a familial predisposition to PMF 13691.


Sites of involveme nt
Blood and BM are always invo lved. In the
later stages of the d isease , EMH (also
kno wn as myeloid metaplasia) becomes
prominent, in particular in the spleen
117731. In the initial stages. randomly distnbcted C034+ prOlJenitors are slightly increased in the 8 M. but not in the
pe ripheral b lood {PBl Only in the tate
stag es they ap pear in large numbers periphe rally (1592, 22091 This increase of
CD3 4 + ce lls in the PB is a ph enomenon
large ly restric ted to overt PMF and is not
seen in non-fib rotic po lycythaemia vera
(PV) or essential thrombocythaemia (ETl
141 ,1 45,17031 . It has been postulated
that EMH is a consequence ot me peculiar ability of the spleen to sequestrate the
numerous ci rculating CD34+ cells 122081.
Liver. lymph nodes. kidney ad renal gland.
dura mater, gastrointestinal tract, lung
and ple ura. b reast skin and sott tissues
are other possible sites of EMH 1216n

3. Demonstration of JAK2 V6t7F or other donal marker (e,g. MPL W515K!L),


in the absence 01 a clonal marker. 00 evidence lhatlhe bone marrow fibrosis et otherc:Nlnges aresecondary
kl mecoon.autorr1rrone dison:ler r:K0lIlerchronic I1ftarnnatory t'a'llIIJon hairyC8lI ~ et OCher IyrnJ:tMjd
neoplasm, metasta1ic mal9'ancy. et klxiC (etvonic) myeIopaltlies"

Minor aiteril
1 .l~ '

2. Increase on serum lactate deIlydrogerIase level'

3, Ar\aemIa.


Small to largemegakaryocyteswith an aberrant nuclearlcytoplasmic ratiO and hyperchromatic, bulbous, or
irregularly loIded nuclei and dense clustering
Requires !he lailure 01 ironrnpiacemenllherap)'to increasehaemoglobin level 10 tile potycythaem~ vera
range in the presence 01 decfeased serum fembn. ExckJsion of poIycylhaemia vera is based on haemoglobin
and haematocrit levels.n red eel massmeasurement is not required,

< Requns the absence oIBCR.ABL.1 ,

" Req!.ns atlMnce01 dyW)'ltliopoiesi$ and:~.
Patients WIth an:libons associaled wilhreactve Ill)'IlIofitlro llfe not
be COIlSide1 lld n std1 cases ~ olhercntena are mel
I Degree of abnorrnalIIy could be borderline or martell .


Myeloprolifera tive neoplasms kl PMf. ;rod . . ~ stxUd

Clinical featu res

Up to 30% of patients are asymptomatic
at the time of diagnosis and are d iscovered by octcctco of splenomegaly during
a routine physical examination or when a
routine blood count discloses anaemia .
leukocytosis and/or thrombocytosis. Less
commonly. the dia gnosis results from
d isc over y of une xplained teukoervmrobtastosis or an increased lactate dehydrog enase (LDH) {366 . 2 16 7, 2 1771. In the
initial p refib rol ic phase of PMF. the only
find ing may be marked th rombocytosis
mimicking ET 12177, 220 11. Therefore. a
sustained thrombocytosis cannot. by itself,
discriminate between prenbrotc PMF and
ET 12201, 2202. 22041. Constitutional
symptoms may include fatig ue. dyspnoea.
weigh l loss, night sweats. Iow-grade fever

and bleeding episodes, Gouty arthritis

and renal stones due to hyperuricaemia
may alsooccur. Splenomegaly of varying
degee is detectedin up to 90% of patients
and may be massive: nearly 50% have
t'epa!l:megaty 1143, 366. 367, 1635, 2 1671.
The JAK2 V617F mutation may be found
n ~50% at patients in the fibrotic pha se:
its incidence in the prefibrotic stage has
no! been well studied. Althoug h helpful in
disllnguishing PMF from react ive condiboos thaI may result in 8M fibrosis, the
mutation is not speci fic for PMF but is
tound in PV and ET as well 121721.

The classical pic ture of advanced PMF

includes a PB smear that shows leukoerythroblastosis and anrsopo'knocvtosrs
(particularly with teardrop-shap ed red
cells) associated with a hvp oceuura r BM
with marked reticul in andlor c ollagen
fibrosis and organomegaly caused b y
EMH, However, the morp holog ical and
clinical findings vary c onsiderably at
diagnosis depending on whether the
patient is first encountered during the
prefibrolic or the fibrotic stage of the
disease (2177, 22041. Bec ause the pr ogressive accumulation of fibrous tissue
parallels diseaseprogre ssion, it is impo rtant to reproducibly and sequentially
grade the amount of BM fibrosis semi~ntitatively by using a sCOfing system
122141(Table 2.05).
PreffJroticandearly stage PMF:No registrybased prevalence ligures are available
b" the incidence otme prehbrotic pha se
ol PMF, but series der ived from various
'llfereoce centres reveal that 30-40% of
patlerlIs arefirsl detected in a prodromal,
preltbmllC phase without a significant increase in reticulin and/or collage n fibres

1297.775.2202,22041 _In these cases the

BM biopsy is nvperceuotar with an increase in the number of neutrophifs and
atypical meqaaarvocv tes . There may be
a mild "left shin- in granulopoiesis, bu t
usually metamyeloc ytes. bands and seqmented forms predominate. Myelob lasts
are not increased in percentage. and conspicuous clusters of blasts or of CD3 4+
progenito rs are not obse rved {2202 ,
22041_ In most cases, erythropoiesis is
red uc ed in qua ntity. but early erythroid
precur sors are promi nent in some patients 122281_ The megakar yocytes are
markedly ab normal, and their ntstotocography and morphology is the key to the
recognit ion of the prefibrot ic stage of PMF,
The megakaryocytes often form den se

Evolution _

clusters of variable size that are frequently

edrecent tc 8M vascular sinuses and the
bone trabeculae 1297.775,2204 .22161 .
Most megakaryocytes are enlarged, but
small megakaryocytes may also be seen,
and theif detection is greatly facilitated by
the use of immunohistochemistry with antibodies react ive with meg akaryocytic
antigens 12201, 22041 . Deviations from
the normal oucrear.cvtoptasmc ratio (an
expression of defective maturation). annormal pa tterns of chromatin clumping with
bulbous, "cloud -like" or "balloon-shaped"
nuclei , and the frequent occurrence of
bare megakaryocytic nuclei are all typical
findi ngs, Overall in PMF the megakaryocvtes are more atypic al than in any other
typ e of MPN. Vascular oronteeanon is

Manifestation - - - - - Transformation










Prefibrotic:-early PMF AdYilnced PMF (MMHJ

Fig. 2.21 ~ oI lhe disease process 11'1

(rr'IllCWI values) arid associaIed fibre ~

PfWnarY lIlJ8lDIiblosis (PMF) withassocialed ~ (lata

Primary myekllibrosis


usual in the 8M 11 214 1, and lymphoid

nod ules are found in about 20% to 30%
1220 1, 22041 . Careful 8M morphological
examination is particularly crucial in distinguishing pretiorotrc PMF with accompanying thromb ocytosis from ET 1712.
796,2 177.220 1.22161. Reticulin fibrosis
is minimal or even absent (corres pon din g
to grades 0 and 1)during this stage 122141;
if present. It is usually foca l and tend s to
be concentrated around vessels . The rnajority of cases with pretrbrotic and early
(reticu lin) fibrot ic stages of PMF even tually transform into overt ubronczscrerotrc
myelofi brosis associated with EMH 1295.
775. 1189 , 2204. 22 181.
Fibrotic stage: Most pat ients with PMF are
initially diagnos ed in the overt fib rotic
stage 1143, 366. 1635, 2 1671. tn this stage
the 8M b iopsy demonstrates clear-cut
reticulin or collagen fibrosis (fibrosis
grades 2 and 3) . The 8M may stilt be
focally nvpercenurer, b ut more often is
normocellular or hypocellular. with patches
of active naerretopoeers alterna ting with
hypocel1ular regions of loose connective
tissue andlor fat. Foci of immature cells
may be more prominent. although myelob lasts account for < 10% of the 8M cells
{297, 775. 22041. Atypical megakaryocytes
are often the mo st conspicuous find ing ;
these oc cur in large c lusters or sheets,
often within dilated vasc ular sinuses 1295,
2204). Sometimes lhe 8M is almost devoid
of haematopoi etic c ells, showing ma inly
d ense reticulin or collagen fib rosis, with
small islands of haematopo ietic precursors
situated mostly within the vascu lar sinuses.
Associated with the de velopmen t of
myelofibrosis is a sign ifica nt proliferation of
vessels showing marked tortuosity and luminal dis tension, often assoc iated with
conspic uous intras inusoidal haemato(1214, 1347, 1463). Osteoid seams
or eooossionarnew bone formatioo in budlike endop hytic plaqu es may be ob served
{775, 22041. In this osteoscl erotic phase.
the bone may form broad , irregular trabeculae that can occupy >50% of the 8 M
space. With exception of allogenei c stern
cell transplan tation 11592. 22131, develop-ment of myelofibrosis in PMF is not significan tly influence d by treatment modalities.
an d is obviously related to disease p rogression 1295. 22 17, 22181 In patients with
a previously established diagnosis of PMF,
the finding of 10-19% bl asts in the P8
and/or 8M and the oerectco by immunohistochemistry of an increased number of
CD34+ cells With cluste r formation and/or

Tlble 2.05 SemiQuanlitati~ grading of bone marrow fibrosis (MF).



MF 0

Scatlemd ftar reticulin WlItl ro IOte~ (CIOS$-OWlI'S), CO!reSpCJnding to normal booemarrow

MF- 1

loose networt of reliaJlin wl\tl many i'ltersections, especiallyin perivasa.dar ereas

MF- 2

Diffuse arr:l dense increase In rebaJlin wrtll eJ:tenSlYe intersedtons. occasionally 'frilh local
burr:lles 01 coIagen and/or local OSleosderosis

MF- 3

0l1fuse and dense II"lCl'eaSe IIIreticulin 'M!tl extensive II'IIer$edIons ilIICl coarse bundles of
collagen, often associated 'frilh ~



Myeloproliferative neoplasms

~~~) ..

Fig. 2.23 Primary myelofibrosis, fibrotic stage, WlIIl ellrameduallary haemalopoiesis in Iivet. A In the Mr, tie
sirtUSOids are prominenUy involved by bilineage prolilerallOll. B Megakaryotyles are the hallrnart. 01 abnonnll
irltrasinusoidal haematopoiesis.

an a normal endosteal loc ation in the 8M

12204. 22091. ind ica te an accelerated
p hase of the disease, whereas ~%
b lasts is consid ered as acute uanstometeo. Patients with PMF may also present
initially in an accelerated phase Of an

acute phase . In cases with 20% Of more

blasts in the PB and/Of 8 M at presentation
in which other find ing s may suggest PMF,
the diagnosis 0 1 acute leukaemia shOOd
be made with only mentiOnof the possible
derivation from PMF.

Extramedullary baenatoooleeta
The most common site of EMH is the
spleen , followed by the liver 117731. The
spleen shows an expansion of the red
pulp by erythroid, granulocytic an d
megakaryocytic cells. Their identification
can be aided by immunohistochemistry
[ 16 13, 2 1991. which also allows an appreciation of an increase in neoanqioqenesis / 144\ . Megakaryocytes are often the
most conspicuous component of the
EMH. Occasionally large aggregates of
rreqakeryocytes. growing COhesively. can
ooocce macroscopically evident tt.mOUral
lesions. In the presence of nodular lesions
and , in general. in any advanced stage
disease with large amounts of EMH, the
PQS&bility 01 a myebd sarcoma should be
c:onsidefed and carefully excluded by perlaming irrmunohistological studies with
CD34 117731. The red pu lp cords may
exhibit fibrosis as well as pooling 01
platelets. Hepatic sinuses also show pr0minent EMH. and cirrhosis of the liver may
occur /21671.
No abnor mal phenotypic fea tures have
been reported .

Fig.2.24 PrWncwy myeIoIilrosis. 6brollc stage . A ThIs penrtIerBl bloodsme<I" shows dac:ryotytes. occasionalnu::MaIed
red bloodeels <n:I irrrnalJ..nI grarUocytes ~l . BA dilaIed sinus corrtans inmaIIft tIaerrI.1qloiet
elements, most notably megakaryocytes (p,f,$ stain) . ThiS intrasinusoidal haematopoiesi$ together oMth VilSClAr
pn:iIeralJon is charadetisbcbutnot liagl'105bC of PMF WIth myeloid rneIapIa:sia. C Megakaryocytes are ol\en the IOO5t
conspicuous haemalopoielic element il the marrow Often !he cells appear to "'s1ream"1I'rough themarrow due 10 the
In:lerI)tlg fitrosis. 0 Mcrled retJctjn and o:tagen Mln:lsII aSD:iated witha srreanHke arrargemenI of megakMyocytes
arld initial osteosclerosis is $hoIrm (slYerstaIn).

No ge netic d efec t specific for PMF has
been ide ntified 11832AJ. Ap proximately
50% of pat ients with PMF exhibit the JAK2
V617Fmutation. Althou gh the presence of
the mutation confi rms the croneltty of the
proliferation, it is a lso found in PV and ET
and thus does not dis tingu ish PMF from
these MPN {163 , 1044 , 1064, 1186, 1288J.
A funct iona lly similar ga in-o f-f unc tio n
mutation of MPL (MPL W5 15K/l ) has
been repo rted in up to 5% at PMF cases.
but in occasional cases of ET as
/16891. Cytoge netic abno rmalities occur in
up to 30% of patients (630, 1832, 21 741.
There is no Philadelp hia chromosome or
BCRABL 1 fusion gene. The presence of
either del( 13)(q 12-22 ) or der(6) t( 1;6)
(q21-23 ;p2 1.3 ) is strongly suggestive b ut
not diagnoslic of PMF [5861. The most
common rec urring abnormalilies inc lude
del (2Oq), and partial trisomy 1q , allhough
+9 and/or +8 are also reported {63O.
1832A, 21741. Deletions aNeeting the long
arms of ch romosomes 7 and 5 occur as
'Nell. but may be associated with prior cytotoxic therapy used to treat the myeloproliferative p rocess.


Postulated cell of orig in

Haematopoi etic stem cell
Prog nos is and p red ict ive fac tors
The time of survival in patients with PMF
ra ng es from month s to d ecades. The
overall p rog nosis de pends on the stage
in wh ic h PMF is firstly di agnosed 11215.
22041. The median survival time is approximately 3 to 7 years in patients diagnosed in the fibrotic stage {142 , 366 . 367 .
630, 2 167/. which contrasts with a 10and ts-vear relative survival rate of 72%
and 59% respectively, in patients diagnosed in the early prefibrotic phase
11215. 12191. Factors at presentation that

adversely affect pro gnosis include age

>70 years . Hb <10 g/d l , platelet count
<1 00x l ()6/l , and an ab normal karyotype
11 42 , 143.366,630, 12 15 , 12 19, 1832A,
2105 ,2174,22041 . The major causes of
morb idi ty and mortality are 8M fa ilure (in.
tecnon . haemorrhage). thromboembolic
events , portal hypertension, cardiac failure
and acute leukaemia (AMl) {21671. The
repo rted frequency of AMl ranges from 5
to 30% 1366, 630 , 21671. Although some
cases of AMl are related to prior cytotoxic the rapy. many have been reported
in patients who have never been treated,
confirming that AMl is pa rt of the natural
history 01 PMF
Primary myelofibrosis


Essential thrombocythaemia

Defin ition
Essen tial thrombocythaern ia (Ell is a

chronic myeloproliferative neoplasm (MPN)

that involves primarily the megakaryocytic
lineage. It is characterized by sustained
thrombocytosis <!:45Ox l()1'A.. in the periph-

eral blood (PS), increased numbers of

large. mature megakaryocytes in the bone
marrow (8 M), and c linica lly by ep isod es of

thrombosis and/OI' haemorrhage, Because

there is no known genetic or biological
marker specific lor ET. other causes for
thrombocytosis must be excluded , including other MPN, inflammatory and
infectious disorders, haemorrh age and

other typ es of haematopoietic and nonhaemat opo ielic neop lasms. The presence
of a BCR- ABL 1 fusion gene exc ludes the
diagnosis of El

IC[).() code


bocytose, haemorrhagic thrcrnbocythaemia.

Sites of inv olvement

Bone marrow and blood are the principal
sites of involvement. The spleen does not
show signilicant extramedullary haematopoesrs (EMH), but is a sequestration site
for platelets 1705. 902. 21751.
The etiolog y of ET is unknown.

1. SllSIairled' platelet count ~45Ox 10"1t

2. Bone marrow biopsy specimen showing proliferation mainly of the megakaryocytic lineage with increased
nlll'11bers of9l1larged. matul'tl megakaryocytes. No signllical1t increase Of Iefl-sMtofOOlItrophiI glanoopoiesis orer,1IWOpoiests

3. Not meetlng WHO atSerialor poIycyIIlaema vera, P'JI'Nf'Y myelofIbrosI$.< BCR-ABL f posiWe ct.ror.:
myeIogenouIlMaetnia' ormyeIodysplaslic syndrtml" Of oIher myeklid ~
4. Demonstration 01 JAK2V617F orolher donal maricer. or in !tie absenteofJAK2V617F, no e-.1dence lor
reeceve thrombocy1osls'

Sustatned ooring the W(ri.-up process.

Requires Itle fcMure of iron repIaoement ItIefapy toincrease IIaemoglcOf1 level10I!'oe polyc)1IIaemia "'llfa
fange Illhe presence of deaeased serum lerTilin. Ex<iJsion ofpo/ytyltIiIllfllia vera is based on haemoglobin
rod hilemiIIocrtIeve!s and red eel mass meiISl.Ifement is not required.
Req.wes!he absence 01 relevartre!iQjn Ibosis. coIagen fitll&s, ~ ~~ ,
Of markedly hyperceIuIar marrow aetOll"C'3ried by megakaryocyte IIUphoIogyIhat III lypicaI for primary
myelofibrosis ifIcludtng smaH 10large rnegakaryocytes WIth an aberranl nuclearl~smic ratio iIfId
hyperchromatic. bulbous Of irregularlyWed noc~ and dense dusterirlg.
Requires the absence of BCRABL 1.
Requires abser'loe ofdyserythlopoies and llysgranulopoiesis.
, Causes of reactive thrombocytosis iIdude I/'Ofldeficiency. splenedomy. StJfgefY. nedion. inllammation.
alM8CtIVe!lssue disease . melastIticcancer. and ~trve disorders However. the presence of
a cendIOOn iIS800ated wllll reactiveborrtlocyt)sis may noI edJde fie possility d ET 't!he fnl wee
criteria are met


Myelopro liferative neop lasms

H M. Kvasnicka
A. Tefleri
H. Gisslinger

The true inc idenc e of ET is unk now n, bu t
when di ag no sed according to the g uidelines of the Polycythaemia Vera Stu dy
Group (PVSG)115491. it is estimated 10 be
06-2.5 per 100 000 persons per year
{1055. 10591. Most cases occur in patients
50-60 yea rs 01 age , with no major sex
predil ect ion. How ever, a second peak in
frequ ency, pa rtic ularly in women , oc c urs
at about 30 years 01age 1705. 902 . 10551.
ET can also be seen in ch ild ren , albeit infrequently 118151, but must be distinguished from rare cases 01 hereditary
thrombocytosis 1585. 24011.

Primary thrombocytosis: id iopathic mrom -

J . Thiele

Cli nical features

More than one half of patients are asvrrptomauc when a markedly elevated platele!
count is discovered lortUitously at the tJml!
of a routine PB count 1705, 802 , 9022 1751. The remaining patients preset
with some manifestation of vascular
occ lusion or haemorrhage 1210, 4581
Microvasc ular occlusion may lead to trarlstern iscnaemc attacks, digital ischaemia
with paraestheeias. and gangrene 1210.
458 . 1473. 18291. Thrombosis of map
arteries and veins also occur. and ET may
be a cause 01 splenic or hepatic veil
thrombosis as in the Budd-Chiari syndrome . Bleedi ng occurs mos t comrrow
from mucosal surfaces. suc h as the gastrointestinal trac t or upper airway passages 1379. 802, 1549. 19551. If h
criteria established by lhe PVSG 101 E1
are used. mild splenomegaly is present
approximately 50% of pa tients at diagnosrs
and hepa tome ga ly in 15-20% 1705, 802.
902, 1549 , 2 175 1 How ever, when !he
WHO classification is applied and patients with thrombocytosis associated
the p relibrotic stage 01 primary myeIcj.
brosis (PMF) are excluded. spIencrneg<I,
is seen in only a minority of patients
ET112151. Rare pa tien ts who meet the
terra for ET have been repo rted to half
noncronat meqakervoc vtoootests eoe I
tower incidence of thrombo tic epi
19011. kry relationship of such cases 10
vast majority of cases 01 ET that
clonal haematopoiesis is not clear.

In ee past, the platelet threshold for the

diagnosis of E'r was :!:600x109/l115 49J,
but some patients have haemorrhag ic or
ltuombolic episodes at lower platelet
cents 11272, 1829, 19031. In order not to
C01lprcmise the diagnosis in such cases,
a number of investigators convincingly
argued tOl" a lower platelet thresho ld for
ee diagnosis of ET. and the WHO has
adopted the recommenda tion of a platelet
COltlt ~450 x 1 l)l'IL, a value that exceeds
!he 95th percentile for normal platelet
counts adjusted for gen der and rac e
(1272. 1897, 1903.21771. Although this
llYeshoid will encompass more pat ients
1Io'!lh ET, it will also include more pat ients
'I4lCCflditions that mimic ET. It is therefore
essential that all Criteria listed in Table
200 for the diagnos is of ET be met to exewe olher recotastc and non-neoplast ic
causes 01 thrombocytosis 12 1771. The 8M
bi:psy is particularly helpful in exc luding
ere myeloid neoplasms associated with
excessive platelet counts. such as myelodysplastic syndrome (MDS) associated
wltrl isolated del (5q). the prov isional
'l'r)'eIodysplasticlmyeloprohferative entity
refractory anaemia with ring sioerobras ts
and thrombocytosis (AAAS-T), and the
cetoronc phase of PMF. Althou gh the
JAK2 V617F mutation is fou nd in only
40-50% ot cases of ET and is not specific
b' ET, when present it does exclu de reectve mrorroocv tosrs 121771. Similarly, in
eeo enocqeroue erythroid and/or meg akaryocytic colony formation, althoug h not
specrlic tor ET, also exc ludes reactive
ltYombocytosis 15941.

a normocel lular or moderately hypercellular 8 M {775, 22161. The most striking abnormality is a marked proliferation of
megakaryocytes with a predominance of
large to giant forms displaying abundant,
mature cytoplasm. and deeply lobulated
and hyperlobu lated (stag- horn like) nuclei. The rnegakaryocytes are usually dispersed throughout the BM but may occur
in loose clusters. Bizarre, high ly atypical
megakaryocytes, such as those observed
in PMF, are not found in ET and if present.
the diagnos is of ET should be ques tioned
1712, 796 , 2200 , 22051. Proliferation of
erythroid precursors may be found in a
few cases, p articularly if the pat ient has
exper ienced haemorrhages. but granuloc ytic proliferation is highly unusual; If

present. the increase in granulopoiesis is

usually only of mild degree. There is no increase in rnvetobtasts nor is myelodysplasia observed, The network of reticulin
fibres is normal or only minimally increased in ET. and the find ing of signif icant retic ulin fibrosis or any collagen
fib rosis excludes the diagnosis of ET
1712, 775, 796, 2177, 2205, 22161. Bone
marrow aspirate smea rs also reveal the
markedly increased numbers of megakaryocytes of large size with hyper lobutared nuclei and . in the background. large
sheets of platelets. Emper ipoles is of BM
elements is frequentl y observed in ET. but
is not a spec ific find ing. Stainable iron is
present in the aspira ted BM specimens of
40-70% of patients at diagnosis 116491.

f ig. 2.27 Essential ttwombocylhaerma, bone marrow aspl'ate smear. AAll increase in the nurrtler and size of the
megailaryocyles. B NoIe the deeply Iobutaledmegaka'yocytic ~, as well astarge pools01 pla te~_ Note that the
aspirate smears fail to reveal the overall marrow archilecture anddistribution of the rnegar.aryocytes thatcan be (Illy
seen in the biopsy,

The major abnormality seen in the PB is
marked thrombocytosis, The plate lets
often display anisocytosis, rang ing from
tiny torms to atyp ica l large, g iant
platelets. Bizarre shapes, pseudopods
and agranular platelets may be seen, but
are rot common. The white bloo d ce ll
(WEq count and Ieueocyte differential
~e usually normal, although a borderline
eevaton in the WBC count may occur
(705,802.902, 21751. Basophilia is usuaMy absent or minimal 115491 _ The red
blOOd cells are usually normocytic and
rcerccnrcnc unless recurrent haerrormage has caused iron deficiency, in
W"Mch case they may be hypochromic
and microcytic. Leckoervtnrobleetosts
d teardrop-shaped red blood cells are
IQ seen I'l ET 121751.
~ rrosl cases, the BM core biopsy shows
Essential thrombocythaemia


react ive thrombocytosis , An abnormal

karyotype is found in onl y 5-10% of patients with ET when d iagnosed according
to lhe previou s PVSG criteria {15491. There ;
is no consistent abnormality. but those
reported include +8, abnormalities of 9q,
and del(2Oq) {939, 1682 1. Ahhoogh isoIatoo
del(Sq) has also bee n reported in ET. cerelui rrorphologic examination is required 10
distinguish such cases from MOS associated with this abnormality 116821.
Postulated ce ll of ori gin
Haematopoetc stem cell.
Prognosis and predictive factors
ET is an indolent disorder characterized

The lTIOfphological findings in the 8M

biopsy are essential to distinguish ET from
other MPN. myeloidosooes and reactive

may initially present wittl thrombOCytosis

without leukocytosis and can mimic ET cl~

conditions tha t p resen t with sustained

ttlrcmbOCytosis , The finding of even a mild
degree of combined granulocytic and erymroo proli feration should raise consideration of prodromal stage poIycythaemia vera
(PV) 122101. and the finding of granulocytic
proliferation associated with biza rre. hig hly
atypical megakaryocytes should p rom pt
concern lor the prefibrotic slage of PMF
12201,22231 . Significant dyserythropoiesis
or dysgranulopoiesis sug gest a d iagno sis
of MOS rather than ET. The large me gakaryocytes with hy per lobulated nucle i of ET
contrast with the medium-sized monoioba ted megakaryocytes associated with de l
(Sq ) as an isolated ch romosom al abnormality in MDS and with the small. dysplastic megakaryocytes associated with the
inv(3)(q21q26 2) or t(3;3)(q 21;q26.2) chro mosomal abnormality. Lastly, some patients
with c hronic mye logenous leukaemia (CML)

ET can be easily distinguished from the

sma ll -dwarf" megakaryocytes of CML. cytogenetic and! or
genetic analysis to exclude a BCR-ABL 1 fusion gene is
recommended for all patients in whom a diag nosis of ET is considered 11841 1.

;cany. AJ1hough !he ""90 rnegaJ<ao,ocytes of


Immunophenoty pe

No aberrant pherotype has boon described

No mol ecular genetic or cytogenetic abnormality specific for ET is known. Approxim ately 40-50% of cases ca rry the JAK2
V617F or a functi ona lly sim ilar mu tation
1163. 1044,1064.1186.1 2881, Thesemutatoos are not specific for ET and are found
in P\I and PMF as well, A gain -of-Iuncti on
mutation of MPL. MPL W515K/L , has been
reported in 1% of cases of ET {16891. None
of these mutations are found in cases of

Table 2.07 WHO diagnosbc cnleria lor posl~ssenlial thrombocythaemia myelofibrosis (postET MF),

R.quired criteria
1. Documenlatiol'l of a prevklus diagnosis of WHQ-defined essential ttlrombocythaemia

2. Bonfl marrow fibrosis grade 2-3 (011 0-3 scale) or grade 3-4 (oo 0-4 scale )

Additional crittril (2 are ~j..-cl)

1. Anaemia' 22{1dl decrease from baseline haemoglol*1leve1
2. A leukoefythrobla pe~ bloodpiclufe

3. Incr&aSingsplenomegaly defiMd as &$ler an Increase in palpable splenomegaly of>5 emfrom baseIne

(lislance Ircm ltIeleft C05laI margin) orIle appearance 01 newly p.alpable splenomegaly
4. Increased LDH (atloYe reference level)
5, Development 01 >1 of3 CXlIlSlrtlllional s~ : >10% weight bss in 6 month$. right sweats, I,Il8lplBined


MyeloproliferatIVe neoplasms

by long symptom-free intervals, inter,

ruptec by occasional ute-mreaten
thromboembolic or haemorrhagic episodes 1705, 802, 902, 12 15, 154 9, 2175
Although after many years a few pat
with ET may develop 8M fibrosis associ-ated w ith mye loid metaplasia (EMH
such progression is uncCll'TYTlOl1 1297, 775.
1189.22201. Precise diagnostic guidelines lor diagnosing post-Ef MF are given
in Table 2 .07 . Strict adherence to
and other WHO c riteria 1143A . 21771
necessary to prevent diagnostic comus
associated with early PMF accompa
by thrombocytosis 1365}. Transformation~
ET to ac ute myeloi d leu ka emia or MOO
occurs in <5% of patients, and when
does occur is likely related to previous
cytotoxic therapy 1705 , 802, 90 2, 1800
M ed ian survivals of 10-1 5 yea rs are
common ly rep orted . Beca use ET usu al~
occurs late in midd le age. the [,Ia
ex pecta ncy is near normal for m an~
patients {1215. 1702 , 2200 . 2430}. Fi nal~
it is noteworthy that the maj ori ty of c lini
stud ies are based on prev iou s d iag l10stic
gu id eline s 11 549 } that fail to d ifferentiate
clearly between the early prefibrot
stages of PMF wit h accompan ying thr
bocvtosrs an d ET ac cordi ng 10 the
classification 11215, 2200, 2205} . A su
stannat d ifferenc e in ove rall prognosis
been reported w hen these two di ffer
ctessmcanon sys tems are ap plied to
same pa tien t population 112151.

Chronic eosinophilic leukaemia,

not otherwise specified

Ctwooic eosinophilic leukaemia (CEL) is a

myeloproliferative neoplasm (MPN) in

which anautonomous. clonal proliferation

01 eosinophil precursors results In perSistently increased numbers of eosiroptliIs in the peripheral blood (PS), bone

(BM) and penooerarnssoes. with

being the dominant baemak*lgical abnormality. Organ damage ccClSS asa result oueceaemc infilt ration or
ee releaseof cytokines, enzymes Of other
proteins by the eosinoctas. Chronic



eosinophilic leukaemia . not otherwise

specified, (GEl. NOS) excludes patients

WIth a Philadelphia (Ph) chromosome,
BCR-ABL llusion gene or rearrangement
In eEL, NOS the eosinophil count is
n5xl ~1L in the blood. There are fewe r
than20% blasts in the PB or 8M . To make
adiagnosis 01CEl. there should be evidence/or clonality of the eosiropbus or an
ecreese in myeloblasts in the PB or 8 M.
In many cases however, it is impossible to
proyeclonalrty 01 the eosoo ptuls. in w hich
case, if there is no inc rease in blast
cells, the diagnosis of "id iopathic hypereosinophilic syndrome" is made . The
idiopathic hypereosinophilic synd rome
(idiopathic HES) is de fined as eosi nophilia (~1.5~ 1CfJ/L) persisting for at least 6
months, for which no und erlying ca use

can be fou nd , and w hich is associated

with sig ns of organ involveme nt and dysfunction 1443, 23821; there is no evidence
for eosinophil clonality. It is a diagnosis 01
exclusio n. and may inc lude some cases
of true eosinophilic leukaemia that cannot
currently be reccqnrzeo. as we ll as cases
01 cytokin e-d riven eo sino philia that are
due to the ab normal release of eosinophil
gr owth fa ctors, e.q . interleukin (IL) 2. 3
and 5, fOf unknown reason s (128 , 443 ,
1971. 2072 , 238 21.



Hypereosinophilic synd rome (not recommend ed) .
Ep idemiology
Due 10 the p revious dilfic ulty in d istingu ishing CEL f rom idiopat hic HES. the
true inc id enc e of these di seases is
unknown, althou g h th ey are rare . Many
patients wh o wou ld until rec ently have
bee n c lassified as hav ing idiopathic HES
ca n now be show n to have C El assoc iated w ith a FJPtL 1-PDGFRA fusion gene
{466 1. Since this co ndition oc cur s mainl y
in ad ult me n, the male dominanc e and the
peak inc ide nce in the four th decad e
prev iously descr ibed in "HES" {443 , 1971 ,
2072, 2382 ) are now exp lained , at least in

BJ. Bain
D.G. Gi lliland
J W , Vardiman
H .-P. Horny

pa rt. The epidemiological features of

cases of HES that rema in idio pathic have
not vet been c learly d efined.

Sites of involvement


is a multisystem disorder. The PB

and BM are alwa ys involved . TIssue infiland release of
tration by the
cytokines and humoral factors from the
eosinophil g ranules lead to tissue damage in a number of organs, but the heart.
lungs , central nervous system, skin and
gastrointestinal tract are commonly invoiveo. Evidenc e of sp lenic and hepatic
invo lvement is p rese nt in 30-50% of
patients 1443. t97 1. 2072 , 23821 .


Clinical features
Sometimes eosinophilia is detected
inc identally in patients who are otherwise
asymptoma tic . In othe r pa tients, co nstitutiona l symp toms , such as fever, fatigue ,
cough, ang ioed ema . musc le pa ins, pr uritus and d iarr hoea are found . The mo st
serious clinical findings relate to endomyoc ardi al fibrosis . with ensu ing restrictive
ca rdiomeg aly. Scarring 01the mitralltricu spid valves leads to valvula r regurgitation
and formation of intrac ard iac thro mbi,
w hich may embouze to the brain or elsew here, Perip heral ne urop athy, cen tra l
nervou s syste m dy sfu nction, pulmonary
symptoms due to lung infiltration, and

Chronic eosinophilic leukaemia. not otherwise specdied


rheoma toroptcar findings are other frequ ent ma nifestations (443, 1971 , 2072 ,

2382 1

In CEL, NOS the most striking feature in

the PB is eosinophilia, there being mainly
ma ture eosinophils with only small numbers of eosi no p hi lic myelocytes or
promyelocytes {443. 710, 12OJ. 1971, 2072,
23821. There may be a range of eosinophil
abnormalities, including sparse granulation
with clear areas of cytoplasm, cytoplasmic
vacuolation, nuclear hype rseg men tation
or hyposeg me ntati on, and enlarg ed size,
These c hanges ma y be seen in cases of
reec uve as well as of neoplastic eosinophilia, however, and are thus not very
he lpful in deciding whether a case is likely
to be CEl {1281. Neutrophilia often accom pani es the eosinophili a , an d some
c ases have monocytosis, M ild basoph ilia
has been reported 17101, Blast cells may
be present but are less than 20%.
The BM is nvoercenotar due in part to
eosinophilic proliferation 1289, 443. 710,
1200, 2382 1 In most cases, eosinophil
maturation is orderly, w ithout a d isp ro portio na te inc rease in m ye loblasts. Ch arcotl eyden crystals are often present.
EryttTopoiesiS and megakaryOCytopoiesis
are usually normal. The finding of inc reased num bers of m yelob lasts (5-19%)
supports a di agn osis of CEl, as does the
ob servation of dysp lastic features in other
cell linea g es. M ar row fibrosis IS seen in
some cases 1289, 7101. Any tissue may
show eosinophilic infiltration and Charcotleyden crystals are often present. Fibrosis is a common find ing . an d is caused by
the d egr anu lati on of the eo sin op hile wit h
the release of eosinophil basic protein
and eosinophil cationic proteins {443,
1931 ,2382} .

Fig. 2.31 Ch ron ic~oop/l i l ic ~uk.aem ia . Peripheral blood smear from a patient With ahistory ofpersjstent eosi1c?*
Immatureaswell as mature eosinophilsarepresent CyloQenebc arlalysis showed trisomy of chromosome 10,

disease 1128. 19311. In addition, a number of neoplastic disorders such as

lym phoma, Hodgkin lymphoma, sys tem ic
ma stocytosi s, acute lym p hob last ic leuk
aemia and other MPN may be associated
with abnormal release of Il2, 1l3, ILS or
GM-CSF and a secondary eosinophilia
tha t mimics CEll 128 , 1168, 1172, 1450,
1616. 1924, 1931,246 11: in systemic mas tocytosis there can also b e eosinop hils
be looging to the neo pl astic clone. The BM
should be carefully inspected for any
process which might explain the eosinophilia as a secondary reaction, such as
vasculitis, lymphoma, acute lymphoblastic leukaemia , sys tem ic m as toc ytosis o r
gran ulomatou s d isorders. Some cases of
persistent eosinophilia are due to the abnormal release of cvtocnes by t-eens that


are immunophenotypical1y aberranl an:!

tha t mayor may not be clonal 1286, 1156.
202 41. When such an aberran t T-c ell pop.
ulati on is presen t, the case is not CEl00
is it idiopathic HES. If the monocyte con
is > 1x1r:P1L a diagnosis of chronic mye;o.
monocytic leukaemia with eosinoptlU
may be more appropriate, but if there are
dysplastic features and> 10% neutrophl
precu rsor s in the PB and no rnonccytoss.
a d iag nosis of atypical chronic myebd
leukaemia with eosinophilia should Sifn.
larly be considered.
The distinction between GEl. NOS. arc
idiopattuc HES is important. Idiopattlc
HES can be diag nosed onl y in fUlly investigated pa tients and on ly when (i) there,
an eosinophil count of <!:1.5x 1()l11l perse
ing lor at least 6 months; (iil reaclM

Differential diagnosis
D iag nosis re qu ires posi tiv e evidence of
the leukaemic nat ure of the co ncnton and
exclusion of cases of MPN with rearrangement 01 PDGFRA. POGFRB or
FGFR1. The diagnostic process often
starts wi th exclusion of reactive eosinophil ia. A d eta iled histor y, physical exam ina tion, b loo d count an d blood film ar e
essential. Conditions to be excluded
include parasitic otectoo. allergies, pulmonary d iseases such as Loetner's syndrome. cyclical eosinophilia. skin diseases
such as anqictymphoid hy perplasia, colla gen vascular d isorders and Kimu ra 's

Myeloproliferative neoplasms

1. There iseosinophilia(eosinophil count <!:1,5x1(ll1L)

2. Thefe is no Ph chrorrosome or BCR-ABL 1 fusion gene or oItIer myeloproliferative neoplasms (PV. ET. PMF)

3. There is nott.5;12)(q31-35.p13) ohIr ream1l9B"*~of PDGFRB


There is no FlP1l1-PDGFRA fusion gene crotherrearrangement 01 PDGFRA

5, There is noI'88rrangemerlt of FGFR1

5. Theblast cell count in the peripheral blood and bone marrow is less than 20"10 and there is 110

'l\'(15)(p13Q22) IX 1(16;16)(p13;q22) IX oIher lealureGagrlosbc ofAML

7. There is a cbIaI cytol}eneIiC or rnolecaar genetic abnormaIrty, IX bIasleels aremore lhan ~ in !he
~ bk:Jod men than 5% in !he bone marn:ow
If apatient haseoiil"lOPhilia bul lhese mlenaare not met !he dial;Joos4S may be reactive eosinopt1ilia,idiOpa1tMc

hypereosinophilia or idiopathic hypereosinophilicsyndrome,














eosinophilia is excl ude d by appropriate

h:lrcxJgh investigatoo ; (iii) AML. MPN, MOS.
MPN/MDS and systemic ma stocytosis are
excluded; (iv) a cytokine-prod ucmq.
~icalty-aberrant. t-een pop ulation is excluded; (v) and there is tissue
damage as a result of hyper eosinophilia .
Hcnteria i-iv are met but there is no tissue
damage. the app rop riate d iagnosis is
ocoamc hyperoosinop hilia .
Patl8rlts in whom a diagnosis of idiopathic
Itypefeosinophilia or id iopalhic HES is
made should be kepi und e r reg ular
review since evidence may su bsequently
Emel'g8 that the con dition is leukaemic in
!'laue, Treatment may also be necessary

Cytochemical stains c an be used to
identify eosinophils bu t they a re no t
essential for diagnosis , Partial degranulaeco can lead to eosinop hils ha ving
reduced peroxidase con tent.

No specific immuno p henotypic ab nermalily has been reported In CEL.

No single or spec ific cytogenetic or
molecular genetic ab normality has been
identified in CEl. NOS . Cases with rearrangement of PDGFRA, PDGFRB or
FGFRI are spec ific ally excluded , The
detectOO d a Ph cbrcroscre or BCR-ABL 1
fusion gene ind icates one of the rare
cases of chronic myelogenous leukaemia
wnh dominant eos inoph ilia . rather than
eEL. Ellen when eosinophilia occurs in
conjunction with a ch romosomal abnormality that is usually mye loid neoplasmassociated, it may be difficult to decide


F"l9- 2.32 kiopaltiC HES. Ablood smeard a pabertWlth ca-dIaclai.n,1eukot'yt:lsi$ and~ .

whether the eosinop hils are pa rt of the

clonal process. since react ive eosi nophilia
can occur in patients with myeloid neo-pla sms 17111. However, the linding of a
recurring ka ryotypic abnormality that is
usually ob served in my elo id d isord er s.
suc h as +8 or i( 17q), does suppo rt the d iagnosis of CEl 1128, 1692 ). Occasiona l
pat ients have a JAK2 mutat ion 1106 41.
x-unkeo polymorphism ana lysis of the
PGK or HUMARA genes c an oc ca sionally
be used in fema le patients to dem onstrate
cionautv 1392, 13501.

Prognosis and predictive factors

Survival is quite varia ble. In some series
in which pat ient s with idiopathic HES as
well as those with probable eosinophilic
leukaemia were incl uded. 5-year survival
rates ap proached 80% 1443. 19 71,2072,
23821. Marked splen ome g aly. as well as
the find ing of b lasts in the b lood or
inc reased b lasts in the 8M , cvtcqeneuc
abn ormalities and dysplastic features in
othe r my eloid lineages have been reported to be unfavourable prognostic
find ings [443, 1971. 2072 ,2382].

Postul ated cell of or ig in

The ce ll of orig in is a haemopoietic stem
cel l, b ut the lineag e potential of the
affec ted cell may be var iab le.

Chronic eosocobtc leukaemia. not otherwise specified



H ,-P' Horn y'

n.o. Metc alfe

J.M . Bennett
B,J . Bain

Mastocytosis is due to a c lonal, neoplastic
prolife ration of mast cells thai accumulate

in one or more organ systems. It is characterized by the presence of mult ilocal

compact clustersor cohesive aggregates!

infiltrates of abnormal mast cells. The d isorder is heterogeneous. ranging from skin
lesions that may spontaneously regress to
highly aggre ssive neoplasms associated
w ith muttiorgan failure and short survival
(Table 2.09). Subtypes of mastocytOSis are
recog nized mainly by the distribution of
the disease and cli nical manifestations . In
cutaneous mastocyt osis (eM), the mast
cell infiltration remains confined to the

Solitary mastoc ytoma

of skin
Indolent systemic
Systemic mastocytosis
Aggressive systemic
Mast cell leukaemia
Mast cell sarcoma

skin, whereas systemic mastocytosis

Mast cell d isease .

IC[)..() codes
Cutaneo us mastocytosis
(urtica ria pigmentosa)
Diffuse c utaneous

9740/ 1

Table 2.09 Classification of mastocytosis.

, Cutaneous mastocytosis (CM)

2, Indol&nt s)'5t&mic mastocytoSis (ISM)

3. Sy5temic mastocytosis wittl associatedclonal

haematological non-mast-celliineage disease

4 AggressiwSy5temic masklc)'toSis (ASM)

5, Mast cellleul<.eemia (MCl)

6. Mast c:eII sarcomlI (MCS)

7. Ertacutaneous meslocytoma

For the partlClpl!lms 01 the Vear 2lXXl Wortung Group

ceeeeece on Mes\OCytOllS ~ flo.ooIved in the
def,r1llJOIl 01 cr<terlll and WHO cIassohcllllOll 01rrestoC)'lOSIS' C Alr,1'l . KF Auslen . Jt,4 Bernett. AD BrI.roning.
l Elicr lbano. H-P Horny. I( lerI'lerI. CVI.J. JB Longley,
G Marone. 00 MelC8Ne. A Nunez . MA P_aresch.
LB Sct>warU. I( Sollar. ~ $perl. P V8Ienl. .IN 'laid..
man. K WOlIf


MyeloproliferatIVe neoplasms

974 1/ 1
97 41/3
97 41/3
97 4213


"AHNMO, ass oc iated naematoioqrce!

c lonal non-mast cell d isorder

(SM) is characterized by involvement of at

least one extracutaneous organ with or
without evidence 01 skin lesions . Mastocytosis shoul d be strictly separated from
mast cel l hyperplasia or mast cell activation
slates without morphological an dJor m0tecuer ab normalit ies that characterize the
neoplastic proliferatio n.

C. Akfl
L Escribaro
P. Valert

Fig. 113 Cutaoeoos maslOCytosiS. Darier"s '91- TIl

skit lesions 01 III bms 01 0Jtane0us II'\a:Stlc)t::s
~ wI'len stroked A. palpable wileaI ~. IN
moments afterhlltJysical sllrIUatIon, lkJe" hi,..
0I1t1slamnt from !he mastcells,

Mastoc ytosis may occur at any age Cutaneous mastocytosis is most common in
c hil dren and may be present at birth.
About 50% of afflic ted chil dren develop
typical skin lesions before 6 months of age .
In adults. CM is less frequently diagnosed
than in ch ildre n 12055 . 2436 1. A slight
male predominance has been rep orted in
C M. SM is generally di ag nosed after the
second decade of life ; the ma le to female
ratio has been report ed to va ry from 1:1
to 1:31 181, 1465, 1694).
Sites of involvement
Approximately 80% of patients with mas toc ytosis have evid ence of skin involvement
{16871 . In SM the bone marrow (BM) is almost alwa ys involved, so morp hological
and molecula r anal ysis of a BM b iop sy
specimen is stron gly rec ommend ed 10
con firm or exclude the diagnosis [287.
290, 971, 12751. Rare ly. the pe riphe ral
blood (PB) shows leukaemia due 10 significant numbe rs of circulating mast ce lls
{972. 14841. Other organs that may be involved in SM inclu de the sp leen. lymph
nodes, liver and gastro intest inal tract mucosa, b ut any t issue may be affected

1287,966.968.973, 1275, 1334. 1466.

1694 1. Skin le sions occur in more than

50% of SM pat ients, and are more often

observed in those with an indol ent course.

Fig. 2.34 Cutaneous mastocytosis, Numeroos typi:;i

eac nar and maCtllop.apular pigmented eseu ct

urticaria ~gmentosa in a young child "

Fig. 2.35 Ditluse artaneous mastocytosrs. T'I'OenC.

reddlSh'peau ~' 1esic:In$ d'Ia'acteI'isbc oIlilta

cutaneous mastocytosis This variant ocan

exdusiYely in d*\'eIl


In contrast. aggress ive va riants of SM

often present without skin lesion s [97 11 .
However, some SM patients withou t skin
escos may on occasion present wit h an
indolent form of SM, most often isolated
8M mastocytosis.

CIricaI features
Cutaneous mastocyt osis includes several
cetrct cmco- nistocettoicqcar en tities.
l esions of all form s 01 CM may urticate
when stroked ("Darier's sign 4 ) and most
snow intraepidermal accumulation of
melanin pigment. The term 'wtcana
ptgmentosa mac roscop ically describes
two clinical features. Blister ing
("b.bJs mastocytosis") does n:lI represent
a separate subtype but rather an exaqgeralion 01 urticaria. Blistering is usually
seen IrIpatients less than 3 years of age.
m may be assoc iated with all forms of
CM 11 68 7, 2055, 24361.
Symptoms in SM at presentation have
beefl grouped into 4 c ategor ies: 1) conSbtUtIOO8! symptoms (fat igue, weight loss,
Mr, diaphoresis). 2) skin manifestations
(prurituS, urticaria, dermatographism).
31mediator-related systemic events (abdcminal pain. gastrointestinal d istress ,
Dushing. syncope, headache. nvpoienson.
tachycardia. respira tory symptoms) and
4) musculoskeletal complaints (bone
pain. oeteoceora'osteoporoers. frac tu res,
<JltIralgias, myalgias) {181, 22901 . These
symptoms range from m ild in many
pabents to severe, life-threatening med iatorrelated events in othe rs, Sym ptoms ma y
also be related to orga n impa irme nt (du e
10 mast cell infiltrates), pa rticularly In
patients with high-grade ag g ress ive or
eukaernic disease variants,
Physical findings in SM at d iagn osis m ay
InClude splenomegal y (o ften minimal).
\lltile~dooopalhy and hepatome galy
are foond at signif ica ntly lower trequencies !966,968, 973. 1275, 1466 1. Organornegaly is often absent in the m ost
rormon variant. indolent systemic mastocytOSis(ISM). but is usuall y p resen t, alo ng
w impaired organ function, in aqq resSNesystemic mastocytosis (AS M) an d in
leukaemic variants. Severe systemic
~s may occ ur in patients w ith ISM
bbwIg eceosve release and generatIOn
rJ bcctemcar mediators including tustaI'!'f'e. eicosanoids. poteases and heparin.
For example, gastrointestinal symptoms
S\.d1 aspeptic ulcer disease Of diarrhoea
n more corrmonly attributed to release
rJ biologiCally active mediators than to

Fig. 2.36 Indolent syslelTllt mastocytosis. Dense

infiltrate conSisting mainly 01 spind~ sti\tJ1Iy

mast eels.



Fig. 2.38 Indolent systel'lic mastoeylOSis. A loo5eIy scattered spmd\Hhaped tlypograrlular mast cells WJlhooI
tendency III awegate. Diagnosis is lacihlatedI'fhen addibonal imrrI.rnostaHWI and moIeaJIar analysis n performed.
B IrrITlIA'lOSlain withCD25 shows an atypical ~ 01 mast eels with rnentlralle assooated reactivity.

Fig. 2.39 Systemic mastocytosis, Skeletal lesions ate common in systemic masloc,1OSiS. This X-ray shows paldty
osteosclerosis, osteoporosls WId multiple IyIiclesions mille lemur,
infiltration of the g astrointestinal trac t by
excessive numbers of abnormal m ast
cells P8 1. 1334 , 2288 1.
Ha ema tologica l abnormalities in 8 M
include an aemia , leukocytosis, blood
eosinophilia (a frequent f inding). neutropenia . and thrombocytopenia 1130,
287.7 13.971 , 1162 , 16871. Bone ma rrow

failure is encountered only in patients with

aggressive or leukaem ic disease varian ts.
Significant numbers of circulating m ast
celts are rarely observed and are suggestive of mast cell leu kaemia 122901. In
up to 3)% of cases with SM. an associated ,

clonal haematological. roo-mast cellileage

d isease (AHNMD) is d iag nos ed before.



2.10.Criteria lor cutaneous end systemic maslocytosis

Cutaneous mastocytosis (CM)"

SIOO lesions demonslrebng!he typical dinicallindlng5 ofUPIMPCM. diffuse cutaneous mastocytosis or soIttary
mastocytoma, and lypiCBltlistoIogical i1filtrates 01 masl cells in a lTlJltJlocal or dlfIuse ceeem in anadequate skill
biopsy. Inaddition. a tiagnosbc prerequiSIte b thediagnosis of CM is theabsence 01 features/aliena
sufficiant toestablish the ~s 01 SM
l/p(laled and &I9llly modified cnteliab skin i1YO/YemerJt in mastoey!OSiS have recetlUy been suggested {<t7A}.

S)'Itemic mastocytosis (SMI

The diagnosis 01 SM CBl be made when the IIIaJOI' critenon and one IIIir'Ia criterion or at least Ihnle mnor
crrteIia are prMel'll

lIIajor crilerion;
t.UlrfocaI, dense rliIlrates rJ mast eels (::!:15 mast celI$ n ~) deleded i1 sections of bone I'IllIITOW
and/or OCher eltraaAaneous organ(s)
Minor criIW:

1. In biopsy sedJons rJ bone nwrow orOlIlItel1raCUlaneOuS organs, :>25%ollhe mast eels r11he
infihle are ~ orhaveatypocaIlll(llllI1CJIog or, d aI mas! eels n bone m.arrtM'asprate
smeaR, :>25% aremnalln oratypical.


2. Deleclion of an ICtiYaII'lg poI"It rnuta\lI:Wl at c:odor1816 of KIT~ bone manow. blocdor anolher eJ:lraCula.

3. MastOBIs itI bone marrow. blocdor oItler eJhcutaneous organs express CO2 and'orC025 in adl;1itlOII ~
nonnat mast 011 maR-eB.
<t 5enJm tolaI tryptase pet1istetllly exceeds 20l'lgIml(unless!here is an associated daIaI myeloid dIsordar, it
wtictI caselhisparamet9f 1$ not valid).

simultaneously with. or after the diagnosis of SM. In princi ple, any defined
myeloid or lymp hatic malig nancy may
occur as the AHNMD. but myeloid neoplasms predominate, and chronic myelomonocy tic leukaemia (CMML) is most
common 197 1, 9 75. 2056, 2066, 2095,
22901. In patient s with SM-AHNMO, clinical sympt oms and disease course relate
both to the associated baematoioqrcat disorder and to SM 11977, 2290).
Serum tryptase levels are used in the
evaluation and monitoring of patients with
mastocytos is, The finding of a pers istently
elevated serum total trypta se > 20 ng/mL
is suggestive of SM and is used as a
"minor" criterion for diagnosis, unless there

Fig. 2.40 Typical skin lesion of a d\Ild WIlh ur1icatia

pigm&nIosa. Aggregales of mast cells Iil Ihe papIIafy
demIII a'ld edllnd as 5he8ls into Ile f'8tJCWr clemis.


Myeloprol!ferative neoplasms

is an assoc iated clonal myeloid non-mast

cell disorder, in which case this parameter
is not valid. Serum trypta se levels are normal to slightly elevated in mos t pat ients
with CM and have also been found to be
independent of the patient's tryptase
hap lotype 11977, 2290).
The diagnosis of mastocyt osis requ ires
demonstration of rnultifocal clust ers or
co hesive aggregates/infiltrates of mast
cells in an adequate 8M biopsy specimen
(Table 2, 10), The histolog ical pattern of
the mast cell infiltrate may vary according
to the tissue sampled 1130, 290 , 7 13, 966,
968 ,973, 1162, 1466 1. A d iffuse interstitial

infiltration patt ern is def ined as loosely

scatte red mast cells in the absence of
compact aggregates. It must be noted.
however, that this pattern is also observed
in reac tive mast cell hyperplasia and in
cases of mveromastccvnc leukaemia. a
term used for cases with advanced
myeloid neoplasms in whom elevated
numbers of immature atyp ical mast cess
are found , but criteria for SM are not met
120651. In patients with the diffuse infiltration pattern it is therefore impossible to
establish the diagnosis of mastocytosis
Without ad ditional studies including the
demonstration of an abe rrant illYT'lUfl(}
phenotype and/or detection of an acliva!
iog point mutation in KIT1977, 978 , 1196
2056,20571 , In contrast, the presenced
rruttifocal compact mast cell infiltrates ora
diffuse-compact mast cell infiltration pattern
is highly compatible with the diagnosis d
mastocytosis during first inspection. H0wever, additional immunohistochemical a'Id
molecular studies are strongly reccnmended even in these cases.
In tissue sections stained with H&E, ~
reactive mast cells usually are loosely
sca ttered througho ut the sample, and
display round to oval nuclei with clumped
ch romatin, a low nuclear/cytoplasmic
ratio. and nucleoli that are absent CI
indistinct. The mast cell cytopl asm is
abundant and usually filled with small
faintly visible granules. Dense aggregates
of mast ce lls are only very exceptionalfy
detected in reactive states or in patere
treated with stem cell factor (SCF) 11 275
1694. 22901. In smear preparations, mast
ce lls are read ily visible in Romanowsky
stains as med ium-sized round or oval
cells with plentiful cytoplasm , con ta in i~
densely packed metachromatic granules
and round or oval nuclei. In norrnarreao
tive states, mast cells are easily dislil'\o
guished from the smaller metactvonac

TIIbIt 2.11 SubdaSSlf?tiOn 01cutaneous mastocy1osis,

1. ~ pioJnenIosa (UP V~

ewneous mastoeylosis (MPCM)


2 DIuse l:lJWoeou$ mastocylO$ls


Sl*arI mamcytomaof skin

basophils which have segmented nuclei,

and larger and fewer granules. With enzyme cytochemistry. mast cells reac t
strongly wrth naphtholASD-chlofoacetate
esterase (CAE) but do not express
rnye!operoxidase In mastocytosis. the
cylOIogy of mast cells vanes, but aboor'!'tal cyIo1ogic features are almost always
oetected. nckJdlllQ marked spindling and
hypOgrarJJlarrty 122901.
Cytanorpnoiogical atypia is pronounced
1'1 higtl-gfade lesions 01 mastocytosis.
ee occurrence of metachromatic
ees cells being a usual feature 01 mast
celleukaemia 122901. The finding of treQUeft mast cells with bi- Of multi lobated
I\dei rpromastocytes") usually indicates
if! aggressive mast cell proliferation.
aIItOJgh these cells may be seen at low
IreQuency in other subtypes of the disease 122901. Mitotic figures in mast cells
Ii) occur, but are infrequent even in the
aggressive or leukaemic variants of SM.
Kl assess mastcell numbers with cowenlO"aISlalning procedures, Giemsa or toiuidine blue are employed 10 detec t the
metachromatic mast cell g ranules and
CAE IS alsohelpful 122901. However, the
roost specitc methods lor ide ntific atio n of
nmature or atypical mast ce lls in tissue
sectons utilize immunohi stoch emic al
staimng fortryptase/chymase and CD 117
and, for neoplastic mast ce lls. C0 2 and
CD25, The morpholog ic features of th e
common subtypes of mas toc ytos is are

~dk19nosis of

eM requires the d emon-

strahon of typical clinical find ing s an d

'VSlOIogical proof of abno rma l mast ce ll
atoo ol the dermis (Table 2.10). In
cases a isolated eM. there is no evide nce
~ systemiC involvement using such oa1I'l"ell!fS as elevated levels of total ser um
ryptaSe or organomegaly. Recently, consnus craeria for the diagnosis of CM
Il8've been further relined. and three

vanants of CM are now recogniZed

1atIIe 2111122861.

Meets arteria b" SM. No"C" findings (see below). No evldence of afl associated non.roastc:elli'leage cJonaj
I1aematOOgicaI mali\1laflc.yldlsonlel" (AHNMOI In !hisvanant. !he mast cellMOefllS low and skin
lesions areaWnosI i'lVaria ~ present

1.' BDnemarrow mastocytosis

As above (ISMI wiIIl bone marrow involvement. but noskin lesions.
1.2 Smouldering systemicmastocytosis
As above (ISM), but wI\tl 2 oc ITIOl'e "8' fn:l1l'lgS but no "C" ffldings.

2. Sptemie mastocytosis with n soeiBted clonal hMmaI~ norHnUt c:.Illl. . . . disease (SMAHNMO)

Meets CriIeria torSU and cntenalor an assoaaled. donIlIl'IIemaloklgicI flOIloITIaII eel lineage disorder.
AHNMO !MOS, MPN .AJ.IL,~ . oc ott. ~ neopasm tIal meets !he aliena b" a
disbnd~ " tie WHO cIasslticaIm).

AggrlSSivt systemic: mastocylosis (ASM)


Meets c:nena b SM. <n oc IOOf8 "'C" Indings. No ll"o'lci8rOI of maslceI-..aema. UsuaIy ri'1oU: sm

Cutaneous mastocytosis (eM)

Table 2.12 Criteria lor variants 01 systemic mastocytosis

3.1 l~hic mastocylOiIs with t<l5ioophilil

Progessive ~ wCh penphefaI bloodeoswlOphIa. orten Wllh extensrve borle
irlvoI'o'emeol. and t\ep<l~ . butusuaIy II'IIlnJI skin lesions. CasesWIltII'NI~~
of PDGFRA weelCkJded.

.t. Mast c:elileukaerrlia (MCl)

Meets cnteria lor SM. Bone marrow biopsy shows a ~ lrlfiIIrabOn. usualy oompacl. by aIypicaI,
immaturemast cells. Bone IT1arnl\lr aspirate smears snow 2O"It or more mast eels In typitaI Mel . mast
cells aa::ountfor 10%oc more of~ blood wtIIte eels. Rarevanllfll: aleukaenK mast c:el leukaernla
- as above. but <1 0% ofwlile bloodcells aremast cells. Usualy wiIhouI sbl lesions


Mas. c:ell 5MComa (MeS)

. lJfIifocaI mast celllurr'OJr. No evidence 01 SM. Oesll'uClive grow\tl pattern. HiQh1lrade cytology,

Extl'illcutaneous mastocytoma
UnilocaJ mast cell ltl'TlOU', Noevidence 01 SM. Noskin lesions. NoOOestruetiYe !1owth pattern, Low-grade

-8" findings

Bone marrow biopsy showing >30% infinratkin bymast cells (focal, ceose aggregates) andlor serumlolal
lryptase level >20 nglmL.

2. Signs of dysplasia or myeloproliferation. in ten-mast ceil lineage(s). but insufficient criteria for definitive
diagnosis of a haematopoietic neoplasm(AHNMD), with nonnal or only slightly abnormal bloodcooors

3. Hepatomega ly withoutimpairment 01 ~v&r function , andlO!" palpatlle splenomegaly without hypersplenism,

and/or lymphadenopathyon palpalfon or imaging
"C" findings
1_ Bone marrow- dyslunction mal1lfasted by ooe Of more cy\OI)a!1ia (ANe <1.Ox10'1l.. Hb <10 gJdl, lX
platelets <1 Clli10"Jt). but noobvious noo-mas! ceU haematopoielic malignancy
2, Palpahla !lepatDmagalywiltl impairment oI ~ver 1uncIlon. ascites and/or portal hyperterlSior1.
3. Skeletal i1'o'Oi'o'eman1 withlarge osteolytic lesions d Ol' palhologtcallractures.
.t. Palpablesplenomegaly With hypetSJlielVsrn.

S. Malabsorption WlIh we9Jl loss due 10 GI mast cell infiftrates,

Urticaria pigmentosa (UP)lmaculopapufar

cutaneous mastocytosis (MPCM)
This is the most lre q uent form of CM. In
child ren,1he lesions of UP tend to be larger
and papular. Histopathology typically reveals agg regates of spindle-shaped mast
cells filling th e papilla ry dermis and extending as sheets and ag gregates into

the retic ular dermis, et ten in per ivasc ular

and pena dnexar pos itions 124361. A subvariant. usually occurring in young children.
presents as non-pigmented. pl aqu e-forming lesions. In adul ts . the lesions are d isseminated, and tend 10 be red ex brown-red
and macular or maculopapul ar. Histopathology of adult UP tends to reveal
Mas tocytosiS


Rg. 2.43 A Booe marrow smear of a patJenI WIth indolent systemiC masUytosi$. The eel is atypical. witIlan indenled nucleus in an eccentric Iocabon, and cytoplasm ... ....
an ~ emson WIt1 ~ dIslr1buIim of ~ 8 Sysl8rlIc rnastlc)tlsIs. The eels may haw bland ru:lel WIIIl moderate ~ of 1* tyqllasm , spinIed _ _ ..
I'MeITtlle fibroblasts. or IctllAated nuclei WIth ab.nln dear C)'kIpIasrn The Ialler eels mayresermle rnonoc:ytes or his/ioq'Ies. and ant more oommooly seenin aggnssift

"' .....

fewer mast cells than observed in children. The numb er of lesoner mast cells
may sometimes ove rlap with the up per
range of mast cell number s found in normal or inflamed skin. In some cases,
examination of multiple biopsi es and
immunohistochemical analysis may be
necessary to establi sh the diagnosis of
e M 12286, 2436).

Diffuse cuta neous mastocytosis

This clin ically remarkable subvanent of
CM is much less frequent than UP and
presents almost exclusively in childhood .
Here the skin is diffusely thickened and
may have a peau chag rine or peau d'aange (orange peel) appearance. There are
no individual lesions. In patients with cl inica lly less obvious infiltration 01 the skin,
the biopsy usually shows a band-like
infiltrate 01mast celts in the papillary and

upper reticu lar dermis. In massively

treted skin , the histological picture !Tll'f
be the same as that seen in solitary mas
cytorna 12055, 24361.

Mastocyt oma of skin

This oc cu rs as a single lesion, almost
exc lusively in infants. without predi lecl~
of site. The histolog ic picture is one ~
sheets of mature-appearing highly metachromatic mast cells with abundant C'/'I>
plasm that densely infiltrate the oa
and reticular dermis . These mast eel
trates may extend into the suocoteoece
tissues (11541 . Cytological atypia is na
detected . This allc:M's separation 01 mas
cytoma from an extremely rare mast eel
sarcoma 01 the skin 119581.



Systemicmastocytosis (SM)


The prerequisites for the diagnosis of So\!

are outlined in Table 2.10. In most cases.
ag greg ates 01 atypical mast cells a1
readily found in tissue sections. The crtt9'll
lor variants 01SM are given in Table 2.12.



Fig. 2.45 SystemiC mastocytosis, booe marrow bklpsy. A The local lesions01 mast cellschenconsist of a central core
ol lymp/lOCyles, surrourldlld by polygonal mast cells with pa~ . faintly lJ"iJrlUlarcyIOplasm. WIth reactive eosinophils at
the outer margirl ol lhe lesion. 8 The lesiOns are often well-circumscribed. and may OCCIJ" irl parauabecular or
perivascular Iocabons, but may be I'lV'ldorTWy dislnbuted in the interll'abeclAar regionsas wei.


Myeloprol!terative neoplasms

Bone marrow
In most cases of SM, multifocal . sllar~
demarcated compact infiltrates 01 rna;
cells are the most common and easily ce
tect able feature in the BM bio psy. The
infiltrates are found pred ominantly If
paratrabecutar and/o r perivascular locations 1290, 965, 971, 977, 978. 11981. The
focal lesions are co mprised 01 varyiOj
numbers of mast ce lls. intermingled w
varying numbers of lymphocytes , eoere
phils , tusnocytes. and fibrob lasts. These
diagnostic "mixed" infiltr ates are o/tell




d isl



seen in ISM and generally show eithe r a

central core of lymphoc ytes surrounded
bymastcells, or a central compact mast
eel aggregate with a broad rim of lymphocytes 19651 In other cases , the lesions are mot e rronorooptec and are
many composed of spindle-shaped
mas! cells that abut Of stream along the
bony trabeculae 1977 . 9781 . Significant
relJCulin fibrosis and thickening of the
adlacent bone are frequently Observed .
ScrnetIITles. the 8 M space is d iffuse ly replaced by compac t mast cell infiltrates ,
which may resemble sheets of fibroblasts
19711. Marked reticulin or even collagen
fibrosi s is frequentl y observed in such
cases 1971 , 977, 9781. Usu ally, there is a
mixture of both spind le-shaped and round
mast cells. Rarely, co mpac t infiltrates may
exclusively consist of round hype rgr anu'af mas! cells, which meets the criteria for
so-called trvptase-c ostnve round cell
l'lfiltratioo 01 8 M (TRDCI-8 M) 19761. In
cmrest to spind le-shaped tryptaseexpresSing cells that are alw ays mast
cells, the round nvptase-posmve cells in
TROCI are either mast ce lls (coexpres9IOl'l li C0111 and c hymase), neoplastic
!laSl:ViIS (primary or secondary basoIt1k leoIo:aemial or myeloblasts in the

should be classified according to established WHD criteria . II is important to note

whether the re is inc reased cellularity of
the marrow or d isturbed maturation of
haematopoietic cell s, because. even if
c riteria lor a coexisting myeloid neoplasm
are not completely fulfilled , hypercetlutarity
Of abnormal myeloid maturation patterns
cou ld be associated w ith an unfavourable
out come (progression to ASM or SMAHNMD) or with a smouldenng variant of
SM in which the out come is uncertain
122901. Inter pretation of findi ngs must include consideration that reac tive , nonclonal mast cell hyperplasia may
accompany a var iety of haematolog ical

disorders, including myeloid and especially

lymphoid neoplasms, such as lym phoplasmacytic lymphoma or hairy c ell
leukaemia 122901. In such reactive states ,
the predom inantly round mast cells lac k
major" cytological atypia. and are almost
always loosely sc attered throughout the
tiss ues. a find ing that c learly contra sts
with the compact aggregates 01 reooiastc
spindle-shaped mast cellsfound in mastocyt os is 122901.
The d ocumentation of 8M involvemen t
accompanying SM is usually established
by examination 01 a 8M trephine biopsy
specimen. However. the analysis of marrow aspirate smears does provi de useful

Fig. 2.46 Systen'ic masb;ylosls, spleen, A Sl)Ieen tom a pa\letIt 'lII'i01 systen'ic maslIXylosls. B Aggregates rJmast

eels may be seen II \tie red orwliIe pulp, orbolh. ~ his case, mast eels ate seen II a penloIi::IJNlocation. of a trvotase-oosmve acute

'l'IyflIOId eokaene.
CaretlJ inspec tion of the 8M no t
at!ected by mastoc ytosis is of crucial
ecctarce. Often, the una ffected 8M is
II1remarkable with a normal distribution of
tal cells and haematopoenc p rec ursors .
Such cases usually eithe r belong to ISM
o\'lthinvOvemen! of skin and 8M , or re preSMt isolated mastoc ytosis of the 8M ,
However, in othe r c ases th e 8M not
drectly infiltrated by mast cel ls may be
extremely hypercellular due to the prolifescoof cells of non-mast cell lineages,
tduding neutrophils, rnonocytes. or less
frequently, eosoopbns or b last cells. DePQ"Ong on the type of proliferating cells,
lindlngs may be reactive (myeloid
~ ), or may indica te the presence
d acoexisting naematoooeuc neoplasm
ll.d! as acute myeloid leukaemia , a
~ollferatiYe neoplasm, a myelodyssyndrome or myelodysplasliC/
~ferati ve neoplasm, Of chronic
...""llc ~. Lymphoproliferahve
diseases, such as plasma cell myeloma
~ malignant lymphoma. are less Ire(JJllfl\Iyseen 1110, 969 , 971, 975.1 147 ,
1484 2056,2066, 20951. In all such cases,
~ associated naematoroorc d isea se




Fig. 2.43 SM-AHNUD (acutemyeloid Iel.Jkaemia). A The streaming, spindled eels of a largemast eel aggregate can
be seen on one side rJ lhe booy lrabecUkJm (arrow), weeeas a rTlCIllOIonoUs J)Opljabon of blast cellsis seen onlhlI
opposite side . B The spiodledcells of mastcell disease abut on a large aggregale of blasts.

Mas tocy tosis


granulomatoid lesions in the caranececular and paratoucurar areas. or within the

lymphatic follicles, or as diffuse infiltrates
within the red pulp. As in other tissue
sites, eosinophilia and fibrosis are frequently observed in areas of mast eel
infiltration. In some cases. an associated
haematolog ical disorder may be present,
but this is often difficu lt to diagnoseusirg
splenic tissues alone 1973, 14661.


Liver involvement in SM usually presen
With disseminated small granulomat
foci of mast cells within the periportal
tracts and as loosely scattered mast eels
within the sousoos . Severe liver i~
rrent is only rarely seen in SM. WiderWg
and fibrosis 0 1 periportal areas is cctmonly found . but fully developed cirrhosis
is rare 1966, 14661.

f~ 2,49 SystemicmastlcyloliswiltI associ8led hl*yt:ell Waerria. A Bone marrow aspi'a'B smear Wllh hairycels
and al)1liCal mast eels B The spirded mast cells M pteSel11 adjacentto the hairy eel i'lfiItJate il lhe intersbbaI
regions oI1he IT\il'I'OW Although hairycelleubemia may occasioRaIy assume a spindledlTW)IJlIlology, in Ihis case lhe
mast eel tryplase lustrated in (e ) dearly demonslrales !he masl eel origin 01 ltle spindled tens. alll! an
imuIostaIn for C020 idenlifles ltle IIaify eels in (D).

additional information and is c rueial lor the

diagnosis of mast ce ll leukaemia and 01
some suovanante of $ M-A HNMD 122901.
In ISM, most mast ce lls are found within

the thicker regions of the aspirated

crushed fragments. Mast cells in ISM,
which should always be assessed in the
thin region s and at a fair di stance from
8 M part ic les , usually com p rise < 1% of all
nucleated marrow ce lls. This is in contrast
to mast ce ll leukaemia, where mast cell
numbe rs b y defini tion equal or excee d

20% of all nucleated cells in aspirate

smears 1290, 977, 978, 2290},
Lymph node
Lymph nodes appear to be rarely involved in 8M in that significant lymphadenopathy is unusual. The mast cell
infiltrates within lymph node s may involve
any of the anatomical compartments but
particularly involve the paraooncat areas.
Mast cell infiltrates can be either foca l or
diffuse, but rarely totally efface preexisting
archi tecture. Hyperplasia of germina l
ce ntres, evide nce of angi oneogenesis,
tissue eosinophilia, plasmacytosis and reticulin/coll agen fibrosis usually accompany
the mast cell infiltrates 1968. 14661. In a
few patients, lymphadenopathy is marked ,
with a progressive clinical co urse mimick ing malignant lymphoma . II Sig nificant
blood eosinophilia is present. such cases


Myeloproliferative neoplasms

have been reported 10 belong to a defined

subset of ASM, namely "Iymphadenopathc SM with eosinophilia" 11484, 22901.
In such cases, studies for rearrangement of
PDGFRA are recorrmeoded, and if present,
the cas e should be reassigned to the category of myeloid neopla sm with eosinophilia and rearrangement of PDGFRA.
The white and red pulp of the spleen may
be involved in SM, with rare case s showing preferential infiltration of the lymphoid
follicles of the wh ite pulp (9731 . Here.
mast ce ll infiltrates often present as focal

Gastrointestinal (GI) tract mucosa

Involvement 0 1 the GI tract mucosa bf
mastocytosis is frequently suspected ctnically but may only rarely be assessed
morpholog ically. As in omer tissues,
least one compact mast cell infiltrate isrequireo to support the diagnosis of SM. IfI
typical cases. these mast cells shOw an
abnormal immunophenotype with expression of CD25, and an activating poirt
mutation of KIT is present. Due to the Irequency of CD25- positive lymphocytes.
careful examination of the tissue is recessary to avoid false positive results. To
eva luate a GI biopsy for mastocytosis,
both antt-trvotase and anti-C0117 anti'
bod ies should be applied in order to
avoid false positive results due to strong
bac kg round staining when only ant~
tryp tase ant ibodies are used. A lew

exceptlOl'l3l cases exhibit a diffuse compact infiltration of the lamina p ropf"ia mu cosae by atypical mast cells , and this
'f'B1 reseroe inlIanTnatory bowel disease
r:1 malignanl lymphomaat first glance . AIklgelher, lour patterns of involveme nt of
theGI tractmucosa by mastocytosis can
be dlscnminaled 1171 1: 1) Loosely scattered mast cellswithout dense ag gregates
W wrth an atypical immunophenotype
and an activating point mutation of KIT,
usual~ in the settinq 01 SM of some duraioo and involving the 8M, 2) Slight increase in loosely-scattered mast c ells
withoccasional dense aggreg ates and an
atypical rrmoopterotvce with expression
ct CD25. usually associated with an actr~ating point mutation of KIT, 3) Diffuse
Cl:lmpaCI infill ralion 01 the mucosa by
atypiCal mast cells, resembling the ag~ive variant of SM in other tissu es
171 1and 4) Localized mast cell sarcoma
(based on one published case with in'OteTlerC oIlhe ascending colon) 111761.

_ 1esK>ns

Of osteoporosis is another frequent find-

ing in patients with mastocytosis, and

may occur in any variant.

Mast eel/leukaemia (MCL)

In mast cell leukaemia , mast cells equal
or exceed 20% of all nuc leated cells in
aspi rate smears 1290 , 977, 9 78, 22901. In
this rare and hig hly ag gressive lorm of
SM , the BM reveals a diffu se, compac t
infiltrate with marked redu ction of fat ce lls
and normal haematopoietic precu rsor s.
The mast ce lls often show sign s of
marked atypia with hypogranu lar c ytop lasm, irregularly shape d monoc ytoid or
b ilobated nuclei (p romas tocy tes), and
may even pr esent as me tach romatic
b lasts 122901. In some cases, the nucleoli
may be prominent. In typ ical cases , mast
cells ac c oun t for 10% or mo re of the
c irculating nucleated cells . If mast cells
comp rise less than 10% the circulating
cens. the diagnosis of an "a'eukaem.c"
variant of MCL is appropriate 122891.

The lfequency of bone changes varies

ee subtype of disease. \-\'hile pu re

tduse ceteoscerosis is unusual in ISM
Iil(:U 6%0), it is observed in about one

Mast eell sarcoma (MCS)

dWl:lol patients with ASM. The most comradlOlOglcallinding associated with

ISM crests of concurrent osteosclerotic
andOSleolytic lesions (45%). Osteopenia

Ma st cell sarcom a is extremely rare and

cha racterized by a localized and destruc tive growth of highly atyp ical mast
cells, which c an be id entif ied only after


application 01 appropriate immunohistochemical markers, particularly anti-tryptase

and anti -CD l17 . AlthOugh initially localized , distant spread followed by a terminal
phase resembling MCl is seen alter a
short interva l. Mast cell sarcomas have
been report ed to occur in the larynx, large
bowel, meninges , bone and skin 1265,
970, 11761 .

Extracutaneous mastocytoma
This localized tumour consists of an
ac cumulation of mature-appearing granulated strongly metachromati c mast cells ,
in contrast to the hig hly atyp ica l mast
cell s observe d in a mast c ell sarcom a.
Extra cutaneous mastocytoma is exception ally ra re, and the reported cases
involved the lung {3981.
Mast cells co-express COO, CD33, CD45 ,
CD68 and CD 117 but lack severa l
rnyelomonOCytic ant9S"S, including CD14,
CD15 and CD16, as well as most T- and
B-eell related antigens 1974, 977 , 978 ,
1073, 1292, 1687, 22901, Virtually an mast
cells , irrespective of stage of maturation
or neoptasnc state , react with antibodies
against trvp tase . a cell not expressing
tryp tase ca nnot be id entified as a mast
cell immunohistoc hemically. Chymase is


expressed in a subpopulation 01 mast

cells. Chymase is highly specific but
much less sensitive for the identification
of atypical and immature mast cells than
C0117, whereas COl17 expression is a
highly sensitive but rather nonspecific
marker of mast cells. Neoplastic mast
cells show a similar antigen profile to that
of normal mas t cells, but in con trast to
normal mast cells. they also coexpress
C02 or C02 and C025, These latte r
observanons are of considerable value in
the diagnosis and in the differential diagnosis of mastocytosis and related tumours,
and can be applied in immunohistochemical as well as in flow cytometry studies
j650, 1655.
The application of antiC025 enuoooree has been found particularly useful in the histopathological
evaluation lor suspected SM. Howeve r.
C02~posilive T-cells are usually present in
tissues and must be taken into account
before an atypical C02-positive mast cell
population can be properly iden tified . p.J.
together, it can be assumed in the routine
diagnostic evaluation 01 mastocytosis that
cells expressing uvptaserctrsmase and
C0117 are mast cells, and cells coaxpressing tryp tase/chymase, COl17 and
C02/C025 are neoplastic mast cells
120571. C025 expression may be inconstant or even unde tectable on mast cells
in some rare subvartants of the disease,
such as welt-dilt erentiated SM or in a subgroup 01patients with mast cell leukaemia

.. ." .

. e


Mastocytosis is frequently associated with
somatic activating point mutations within
K IT 121761. In most cases, co don 816
mutations in the tyrosine kinase domain
are detectab le. Rare familial cases with
qecmune mutations of KIT have bee n
repo rted [ 14,15, 1331,1332, 1333, 1557,
21761. In patients with SM-AHNMO additional genetic de fects are det ec ted,
depending on the type of AHNMO,
Somatic point mutations of the KIT protQoncogene that encodes the tyrosine
kinase recept or for SCF are de tected as
recurring abnormalities in mastocytosis
11 4,15, 1331, 1332, 1333, 1557, 1656,
21761 _ The most commonly observed
mutation shows substitution 01 Val for Asp
at codon B16 (D816V). This mutation
results in ligand-independent activation 01
KIT tyrosine kinase and provides relative
resistance to the prototypical tyrosine
kinase inhibitor imatinib 1995, 15571.

Myeloproliferative neoplasms

Fig. 2.53 Mast celleull.aem&a A ~ blood smear. Note lhe biIobed ru:tel and relatively ~
cytoplasmoften seen in Itll5 awessive form of rnastIcykIIas. B Theborle marrow biopsy is li1IuseIy inIiIlr.*ldby
~slJC mastcells, C derronslriIles !he 'dear aIr appearance !hat is due ~ !he poorgratlJIalion of the
ltIatis typical of inmature mast eels ofmast eelleukaernia. 0 All irmI.JnohisD::h slainbr masteel ~

""""' .......

The DB16V mutation is identified in the

mast cells of 95% or more of adults with
SM when sensitive methods are used, inclu din g nested PNA-PCR or PCR on
poo led micro-dissected single mast cells,
Other activating point mutations of axon
17. such as DB16Y, D816H and 08 16F
are rarely seen {756. 1332, 1333, 20561 .
The DB16V mutation is seen in only about
one third 01CM in paediatric patients 114,
1331, 1332) and the frequ ency of point
mutations other than 08 16V is significantly
higher in CM than in SM, In patients with
SM-AHNMO, add itional ge netic defects
may be detected, depending on the type
of AHNMO. For example, in SM associated
with AML, the RUNX1-RUNX1T fusion
gene may be found , whereas in cases of

SM associated with myeropronteratse

neoplasms. JAK2 V617F may be found
The de tection of the FIPIL 1-PDGFRA
fusion gene has been reported in patients
with mast cell proliferation and eosinophilia
122861. Although patients presenting wlt'I
elevated serum trvptase levels. clonal8M
eosinophilia with a F/P1L1PDGFRA
fusion ge ne and a few scattered atypical
mast ce lls have been described as having
an unusual variant 01SM {130, 713, 11621
most of these patients do not fulfili 8M
criteria, particularly as compact mast cel
infiltrates are missing , and they are best
classified as a mye loid neoplasm With
eosinoph ilia and rearrangement 01
PDGFRA (See Chapter 3) 122871.

Postulated C~ II of oriQin
Haematopoietic stem cells.
Prognosis and predictive factors
In children, CM usually has a favourable
outcome and may regress spontaneously
before or during puberty. In adul ts, cu taneous lesions generally do not regress
and are. in contrast to a previous belief,
oI1en associated with SM, usually the
ocoient variant. One study identified
predictors of a poorer prognosis as rate
onset of symptoms , absence of CM.
ttrembocytopenia. elevated lactate dehyciogenase (lOH). anaemia. 8 M hypercelk81ty. qualitative PB smear aboorrehtes.

elevated alkaline phosphatase and hepatosplenomegaly. The perce ntage and morphology of mast cells in 8M smears have
been ide ntified as additional important
and independent pred ictors of survival in
mastocytosis 122901Currently, there is no cure lor SM. and the
prognosisdepends on eediseasecategory
1228 7, 22881. Patients with high-grade
(agg ressive) disease inclUding mast cell
leukaemia may survive only a few months,
whereas those with indolent SM usually
have a normal life expectancy 12287.
22881. SM patien ts with cutaneous
invotvement usually also follow an indolent
course, whereas patients With aggr essive

disease often have no skin lesions 122901

However. isolated 8M mastocytosis as a
sobvanant of ISM with excellent prognosis
also presents without cutaneous lesions.
If there is an associated baematoroqrcet
malignancy, the clinic al course and prognosis are usually domina ted by this related haematological malignancy 19751_
Patients with aggressive SM generally
show a rapid cl inical course with a survival of only a few years. MCS shows a
prog ressive course with death within
months . Patients with ASM, Me l and
MCS are thus candidates lor cvtoreduc tive therap ies.



Myeloproliferative neoplasm,

The designation. myeloproliferative ne0plasm. unctassmaore (MPN . U) should be
applied only 10 cases that have definite
cl inical, labora tory and mor pholo gical
fea tures of an MPN but that fai l 10 meel
the criteria for any of the specific MPN
entities, or that present with featu res that
overlap two or more of the MPN ca tegories. Most cases 01 MPN. U, will tall into
one of three groups: 1) Early stages of
poIycythaemia vera (PV), primary myelofibrosis (PMF) or essootial thrcmbocythaemia
(El) in which the c harac teris tic featur es
are not vet fully d eveloped: 2) Advanced
stage MPN, in wh ic h p ronounc ed myelofib rosis. osteosclerosis. or transformation
to a more aggressive stage (r.e . increased
blasts and/or dysplasia) obscures the
underlying disorder 1775, 1216, 2206,
22 16,22221 : or, 3) Patients with convincing
evi de nce of an MPN in whom a coexisting
neoplastic o r inflammator y d isord er obscures some of th e diagnostic c linic a l
and/or morp hological featur es , The presence of a Philadelphia (Ph) ch romosome,
BCR-ABL 1fusion gene or rearrang eme nt
of POGFRA, POGFRB or FGFR 1 genes
excludes the diagnosis of MPN ,U.
The diagnosis MPN,U shou ld not be used


Myeloproliferative neoplasms

wren clinical data necessary for proper

c lassification are insufficient or not available, when the bone marrow (BM) specimen is of inade q uate q uality or size for
acc urate evaluation (1216, 22 16 , 22221, or
w hen there has bee n rece nt cy totoxic or
growth factor therapy - p rob lems that account for the ma jority of the unclassifiable
cases encountered in routine practice . In
such cases it is often preferable to describe the morphological findings, and to
sug gest additional cl inical and laboratory
p rocedures tha t are nee ded to further
classify the p rocess, inClud ing ad eq uate
pe riphe ral blood (PB) and BM biopsy and
aspi rate specimens. When a d iag nosis of
MPN, U is made, the repo rt should summarize the reason for the difficulty in
reaching a more specific diagnosis, and.
if possible, specify which of the MPN can
be excluded from consideration .
If a c ase does not have the features of
one of the we ll-d efined entities, the possibility that it is not an MPN must be
strongly consi de red, A reac tive 8 M response to infection and inflammation, loxins, chemotherapy, and administration 0 1
growth tactors. cvtokmes and irrmunosuppressive agents may closely mimic
MPN and must be exc luded, Furthermore,

H.M. Kvasnicka
B.J . Bain
J , Thiele
A. Orazi
H.P. Horny
JW , vardiman

a number 01 other naenatopoeuc and

rco-neenatcooenc neoplasms, suchas
lymphoma or metastatic ca rcinoma , may
infiltra te the marrow and cause reactive
changes, inc lud ing dense fibrosis and
osteosclerosis that ca n be misconstrued
as an MPN 122061. Dete ct ion of a clonal
cytogenetic abnormality, a JAK2V617F a
othe r functionally similar JAK2 mutatIOn,
or an MPL IMP/.. W515K1L) rrutation
distinguish an MPN from such reaclrve
conditions, although not all cases of MPN
U express a currently recognized aeretc
marke r 12171, 21771. In add ition, thedefining c harac teristics of each MPN must be
considered with the realization that, as with
any other biological process, variations 00
occur, and they may progress thrt:llJ!1l
different stages so that the c linical 31"(1
morphological manifestations of the disease will change with time 12177, 22161
ICD..Q code

997 513

Epidem iolog y
The exact incidence of MPN, U is ur*~
but some reports indicate that the pelcentage of unclassifiable cases ecccn
for as many as 1~ 15% of all cases Ii
MPN 1775, 2222 1, The frequency varies

significantly aCGord ing to the exper ienc e

l1lhe diagnostician and the specific erassfication system and criteria utilized to
dassifyMPN 11216, 22161.

The cause is unknown.

Sites 01 W1voIvement
5mlar to the other MPN

cncaJ leatures

r-e dI1icaI features 01 MPN. U are similar

Iltoseseen in the other MPN, In pat ients
, . early, tn:: lasgjfjable disease, organo-regaly may be minima l or absent. but
sclen:lmegaIy and hepatomegaly may be
'T'8SSNe i1 those with advanced d isease
" "IIto'n 8M scecerees are characterized
0, ~ myek)flbrosis and/or increased
rurtlers of blasts 122161. The baemato~ valles are also variable , and range
\rem mild leukocytosis and moderate to
'I'.arlo:ed thrombocytosis, with or without
~nying anaemia, to severe cvtoPfJ'8S ae 10 8M failure. Some patients wilt1
1IlN. Upresent WIth otherwise unexplained
p:fIai or splanchnic vein thrombosis.

'krrtcases that are diagnosed as MPN. U
tJemQ to very early stage disease in
iI'tlCJ the differentiation between ET, the
p"elibrOlic stage of PMF, and the preJ:dycythaemic stages of PV is difficult
11216, 2223, 22241. Often, the PB smear in
li.dI cases shows thromboc ytosis and
Ia'iatlle neutrophilia. The haemog lob in
concentration may be normal, mildly d eeeasec or borderline incr eased . The 8M
bqJsy specimen frequently shows hyperterlJiarityand often prominent megakaryoClI'= proliferation, with variable amounts of
Q'a1\Jlocytic and erythroi d prol iferation
12216,2223,22241, If the guid elines suqgested in the previous sections for each
specdic MPN are carefully applied wi th
ti:lSe attention paid 10 the megakaryocy' morpholog y and histotopography,
'lOSt cases can be accurately assigned
1I 8spedic subtype; but if not. the des."a1OO ot MPN, U is preferable until
follow-up data or adomonar lebo'By studies provide evidence leading
1)8 precise diagnosis.
lJe-stage disease. the BM specimens
-eseal dense fib rosis and/or os teo~, indicating a terminal or
...m<lA stage, and distinction between
oost-polycylhaemic stage of PV

(post-Pv MF) or rarely ET (post-ET MF)

1143A1 and lhe overt fibrotic-osteosclefotic
stage of PrlAF may be impossible if there is
no previous history or histology for review
12203, 22CX'i, 2216, 22221 Although Chrc:K1ic
myelogenoos leukaem ia (CMl) may also
be accompanied by marked myelofibrosis, the sma ll size of the megakaryocyt es
will alert the morphologist to the correct diagnosis, and cytogenetic and mole cular
qenetc demonstration of the Ph chromosome or the BCR-ABL 1 fus ion gene will
con firm the di agnosis of CMll775, 2216.
More than 10% b lasts in the PB or 8M
and/or the findin g of significant myelodysp lasia gen erally indica tes a transition of
the disease to a more agg ressive, often
terminal b last phase. If the initia l diag nostic speci men has features of a myeloproliferative proces s that cannot be
spec ifically ca tegorized , but shows
10-19% b lasts in the PB or BM, the diag
nosis of an accelerated stage of an
MPN, U, is appropriate, Irrmu notlistochemical staining of the 8M biopsy sec tions for
CD34 ma y be of diagno stic value in these
cas es by demonst rating increased number s an d/or clusters of blasts 12216,
22221. If bl asts account for 20% or more
of the perip heral white blood cells or nucleated 8 M cells in the initial specimen ,
then the diagnosis is acute leukaemia ,
and the suggestion that the case may be
a bl ast transformation of a previous but
uncl assifiable MPN is appropriate, Myelodysplastic features may appear dur ing
the natur al p rogression 01 an MPN even
without prior cytoreoucuve therapy. How ever. if the initial pretreatment specimen
demonstrates myelodysplasia , the diagnosis of a myelodysplastic syndrome or of

a myelod ysplaslictmyeloproliferative reoplasm, incl uding the provisional entity, refractory anaemia with ring sidercblasts
and thrombocytosis, should be considered
11 27,1 29,865.1 245,1406.2082,2169/.
No abnormal phenotype has been
ported for this group of patien ts.


There is no cvtcqenetc or molecular
genetic finding specific for this group.
There is no Philadelphia chromosome,
BCRABL 1fusion gene , or rearrangement
cases with a mutation of JAK2 as a sole
genetic abnormal ity do not meet the criteria for a specific MPN or any other speci fic disease ca tegory, and are thus best
ca tego rized as MPN, U.
Postulated ce ll of origin
Haematop oietic stem ce ll.
Prognosis and predi ctiv e factors
In patients with the initial stages of an
MPN that is urctassmabie. follow-up studies performed at intervals of 4-6 mon ths
wilt etten provide sufficient information for
a more precise classification {2216, 2222/.
Such patients in the early stages of disease will have a prognosis similar to those
of the group into which their disease
eventually evolves. Patients with advanced
disease in whom the initial proc ess is no
k>nger recognizable due to 8M fibrosis or
bla stic infiltration wou ld be expected to
have a poor prognosis.

Myeloproliferative neoplasm, unciasSlfiable


Myeloid and lymphoid neoplasms

with eosinophilia and abnormalities of

Myeloproliferative and lymphoid neoplasms
associated with rearrangernenl of PDGFRA.

PDGFRB and FGFA1 constitute three rare

B,J . Bain
D,G Gilli land

H.-P. Horny
JW. Vardiman

specific disease groups, which have

sore sha red features and some that differ. All result from lormalion of a fusion
gene encoding an aberrant tyrosine ki-

nase. Eosinophilia is characteristic but not

invariable. II has been established that, in
the case 01 POGFRA and FGFR t-related
neoplasms. the cell of origin is a mutated
plu ripotent (lymphoid-myeloid) stem cell.

It is possible that this is also true for


neoplasms, but this has

yet to be established.

All three disorders can present as a

chronic myeloproliferatIVeneoplasm (MPN) ,
but the frequency 01 manifestation as a
lymphoid neoplasm varies . The clinical

.'. ..
. '.'

and neen ercoocer features are also influenc ed by the partn er g ene involved . In
the c ase of PDG FRA-related disord ers,
prese ntation is usua lly as c hronic eo sinop hilic le ukae mia (CEl) with promi nent
involve ment of the mast cell linea ge and
sometimes of the neutr oph il lineage. l ess
often , pr esent ation is as ac ute my eloid
leuka emia (AMl ) or precur sor-T lymp hoblastic lymphoma (T-LBL), in both instances
with ac companying eos ino philia , In the
c ase of PDGFRB-related disea se, the features of the MPN are more va riab le but are
often those of c hronic myelomonocytic
leukaemia (CMML) with eosinophil ia, Proliferation of aberrant mast c ells can again
be a feature. Acute tran sformations that
have been d escribed to date have been
myeloid . In the case of FGFR r-reteteo disease, a lymphoma tous presentation is COOlmon, pa rticularly T-18L with accompanying
T~" 3.01


f ig. 3.01 FIP1L 1-PDGFRA-ffllaled etvonic ~leu kaerlia. A PenpheraI blood IilmstIOlWIg Ihree rrlllder*f
degranulated eosinopl'lils. Romanowsky stain. B Trephine biopsy section. Abundanl eosinophils and eosI'q)lli
precursors, Giemsa stain. C Trephine biopsy S&ClIOO. Abundalll mast cells. many of wI\it:tI are spindle-shaped,
Iormingsmalloose dosleB, Masteel tryp\lIS8 staining, 0 Trephinebiopsy section. CD25expression in tilemast CIk

eosinophilia, Other patients have had CEL,

precursor-B lym phoblastic leuka emia /
lymp homa or AML.
The importance of recog nizing these di so rde rs is that the aberrant tyro sine
kinase activity can make the d isea se
responsive to tyrosine kinase inhibitors,
This hope ha s already been reali zed for
MPN with rearrangemen t of PDGFRA o r
PDGFRB, whic h are resp onsive to imatin ib and some related ty rosine kinase
inhibitors . Similar specific therapy has not
yet been de ve loped for FGFR 1-relale d
disease. Rele va nt c ytogenetic analysis,

Diagnosticctitena of an MPN' wilt1 eoslnophilia associated witt1 FIP1U -PDGFRA.

AmyeloproIlferatMl neoplasm .",111 promnenl eosmoph~ia

molecular genetic analysis or both should

be car ried out in all patients in whom MPN
w ith eosinop hilia is suspected and also
in pat ients presen ting with an acute
leukaemia or lymphoblastic lymphoma
with eosinophilia. Recognition of PDGFRA
related disease usually requires molecular
genetic ana lysis, sinc e the majority of
cases resu lt from a cryptic deletion,
whe reas c ytogenetic anal ysis will reveal
the ca usative abnormal ity in the case of
PDGFRB- and FGFR1-related d isease.

Myeloid and lymphoid

neoplasms with PDGFRA

Presence of a FIPILl-PDGFRA fusion gene'


Patients preserUlg witt1 aculemyekidledaema or tyr1lJhDbIastic ~ with8CJSinOPt*l and

a FIP1L1.f'OGFRA lusion geneare also aSSlgfllld tobs categoIy.
! II appropnate OI)IeaJar.-.alysis is not 1IYIilable.lhisliagnosis slJ:ll*S be suspected ilU1ere is. Pt\-negalrve
MPN lIiIlIh Ihe ~ teahns of chronic eosirq:lhIc leukaemia assooateeI WIfI ~,
marked ~ of 58I0OI YltaJfWI812. eIeYaliort of serum tryplase and incteasecI bone Il'llWI'lM mast llllI!.

The most common MPN assoc iated wll1l

PDGFRA rea rrangement is that asSOCIated with F1PIL l-PDGFRA formed as a
result of a cryptic de letiorl at 4q 121466l
(Table 3.0 1). Presentation is generally as
eEL but can be as AM L, TLBL or bon


Myeloid and lymphoid neoplasms with eosinophilia and abnormalities 01 PDGFRA . PDGFRB Of FGFRI

smcuaneously (14691. Acu te transformation can follow presentation as GEL.Organ

damage occurs as a result of leukaemic
infiltration or the release of cvtokines. en zymes or omer proteins by the eoeropnns
and possibly also by mast cells. The peripheral blood (PB) eosinop hil count is
markedly elevated (in cases reported to
dale it has almost always been ~ 1.5x1rPlL)
atthough it should be noted that. in some
series of patients . investigation was confined to patients with eosinophilia. There is
no Ph chromosome or BCR-ABL 1 fusion
gene. Except when there is transformation
kl acute leukaemia, there are <20% blasts
fl the PB and bone marrow (8M),

roo _ a
The provisional code proposed for the
fourth edition of IGOoO is 996513



~opi . .. . ,

1',...... eEL_


---, --I



b60CIaY Met




Chronic eosinophiliC leukaem ia: chron ic

eosinophilic leukaemia wilh FIPIL1PDGFRA; myeloproliferat ive var iant of
the hypereosinophilic syndrome.

The FIP1Ll PDGFRA syndrome is rare. It
is considerably more common in men
than women; the M:F ratio is - 17:1. Its
peak incidence is bet ween 25 and 55
years (median age of onset in late 40s)
with reported cases ranging in age from 7
10 77 years 1131).
The cause is unknown, althoug h several
cases have been reported following c ytotoxic chemotherapy 11 625, 2157) and a
case of chronic myeloid leukaemia with a
BCRPDGFRA fusion gene also followed
combination chemotherapy 119061 .
Sites of involvement
GEL associated with FIP1L1-PDGFRA is
a multisystem disorder, The PB and 8 M
are always involved , Tissue infiltration by
eosinophils. and release ot c v tokmes and
humoral factors from the eosinophil granuleslead to tissue damage in a number of
organs, but the heart, lungs , central and
peripheral nervoussystem. skin and gastrointestinal tract are commonly involved .
The spleen is enlarged in the majority of
Cinical features
Patients usually present With fatigue or
pruritus, or with resp iratory. cardiac or




--_.......... @ e



f _ I ...u..tI.1(11 nut




idiopathic HES

Fig. 3.02 Flow diagram showing the diagnostic process in hypereosinophilia, e EL, chronic eosinophilic leukaem ia
The definitivediagnosis is shown within blue circles/ovals,

gastrointestinal symptoms 1466 , 139 1,

2309 1. The majortty of p atients have
splenomegaly, and a minority have hepatomegaly. The most serious cl inical findings
relate to endomyocardial fibrosis, with ensuing restrictive cardiomyopathy. Scarring
of the mitral/tricu spid valves leads to
valvular regurgitation and formation of in
tracardtac thrombi, which mav emtonze.
Venous thromboembolism and arteria l
thromboses are also observed . PulrTl()l1ary
disease is restrictive and related to fibrosis; symptoms inc lude dyspnoea and
cough; there may also be an obstructive
element. Serum tryptase is increased
(> 12 ng/mJ). usually to a lesser extent
than in mast cell disease but with some
overlap. levels of serum vitamin B12 are

markedly elevated (2309). FIP1L 1-PDGFRAassociated GEL is very responsive to imatinib , the gene prod uct being 100-fold
more sensitive than BCR-ABl 1 1466J.
The most striking feature in the PB is
eosinophilia. the eosinophils being mainly
mature with only small numbers of eosinophil mveiocvtes or promyelocytes . There
may be a range 01 eosinophil abnormalities,
inclUding sparse granulation with clear
areas " cytoplasm, cytop4asmc vacuolation,
smalle r than norm al granules , immature
granules that are purplish on a
Romanowsky stain . nuclear hypersegmentat ion or hyposegmentation and
increased eos inophil size 1466, 23091.

Myeloid and lymphoid neoplasms associated with POOFRA rearrangement


These chanQes may, however, be seen in

cases of reactive as well as 01 neoplastic
eosinophilia 11281 and, in some cases, of
FIPIL I-PDGFRAassociated CEL, the
eosinophil morphology is c lose to normal.
Only a minority of patients have any
increase in peripheral blast cells 123091.
Neutrophils may be increased. while basophil and monocyte counts are usually
normal 118541. Anaemia and thrombocytopenia are sometimes present. Any tssue may show eosinophilic infiltration. and
Charcot-leyden crystals may be present.
The 8M is hypercellular with ma rkedly
inc reased eosooprars and precursors. In
most cases . eosinophil maturation is orderly, without a d isproportionate inc rease
in blasts. but in a minority the percentage
of blast cell s is increased. There may be
necrosis and Charoot-leyden crystals. particularly in those cases where the disease
is becoming more acute 14661. Bone marrem mast cells are often but not always increased on trephine biopsy 11163. 1688}
and mas t cell proliferation should be rec ognized as a feature of FIP1L 1-PDGFRAassociated MPN. The mast cells may be
sca ttered Of in loose noo-cot1esive clusters
orin cohesive clus ters {1163. 16881. Many
cases have a marked increase in C025+
spindle-shaped atypical mas t cells , and in
occasional c ases morpho logical features
are indistinguishable from those of systemic
mastocytosis. Aeticulin is increased 111631.
Patients presenting with AMl or T-l Bl
have had coexisting eosinophilia (PB counts
1 4- 172x 109/l ) and in the majority of
cases ore-extsunq eosino p hilia was also
documented (1469 1.
Cyt ochemi stry
Cytochemical stains are not essen tial for
diag nosis. The reduced g ranule conten t
of eosinophils can lead to reduced pe roxidase con ten t and inaccurate automa ted eosino phi l counts.
Immunoph enotype
Eosmcptuls may show immunophenotypic
evidence of ac tivation such as expression
of C023, C025 and C069 11163}. The
ma st cells in this syndrome are usually
11162} but
some times are C02-negative C025
negative 114691 and occasionally C02
positive C025-poSitive 11469J. In conpanson , the mast cells 01 systemic mastocytosis are almost always C025-positive
and are C02-positive in about two thirds
of cases.



Fig. ] .03 Myeloid neoplasm with eosinophilia associated WIlt! PDGFRB rearrangement Penpheral blood lWn d
a palienl 'MIh 1(5;12) showing numerous abnoImaleosiIlOphis; eosmphis were 40% cIleukoc)1eS.
Usually cytogenetic ana lysis is normal,
with the FIPIL I-PDGFRA fusion gene
resu lting from a cryptic del(4)(q12).
Occasionally there is a chromosomal
rearrangement with a 4q12 breakpoint
such as t(1:4Xq44:q12) 14661 or 1(4;10)
(q12;p1 1) /21631. In other patients there
is an unrelated cytogenetic abnormality.
e.g. trisomy 8, which is likely to represent
disease evolution. The fusion gene can
be detected by AT-PCA, nested ATPeR
often being required 14661 The causative
deletion can also be detected by fluorescence in situ hybridization (FISH) analysis,
often using a probe lor the CHIC2 gene.
which is uniformly deleted , or using a
b reak -apa rt probe that encompasses
FlP tL 1 and PDGFRA. Since the maiontv of
patients do not have an increase of blast
cells or any abnor mality on conventional
cytogenetic analysis, it is usually the detection of the F/P 1LI -PDGFRA fusion gene
that per mits the definitive d iag nosis of a
myeloid neop lasm . Cytoge netic ab no rma lities ap pear to be more com mon when
evolut ion to AML has occurred (1469 1
Postulated cell of origin
The c ell of origi n appe ars to be a p luripotent haemopoietic stem cell able to give
rise to eosmophtts and in some pa tients
neutrophils. rronocytes, mast cells. T cells
and B cells {18541 . The detection 01 the
fusion gene in a lineage does not necessarily correla te with morphological evidence 01 involvement 0 1 that lineage .
lymphocytosis. for example . is not usual,
even in those with apparent involvement
of the B or the T lineage 118541. In
chronic phase disease, involvement is
predominantly of eosinophils and to a
lesser extent mast cells and neutrophils.
Acute phase disease may be myelOid or
T lymphoblastic 11469}.

Prognosis and pred ictive teeters

Since FIPtL 1-PDGFRA-assoc iated GEL
and its imatinib responsiveness were
recognized lor the first lime only in 2003
14661. the Iong-Ierm prognosis is not yet
known . However. prognosis appears
favourable if cardiac damage has not
already occurred and imatinib treanre
is available. lmatinib resistance can develop, e.g . as a result of a T6741 mutation
(which is equivalent to the T3 151mutation
that can occur in the BCR-ABL 1 gene)
1466. 844} . Alternative tyrosine kinase
inhibitors such as PKG412 and sorafenib
may be effective in these patients 1468.
1297. 2 103}. Patients presenting as AMl
or T lymphoblastic lymphoma can achieve
sustained complete molecular remission
with imatinib 114691.
A number of possible mo lecula r variants
of F/P1L 1-PDGFRA-associated GEL have
been recognized in wh ich there are
other fusion genes inco rpo rating part of
PDGFRA. A ma le patient with imatinibresp onsive CEL was found to have a
K /F5B-PDGFRA fus ion gene assoc iated
with a com p lex ch romosomal abno rmality
invol ving chromosomes 3. 4 and 10
119 79 1. and a female patient had a
CDK5RAP2-PDGFRA fusion gene associated with ins(9:4)( q33:q 12Q25) 123541. A
male patient with t(2;4)(p24:q 12) and a
STRN-PDGFRA fusion gene 14971 and
ano ther with t(4; 12)(q2?3;p1?2) and an
ETV6-PDGFRA fusion gene, both with the
haematological features of CEL responded
10 low-dose imatinib 14971.
Patients with t(4 :22)(q12;q1 1) and a
BCR-PDGFRA fusion gene, four cases
which have been described, have deease characteristic s intermediate betweer.
those of FIPIL 7-PDGFRA-associaled
eosinophilic leukaemia and those
BCR-ABL t-poseve chrcnic myeIogenec:l.lS

Myeloid and Iymphotd neoplasms With eosinophilia and etoomannes of PDGFRA. PDGFRB 0' FGFR 7






leukaemia; eosinophilia mayor may not

be prominen t 1162 , 765, 1906, 22661. Accelerated phase 11621 and T 11 621 and B
lymphoblastic transformation 122661 have
been report ed . The condi tion is imatinibsensitive 11906, 2266/ .

Myeloid neoplasms with

PDGFRB roanangement

Table 3 02 Diagnostc criteria of MPNaSsoclated witll ETV5-POGFRB tusioo gene oroItIer rearrangement of PDGFRB
fn:I ecreeres witt1 ~ orflUlX)'tlsis
f'ntsence of 1(5:12)(q31""Q33;pt2)or a variant translocatiOn' or,demonstrabor1 of an ETV6-PDGFRB fusion
gene or of reBlfBngememof PDGFRB
A~~ , often -MIl ~eosilqlhIa

, Because t(5;ll)(q3t""Q33;p12) does IIOl always INd 10 an ETV6-PDGFRB fusion gene, rnoIei::uIM conlirmation
is ~ (lesjrable If I'lJClIe(Uar ana/ySiS is not avaiable. Ihis dtagnosJs sho\j:j be suspected if there IS a f'Il.
negative MPN asscrialed wi1tI eosirqIhiIiIlnd witha ~sIocaborl Wllh I 5q31-33 brealqloint.

Table 3 03 f.Aljecu1ar variants of MPN associated WIth ETVU'DGFRB Modified from It31)
FUIlon V&I1t

A distinctive type of myeloid neoplasm
occurs in association with rearrangement
~ PCXiFRBat 5q31-33 (Table 3 .02) . UsuaIy there is t(5 ; 12XQ31 - 33 ;p 12) with formalion of an ETV6-PDGFRB fusion gene
1812. 11341. In l/OCOITITlOfl variants. other
"ansIocations with a 5q31-33 breakpoint
lead to the formation of other fusion genes,
incorporating part of PrX;FRB (Table
3.03). In cases with t(5 ;12) . and in the
variant rransiocatcne. there is synthesis
~ an aber rant, consti tutively activated ty!OSine kinase. The haematological features
are most often those of CM ML (usually
With eosinophilia) but some patients have
been charac terized as atypical ch ronic
myeloid leukaemias (aC ML) (usually with
eosinophilia), CEL and MPN w ith eosinophilia 1131. 20851; Single cases have
been reported of AML. probably superimposed on ch ronic idiopathic my elofibrosis
12245). and of juve nile my elomon oc ytic
eukaemia 115 13J, the latter associated
/jith a variant fusion gene . Eosino philia is
usual but not inva riab le 12085 1 Acute
sensiorrnaton ca n occur, ofte n in a relatively short period of tim e . MPN with
PDGFRB rearra ng eme nt is sensi tive to
tyrosine kinase inhibitors such as imatinib





d8r(1lll1 ;5)(p34:q33).
der(11 )ils(11;5Xp12:ql5q33)












l(5:7)(q33;q1t .2)

CMML WIth eosirloptlia



aCMLWllh eosinoph6a, MPD with eosinophN






Pl'H'lega1ive CML (13% eoV1ophils)



CMML wrlh eosinophilia



Ph-negabveCML with prominent eosinoptlIa




t(5:17)(q33:pt 3)



t(5;17}(q33: pl1.2)



aCML. alypical chronicmyeloidl6ukaemia; CEl , chrooic eosinophilk:leukaemia: CML, chronic myeloid

leukaemia: CMML, chronic myelornonotybc leukaemia: JMML, juvenile myelomonocytiC leukaemia: MPOIMOS,
myeloproliferativeJmyeioctysplastic syndrome: MPN, myeloproliferative lleOpIasm.

ICD-O code
The provisional code pro posed for the
foorth editio n of ICO- O is 996613.

Chronic mvetomonocvnc leukaemia with
!IOSinophilia associated with t(5 ;12) .


T!'IIS neoplasm is considerab ly more com~

in men (M :F.,2:1) an d has a wide

age range (8-72 yea rs) with the p eak

rcoerce being in mi ddle-aged ad ults;

reoen age of onset is in the late 405



Fig. 3.04 Myeloid neoplasm wI\tI ~ associa1ed wilh PDGFRB ~ Trephine biopsy sedion In:lm
a pa\llll'It WIth 1(5;12) showing a mar1o.ed increase in eosWlclphiII.
Myeloid and lymphoid neoplasms associated

W Ith

PDGFRB rearrangement


Sites of involvem ent

MPN associated with t(5; 12Xq31-33;p12)
is a mul tisys tem disorder, The PB and BM
are always involved, The spleen is enlarged in the majo rity of pa tients. Tissue
infiltration by eosmoctats and release of
cvtounes. humoral factors or granule
contents by eosinophils can contribute to
tissue damage in a number of organs.
Clinical features
Patients often have splenomegaly, with
hepatomegaly being present in a minority.
Some patients ha ....e skin infiltration and
some have cardiac damage lead ing to
cardiac failure . Serum tryptase may be
mildly or moderately elevated The great
ma;ority 01 patients who have been
treated with erenmo have been found to
be responsive.

The white cell count is increased . There
may be anaemia and thrombocytopenia
There is a ....anabre increase of neutrophils . eosooonne. rrooocvtes and eosinophil and neutrophil precursors. Rare ly.
there is a marked increase in basophils
{23551. The 8M is hype rcellu lar as a result
of active granulopoiesis (neutrophilic and
eosinophilic). Bone marrow trephine b iopsy
may show, in ad d ition , an increase 0 1 mast
cells and these may be spindle-shaped
1503,23551. Bo ne mar row reticulin may
be inc reased 123551. In c hro nic p hase
di sease, the blast cell co unt is less than
20% in the PB and 8 M.
The eos inop hils, neut rophile a nd mono c ytes show the expecte d c ytoc hem ical
reacti ons for ce lls of these lineages,
Immunoph enotype
Immunop henotypic analysis of the mast
cells has show n exp ression of C02 and
C025, as is also obse rved in the majori ty
of cases of ma st cell disease [23551.

Geneti c s
Cytog enetic analysis usually shows t(5;12)
(q 31-33 ;p 12 ) with the translocation
result ing in formatio n of an ETV6-PDGFRB
fusion gen e {8 12/ (p re viously known as
TEL-PDG FRB), In one patient ETV6
PDG FRB resulted from a four-way translocation, t( 1; 12;5 ; 12 )(p 36 ;p 13;q33;q24)
{489J, and in anomer occurred in
association with ins(2 ; 12)(p21;q?13q?22)
15121. The 5q breakpoint is sometimes
assigned to 5q3 1 and sometimes to
5q33, although the gene map loc us of
PDGFRBgene is 5q3132.
Not all translocations characterized as
t(5 ;12)(q31 ;p13) lead to ETV6-PDGFRB
fusion . Cases without a fusion gene are
not assigned to this category of MPN and.
importantly. are not likely to respond to
imatinib; in such cases an alternative
Ieukaemogenic mechan ism is upregulation
of mterleukin 3 (IL3) 146 71. AT-PeA. using
primers suitable for all known breakpoints, is therefo re rec om me nd ed to
confirm ETV6PDGFRB {498 / but if
molecular analysis is not available a Irial
of imatinib is justi fied in patients with an
MPN assoc iated with 1(5; 12).

A number of molecular variants of MPN
with ETV6-PDGFRB fusion have been
reported 1131, 20851. In addition, a patie!t
who acquired eosinophilia at relapse (j
AML was found to have acquired 1(5:14
(q33;q22) with a TRIPl1-PDGFRBf
gene. A number of other patients ha",
rearrangement of PDGFRB but With
second gene involved being unl<.novo1l.
Complex rearrangements appear to be
common (e .g. a small inversion as~.
translocation) 120851. Because of the
apeutic impl ication s, FISH (break~
FISH with a PDGFRB probe) is indicaled
in all patients with a presunptive
of MPN who have a 5q31-33 break
particularly. but not only. if there ,
eosinophilia. However, FISH analysis
not always demonstrate rearrangemercd
PDGFRB, even when it is detectable
Southern Blot analysis 120851. MoIect.iJ
analysis is not indicated if there is
5q31-33 breakpoint on classical
genetic analysis since all cases re
to date have had a cytogenetically delectable abnormality.

Postulated cel l of origin

The cell of origin appea rs to be a multipo tent baemocorenc stem cell , which is
able to give rise to neutrophils, monocytes.
eosinophils and probably mast cells,

Myeloid and lymphoid

neoplasms with FGFRI

Progn osis and predi c tive factors

Pre- imatinib, the med ian survival was less
than 2 yea rs, Ther e are not yet re liab le
data on surviva l of imatini b-treated
pat ients, but in a small series (10 patients)
the med ian surviva l was 65 mont hs 15121 .
Med ian survival is likely to im prove as
patients are recog nized and sta rted on
approp riate treatment at d iag nosis rather
than when c ardi ac d ama ge or transformati on has alread y occurred

Table 3.04 Diagnosbc 0'Itetia of MPNor actIIe leuk.aerria associated withFGFRf rearrangement
A myeIoproIlleralive neoplasm lMlh promIfIent eosmpI1E and sometines withneutrophilia or rTW:IAClC)'Iosi


Acute myebd leukaemia or preanor T<eIIor preanor EkeII tymphoblasliC ~ {~

associated with periphetaI blood or bone JTIilITlI'W eosonophIia)

Preseoce r:A .8;13)(P11;q12) or. v;nnl\Jallsb..aboil!eadlng kl FGFRf~ delrorkStJaIed in
ITI)'8Ioid eels, ~sts or boItl


Haematoroqrce! neo plasms with FGFRJ
rea rrangemen t are hetero geneous.They
are de rived from a pluripote nt baemaio
poietic stem ce ll, altho ug h in differet'l
patients or at d ifferent stages of the disease
the neop lastic ce lls may be precursa
cells or mature ce lls. Presentation call be
as an MPN or, in tra nsfor mation, as AML
T or 8 lineage lymphoblastic lympt'loo'lQl
leukaemia or mi xed p heno type acute
leukaemia (MPAL) (Tabl e 3.04).
ICD-O code
The provisional code proposed fOf tl"E
fourth enuon of ICO-o is 996713.

8p 11 myeloproliferative syndrome, 8p11
stem cell syndrome, 8p1 1 stem eel
leukaemiallymphoma syndrome.

This neoplasm occurs across a wide age
range (3-84 years) but most patients are
young . with a median age of onset iJi

Myeloid and lymphoid neoplasms With eosooobne and abnormalities 01 PDGFRA. PDGFRB Of FGFRI

aroun d 32 yea rs {1354 1. In contrast 10

MPN with rearrangemen t of POGFRA and
PDGFRB, there is only a moderate male
predominance ( 1.5:1)

Sites of involvement
Tissues primarily involved are 8M , PB,
lymph nodes, liver and spl een. lymphadenopathy is the result of infiltration
byeither Iymphoblasts or myeloid c ells.
Clinical features
Some patients present as lymphoma with
mainly lymph node involvement . while
others present with myeloproliferative
leatures. such as splenomegaly and
hypermetabolism. and yet others wilh
features of AML or myeloid sarcoma 13.
1006. 13541. Systemic symptoms such as
fever. weight loss and night sweats are
otten present 11311.

Presen tation may be as CEL, AML,
T-LBL or. least often. precursor B lymphoblastic leukaemiallymphoma . Cases 01
acute leukaemia/lymphoblastic lymphoma
may be of mixed phenotype . In patients
who present with CEL. there may be subsequent transformation to AML (including
myeloid sarcoma), T or B lineage lymphoblastic leukaemiall ymphoma or MPAL.
Lymphoblastic lymphoma ap pea rs to be
rrore common in patients with t(8;13) than
in those with variant transiocatons 113541.
Patients who present in chronic phase
usually have eosinophil ia and neutrophilia
and, occasionally. mono cyto sis. Those
who present in tran sformation are often
also found to have eosinop hilia, Ove rall,
about 90% of pat ients have PB Or BM
eosinophilia (1354). The eosinophils belong to the neop lastic clone, as do the

Iymphoblasts and myeloblasts in cases in

transformation. Basoph ilia is not usual but
patients with BCR-FGFR1 fusion may
have basophilia {18791. An association with
polycythaemia vera has been observed in
three patients with t(6;8)1FGFRIOP I-FGFRI
fusion 11770, 23401 .
T precursor lymphoblastrc lymphoma
charact eristically shows eosinophilic
infiltration within the lymphoma.
Cases should be classified as leukaemia!
lymphoma assoc iated with FGFR1
rearrangement, followed by further details
of the specific p esenatco. e.g. "~
lymphoma assoc iated with FGFRI
rearrangement/chronic eosilophilic IelJ<ae.
mia, T precursor IyrrVlobIastic lymphoma.
or "leukaemia/lymphcma associated with
FGFRI rearrangemenl/myeloid sarcoma".

Neutrop hil alkaline phosphatase score is
often low, but cytochemistry is not important in the diag nosis.
Immuno phenolypic analysis is not useful
in chronic phase disease, but is importa nt
to demonstrate the T or B lineage 01
precursor Been or pr ec ursor
leukaemiallym phoma.


A var iety of transloca tions with an 8p 1 t
breakpoint ca n underli e this syndrome,
Secondary cytogene tic abn ormalities
occu r, among wh ich trisomy 2 1 is most
often obser ved. Dependi ng on the partner
chromoso me, a variety of fusion gene s
inco rpo rating part of FGFR1 are formed .
All fusion genes encode an abe rrant tyrosine kinase (Tab le 3,05)

Table 3.05 Chromosomal rearrangements and fusion

genes reported in MPN associated wiltl FGFRt
rearrangemenl. Modrtied from (1311.




1(8; 13)(pl l;q12)


t(8:9Kp11 ;q33)






(l' .8l(q34:pl1 )










tI adclillon, FGFRJ fl!IilfTiIl'iQt!ilelt has been ku1d II

iISSfJciaIio'. will ~: 12l(p11;q151aocl.8:17XP1l;q25)
but h suspected IwoIYement d FGFRt 1I1(8:tl )
(p11,pt5) wasnot confrmed.
I rvrtln ~ tern MaI::OoniIId iIl"Il Cross (1354).

Postulated cell of orig in

The cell of origin is a pluripotent tymphoidmyeloid naema topoietlc stem cell.
Prognosis and pred ictive factors
The prognosis is currently poor. There is
no estab lished tyrosin e kinase inhibitor
therapy for MPN with FGFRI rearrangement. althou gh PKC 142 was effect ive in
one case 14001. Interferon has induce d a
cytogene tic response in several pa tients
11354. 14021. Until specific therapy is
develop ed. haematopoietic stem cell
tran splantation should be considered .
even in those who present in chron ic

Myeloid and lymphoid neoplasms associated WIth FGFRI abnormalities



Chronic mye lomonocytic leukaemia
Atypical chronic myeloid leukaemia. BCR-ABL 1 negative
Jwenile myelomonocytic leukaemia
Myelodysplasticlmyeloproliferative neoplasm. unclassifiable

Chronic myelomonocytic leukaemia

A. Orazi
J. M. Bennett
U. Germi ng
A.D. Brunning
B.J. Bam
J . Thiele

CIvLric~ IeU<aenia (CMML)
is a clonal baematopoletrc mal ignancy
that is characterized by features of both a
myeloproliferative neoplasm and a mye lodysplastic syndrome. It is characterized
by : 1) persistent monocytosis >1x 1()9/L in
the peripheral blood (PBl; 2) absence of
a Philadelphia (Ph) ch romosome and
BCR-ABL 1 fusion gene; 3) no rearrangement of POGFRA or PDGFRB (should be
specifically exclude d in cases with
eosinophilia); 4) lewer than 20% blasts

(promonocyles are considered as blast

equivalents) in the PB and bone marrow
(8M) ; and 5) dysplasia involvi ng one or
more myel oid lineages. Howe ver, II c onvinc ing myelodysplasia is not pre sent, the
diagnosis of CMML can still be mad e if
the other requ irements are mel, and an
acqu ired. clonal cytog ene tic or molecular
genetiC abnormality is present in the 8M
cells . or if the monocytosis has per sisted
for at least 3 mon ths and all other c auses
of monocytosis. such as the presenc e of
malignancy, infection or inflammation,
have been excluded, CMML is further
subdivided into two subsets. CMML 1
and CMML2 , depending on the number
of blasts plus promonocytes in the PB and
BM. The clinical, haematological and morphological features of CMML are heterog eneou s, and vary along a spec trum from
predom inantly myelodys plastic to ma inly
myeloproliferative in nature. In contrast with
the BCRABL 1negative myeloproliferative



No ~ cf1romosomeor BCR-A8L11usion gene


No rearrangement of POOFRA or POGFRB (sllouldbe spealicaRy e~duded 11 cases Wlth eosinophial

Fewer than 20% blasts" in the blood al'(j in ee bone marrow


Dysplasia In oneor more myeloid lineages. If myelodys~asia is absent or minimal. the diagnosis of CMM,.
may stil l be made iflhe other requirements aremet. and'
anacquired, ctooa l cylogenelic or moleculargenetic abnoonality is present in thehaemopoietic cells. r:r
the monocytosis hasp&rSisted forat east 3 months and
aijother causes 0( monocytosis have been e~duded

Blasts irl<:IWe myeloblasts. monobIasts and prornotlOC)'le5. Promonocytes owe monocytic precursors WI1Il
ab\.IIdallt light grey or sIif1Iliy besophilic cytoplasmwitha lew scattered. h liIac-<::oIoIJ-ed p1UIes. finelydislrtluled. sWied nudear etwomabn. variably prominent nudeoIi. WId delicale nud8arloIding oroeasilg. rd
in tIIisdassilicaliorl are equivalenl lO~. AbnormaIITIClI'IOCy1eS wnen can be present baCh ti the ~
blood and bone marrow are excluded from lhe blastCCUIIl

neoplasms. JAK2 V617F mutation is uoccmmon in CMML 11058. 20821



There are no reliab le inc id enc e data for
CMML. because in some epidemiolog ica l
surveys CMML is grouped with chronic
myeloid rewaemras and in others is
rega rded as a myeioovsptasnc syndrome
(M OS) \108] In one stud y in which CMML
accounted for 31% of the cases of MOS.
the incidence of MOS was estimated to
be approximately 12,8 cases per 100 ()(X)
pe rsons per year (2414). The median age

Myelodysplastic/myeloproliferative neoplasms

at dia gnosis is 65--75 years. with a male

predominance of 1.5-3:1 148. 683. 777
The etiology of CMML is unknown. 0CCupenona t and environmental carcinogens
and ionizi ng irradi ation are possible
causes in some cases 1108. 20261 .
Sites of involvement
The PB and BM are always involved. The
spleen. liver. skin and lymp h nodes arethe
most common sites of extramedu llary
leukaemic infiltration 148. 683, 777).

Clinical features
Inthe majority of patients, the white blood
cell (WBC) count is increased at the time
of diagnosis. and the disease appears as
an atypical myeloproliferative neoplasm.
Inother patients, however, the WBC is normal or slightly decreased with variable
neutropenia and the di sease resembles
MOS. The incidence of the most common
presenting comp laints of fatigu e, weight
css. fever and night sweats is similar in
re two groups 01pa tients. as is the rate of
otectooand of b leed ing due to thrombocytopenia 148, 683 , 777, 2047 , 2 1021. AI
ilough splenomegaly and hepatomegaly
rn'irf be present in either gr oup, they are
more frequent (up to 50%) in patients with
leukocytosis 177n

Morp/loklgy and cytochemistry

Peripheral blood monocytosis is the hall mark of CMML. By definitIOn, monocytes
are always >lxl Q91l and usually range

from 2 to 5 x10~/L, b ut may excee d

8Ox 1()91l [48. 683, 1396, 14711. Monoc ytes
are almost always > 10% of leukoc ytes
\ 189.20031 . The monocytes generally are
mature. with unremarka ble mo rphology.
bu t can exhibit abnormal granulation, or
unusual nuclear lobation or chrom atin
pattern 111851. The tatter cells are best
termed abnormal monocvtes -a designation used to describe rronocvtes that
are immature, bu t. in com parison to
promonocytes (and monoblasts). have
denser chromatin, nuclear c onvolu tions
and folds, and a more gre yish cytoplasm ,
Blasts and promonocytes may also be
seen , bu t if the sum of blast s plus the
promonocytes is 20% or more , the d iagnosis is AML rather than CMML. Other
changes in the PB are variable . The
may be normal or slightly decreased . with
neutropenia, but in nearly one half of
patients it is inc reased due not only to
monocytosis bu t also to neu troph ilia


(777, 1396. 164 51 . Neutrophil precu rsors

(promyelocytes, myelocytes) usually account for < 10% of the leukocytes 1189,
2003 1. Dysgranulopoiesis. including neutrophils with hypolobated or abnormally
lobated nuclei or abnormal cytoplasmic
granulation . is present in mos t cases , but
may be less prominent in patients with
leukocytosis than those with a normal or
low wac 1'185, 13961. It may be difficult
in some c ases to distingu ish between
hypogranular neutroph ils and dysp lastic
moooc vtes. Mild basophilia is sometimes
present. Eosinophils are usually normal or
slightly inc reased in number, but in some
cases eosinophilia may be striking. CMML
with eosinophilia may be diagnosed when
the criteria lor CMML are present. but in
addition the eosinophil count in the PB is
2: 1.5xlQ1JIl. Patients in this category ma y
hav e complication s related to the
degranu lation 01 the eosinophils. These
"hypereosinophilic " cases of CMML may

f1. U 2 Chn:nc myeIomonocytic IeukaenU-l. The degree of ~s, neutrr.optMia and dysploIsia is YiWiabIe .. CUt.4L. A The ..... bIoocI eel Cl:Ullis eIINaIed wiIh rnirImaI

in !he ~ series. B A noonaI wtJIe bIoocI eel axn WIth absokJte monocytOSis. ~ and dysgrarUopoiesls. C A bone marrow biopsy splDnen Inlm a
CJM..1. Oftsn, " grarUoqIlc WI.-u"" ~ is mosl obYil::lIJs lin se biopsy ~, iW'llI monocyI8S may nol be rNliIy appreoaIed. D The tllded ru:IeIlnl dek:aIe
.... c:t'ttInRn em..... iiIic fA monocyI8S CM be appreciated IIIIO'IQ 1he~.
..,.. .

Chrorllc myelornooocylic Ieuka8ffila


closely resemble cases of myeloid neoplasms with eo sinophilia associated with

specific cytogenetiC/mol ec ular genetic
abnormalities involving POGFRA or
PDGFRB genes. for which suc h c ases
should always be exam ined . These d isorder s are con sidered sep arately from
CMML. Mi ld anaemia . etten nor mocytic
but som etimes mac rocytic. is c ommo n.
Platelet counts vary, but moderate thrombi>
c yto pen ia is often pre sent. Atypical , large
platelets may be ob served 148. 13961
The BM is hyperc e llular in ove r 75% of
cases. bu t rorrrcc enorer and even hypoc ellula r sp ecimen s also occur (1471,
21021. Granu loc ytic prol iferation is often
the mos t striking find ing in the BM biop sy
but an increa se in erythroid pr ecursor s
may be seen as well (189. 14711. M0nocyt ic proliferation is invariably present. but
can be d ifficu lt to appreciate in the biopsy
or on 8M aspirate smears. Cytochem ica l
and immunohistOChemicalstudies that aid
in the identificatiOn of mcoocvtes and their
less mature term s a re strong ly recommended when the d iagn os is of CMML is
suspected 121701 Dysqranulcpoiests.
similar 10 that found in the blood. is present in the 8M of most panent s with CMML.
and ovsevmroooesrs (e.g. megaloblastic
changes, abnormal nuclear contours. ring
srderoblasts) is observed in over one ha lf
of patients 177 7, 1396 , 147 11 . Micromegakaryocytes and/or meqekervccytes
with abnormally lobated nuclei are found
in up to 80% of patients [1396. 1471 1.

A mild to moderate increase in the amount

of reticulin fibres is seen in the 8M of
nearly 30% of patients with CMM L 114061.
Nodules c omposed of mature p lasma cytoid de ndritic c e lls (plas mac yto id
monocytes) in the BM b iopsy have been
reported in 20% of cases 116491. These
cells have round nuc lei. finely d ispers ed
chromatin, inconspicuous nuc leoli and a
rim of eos inop hilic cytop lasm. The cytop lasm ic membrane is usua lly d istinc t.
with we ll-defined cyto plas mic borders.
This imparts a c ohe sive ap pearanc e to
the infilt ratin g c ells. Apoptonc bodies.
often within star ry sky testrocvtes. are
frequently pre sent. The rela tionship of the
plasmacytoid dendritic cell proliferation 10
the leuka emic ce lls has been consider ed
uncertain 1120, 655 , 895 , 9671. A recent
study. however. has show n that they are
c lon al. neo pl astic in nat ure , and closely
related to the associated myeloid neoplasm 123351.
The splenic enlargement in CMML is
usua lly due 10 infiltration of the red pu lp
by leukaemic cells. Lym phadeno pa thy is
uncommon, bu t when it occurs. it may
signal transfor mation to a more acut e
phase. and the lym ph node may show
d iffuse infiltration b y mye loid blasts.
Sometimes, there is lymph node and (les s
commonly) sp len ic involveme nt by a
diffuse infiltration of plasmacytoid dendriti c
cells. In some patients generalized lymphadenopathy due to tumou ral prol iferations
of plasmacytoid dendritic ce lls may be

the presenting manifesta tion of CMML

Blast cells plus oromonocvtes usually
account for fewer than 5% of the periphera;
b lood leukocytes and fewer than 10% ci
the nucleated BM cells at the time of
d iagn os is. A higher number of blasts
(p lus promonocytes) than this may ident4y
pat ients who have a poor prog nosis or a
greater risk of rap id tran sformation to
acut e leukaemia {48. 682, 683. 833. 2102.
2 170. 24431. Thus. it is recommelldecl
that CMML be furt her d ivided into two
subcategories. dependil"lQ on the runt:lEJ
of blasts (plus promonocytes) found i'l
PS and 8M . as follows :

Blasts (including promonocytes) <5% r:
ee PS , <10% in the BM ;
Blasts (incl uding promonocytes) 5-1 9\
in the PB or 10- 19% in the 8M . ex I'tte1
Auer rod s are present irrespective of the
b last p lus p romonocyte cou nt.
The value of this approach has been recently con firmed 17801.
Cytoc hemic al or immunop henotypic studies are strongly recommended whenever
the d iagnosis of CMML is c onsidered
When performed on P8 and 8M aspirate
smears. alpha naphthyl acetate esterase
or alpha naphthyl butyrate esterase, used
alone or in combination with naphtt'dASD-chloroacetate esterase (cbioroacetae

A;. 4.03 Chronic myelomonocytlc teokaemia-2. A Blood smear from a newly ~ patient. 0C:casi0naI bl9:sls W8f1l noled.,!he perVleIaI blood smear. B Bilpsy~ ..

same palJefW. The Im\aIJ.ny of !he ba1e fllamlW BIemenIs c:ar1 be rea:iIy appreciated. C BIasts.-.d pI'Ofl'IOf'IOC) ICCOU'IC lor 12".110 of !he I'fllIm)fr eels (~ ~

Myelodysplasticlmyeloproliferative neoplasms

esterase, CAE) is extremely useful to assess the monocytic component.

The PB and BM cells usually exp ress the
expected myelomo noc ytic antigens, suc h
asCD33 and C013, with variable exp ression of C01 4, C068 and C064 1243,
1377, 24421. The PB and BM monocytes
often express aberrant phenotypes with
:...oar more aberrant features by flow cvtometric analysis. Some, such as decreased
expression of C0 14 , may reflect relative
rronocyte immaturlty_ Other aberrant
characteristic s include overexp resscn of
C056, aberrant expression of C02 or
cecreesec expression of HLA-OA, C0 13,
C015. CD64 or C036. There may be aberrn phenotypic features on maturing granulocytic cells and neutroonas may also
stlCM' aberrant scatter properties . An
percentage of CD34 + cells or
emerging blast population with aberran t
.rrrnunophenotype has been associated
tilth early transfor mation to acute
eukaerma (AML) 1626. 2442 , 24591.
Irrmunohistoc hem istry on tissue sec tions
b the identi fication of monocytic cells is
-etanvelv insensitive as compared with
cytochemistry or flow cytometry. The most
reliable marke rs are CD68R and CD l63
11649J. Lysozyme used in conjunction
with cytoc hemistry for CA E can also faci l~ate the id entifica tion of monocytic cells,
...nich are lysozyme- positive but negative
lor CAE, in contrast with the c renulocytrc
precursor ce lls, wh ich are pos itiv e for
bolh, An increa sed perc entag e of C0 34 +
cells detected by immunohistochemistry
has also been ass oc iated with tran sfo rmation 116491 .
The plasmacytoid d endritic cells associated
\II'ithCMML have a c haracteristic immunopeeootype. They are positive for C 0 123,
CD14, C0 43, C068, C 068R, C 0 4SAA,
C033 (weakly) and CD4. Granzy me B is
also regularly exp resse d. but TIA 1 an d
perforin are not. Variable C056 expression
is seen in a minor ity of the cases, whi le
tceu-assoctateo an tig ens suc h as C02
!'Id CDS can also be present.


F"tg.4.04 Onncmyelomooocylic leukaemia, Some dl9'8801fibrosrsmay beseen in upb3O"1i 01 cases. A,8 These
pl1oklmicrographs 1ustra1e retiaJIin fibnls$ in a mafTllW blopsy specimen 01 a pabefIl WIIt1 CMML.


Fig, U 5 CI.-onic myelornonocytIc leukaemia ANodI.*s COfl'IPOMd 01 pIastr1ac:ybd tter'01tiC eels in the bone R'IiIrrow 01 a patient WIIt1 CMML. B com is posilMIin pIasmaqtid dendriIic eels

mutations of RAS genes at diagnosis or

dunnq the d isease course {1686, 2 118,
24171- The approp riate categorization of
baematoroqrcat neo plasms associated
w ith isolated isochromosome 17q is uncertain at this tim e. Although a p roportio n
01c ases meet the crite ria for CMML, others
may be more ap propriately ca tegorize d
as MDS/MPN , uncrassmabre {708 . 14371Abnormal ities of 11q 23 are unc ommon in
CMML, and instead suggest the diagnosis
01 AML.
Cases of MDS/MPN with eos ino phi lia
associated with t(S;12)(q31 -33;p1 2) and
an ETV6-PDGFRB fusion gene, whic h
were formerly incl uded in the CMML
c atego ry, a re no w co nside red a d isti nct
en tity, Cases resembling C MML may
express the p1 90 BCR-ABL 1 Isotorm and
should be c lassified as ch ronic myelog enous leukaemia (CM L). Thus, if a
t(9 ;22)(q 34 ;q 11) is not detec ted by cytog enetic analysis it is insufficient 10 use
only PeA analysis for the presence of
p 210 to exclude CML.

is 20-40 months {48. 682 , 683. 777 , 779.

833,2047,2102,2170.2443 1_Progression
to A ML occurs in approximately 15-30%
of cases. A num ber of clinical and
haematological pa rameters, includi ng
splenomegaly, seve rity of ana emia and
degree of leukocytosis, have been reported to be important factors in predicting the cou rse 01the di sease . However, in
virtually all studies, the percentage of PB
and BM blas ts is the mos t important factor in de term ining survival j48 , 480 , 682,
683 , 777 , 780, 833, 2047, 2102 , 2170 ,
2443 ).

Cb'lal cytogenetic abnormalities are found
in 20-40% of pat ie nts w ith CMML, but
rme is specific 148, 683 , 684 , 777 ,867,
2102, 2170, 2260 1_ The most frequent re:urng abnormalities include +8. -7/deI(7q)
ind structural abnormalities of 12p. As
many as 40% of patients exhibit point

Postu lated cell of origin

Heerropoeuc stem cell.

Prognosis and predictive factors

Survival of patients with CMML is reported
to vary from one to more than 100 months,
but the median survival time in most series
Chronic myeklmonocytic IeukaerTlla


Atypical chronic myeloid leukaemia,

BCR-ABL 1 negative

Def inition
Atypical chronic myeloid leukaemia.
BCR-ABL 1negative (aCMl) is a leukaemic
disorder with myelodysplastic as well as
myeloproliferative features at the lime of
initial diagnosis. It is characterized by
principal involvement of the neutrophil lineage with leukocytosis resulting from an
increase 01 tnOfphologically dysplastic
neutrophils and their precursors. However,
mullilineage dysplasia is common and
reflects the stem cell origin 01 aCML. The
neoplastic cells do not have a BCRABL 1
fusion gene.
ICD-<l code



Atypical chronic myeloid leukaemia.

Epid emiology
The exact incidence of aCMl is not krlOWn,
but is reported to be only 1- 2 cases for
every 100 cases of BCRABL 1 positive
C ML 1200 31. Patients with aCMl tend to
be elderly. In the few series repo rted to
dat e, the med ian age at di agnosis is the
seve nth or eighth d ec ad e of life bu t th e
d isea se has been reported in teen ag ers
as we t11266 , 928, 1208, 1396,20031 , The
report ed maie.temare ra tio var ies , b ut
based on the larger series reported , is
approximately 1:1 1266 ,928 , 1208,1 3961.
Sites of involvem ent
The pe riph eral blood (PB) and bone ma rrow (BM) are alwa ys invol ved: sp lenic and
hep atic invo lvement are also common.

Table 02 Dl3QOOSoc critenalor at)1Ial dlronic myeloid leuUemIa, BCR-ItBL nega!lYe (acML).
~ t*;lod

Ieukocylosi$ (WBC 2: 13alO'1l) cl.Ie 10IllCtlliIsed runbers 01 neutn;lp/'iIs arKI their

prewrsor5 WIth prominent ~

NoPh dlromosome or BCR-ABI..1 fIlSIOIl gene

NorearrMgBI'IlllI 01 PDGFRA or POGFRB
Neulrophi prectJS(n {pfomyelocyles, myeIocyles,~) ~1 0% 01 leukocytes
hh'naIlIbsokIIe ~ : b9soptlis USUIIy 4"4 0I1IIukocyles

Ncor II'III'IirrIClI absoUe~ ; lMl'lOC)1eS <10'1t oI~

pi" . '

~arbone mafTtM'wiII~
and ~~. W!ltl or wrtloul
dysplasia n h etyflroict and megakaryocyIc Irl9Iges

less than m bIiIsts n fie blood and n h bone rr8lUW

counts in excess 01 3OOx1091l 1266, 928,

1208, 1396 ,20031. Blasts are usually less
than 5% and always less than 20% 0I1eu~
cvtes. Neutrophil precursors (promyelocvtes. rnveiccvtes and metamyelocytes)
usually comprise 10 - 20% or more of the
leu kocyte d ifferent ia l. Although the absolute monocyte count may be increased,
the perc entage of rnonoc yte s ra rely exceeds 10. Baso p hilia may be observed
but is no t prominent 1189 . 266. 928. 1396 .
20031. The ma jor feature that characterizes aC ML is ovsqranctoooese. which is
often pronounc ed , Ac qu ired Pelger-Huat or
othe r nuc lear abn or malities, suc h as abnorm ally clumped nu c lear c hroma t in or
bi zarrely seg me nted nuclei, and abnormal
cytop lasmic granu lar ity m ay be obse rved
in the neutrop hils. Mod erate anaemi a is
frequ ent and the red blood cells may show
c hang es indi ca tive of dysery th ropoiesis,
inc ludi ng macrcovaiocvtosrs. The platelet
cou nt is variab le, b ut thrombocytop enia is

Cl inic al features
There are only a lew reports of the clinical
featu res of pa tien ts with aC ML. Most patients have symptoms related 10 anaemia or
some times 10 thrombocytopenia. whereas in
others the chief complaint is rela ted to

spleromega" 1266. 928 .1206. 1396.20031.

Mor phology and cytochemistry
The white blood cell (WBC) count is
always ~ 13x 1r1fL 11891 but median values
ra ng ing from 24-96x1Ql'1L have been
reported and some patients have WBC

JW, Vardiman
J.M. Bennett
B,J, Bain
R D , Brunning
J , Thiele

MyekldysplasticJrnyeloproliferative neoplasms

common 1189 , 928,1396,20031 .

The BM biopsy is hypercellular due to an
increase 01 neutroph ils and their pecesos
Blasts may be modestly inc reased 111
number, but are always less than 20'%:
large sheets or clusters of blasts are rICK
present. Dysgranulopoiesis is a constant and the changes in the neutroptil
lineage observed in the 8M are similar to
those described for the blood, Megakaryocvtes may be decreased. no rmal or increased in nu mber, but in most cases
some oysmeqakarvopoiesrs is present
including sm all me gaka ryocytes and
mic rorreqakarvocytes and/or megakaryo.
cvtes with hy po lobu laled or non-lobulated
nuclei 1266, 9281. Usually the M:E ratio is
g reater than 10:1, but in some cases ery
th roid p rec ursors ac count for ove r 30% 01
the 8 M ce lls, Dy serythropo iesis is present
in at leas t 50% of c ases 11 89, 266, 9281_
Inc rea sed reticu lin fibres are seen in some
c ases at the time of d iagno sis , or may

- .....

Fog. ' .07 Atypical chrOIlIt myeloid leukaemia. A Bone IT\lIITOIfI'biopsy shows 1Iypetc:eIIWnty. 0Je to~ proMerabon B NcJ(e anncrease "' Ihe l1JITtler of rnegak.afyocytes,
... smal abnonnallorms From the biopsy alone. !he fT'OlIhology wWd be dlfliQjt to tjft'erentlale from BCR-ABl. po5IbYe chronic myelogenous leukaen'ia C Bone marrow
. . smear. Oysplasia in !he ~ and the megakaryo:;ybC lineages is eWlenI.

appear later in the course of the disease.

Most cases reported as the 'syndrome of
a~mal chromatin clumping " can be
considerec:l as a ....ariant of aCML 1276. 680,
10071. These are characterized in the P8
.nt 8 M by a high percentage 01 reuno:tits and precursors that exhibit exagger
eeock.mping of the nuclear chromatin .

'> specific cytochemical abnormality has

been reported 10 date, although stains to
detect a significant rnoncx:ytic component
can be use ful to exclude chronic myelomonocytic leukaemia (C MML) . A nonSPecific este rase react ion performed on
a BM asp irate may identify sign ific antly
more monocytes than are ap prec ia ted by
routine stains. l e ukoc yte alka line phosphatase scores may be low, normal o r

elevated. and thus are not useful for

diagnosis 11208. 13961 .
No speci fic imm unop henotypic c haracteristics have be en reported to date, A s
with cytoc hemistry, immunohistochemical
studies for CD 14 o r CD68R on biopsy
sections may he lp to id entify monocytes:
fnding a significant 8M monocytosis
sllould call the di agn osis of aCML into


Karyotypic abnormalities are reported in
up to 80% 01 patients with aCML. The most
CCfTITlOlI abnormalities are +8and del(2Oq) ,
but abnor malities of chromosomes 13, 14,
17,19 and 12 are corrvnonly repor ted as
'Nell 1266, 928.13961. Rarely, patients whose
neoplastic c ells have an iso lated isochromosome 17q may have features of aC ML
although most will fulfill the cr iter ia for
CMML 11437f.
There is no BCRABL 1 fusion gene.
Cases with rearran gement of PDGFRA or
PQGFRB gen es are also specifica lly
excl ude d. The ac tiva ting JAK2 V617F
mutation has been reported in some c ases
of aCML {1064, 12871. Approx imately 30%
of cases are ass ociated with acquired
mutat ions of NRASor KRAS1 2311 1,
Some c ases of t(8; 9)(p22;p 24 ) with the
PCM1..JAK2 fusio n gene have bee n
reported as "aCML" 1259, 18331 but d ata
cu rrently ava ilable suggest they hav e
eosinophilia and lack mye lody sp lasia and
may be better regarded as chronic eosinoph ilic leukaemia. Meticulous description of
the morpholog y of atypical mye loid proutera tions associated with var ious geneti c
defects will be necessary to assign them
to appropriate ca teg orie s,

Postulated cell of origin

Bone ma rrow haematopoietic stem cell.

Prognosis and predi ctive factors

Patients with aCML fare poorly, The series
reported to the present time include only
small numbers of patients, but median
survival times range from 14 -29 months
1266, 928, 1208 , 20031. Age >65 years ,
female sex. W8C >50x 1Q91l thrombocytopenia, and Hb <10g1dL have been
repo rted to be adverse prognostic findings {266. 9281. Howeve r, pa tients who
rec eive 8M nansptantanon may have an
improved outcome 111781. In approximately
15- 40% of patients, aCM L evolves to
acute mye loid leukaemi a. wherea s the
remain de r die of marrow fail ure {266.

AtypIcal crvooc myeloid leukaemia. BCR-ABL 1 reqanve


Juvenile myelomonocytic leukaemia

Juvenilemyel:m:>nocyt<; ""-'<aemia (JMMLI
is a clonal haematoocietrc disorder of
childhood characterized by proliferation
p rinci pally of the gr anulocytic and m0nocytic lineages. Blasts pius promonocytes
account for <20% of cells in peripheral

blood (PB) and bone marrow (8 M). Erythroid and megakaryocytic abnomaunes
are frequently present 132. 303, 14771.
BCRA8L , is absent, whereas rrctato-s involving genes althe RASIMAPK pathway
are cha rac teristic .



The inci dence of JMMl is estimated to be
approximately 1.3 per millio n ch ildren
0- 14 years of age per year. It accounts
for less than 2-3 % of altleukaemias in
chi ldren, but for 20-30% of all cases 01
mye lody splasl ic and mye loproliferative
disease in patients < 14 years of age 1907.

17041. The age at diagnosis ranges from

one month to early ado lescence, but 75%
of cases occur in child ren <3 years of age
1345, 1346 , 1595 1, Boys are affec ted nearly
twic e as freq ue ntly as g irls , Ap proximat ely 10 % of cases occur in c hild ren
with the c linica l diagnosis of neurofibromatosis type 1 (NF l) 1345 , 1595,2 10 11.

The c ause of J MML is not known . Rare
c ases have b een repo rted in identical
twins \17051. The association between NF 1
and JMML has long been established 1345.
1595 , 2 1011. In contrast to adults who
hav e NFl . children with NFl are reported
to have a 2OQ. to 5(X).fold increased risk
of developing myeloid malignancy, mainly
J MML 115951.Occasionally young infants
with Noonan syndrome develop a JMML-like
disorder, which resolves without treatment
in some cases and behaves more aggressively in others 11211 , These children carry
germhne motanons in PTPN11,lt1e gene
encocting the protein tyrosine phosphatase
SHP2121621 or in KRAS 119741 .
Sites of involvement
The PB and BM always show evidence of
myerononccvnc p roliferation. Leukaemic
in filtra tion of the liver and spleen is found
in virtually all cases, Although any tissue
may be infilt rated, lymph node, skin an d
t he resp iratory t rac t are other co mmon
sites of invo lvem ent 1345, 134 6 , 15951.

Clinical features
Most patients p resent w ith constitutio na l
sym ptoms o r ev idence of inf ect ion \34 5 ,
1346, 1595l . There is generally ma rked
hepatosplenomegaly, Oc casionally sp leen
size is no rm a l at di agn osis but rap id ly
inc reases thereafter, About half the patient s

Table 4.03 Diagoosticarteria of juveoile myelomonocytic leukaemia"

1. F'eflpheralblood ~ >b lO'IL

2. Blasts (ird.Jdlng ~)" In <:!(l%of lie leUor.ocyles II eeblood 1Rl of !hermeated beneITI8ITtlW eels

3 No Ph d\lomosome or BCR-ABL1 fusion gene


Plus two ex more dille loIowing:

- HaemogIoI:lln F irocrea&ed lor age
- Irm'Iature granulocyles in the peripheral blood
- WBC counl >10J;10"/l
Clonal d1I01TC1SOm111 abrlormIldy (may be monosomy 7)
GM.csF hyper'5enIIbviI of myeIold progerIIIor5 on I'itro

"McOfled from 11596}.

."In IIliScialslkalJon. protI'I(lllCICy In equivaIer( 10 bIa5ts.


Myelodysplastic/myeloproliferative neoplasms

I Ba umann
J ,M. Benn ett
C.M. Niem ey er
J , Thiele
K , Shannon




..hJyrie myek:m:lnocytlc IUaeITia I.MU

PenpheraI blood smeal" shoWn;l abnornIaI ~
wotrl C)t:IpIasmic vacuolesand two oormoblasl5.

have lymphadenopathy. In addition , Waemic infiltrates may give rise to markedy

enlarged tonsils . Signs of bleeding are
frequent and about a quarter of the caress
have skin rashes. Cafe au tait spots are
noted in patients with NFl .
A remarkable feature of many JMML cases
is a ma rke dly increased synthesis 01
haemoglobin F, specifically in cases WIth
a normal ka ryotype 1345. 1595 1. AddrtiClrl!
fea tures include polyclonal hyp ergammaglobulinaemia and the p resenc e of autoantibodies 1345, 159 5 1. The cl inical and
laboratory featu res of JMML sometimes
clos ely mimic infectious diseases, including
those du e to Epstein-Ba rr virus , cytomegaloviru s, human herpesviru s 6 and others
11 376, 1596, 17511, Ap p ropriate laboraicv
testing inc luding mo lecu lar stud ies and if1
vitro c ultures may be requ ired to exclude
infec tions as a c ause for the clinical arc
haematoroqc find ing s
In vitro, there is ma rked hy persensitivityol
myeloid progeni tor cells to GM -CSF 16441;
this has become the hallmark of the d isease
and represents an important diagnostic lo:t
Morphology and cytochemistry
The PB is the most important specimen III
proving the d iagnosis. It gener ally stoes
leukocytosis, throm bocytopenia and
anaemia 1345.1346. 15951. The median reported .....tIile blood count ('NBC) varies lrcm
25-30x1Ql1Il, but rarely is >l00xll1i\.
The leukocytosis is comprise d mainly aI
neutroohns. with some immature ceus
such as promyelocytes and mveocytes.


as well as of roonoc ytes . Blasts (includ ing

promonocytes) usuall y account for fewer
than 5% of the white cells, and always less
than 20%. Eosinophilia and basophilia are
ooseved in a minority of cases, Nucleated
red blood cells are often seen . Red blood
cell changes include macrocytosis, partieularty in patients with monosomy 7, but normcx:ytic red cells are more common, and
recrocv tosrs due to iron deficiency or acQOired thalassaemia phenotype 1961} may
be seen as well Although platelet counts
are variable , thrombocytopenia is usual and
may be severe 1345, 1346, 1595, 17051.
Bone mar row f indings are not by themselves diagnost ic . The 8M aspi rate and
biopsy are hyperce Uular with gral'lUloCytic
proliferation , although in some patients
erythfoid p recursors may p redominate
\1595, 17051. Monoc:ytes in the BM are
often less impressive than in the PB .
generally accounting lor 5-10% 01 the
BM cells. Blasts (including prorooocytesj account tor <20% 01 the 8 M cells.
and Auer rod s are neve r seen . Mos t often
dysplasia is minimal. However, dysgranuccorese. including pseudO Pelqer-Heet
neutrophils or hyp:>granularlty may be noIed
n some c ases and eryt hroid precursors
may be enlarged, Meg akaryoc ytes are
cnen reduced in number, but marked
rregakaryoc ytic dysplasia is unusual 1345,
1595, 17051 . Reticulin fibrosis has been
noted in some patients 13451.
Leukaemic infiltrates are common in the
skin where myelomonocyt ic ce lts infiltrate
the superfic ial and d eep der mis , In the
IUl"Ig, leukaemic cells spread from the capillaries of the alveo lar septa into alveola e .
ld il"l the spleen they infiltrate the red pulp ,
and have a predilect ion for trab ecular and
central arteries , In the liver, the sinu soids
the portal tract s are infiltrated ,
~ specific cvtocterracai abnormalities have
been repor te d in JMML. In 8M as pirate
smears. c ytoc hem ical sta ins for alpha
naphthyl acet ate esterase Of butyrate
esterase, alone o r in combin ation wi th
naphthol-ASD-chloroacetate esterase,
may be helpf ul in detection of the monocytic compone nt . A lthou g h leu kocyte
all.aline phos p hatase scores are reported
to be elevated in about 50% 01 patients,
this test is not helpful in establishing the
diagnosis 113461.

Fig. U t Juvenile myeIomooocytlc leukaemia, A The bone marrow- aspole &IM3f usuaty refIecls thed\afIge$ noted
in the blood. buI !he monocyle ~ lllIlI is dmft10 appreciate, 8 ACOlTiw'oed alpha naplhyI acela1e eslefase and
naptl~ esterase ' eaclion idenblies the vanulocytlt (blue reaction product) and the ITIOflOCYlIC
component (brown feacbon product). A lew eels contain bolh pnxIuct$

Fig. 4.10 Juvenile ~ lOCytJc leukaemia, A The b<:Jre marrow is ~ wrlh g~pn:lilefabon.
B The megakalyocytes are reduced in IlUfTlbef, but appear rTlOIphologlcally IlOffIIII in Ihe biopsy Blasts are not
substantially ineteased in rvnber.



- type

"' speo!ic ~abroonaJ'"

rave been reported in JMML. In extra~ 1JSSUeS, the monocytic COflXIl8llI

Fig. 4.11 JU'.'OOile rnyeIofnoncq1ic leukaemia. The leukae ~ infiltrate in the Iivef isin the portalregiOns (AI as wei as
in !he hepalic sinusoids (8) , C The leukaemicI1filtrale in !he red pulp of !he spleen encroadles ~ !he gemiIIaI ten.
Int. 0 The infiltJale is compfised mainly of immalufltand maluflt neutrophils and fTIOflOCY\es.

is best detected by irTVTlunohistochemica l

techni ques that detect lysozyme and
CD68 R. However, individual cases may
show almost excluswetv infiltration by
myeloperox idase-positive granulopoietic
precursor ce lls .

Gene tics
Karyotyping studies show monosomy 7 in
about 25% of patients, other abnormalities in 10%. and a normal karyotype in
65% 115951. Philadephia chromosorneand
the BCR-ABL I fusion gene are absent.
JlIVenile myebnonocytic leukaemia


There is evidence that JMML is, at least in

part. due to aberrant signal transduction
resulting from mutations of components of
the AAS/MAPK signaling path way, Somatic mutations in PTPN 11 occur in 35%
of patients 11329, 21621. and oncogenic
mutation of the RA$ genes, NRAS and
KRAS2, and of NFl are each seen in appro ximately 20% 121621. Mutations in
PTPN1' , the RAS genes and NFl are
largely mutually exclusive, suggesting
that pathOlogical activation of AAS dependent pathways plays a central role in
the pathophysiology of the disease.
In JMML cells of children with NF 1, unrparenteral dlsomy results in dUplication of
the mutant NFJ allele 1714, 20961 . Since
the NFt gene product, neurouoromo. is a
negative rroourato- 01 AAS function, the
loss of the normal NFt allele is associated
with AAS hyperactivity 119971,
Postulated cell of orig in
Haematopoietic stem cell.
Prognosi s and pred ictive factors
Although JMMl rarely trans forms into
acute leukaemia. it is a rapidly fatal diso rder for most children If lelt untreated . The
median survival time Without allogeneic
stem cell transplantation (HSCT) is about
one year. Low platelet co unt, age above 2
years at diagnosis and high haemoglobin F
at diag nosis are the main pred ic tors of
short survival 1345. 1595. 17051. In the absence of effective treatment, most children




G, b2
Ga b2!

SHP-2 - -

R a s -GDP

~ --.......r-,




PTPNU Mutation

I EttK tor Path ways

Fig.4.12 Molecular lesions ~ Ras sir'*'!l prOWlS in JMM.. GM-CSf normaIy binds kI its rec:epD". in1al
I'IeterIXlin1er d asserrbIes 8 ~. d S9'*9 mclIo.JIes a'ld adaplets flat i'le1.I::les She: and GttI. ThesI
proieln$. " un. ftICI"Uit Gab2. SHP-2 and 505. 1IltliCh eataIyzeI ~ IWJd80lIde ~ lllI Ras and iwnases


irr.IoeI.D"leYeIs d Ras-GTP.
aetvaaed, Ras-GTP ~ ..... rurtJerd ~ elfectIrs, The Gw.
lIdMI\log proB1s pt2OGN' and net.6OIibn:mn brld kIRas-GTP and aoc:eIerate lXlfI'o'eIWn d Ras-GTP kI Ras-W'
~ kI GM-CSf is a ceIlW haImart. d JtAt. ltIal resulls from a rurtJer d lisln::l genetic ~
t.lJtaIioI1s in PTPNfl increaseSHP2 phosphatase acIYlty a'lderNIce Ras SigrlafrIg. SiTI1arIy. cancer-associaled . . .
acid Slbsl.iluIiCI'I in NRAS or KRAS2 red in /TJJlarIl: Ras prol8in:s IIaIlICO.Il1Jiate " ee acINe. GTP-b:u1d c:onbmalion. FnaIy. inacIivaIiorI ofllle NF l ~ ~gene ~ Rassigoahng ItlrtXJgh loss ofneurofib'orm

die from organ failure. such as respiratory

failure. due to leukaemic infiltration .
Haernatc poietic stem cell transplant
(HSCT) from a related or unrelated HLA
com patible donor c an cu re about half the
patients 113261. Relapse is the major
ca use of treatment failure, There is clea r
evid ence that graft versus leukaemia

effect plays an impo rtant role, since a

substantial proportion of children can be
cured alter a failed HSCT by donor 1ymphocvte infusion and immunomodulatory
therapy 117871. The role of anti-leukaemic
eeaov prior to HSCT is currentlyu-ceten





MyelOdysplasticJmyeloprolilerative neoplasms

neoplasm, unclassifiable

JW. Vardiman
J.M . Bennett
B.J, Bam
I. Baumann
J , Thiele
A. Orazt

Myelodysplastic/myeloprohferative neopIasm. lI'lClassifiabie. (MDWPN. U) meets
!he criteria lor the MDSIMPN category in
lhat, at the time of irntial presentation ,
eee are clinical, laboralOf'y and rrceprobgicaI features that overlap both MOO and

MPN. Cases classified as MDS/MPN, U

00 not meet the criteria lor chronic
myelomooocytic leukaemia . juvenile
myelomonocytic leukaemia or atyp ical
d'rlnc myeloid leukaemia The finding 01 a
oc:R-ABL , fusion gene or of rearrangement
11 PDGFRA, POGFRB or FGFR' excludes
tie diagnosis of MDSlMPN , U .

It is important that the designation

UDSnvtPN, U not be used for patients with
aprevious, well-defined MPN who develop
Oysplastic featu res in ass oc iat ion with
eans'ormeton 10 a more aggressive
rrase. HoNever, MD5'MPN, U may inc lude
sere patients in whom the c hronic phase
01 an MPN was not previously detected.
:rld who initially present in Iransformalion

MIh myelodysplasticfeatures. If the under~ MPN c annot be identified . the desigration of MDS/MPN , U is appropriate. If
there has bee n any rece nt cytotoxic or
arowth fact or therapy, follow-up clinical
and laboratory observations are esse ntia l
kl demonstrate that the peripheral b lood
(PS) and bone marrow (BM) c hanges are
'lOt due to the treatm ent.

ICD-O code


\lIXed myeloc routerawe/myelocysptastc
syndrome , unctasstnebre : "overlap" synacme, unclassilia ble .

&las of involvement
The BM and PB are always involved:
spleen, liver and other extramedullary
':ISSUeS may be involved.

The case has dirucaI, laboratory and ~ IN!ufes rJ onerJ !he ca1egories rJ MDS (reifacklry
~ WIItl unineage: dysplaSIa, relraalryaJla&mia WI\IlI'IIgSiCIerObIasIs. reIracIory tyqlenia 'MIhIlUbIileage ~. relradory anaemia -.ilh elC8SS 01 blasts) and <20"4 blasts in the blood and bone marrow

no ""

Has proITWlenI mye!oploilelalMlleatLres, e.g. pIMeleIaut a 45OJ;10'lt associaIed -.ilh megakaryotytlc

proIileration, or WBC COld~ 1 h1 l1'lt , MIh or WI1hOul P'tJn*Ienl spIeIlllfTIllgaIy
tia$ preceding tGlfy rJ In ~ W'N or rJ KlS , no hlst:lryrJ n!CeflI L)'k*JXlC or ~ Iador
\hel'apy ~ ccokl e.'(j)lain !he ~ or 1ll)eIopi00000llti.. feaUes , IIfId no F'hiadelphia
chCfl'CSOlII8 BCR-ABL1 k.tsion 98"8, no realral'9lll,.ltrJ PDGFRA. PDGFRB or FGFRf,1IfId no
isolated del(5q},l(3:3)(Q2I;(l26) or1fI'l'(3)(Q21q26)

The palienlhas de rICM) disease WI\tl nned myeIoprolilnlrt'8 and myelodyspIastIc features IIfId eatnlt
be assigned to i1It'/ olhercategory rJMOS, MPNrJMDSIMPN.

Morphology and cytochemistry

These disorders are charac terized by proliferation of one or more myeloid lineages
that is ineffec tive, dysp lastic or both and
simultaneously, by effective pro liferation .
with or without dysplas ia, in one or more
of the other mye loid lineages, l aboratory
features usually include anaemia of variable
severity, w ith or without mac rocytosis and
ofte n d imor ph ic red blood c ells o n the
per ip heral smea r. In addition, there is evidence of effec tive proliferation in one or
more lineages, e ither as thrombocytosis
(platelet count ~ 45Ox1Q91l) or leukocytos is
(w hite b lood c ell c ount ~ 1 3 x 1 09/l ) , Neutroph ils may show dysplastic features and
the re may be g iant or hypog ran ular
pl ate lets, Blasts ac count for <20% of the
leukocytes in the PB and of the nucleated
cells of the BM , and a find ing of > 10%
bl asts in the PB or BM likely indicates
tranetoenetoo to a more agg ressive staqe.
The 8M bio psy specimen is hypercellular
and may show proliferation in any or all of
the myeloid lineages. However, dysplastic
featu res are simultaneously present in et
least one ce ll line .
Cytochem ica l find ing s may be similar to
lhose seen in MDS or in MPN,

~icaI featu res

The c linical features of MDSlMPN , U


OYerlap those found in d iseases of the

l.tOS and MPN categories 1129. 1588.

May be similar to findings in MDS and/or



There is nocvtooeoetc or rooIecular genetic

finding specific tor this group. A Philadelphia
c hromo some and BCR-ABL 1fusion gene
should atways be excluded prior to making
the diagnosis of MDSlM PN, U. Cases with
rearrangeme nts of POGFRA, PDGFRB or
FGFRI or w ith iso lated de l(5q) or 1(3 :3)
(q2 1:q26) or inv(3Xq21q26) are excluded
from th is category as well. In diff icult
cases . the p resence of a JAK2 V617F
mu tation may help to confirm a haematopoietic neoplasm. thoug h the significance
of such mutations in this entity is unce rtain.
Occasional cases w ith isolated del(5q)
and JAK2 V6 17F mutation have been repo rted to have features that overlap MDS
and MPN 110051.
Postu lated cell of origin
Haematccoretrc stem cell.

Refractory anaemia with ring sideroblasts

(RARS) associated with marked
throm bocytosis


In the third editionof the INHO Ciasetcaton

RAR$- T, previously also referred 10 as
essentia l thrombocythaemia (ET) with ring
sioerobiasts . was proposed as a provisiona l entity to encompass pat ients who
have the cuncat and morphological features of the myelodysplastic syndrome,

MyelodysplasticJmyeloproliferative neoplasm, uoclassifiable


AARS, bu l who also have marked thrombocytosis assoc iated with abnormal
megakaryocytes similar to those observed
in the BCR-ABL 1 nega tive MPN, such as
ET or eartv-staqe primary myelofibrosis
(PMF) 1865,1077,21091. However, some
investigators have suggested that MAS- T
is not a unique entity but instead rep resents cases of other subtypes of MDS or
well-defined MPN that have acquired ring
sidercbtasts as a secondary form of
dysplasia 119661. It is not clear whether
AAAS-T is a distinct entity, one end of the
spectrum of AAAS . a progression of
AAAS due to an addrtiooat acquired
genetic abnormality. or less likely. Ihe
occurrence of two rare diseases in the
same patient. Therefore . until these questions are more ctearly answered . AAAS-T
remains a provisional entity
In support of a myeloproliferative component to this neoplasm, the majority of
cases reooeted as RAAS- T have shown
the JAK2 V617F mutation, or much less
commonly. the MPL W515KIL mutation
1234. 354 , 762, 1835. 1839. 1969. 2081 ,
2 139. 2358 1_ On the other hand. the few
reported cases with this mutation that
have been studied for endogenous colony
form ation in vitro have demonstrated a
pattern mo re akin to that of MDS 1234.
18351 . Thus it may be that the provisional
design ation of an MDS/MPN accurately
reflects the underlying biology in a substantia l pr oportion of the p atients 1762J;
more stud y is neede d to further ctarify this
diso rder.
Cases with isolated del(SQ),t(3;3)(q21;q26)
or inv(3)q 2 1q26) are exc lude d from this
ca teg ory, as are cases with a BCRABL 1
fusion gene, In ad dition, if there has been
a prior d iagno sis of an MPN without ring
sioerc otasts. or there is evide nce that the
ring stoerotsasts might be a consequence
of therapy or represent disease prog ression in a patient wi th features tha t meet
the crite ria of another well-de fined MPN,
this designation should not be used.

IC().() code


These cases have features of AAAS
(anaemia With no blasts in the PB and
dysplastic , ineffective erythroid prolif8fation
often with megaloblastoid features, ring
sideroorasts :2:- 15 % 01 the erythroid precursors. and <5% blasts in the BM) and
thrombocytosis With a platelet count
:2:- 450x1CJ1Il associated with proliferation


Fig.' .13 Refractory eneema WIth ring SideI'Ob~s andlhfombocylosis This sequence of rnitrophotogriljtls AtsIr3lt
blood and bone marrow 01 a 62-year-old man who presenled with severe anaemia anda plateletcount oI85lb:10"l
A Abnormal red cells and Ihrontlocylosis. B El)'lhroid proliferation and abnormal megakaryocylll$ reserrtIing megNyccytes seen in ET. C Mild dyserythropote$is. 0 The majority01 erythroid pIlICllfSOrS were ring sicleroblasts.

of targe atyp ical mega karyocytes similar

to those observed in BCR-ABL 1negative
MPN (See Chapt er 2).
The minimum plat elet co unt requ ired for
inclusi on has been lowered to 450xl CY'/L
from 600x 109/L for consis tenc y with the
d efining criterion for ET, and because
severa l studies have demonstrated that
pa tients with platelet coun ts lower than
6OOxlCY'/L may have biological features,
includ ing JAK2V6 17F mutations, similar
to those with coun ts ~x1Cf1A..1354I . It is
importan t to note that the criteria for
AAAS-T includes morphologically abnormal meqakarvocytes similar to those
observed in ET and in PMF. This criterion
should aid in distinguishing AAAS-T from
those cases of RAAS commonly reported
to have a modest increase in their platelet
count. Nevertheless, we recommend testing for JAK2 V6 17F when the platelet
count is elevated in patients with AARS
until the borderline between AAAS and
AAAS-T is more clearly defined

MyelodyspiastiC/myelop rollferallVe neoplasms

The recent discovery that up 10 60% of
pa tients with AARS-T harb our the JAK2
V617F mutation (an inc idence similar to
that found in ET and PMF) or less cornmon ly, the M PL W515KjL mutation, not
only elucidates the reason for the proliferative aspect of AARS-T but also woold
seem to move it closer to the MPN catego)
1234, 354. 762. 1835, 1839, 1969,2081,
2139, 23581. Thus. studies for JAK2V617F,
and. if ind icated, for the MPL W515M
mutation should always be performed in
such cases .


Myelodysplastic Syndromes

Myelodysplastic syndromes/neoplasms. overview

Refractory cytopenia with unilineage dysptasia

Refractory anaemia with ring siderobtasts
Refractory cytopenia with multilineage dysplasia
Refractory anaemia with excess blasts
Myeladysplastic syndrome with lsoleted del(Sq)

Myelodysplastic syndrome, unclassifiable

Childhood myelodysplastic syndrome

Myelodysplastic syndromes/neoplasms,

The mve'oovsptasnc syndromes CMOS)
are a group of clonal haematopoienc

A.D. Brunning
U. Germing
M .M . Le Beau

I. Baumam
J .W. Vardiman
E. Hellstrom-Lindberg

stem cell diseases characterized by

cvtopeorats). dysplasia in one or more of
the major myeloid cell lines. ineffective
baematopoesis. and increased risk of
development 01 acute myeloid leukaemia
(A ML) 1190. 353, 23101. There is an enhanced degree of eoootosrs which contributes to the cytopenias 12601. The
thresholds for cytopenias as recommended in the International Prognostic

SCoring System (IPSS)

lor risk stratification

in the MDS are haemoglobin < lOgJdL.

abso lute
< 18x l(Jl/l and platelets <l00xl(JlL 1833.
833AI. Values above these thresholds
are. however, not exclusionary for a diagnosis of MDS If delinitive morphologic
and/or cytogenetic findings are present
123271. The dysplasia may be accompanied by an increase in myeloblasts in the
pe ripheral blood (PB) and bone marrow
(BM) b ut the numbe r is <20% , wh ic h is
the req uisite thres hold recommended for
th e di ag nosis of A ML. It is important 10
recognize that the threshold of 20% b lasts
in the PB or 8M for the d istinction of A ML
from MDS does not represent a therapeutic mandate for treat ing pat ient s w ith 20%
blasts as acu te leukaemia . A treatment
dec ision 10 manag e the patient as AML or
MDS mu st be b ased o n seve ra l fa ct or s
including age, prior history of a mveoovsplast ic syndrcrne, overall clinical assessment
and tempo of the proc ess, wh ic h are the
same determi nant factors for patients w ith
30% bla sts. Althoug h progr ession to AML
is the natural course in many cases of
MoS, the perc entag e of pa tien ts who
p rogr ess varies substantially in the various
subtypes; a higher percentage of MDS wittl
increased myelo bla sts transforms to AML
178 1.1 3 711 Althoughthemajorityof MOS
are c haracterized by prog ressive 8 M Iailure. the b iOlogiC course in some patients.
e.q. refrac to ry anaemia with unilineage
dysplasia (RA) and refrac tory anaemia
wit h ring sroerobtests (AA AS). is p rolonged and indolent with a very low incidenced evokJIi:rI toM1L 1781. 1370. 2327 1.

Myelodysplastic syndromes



Fig. 5.01 Bone mamJIIIII smear from a pa\lel1t 'Mlh

~s B19 irltedlon showing mal1<.ed eryttvoid
hypoplasia wiltI occasional pi eryttYoblasts 'Mlh
dispetsed dwomalin and line cyIqllasmic YlICUllIM.

Fig.5 .02 Bone marrow smear from a . 1.year-d:l

'Mlh pancytoperia being cIYooic:aIy poiscWled
lneIic. There is ma'ked ~

Fig. 5.03 Bone marrow smear from a 57-yeaf-okl woman

r1'Io received several dl&molh&rapetJtlC ageots lor breast
carcinoma ir.clooing loIic acidantagonists.

Ep ide miology
Myetodysplastic syndromes occur princ ipally in olde r adu lts with a median age of
70 years . with a non-age corrected annual
incidenc e of 3-5/100 000 p ersons bu t
rising to >20/ 100 000 amo ng tho se ove r
the age of 70 years {109, 7831. App roximately 10 300 inciden t cases of MOS
were d iagnosed in 2003 in the USA
{1351 1. There is a male predominance .
Thera py-related mveioovsptasuc syndromes are discussed in Chapter 6.
Cli nic al featu res
The major ity of patients present with
symptoms related to cvtooentats): most of
the patients are anaemic and transfusiondependent. less frequent are neutropenia
and/or thrombocytopenia. Organomegaly
is infrequ ently observed.

Prima ry or de novo MOS oc cu rs without a
know n history of c hemotherapy or race
expos ure. Possible etiolog ies for pre
ma ry MOS Include benzene exposure at
levels well abo ve the m inima allowed by
most government age nc ies. cigarette
smoking, exposure to agricultural cherricats or solvents an d family history ci
heematoootenc neoplasms 121131. Some
inherited haematolog ic al d isorders. SUCll
as Fanconi anaemia. dyskeratosis Cl)f\o
geni ta. Shwachmann-Diamond evnocre
and Diamond-Brackten syndrome are
also associated with an increased risk


The morphological classitication 01 MOO
is principally based 00 the percent
blasts in the 8M and PB. the type an:!

degree of d ysplasia and the pr esence of

ring sideroblasts {1 90 I. The cy topen ias
generally co rrespond to the d ysp lastic
lineage. but discordance may be present
(Table 5.0 1) 123271. To determi ne the
blast perc entage in the BM, a 500-ceU
differential of all nucleated cells in a smear
ortrephine imprint is recommended and in
the PB, a 2QO.leukocyte cnnerentrat In
severely cvtooenrc patients, butfy coat
smears of PB may tacuuare performing the
The charac teristic s of the d ysplasia are
relevant when diSlinguishing between the
various types 01 MOS and may be important in predictmg biology. In addition ,
some cytogenetic abnormalities are
associated with characteristic d ysplastic
features, e.g isolated del(Sq) and hypolobated and non-lobated megakaryocyte

nuc lei and det( 17p ) with hypo lobe ted

neutrophil nuclei / 12371
Assessment 01 the deg ree of dysp lasia
may be pr ob lematic depending on the
quality of the smear preparations and the
stain. Poor quali ty smears may result in
misinterp retation of the presence or absence 01 dysplasia particularly in assessing
neutrophil granula tion . Because of the
critical importance 01 recognition of dys pl asia to the diagnosis of an MOS, the
necessity 01 high quality slide preparations
cannot be overemphasized. Slides for the
assessme nt of dysplasia should be made
from freshly obtained specimens ; specimens exposed to anticoa gulants for more
than two hours are unsatisfactory
As a general precaution, no patient
should be diagnosed as having MOS
without knowledge 01 the clin ical and

"'ReIrDIlyq10perIIas 'III\I1lriineage dysplasia (RCOO)

Refraclory anaemia (RA); Relracloryneutropenia (RN);

_ _ IRT)

Retacklry anaemiI WIth nngsidetobltsts (RARS)

drug history and no case of MOS should

be reclassified while the patient is on
growt h teeter therapy, inclu ding erythropoietin. In add ition, cytopenia(s) in the
absence of dys pl asia shoul d not be
interpreted as an MOS. A presumptive
diagnosis of MOS may be made in the absence of dysplasia il certa in cytogenetic
abnormalities are present (See Genetics).
Persistent cytopenia without dysplasia and
without one of the specific cytogenetic
abnormalities c onsidered as presumptive
evidence of MOS should be viewed as the
recent ly described "idiopathic cytopenia
of undetermined siqrufcance" ( leUS),
and the patent's haematologic and cytogenetic status should be cerefuny monitared 124221 .
In an attempt to more accurately pred ict
chnical behaviour, cases of MOS without

~ or bicytopenia'

tI or rareblasts 1%)1

No "''''

No or fare blasts 1'10)2
<'~10"11. monocytes

IJn*Ieage dysplaSIa. 2:10% dille cells Ifl onemyebd i1eage


<15'10 01 eryIhrOId precursors are nngSlderobIasts

2:15% 01 eryIhroid precursors on rilg SlderobIasts

Erylhmid dysplasia only

Dysplasia i'I 2:10% 0I1I'le cells in 2: two myeloid Iil'le<tges

(neutrophil and/or erythroid prealrsOfS and/or megallaryocyles)
<5'10 blasts in marrow
NoAuIM rods
1;15'10 ringsideroblasls

Refradory anaemia With e~C8SS b1asts--1 (RAEB-1)

NoAutlr rod s
< 1 ~1O"fl mooocytes

Unilineage or ml,lttl l~age dysplasia

5-9% blasts l

Refractory ana&mia with excess blasts-2 (RAEB2)

Cytope nia(s)
5-19% blasts
Auerrods t 1

Unilineage ormullilineage dysplasia

10-1 9"1o blasls
Auer rods 1;1

<1~10'J1. mooocytes

M)'elodj'Splastic syndrome - undaSSifJed (MDS-U)

5:1% blasts '


UsuaRy J'M)n1I3I or
we.ased pIaIeIet COUI1l
Noor rareblasts ,%)

Uoequivocal d~sia in less \Il<In 10% 01 eels ill one

or moremyeloid cell joes v.t1en a<:compaflied by a C)'\ogene~c
abnormallt)' considered as presun1pIlve evideflCe fora diagnosjs
01 MDS (see Table 5.(4)
Normal 10increased megakaryocytes WJ1h

tJwoIobated fIUdei

<5% blasts
Isolated _
del{5q) cytogenetic al:inl:lrmlliTy

8q'qlenIa may 0CCiI5i0naIy be obseMld cases Wl1l'I pancytopenia should be classified as t.I05--U.
myeloblast perc:entBge is <5% bul1tlEWe ere 2--4% myeIoblasls nee blood, ee liagnosticdass1Iic:aticrl is RAEB 1. Cases 01 RCUO and RCMDIIo'ilh I %Il)'IlIoblasts IIIlhll blood shoUlIbe dassifled as MOS, U

I . . . JIlafl'DW

Cases W1111wfII rods nI <5% myetlbIasls III 'lie blood arw3 0(10% inee I'!llll1tIW sInJId be d8s$lIied ... RAEB 2.




Fig. 5.05 A Blood smear from a pa\J8I"It on grarUocyte COOny sbmulating!acttJr. A neutrophil W'IIh a bIlobed nucleus
and naeased azuror:I* grClruabon. B The same SI)Itinen as (A) showing a myeloblast.

an increase in blasts are recognized as

manifesting ei ther unilineage or multilin-

eage dysplasia In RA and RAAS. the

dysplasia is generally confined 10the erythroid lineage. Unilineag e dysplasia may
also occur in the neutrop hns. refrac tory
neutrop enia (AN), an d megakaryocytes.
refrac tory thrombocytopenia (AT), but
these processes are much less frequ ent
than unilineage dysplas ia invo lving the

erythroi d cells. In refractory cytopenia

with mul lilineage dysplasia (RCMD) with
or without ring sioe robleete. significant
dysplastic features are rec og nized in two
or more of the major myeloid cell lineages.
The reco mmended req uisite percentage
of cells manifesting dys plasia to qualify as
sig nific ant is ~ 10% 11864J in the erythroi d
p rec ursors and granulocytes, Significant
megakary ocyte dysplas ia is defin ed as

Tab le 5.02 Summary of cytopenias anddysplasia characteristics in MOS without an illCfease of marrow blasts.





Refractory cytopel1ia with unilineage

dysplasia (RCUD)
Refractory anaemia (RA)
Relfactory I'le(Jtropenia (RN )
Relfactory tnrombocylcpenia (RT)

p- -"---...

UflIinelIge and


(2:2 myeloid eels Ines)



Relr<lclory aI1aerTlla with ring SIIiIroblasts (RAAS)

2:15"" ringSideroblasts

Myelodysplastic Syndromes

MyelodysplaslJc syndrome. uocIasS/fled (MD5-U)

Retractory cyIOpenia Wllh mullilneage d:y$plaSiII


~ 1 0% dysplastic megaka ryocytes basec

on evaluation of at least 30 megakaryo.
cvtes in smears or sections, Future snoes
may result in modification or this reccomendation 114201. Mcromeqakaryocves
and mullinucleate megakaryocytes are
the most reliable dysplastic findings inttl
megakaryocyte series 11420. 23271.
Although the majority of patients w
MDS and unlineage dysplasia pre
with a single cytopenia. this revised
etcatoo allows lor bicytopenia in refracb'y
cytopenia with lXlilineage dysplasia (00,.q
and RARS (Table 5.02). The majority ~
patients with RCMD have 2 cytopeMS

Ch.aracteristics of dysplasia
Dyserythropoiesis is manilest prine
by alterations in the nucleus ine
budding, internuclear bridging , karyCIrhexis , mu/tinuclarity and megalobla
changes; cytoplasmic features .
ring siderobIasls. vacooIisalion and penxk
acrd-Sctnf positivity. either diffuse (I
granular (Table 5.03). Dysgranu!opoiesl
is characterized primarily by nudelJ
hypolobation (pseudo Pelqer-Hoetj a~
hypersegmentation. cytoplasmic hypogranularity. pseudo Chediak-HigaS'J
granules and small size. MegakaryocytP
dysplasia is characterized by micromegakaryocytes with hypolobated nuclEi,
non-lobated nuclei in megakaryocytes Ii
all sizes, and multiple, wrderv-seoaraiea
nuclei, Megakaryocytic dysplasia maytlt
more readily app recia ted in 8M secncs
than smears and both types 01 specimers
should be eva luated
The cha racteristics of the dysplasia maj
be relevan t in pred icti ng biology of a
mveicoysorastc d isorder and the relatcoship to specific cy toge netic abnormalities,
ego Sq-syndrome {2327}, Unilineagedysptaaia is o bserved in RCUD and RARS
Multilineage dysplasia involving two c.
three of the myeloid ce ll lines is rTlOfe
frequently observed in the high-graClt
MDS an d is used to distinguish ReM!)
from ACUD 118641. Similarly, the presence
01 multilineage dysplasia is used
separate RARS from RCMD with n
sroerobtasts. the latte r of which has a
similar clinical course to RCMD_
increased number of ring sioerotnasa
occasionally> 15% of the erythroid precursors. may be observed in refract
anaemia with excess blasts (RAEB). TIt
defining criteria of RAEB- l or RAEB-2
dictate the classification in such cases

of AAEB-2 o r CM ML-2 in the con tex t of

MOS or MOS/MPN rega rdless of the blast
perc entag e. This concept is reta ine d in
the p resent classification. Cases of MOS
with <5% blasts in the 8M and < 1% in the
P8 may rarely have Auer rods. These
cases have be en reported to be associated with an adverse prognosis 124151.

Fig. A AtmrmaI bcaizaIon 01 inmaIu'e~.

Bone marrow sectJon lI'om I ease 01 RAE&-l
allIlain$ I locus 01 immature myeloid preo.nor$.
SAlocus 0I1nmnJrec:eIIs in. bone rnatTOW biopsy from
aesse 01 RAE&-2 reacted wl1t1 I nbbody kI C034. A
lI'Iap:II'Ity oIlhe mmature eels are posilMl.

The relationship betw een cvtopenras.

type of dysplasia. and classification is
summarized in Table 5.02 .
The significance of the Auer rod in
myeloid disorders has histo rically been
sonewttat uncertain. For severa l d ecades
Its detection was viewe d as virtually di agnestle of AML. There was no specificity
applied to it with the introduction 01 the
concept of MDS by the FA8 gr oup. In the
revised FAB c lassi fica tio n of 1982 it was
veweo as evid ence of a high -gr ade MOS.
refrac tory anaem ia with excess of b lasts
in transformat ion , (RAEB t ), irresp ectiv e
of the blast perce ntage in the PB or 8 M
11901. In the pri or WHO Class ification of
the MDS it was considered as evidence

Differential diagnostk: considerations

A majo r problem in the diagnosis 01 MOS
is the determination whether the presence
01 myelodysplasia is due to a clonal disorder or is the result of some other factor.
The presence 01 dysplasia is not in itsell
definitive evidence of a clonal disorder.
There are seve ral nutnnoner. toxic and
other factors which may cause myelodysplastic changes, including but not limited
to vitamin 8 12 and folic acid deficiency,
essential element deficiencies and exposure to heavy metals, parncutarts arsenic
and several commonly used drugs and
biologic agents 12601. The antibiotic
cotreroxezoie may cause marked neutrophil nuclear hypolobation indistinguishable from the changes observed in MOS.
In some patients on multiple d rugs it may
be d iffic ult to id entify the causative agent
of the neut rophil changes 11136. 2 1411.
Congenital r eematoioqcat disorders such
as conge nital dyseryth ropoietic anae mia
must also be considered as a cause of
dysp lasia when it is con fined to the erythroid cells. Parvovi rus B 19 infection may
be assoc iated with ervtn robreetopente
wil h gi ant megaloblasl oid eryl hrob lasls:
the imm unosu p p ress ion age nt mycophe nolate mofetil may also be associated
with erythrob lastopenia. Chemotherapeutic
age nts may resu lt in mar ked dysp lasia of
al l mye loid ce ll lineag es. Granuloc yte
colony- stimu lating fact o r res ult in mo rp holog ic alteratio ns in the neo trophns.
incl udin g m arked hypergranularity and



f.. 5.01 M~a stJc dysery1hropoIeSil. Bone

MlIo ~ Inm., ao:Ul JT8B -Mlh fefracUy ~
.. rrUl*leage dysplasia (RCMD) and complex
~ 8t:n:lnnIIlItle N:tdng del(17p) and del(Sq).



Fig. 5.09 Dysplasbc megakaryocy\eS. Bone n'llWl'OW as-

pirate smear from a 37-yearl male WIIh ~

stIotMg megaka-yocyleswithdysplaslic features.

Fig. 5.10 Neutn:lphi WIlll a r'lOI'Hlbaledru::Ieus (pseuclo

PeIger-HuiIJ in. bbXI smear from a paIienl on ~
mol3ZOle. ApproXllTlalely 50 percent 01 the neuIrtlpt*
had a simiar appearance.

FIg. 5.11 BtnucIeate mega~ in a bone marrow

smear from a pabeflt with ~ history 01 refrackIry
1hrontlocytopen There is a central !13f1JIOt'nere and a
peripheral hyalomere.

striking nuclear hypolobation 11968): blasts

may be observed in the PB and may
reach levels of 9- to% and rarely higher
in p atients with no evidence of AML or
MOS. The 8 M b last perc entag e is generally normal, but may be inc reased as well.
Paroxysmal noct urna l hae moglo binuria
may also present with features similar 10
MOS. As a result 01all these possibilities.
it is extremely impor tant to be aware of the
c linical history including expos ure 10
d rug s or c hemica ls and cons ider nonclo nal d isorde rs as possible etiologies
when evalua ting cases with myelod ysplasia, particularly those c ases with no increase in b lasts. Repeat ed 8 M biopsies.
including cytogenetic studies, over a period of severa l months may be necessary
in d ifficu lt cases.
Histopatho logy
The value of the BM biopsy in MOS is well
established 116471. It may aid in confirming
a suspected diagnosis by excluding
reactive conditions in which ovsnaematopoietic changes may also be observed: it
can also increase the diagnostic accuracy and helps in refining the IPSS score
123281. Assessment of 8M cellularity and
strcmal reactions, e.g. fibrosis. B!eadditi:Jrl<W


cases of MDS with inadequate aspirates,

the blast determination requires a aM
biopsy and immunohistochemical studies
for C034 may prove invaluable.

Fig. $.12 A Bone marrow bI:lpsy from a case of MDS (RAfB) WIth /I'I)'eIOfb'osi 5everaI ~ iIIe
presenl B Retio.anstain ona marrow bclpsy from a case of MDS wilh myelofibrosis. There is a marked inaease II
retia.Wl MIres.

important diagnostic features of the

biopsy. The 8M in MDS is usually hypercellular ex oormocenutar: the cvtopenras
result from the ineffective reenatcooese.
Histologically, aggressive MDS may be
characterized by the presence of aggregates (3-5 cells) ex clusters (>5 cells) of
blasts in 8M biopsies usually localized in
the central portion of the 8 M away from
the vascular structures and endosteal
surfaces 01 the bone trabeculae. These
are frequently present in RAEB. The blasts
can also be identified by immunohistochemistry with an libody to CD34, an antigen expressed in p rog enito r cells and

Table 5.lJ3 Morphologic marule$tabons 01 ~


Noclear budding
Int&rTll.lClear bridging
Mll ~inuclearity

Nuclear hyperlobation
Megaloblastic changes
Ring sideroblasts

PeriodiC acid-SChiff positvily

~granulopoie. l.

SmaI or oousually largesize

Nuclear hypoiobaliOn
(pseudo Peiger-Huet: peIgeroid)
IrT9{PJIar hypetSl:lgmentation
Decreased granules : agrarWrity
PseucIo QledIak-HtgastH ~arws

.... """


~l)'ocytopoiIs ls

NudNt hypoklbllJon
~ (normaI .,..katytq1es in
I.lI'W'IJl:illI wilh kltdaled nudeI)


Myekxtysplaslic syndromes

early p rec ursor 8M cells in lhe majorIty of

cases. Antj-C034 can be used to demonstrate pathologic accumulations of blasts
both singly and in clusters in aggressive
subtypes of myeloid neoplasms 120501.
With some fixatives, CD34 will also immunoreact with megakaryocytes in MOS ,
IrTYTlunohistologicanalysis with anti-C034
may be especially useful in cases 01 MDS
with fibrosis or hvpoceuuiar marrows as
well as therapy-rela ted cases to assess
b last percentage. In these instances the
p resence 01 fibrosis ()( fany changes in the
8M may make accurate cbaractenzanon
of the process very di fficult.

Hypoplas tic MDS

In a minority of the cases of MDS, approximately 10%, the 8M is hypocellular. These
c ases have been referred to as hypoplastic
MOS. This group , which has
independent prognost ic signific ance per S8,
may lea d to d iffic ult ies in the d if/eren lial
d iag nos is w ith aplas tic a naelT)i~ 1
1648 1. In add ition, anti-thymocyte g lobulin
and other therapies used for aplastic
anaemia have been used with some deg ree
of success in this sub group 1260, 1302,
2477, 24781. It is also impo rtant when consid ering the diagnosis of hypoplastic MDS
10 excl ude toxic myelopathy and au toimm une di sorders .


MDS with myelofibrosis

Sig nilicant degrees of myelofibrosis are
o bserved in ap proximately 10% o f the
cases of MO S. These cases have been
referred to as MDS w ith fibrosis (12461.
Most of the cases with fibrosis have excess of blasts and an aggressive clinical
course. Such cases may erroneously be
consid ered low-grade MOS if only the
blast count determined from the 8M aspirate, which is usually diluted With P8 , is
evaluated. In the fib rotic group, as in other

Published studies on immunophenotyprg
by flow cytometry in MOS have focused CI'l
several stra tegies, including determrwg
the size and immunophenotype of ee
blast population and assessing the maturation pattern 0I1he myeloid cell popUatol
More specifically. these studies included
immunophenotyp ing of CD34+ cells, ap.
plication of SCOfing systems, and pattern
recognition strategies uSing muttiCOO
analysis and comparison with norrn;iI
reactive PB and 8M.
There is generally good correlation between the percentage of blasts as ceremined by morphologic examination iJ
fOJtine smearor irr'pV'ltor ~
preparations and percentage of CD34.
cells determined by flow cytometry ( FC~
However. in some cases there may be
significant discordance due to signilicart
myelofibrosis and haemodilute samples
As a result, Fe percentages 01 CD34+ eels
cannot replace differential counts 00
smears, However, Fe may be informal1Ye~
abnormal phenotypes of C034+ cells are
detected: this could be additional evidence
dysplasia. In addition, an emerging
athological population of CD34 IJ
01 17 cells in low-grade MDS could Sl.I9"
gest evolution of the d isease 116221.
Ma tu rat io n pa tte rns of erythropoie tic
g ranuloc ytic, and monocytic difterentiatcn
in the normal/reac tive 8 M, as well as the
immuno phenoty pe of the mature cells in
PB have been thorough ly desc ribed using
fou r-co lor FC. Erythroid abnorm alities as
de termined by the pattern of exoressce
of H-ferritin , CD7 1 and C010S in gly
cophorin A (GPA) posi tive nucleated cells
reportedly ca n pred ic t morphological erythroid dysplasia with 98% sensitivity [5501,
A be rran t maturation patterns in granulopoiesis could pred ict morphological
dysplasia and abnormal cytogenetics in
ap proximately 90% of cases 112121. ThJs
flow cytorretrv results co rreiate well with
morphology and cytogenetics in MDS
However, in cases with borderline dys.
plasia by morphology and no cytogenetic
abnormalities. FC results are highly suggestive for MOS only if there are three IJ
more aberrant features in erymropoietc.
g ranulocytic or monocytic maturation;
single aberrant features by FC are na


signific ant. .Cases with inconclu sive

morphologic an d cytogene tic find ing s
and three or mo re aberrant fea tures by
flow cytometry should be reeva luated
over seve ral mon ths for definitive rrorprologic or cytogenetic evidence of MOS,

Cytogenetic and molecular studies have
a major role in the evaluation of patients
with MOS in regard to prognosis, determnaton of clonality {833, 16411, and the
'ecognltion of cytogenetic , morphologic ,
m clinical cor relates . Clonal cytogenetic
abnormalities are observed in - 50% of
I,()S cases. Myekxtysptastic syndromes
associated with an isol ated del(5q) occur
orinarity in women, are c ha racterized by
megakaryocy1es with roo-ocetec Of hypoklbated nuclei, refractory macrocytic
anaemia, normal or increased platelet
Cl:lOO t, and a favourable clinic al c ou rse,
and are recccneec as a scecinc type of
MDS in this c lassification , The oc c urrence
(j 17p loss is assoc iated wi th MOS or
AML with pseudo Pelger-Hu6t anomaly.
small vacuol ated neutroohlrs. TP53 mutation and unfavourable c linical course: it is
rest common in therapy-related MOS
(12371 Complex karyotypes (2:3 abnormalities) typically include chromosomes 5
andfOf 7 [-S/del(5q), -7/del(7q )), and are
generally assoc iated with an unfavourable
clinical course . Several olher cytogenetic
lindings ap pear to be assoc iated with
characteristic morp hologic abnormalities
such as isolated del(20q) w ith involve ment of eryt hroid ce lls and meg akaryocvies. and abnormalities of c hromosome
3 (irw (3)(q2 1q 26 ,2) or t( 3 ~ 3)( q 21 :q26,2 )].
which are associated with MOS and AML
withincreased abno rma l meg akaryoc ytes
1289, 866, 1207j.
Some clonal cytogene tic abnor mal ities
occuring in MOS are not definitive evidence for this disorde r in the absence of
morpholog ic al crtterte. e.q . -Y, +8 or
ool(2Oq) as the sale abnormali ty, The
other abnormalities listed in Tab le 504 in
presence of a refractory c ytope nia ,
but no morphologic evidence of dysplasia,
are considered presumptive ev idence for
MOS. It is recommended tha i tnese pallefllS be followed caretcuv lor emerging
roorphologi c al evidence of MOS. FISH
tJOVides increased senSitivity in monitoring
Sl.Ch pateots.once a recurring abnormality
res been identified ,


Tabl. 5.04 ReCl.lning cluumosomal abnormalities and

their frequency in re myelod~aslic syndromes at

Postulated cell of origin

Haematoooetic stem cell.
Prognosis and predictive factors
The morphological subtypes of MDS can
be generally categorized into three risk
groups based on duration of survival and
incidence of evolution to AM L. The Iow-risk
groups are RCUD and RARS. The intermediate-risk groups are RC MD with or
without ring srderobrasts and RAEB-1 , Patients with RAE&-2 constitute the high-risk
group. It shou ld be noted that patient s with
bcvtopema in RCUO and RARS have
been reported to have a shorter surviva l
tha n patients with one cyt openia 123271.
Pat ients with one cyt openia in the con text
of RCMD had a longer survival than patients with two cvtocenra s 123271
The importance of c ytog enetic studies as
a prognostic indic ator in MDS has been
recogniZed and c od ified by the International My ekxtysplaslic Synd rome Work ing
Group 18331 Three major risk categ ories
of cytogene tic findi ng s have been d efined : i) good risk -normal karyotype,
isolated del(5q), isolated del (2Oq) and -Y;
ii) poor risk ---com plex abnorma lities, l.e.,
2:3 a bnormalities, or abnormalities of
ch romosome 7; and iii) intermediate risk
- all other abnormalities.
A scoring system for predicting survival
and evolution to A ML based on percent
8 M blasts. type of cy togenetic abnormalities , and degree and number of cytcoentas has been pro posed by this g roup
(Table 5.05) 1833, 833A I, Four risk g roups
based on this sc oring system are recog nized : low, O' INT (inte rme diate) - 1,
0 ,5- 1.0; INT-2, 1,5- 2.0; and high , 2:2 ,5. In
general, the higher-risk groups are related
to higher 8 M bl ast percent ag e, mo re unfavou rab le c ytogenetic find ings and mo re




' 0%
' 0%
' 0%

' S'

1 or del(7Q)
-5 or del(Sq)

. ..

- ,'

. S%

~ 17Q)

or l(17p)
.13 or del(13Q)
del(12p)Of 1(12p)





' .2%
' .2%



1( 11;16)(q23,p13.3)
1(32 1)(q262;q22.1)

~3)(q21 q26.2)




, The ceseece of these at:JnormaIIies as the sc*l

~ abrmnaiIy 11 !he absence of rrupho-

logic aTlenais no! considered deMiIive evidence lor

1.40S, In !he seltlng of persistent eytapenias ol
~ origin. lhe oll'ler abnormahties shoWn
are IXIO~ ~ve evidence 01 MDS in the
absenc:e 01 defu'itive ITlCfPlIOIC9C features.

severe degree of cytopenia.

Constderatoo of age improves predict abilityof survival ; patients young er than 60
years of age have impro ved survival in the
ind ividual risk ca tegories compa red with
patients older than 60 years.
The cytoge netic subg rouping of the IPSS
system also has an independ ent value in
pred ict ing the outco me of allog eneic stem
cell transplantation in pati ents w ith MOS


Table 5.05 International Prognostic SC:or1'1g System(IPSSllor MDS (833,833Af. See Prognosis and pt'edidive faclQrs

lor interpretation,


Prognostic variables
" bone marrow blasts
C~s -


5-1 0%





11 - 19"110




"This ~ is ~ as AML in the wtK) classificabon.

- Karyotype:
Good" normal, -Y,del(5Q). del(2Oq).
Poor " ~l ~ lIbnormaIiIies) or ....~~mlTlOSOl""'m..
18 7...::ma1ies:
Intermecliate " otherIIbnormaIrt.oes
- Cylopenias:

NeutropIiIs <1.8xlll'11.

PIaWets <1 00x 1 ~



Refractory cytopenia with

unilineage dysplasia

Refractory cytopenia with unilineage dysplasia (RCUD) is intended to encompass
those myelodysplastic syndromes (MDS)
which present with a refractory cytopenia
with unilineage dysplasia and includes
refractory anaemia (RA) , refractory neutropenia (RN) and refractory thrombocytopenia (AT) . Although refractory anaemia
with ring sioercoiasts is also characterized
by unilineage dysplasia. it is considered
as a distinct entity of its own . Refractory
bicytopenia may be inCluded in the AGUD
category il accompanied by unilineage
dysplasia. It is recomnet ICIed that refractory
pancytopenia with unilineagEl dysplasia be
placed in the category 01 rnyelodysplastic
synd rome. unctassrnaore (MDSU). The
recommended level lor dysplasia is ~ 1 0%
in the cell lineag e affected. The recommen ded levels for defining cytopenias are
haemoglobin <10g/dL. absolute neutrophil count (ANG) < 1.8x1Ql1IL and platelet
count <100x1(19/l1833, 833AJ. However,
values above these levels do not exclude
MDS if definitive morphologic and/or cytoge netic ev idence of MOS is p resent. The
typ e of c ytopenia in the majo rity of cases
w ill cor respon d to the type of unilineage
dy spl asia , e.q. anaemia and eryth roid

dys plasia, although discordance between

type of cytopenia and cell lineage dysplasia may be observed 123271. Some of the
cases previously classified as M05-U may
be included in this category. e.q. RN, RT
All non-clonal causes tor the dysplasia
must be explored and excluded before
the diagnosis of MOS is established
These inc lude, but are not limited to, drug
and toxin exposure, growth factor therapy.
viral infections, immunologic crsorcers.
congenital disorders, vitam in deficiencies
and possible essential element deficiencies, such as copper deficiency 18371_
Excessive zinc supplementation has also
been reported to be associated with severe cytopenia and dysplastic changes
110 10 1. It a clonal cytogenetic abnormality
is not present, there should be a period of
observation of six months from initial
examination before a diagnosis of MOS is
established unless more definitive morprologic or genetic evidence eme rges during
the observation per iod .
The presence of pe ripheral blood (PB)
blasts esse ntially excludes a diagnosis of
RCUD although in an occasional case a
rare blast may be id entifie d: pa tients w ith
the find ings of RCUO and 1% blasts in the
PB and <5% in the bone ma rrow (BM) on

A.D. Brunning

A.P. Hasserjian
A . Porwit
J.M. Bennett

A. Orazr
J. Thiele
E. Heustrorn -Ltndberq

two successive evaluations should be

placed in the category of MOS-U because
of the uncertain biology of this constellation
of findings. Patients with 2-4% blasts 11"1
the PB and <5% blasts in the 8M should
be classified as refractory anaemia With
excess btasts-t (RAEB-1) if other cntere
lor MOS are present. The number d
cases with these findings is very low ana
these patients stoJd be careftAly coseoec
for increasing 8M blast percentage 111651,
Refractory cytopenia with unilineage
dysplasia should not be equaled wiVl
"Id iopa thic cytopenia of undetermined
signiftcance" (ICUS) which lac ks the
minimal morphologic or genetic criteria
requisi te tor a diagnosis 01 MOS and
should not be considered as such [24221.

Refractory anaemia.
Refractory cytopenia with unilineage
dysplasia comprises 10-20% of all cases
of MOS 1782, 1371/. It is primarily a dsease of older adults; the median age is
around 65-70 yea rs There is no signifi
cant sex pred ilection , The vast majorityo!
RCUD c ases are RA. Refractor y neutropen ia and refr actory thrombocyt openia
are rare an d extreme c aution should be
used in making either of these d iagnoses.
Sites of involvement
The P8 and 8 M are the p rinci pal sites 01
Clinical feature s
In RCUO. the presenting symptoms are
related to the type of cytopenia, The cytoper nas are refracto ry to haernauruc therapy, but may be respo nsive 10 growth
factors 19831.

Refractory anaemia
code 998013)
In the PB in RA, the red blood cells are
usually normochrcmic, normocytic or normoctYomic, macrocytic. Unusually, there is
anisochromasia or dimorphism with a


Fig. 5.13 Refradory WIlIeIT'Iia, This bone IIWTt7W smear speomen shows dyspIasbc Jeatures criy in !he8f)1tVOld
preo.nors; octaSiOnaI erythrobIasl$ sI'lClW vacu:lIat8d c:ytopIasm Mel ~ megakXVst*! 1'oldBi.


Myelodysplastic syndromes


Fif!. 5.14 A Refraclory neuuopel'lIa Bklod smear m a 56-year-old male;!tiel'lIllAJq)hI in lhe bwer IeflIS normal aweamg with weI-grarIJIated cytJpIa$ITI and a namaIy M!1I'*'*I
1IJdIus. The A8IA"ophI inltle l4lP8l'
is dysplastic wiIh ~ ~ cyq:.Ia$mWld oc:casionaI 0CHe bode&. The I1.JdM; shows retarded MglIl8lI!alJOll. ApprounaleIy
IlIIf01 fie nMropI'Iis 'III'8l1l dyspIaslic. Cytogenetic S!I..des showed .. extra toP'I d cnomosome 8 lWld perlOlft'lc rNer1ion d ctvornosare 12. B A tIyspIastic megakaI)uyte in a
~ ItTl8al' from a ll-year-okl male WIlIl a two year hISlory oIrelradory II1rtlmbocyk:Jp Theie is ~ Ikdearcylopiastllc dewelopll.,1 '/IIllh a ~
~ and 8 norHobated mnaltn nucleus. CytIgeoelic slldIes ' I this !line stoNed a missing Y chromosome. There was SlbsequenC evokIIIon at which lime ~
-.oes shcMoed a rrWsSlI'lg Y, addltIonaI9 and deletion 13.


population of hypochromic red blood cells.

Anisoc ytosis an d po ikilocytosis va ry from
none 10 marked. Bla sts are rarely seen and,
if present, acc ount for <1% of the while
blood cells. The nectrocnns and p latele ts
are usually normal in number and rrorpno-

Neutropenia secondary to drug therapy,

toxic exposu re, infectious processes , immune mechani sms, or other causative factors must be exclud ed , The other myeloid
cell lines do not show signific ant dysplasia


logy. How ever, some degree 01 either

neutropenia or thrombocytopenia may be

The erythroid precursors in the 8M in RA
vary from decreased to rnatkedty increased ;
<tyseryltYopoie variestrern slight to mode ere. unequivocal evidence of dysp lasia
met be present in 10% or more erythroid
precursors. Dyserythropoiesis is manifest

principally by alterations in the nucleus

includ in g budding, internuclea r br id ging ,

karyorrhexis. multinuclearity and mecatoblastoid ch anges: cytoplasmic features in.

coos vacuolization and periodic acid-Schiff
positivity, either diftuse or granular. Aing
sideroblasts may be present but are <15%
iJ erythroid precursors. Myelob lasts acooun1 for <5% of the nucl eated BM cel ls,
The neutrophils and megakaryocytes are
'l:lm'IaI or may show rnnimaJ dysplasia, but
~ways < 10% in either cell line , The BM
biopsy is generally hypercellular due 10
rcreased erythroid precursors. but may be
rorrccenoiar or even hypocellular.

Refractory neutropenia
(lCD-O code 999 1/3)
Refractor y neutropeni a is ch aracterized
by~ 1 0% dysplastic neutrophils in the PB or
3M; the dysplasia is principally manifesl as
ru:::1ear hypoIobation and hypogranulation.


Refractory thrombocytopenia
(ICD-O code 9992iJ)
Refra ct ory thrombocytope nia is characterized by 2': 10% d ysplastic megakaryocv tee of at lea st 30 megakaryocytes
eva luated : hypolcbate megakaryocytes,
b inucleate and multinucleate megakaryecytes and mrcromeqakarvocvtes are the
most reliab le and reproduci ble featu res
of mega karyocyte dysp lasia , Dyspl astic
megaka ryocyles may be more eviden t in
sections than smea rs and usually well
exceed the 10 % threshold . The megakarvocvtes may be increased or decreased . The other myeloid ce ll lines do
not show sign ificant dysplasia (<10%).
Distinction frem chronic autoinvnune
thrombocytopenia is cntc at and may be
extremely difficult clinica lly and morphologi ca lly. Cytogenetic studies may be of
consi derable aid in this distinclion 18661.
In refractory anae mia abe rrant immuneph enotyp ic features of erythropo ietic
precursors can be found by flow cytometry
ana lysis 15501. There are no d ata on RN
and RT.

Genetic s
Cytogenetic abnormalities may be observed in up to 50% of ca ses of refractory
anaemia 1782J Several difterent acquired
clonal chromosomal abnormalities may
be observed. and although useful for
establishing a diagnosis of RA, they are
not specific. The abnormalities generally
associated with RA include del(2OQ), .8
and abnormalities of 5 aod/Of 7. The number 01 reported case s of AN and
is 100
low to allow for generalizations, although
del(2Oq ) has been reported in AT 1866.

Postulated cell of origin

Haematopoietic stem cell.
Prognosis and predictive factors
The clinical course is protracted ; the
median survival of patients wilh RA in one
series was approximately 66 month s and
the rate of progression to AML at 5 years
was approximately 2% 17821 . In another
study, the median survival tor pat ients
over 70 years 01 age with AA, RARS and
MOS with del(Sq) was not sigml icantly
different frem the non-affected population
11371 1. Approximately 90-95% 01patients
with RA have low or intermediate International Prognostic Scoring System (IPSS)
scores 1833, 833AI. Approximately 80-85%
have good to intermed iate cytogenetic
profiles 1782, 13711, Most patients with AT
have tow IPSS scores and 90% of the patients live more than two years 119381.

Refractory cytopenia with unilineage dysplasia


Refractory anaemia with

ring sideroblasts

R.P. Hasserjian
N. Gatterman n
J.M. Bennett
A.D. Brunning
J . Thiele

Refractory anaemia with nng stderoorasts
(RARS) is a myelodysp lastic syndrome
(MDS) cha racterized by anaemia. morpho-

may be symptoms related to p rog ressive

iron overload .

logic dysplasia in the eryth roid lineage

and ring eoercoteste comprising ~ 1 5% of
the bone mar row (B M) erythroid precursors , There is no signif icant dysplasia in
non-erythroid lineages. Myeiobiasis comprise <5% allhe nucleated 8 M cells and
are not present in the peripheral blood
(Pe) , Secondary causes of ring sroeroblasts must be excluded.

ICD-O cod e


RARS accounts for 3-11% of MDS cases.
It occurs p rimarily in older indivi dua ls with

a median age of 60-73 years and has a

simi lar freq uenc y in males and females

1267.782. 13711.
Ring sideroblasls represent erythroid pre-

cursors with abnormal accumulation of iron

within mitochondr ia. includi ng some deposited as mitoch ondria l ferritin 1352, 82 7f.
Primary def ect s of haem synthes is (such
as the a-amlnolevonruc acid synthetase
defect in hered itary X-link ed srderoblastc
anaemia) ca n largely be exclud ed be cause p rotoporphyrin IX, the end prod uct
of po rphyr in synthes is, is not decreased
in RARS 11 2091. Furthermore , acqu ired
mutations in g enes of the haem synthetic
pathway have not been demonstrated in
AAAS {20841 Therefore. a pr imary defect

of mitochondrial iron metabolism is suspect ed . This de fect ma y be caused by

soma tic mutations or deletion s in nuclear
or mitochondrial DNA. Potentially analogous congenital d isorde rs inc lude the
Pearson mar row-pancreas synd rome ,
whic h features s.oerooiastc anaemia and
is caused by congenital large oeetcos of
mitochondrial DNA 1478/ . Somatic point
mutations 01 mitochondrial DNA have
been ident ified in the BM 01 some patients
with AA AS t7631 bu t it rema ins 10 be
established whether they cause the soeob lastic p henotype 11 4221. Clona lity 01
CD34-positive progenitor cells and
erythroid and granulocytic elemen ts has
been demon strated in RARS patients by
x-cbrorosome inactivation analysis {549.
2 1261. Stem cells from AARS patients
d isp lay poor eryt hro id colony formation
in vitro and manifest abnormal iron deposition at a very ea rly stage 01 erythroid
deve lopment {444, 2 1781 . This evide nce
suggests tha t RARS re prese nts a clonal
stem cell d efect that manifests as abnormal iron metabolism in the erythroid lineage
and results in ineffec tive eryt hropo iesis .
Sites of involvement
The PB and BM are the prin cipal sites of
involvement. The liver and splee n may
show evidence of iron over load.
Clinical features
The presenting symptoms are related to
anaemia. which is usually of mode rate degree; some pati ent s may additiona lly be
thrombocytopenic or neutrop eni c . There

Patients typically p resent with norrTll'>
ch rom ic macrocytic or normochromic
normocytic anaemia. The red blood eels
in the PB smear may manifest a d imorphic pattern with a major population 01
normochromic red bkxxt cells and a
minor population 01 hypochromic cells
Blasts are not present in the PB. The 8M
aspirate smear shows an inc rease in erythroid precursors with erythroid lineage
dysplasia. inc ludi ng nuclear lobation and
megaloblastoid fea tures . G ranulocytes
and megakaryocytes show no significant
dysplasia 10% dyspl astic forms).
Haemo sid erin-Iaden macrophages are
often abundant. Myelob lasts are less mao
5% of the nucleated 8 M cells. On an ironstained aspirate smea r, 15% or more of
the red cell prec ursors are ring srceroblasts, as defined by 5 or more iron g ranules enci rcli ng one thi rd or more of the
nuc leus. The 8 M biopsy is norrnocellularto
markedly hyperceIlular. usually witha marked
erythroid proliferation. Meqakaryocytes are
normal in number and morphology.
Ring sid eroblast s are frequen tly observed
in other types 01MDS 1776, 10781. For examp le , c ases with ring sideroblasts that
hav e exc ess blas ts in the PB or 8M are
cl assifi ed as refractory anaemi a with
excess of blasts (RAEB). When ring stoero
bl asts a re 15% o r more of the eryth roid
precur sors but there are 10% or more dyspl astic cells in any non-erythroid lineage.

Fig. 5.15 RefratQy..aema WItl'l rtog siderobIasts. A Blood smear wilh dmorphic red bklod eels and macrocyIeS (WrJItII-Giemsa). B 8lnI 1l\WfOlf aspt'aIe smear stlowIWlg I
marked 8l)'ttlroid proIiferallon with a d)'5!JIBstlc Mderate bm (WrVrt-Giecnsa). C Ironslain d bone Il\WfOlf iISpQI8 sIll:JrMng I'U"I'letOUS ring sdetoblasts.


Myelodysplas!iC svnorores

and bla sts are < 1% in the PB and <5% in

the 8M with no Auer rods or mo noc yto sis,
the case is cl assi fied as refractor y cytopenia with mullilineag e dy sp lasia (RCMD ),
Such patients have infe rior surviva l to
patients with AARS.
tbHleoplastic causes 01ring sideroblasts .
includ ing alcohol. toxins (lead and benzene). dr ug s (isoniazid), zinc aorrurustraton. copper defic ienc y and congenital
sderootastc anaemia, must be excluded

In refractory anaemia with ring stderooests . aberrant immunophenotypic tealures of erythropoietic precursors can be
lound by flow cytometry analysis 15501.



.~ 60



RCMD with 2:15% RS










Clonal chromosomal abnormalities are
seen in 5-20% of c ases of AARS and,
when presen t. typic ally involve a single

chromosome 1267. 776. 7781 .

FIg. 5.16 Stn;vaI Ctro'eS aller long-lenn ~oI' 161 patients WIth RARS and 318 RCMO patients WIltJ 2'15%mg
siderotlIasts (RSI. showing i'ltenor survival lor lIIe pallents WIth mg sideroblasts and nUtiIineage dysplasia
(p:O.ClCIOOS)(Datafrom ltIe Dusseldorf UDS regislry),

Postulated cell 01 orig in

Haematopo ielic stem cell.
Prognosis and p red ictive fac tor s
Approximately 1- 2% of cases of AAA S
evolve to ac ute mye lo id leukae mia. The
reported ove rall median survival is
69- loa months 1549, 7781.

Aefractory anaemIa with ring



Refractory cytopenia with multilineage


Refractory cytopenia with multilineage
d ysp lasia (ACMD) is a type 01 myelodysplastic syndrome (MOS) with one or more
cytopenias and dysplastic changes in t'NO
or rrore of the myeloid lineages: erythroid .
9mnulocytic. n-egaka<yocytjc 118641. rtere
are < 1 % blasts in the peripheral blood
(PS) and <5% in the bOne marrow (8M) ;
Auer rods ere not present and the mono-

cytes in the P8 are less than l xHJ'I\.. The

recommended levels for defining cytopenias are haemoglobin < lOgfdL absolute
neutrophil cocnt <1.8xl()9/l and platelet
count <100xl()11I\.I633. 833A1 . However,
values in excess 01 these thresholds are
not exclusionary of a diagnosis of MDS if
definitive morphologic and/or cytogenetic
findings are consistent with a diagnosis.
e.q. complex cytogenetic abnormalities .
The thresholds lor dysplasia are ~10% in
each of the affected cell lines. In assessing dysp lasia it is recommended that 200
neutrophils and precursors and 200 erythroid pre cursors be evaluate d in smear
and /or treph ine imprint preparations. The
neutr oph il dysplasia may be evaluated in
PB or BM smears. At least 30 meg akarycc ytes should be evaluated for dysplasia
in BM smears or sec tions, In some ca ses,
dysplastic meg akaryocyt es may be mor e
readily identif ied in sec tions than smears,
In particul ar the presenc e of micromegakaryocyte s should be noted . Cases
with multilineage dyspl asia and 2-4%


Myek:!dYSplastlC syndromes

R D. Brunning
J ,M . Bennett

E. Matures
A. Orazi
J.w. Vardiman
J. Thiele

b lasts in the PB, <5% in the BM, and no

Auer rod s should be classified as refrac tory ana em ia with excess of blasts
(RAEB)- l ; cases with 1% blasts or fewer
in the PB and <5% blasts in the BM, and
Auer rods should be classified as RAEB-2 ;
cases with 1% blasts in the PB and <5%
in the 8M and no Auer rods should be
classified as MDS-U. Some cases of
RCMD have 2:15% ring sideroblasts (782 .
137 11 .


Epid emiology
Refractory cytopenia With multilineage
dysplasia occurs in older ind ividuals: the
median age is approximately 70 years.
There is a sligh t predominance of males.
The peak incidence for males is 70-74
years, for fema les 75-79 years (7821. It
accounts for -30% of cases of MDS 1782.
137 11 .
Sites of involv ement
Blood and bone ma rrow
Clinical features
Most patients present with evidence 01
BM failure with cy topenia 01two or more
myeloid cell lines.
The BM is usually hypercellular. Neu trophil dy splasia is cha racte rized b y

Fig. 5.1' Refractooy ~ withrn.J~~
Bone marrow smear shows eviOenCe 01
ee erythroidprecursors andthe neutropnils. The maI\tt
neutrophils aresmall andMvallypolobulated rn.cIeI.

hypo granulation and/or nuclear hyposeq.

ment ation with ma rked clump ing of the
nuclear ch romatin (p seudo Pelqer-l-iuet
nuclei), The nuc lear hyposegm entation
may occur as two clumped nuclear lobes
con nec ted by a thin chromatin strand
(ptoce-nez type) Of marked ly clumped
non-lobated nuclei , Myeloblasts account
for <5% of the 8 M ceus. In some cases
there is a marked inc rease in erythroid
precu rsors . Erythroid p recursors may
show cytoplasmic vacuo les and marked
nuclear irregularity, inclu ding internuclear
chromatin bridging, multilobation, nuclear
bu dd ing, multmucleation and megalobrastord nuclei. The vacuoles are usually
poorly defined and dissimilar to the
sharply demarcated vacuoles observed
in toxic alterations such as alcoholism
The vacuoles may be pe riodic acid-Schlll
(PAS) positive; there may also be diffuse
cytoplasmic PAS positivity. In RCMD,

variable numbers of ring stoercorasts may

be identified Megakaryocyt e abnorma lities which may be obse rved inclu de nonlobated nuclei, nvpotonered nuclei,
binucleate or multinucleate megak aryocvtes and micromegakaryocytes; the micromegakaryocyte is defined as a
megakaryocyte approximately the size of
a promyelocyte or smaller with a nonlobated or bitobed nucleus and is the
most reliab le and reproducible dysplastic
feature in the megakaryocyte series
{1 4201_

See Chapter on mye lod ysplastic synoromesrneo otasms. overview.
Clonal cytog enetic abnormalities including
trisomy 8, monosomy 7, del(7q). monosomy 5, del(5q ), and del(2Oq), as well as
com plex karyotyp es, may be found in up
to 50% of patients with RCMD {782, 8331.
Postulated cell of origin
Haematopoietic stem cell .

Prognosi s and pred ictive factors

The clinical course varies. The majority of
patients wilh RCMD has International
Prog nostic Scoring System (IPSS) scores
in the intermediate category 1833, 833AI.
Prognosli c factors relate to the degree ot
cytopenia and dys plasia . The frequency
of acute leukaem ia evolution at two years
is - 10% in RMCD 17821. The overall median survival is approximately 30 rron ms.
Patients with complex karvorvpes have
survivals similar to patients with refractory
anaemia with excess of blasts (AAEB)

Refractory cvtooeoa With multJ!ineage dysplaSia


Refractory anaemia with excess blasts


R D. Brunning

R P. Hasserjian
U. Germing
J. Thiele

Refractory anaemia with excess blasts
(RAEB) is a myelodysplastic syndrome
(MDS) with 5-19% myeloblasts in the
bone marrow (BM) or 2-19% blasts in the
peripheral blood (PB) Because of differences in survival and inc idence of evolution to acute myeloid leukaemia (AML).
two categories of RAEB are recognized:
AAEB-l, defined by 5-9% blasts in the
BMor 2 -4% blasts in the PB, and RAEB-2 ,
defined by 10-19% blasts in the 8M or
5-19% blasts in the PB 18331. The pres-

ence of Auer rods in blasts qualifies a

case as RAEB-2 irrespective of the blast
percentage 17811.
ICD-O code


This disease affec ts primarily individuals
over 50 years 01 age . It accounts lor approximately 40% of all patients with MOS.
The etiology is unknown. Exposure to environmenta l toxins, including pesticides,
pet roleum derivatives and some heavy
metals inc reases risk, as d oe s cigarette
smok ing 12113AI.
Sites of Involve me nt
Blood and bone marrow ,
Clinical features
Most p atients initially present w ith symptoms rela ted to BM fail ure , includ ing
anaemia, thrombocytopenia and neutrope nia.

The PB sme ar freq uently shows abnormali ties in all th ree myeloid cell lines.
including red cell anisopoikilocytosis.
large, giant or hypogranular platelets and
abnormal cytoplasmic granUlarity and
nuclear segmentation of the neutrophils.
Blasts are commonly present. The BM is
usually hyperceHular. The degree of dysplasia may vary. Erythropoiesis may be
increased with macrocyticlmegaloblastoid
changes . The erythroid precursors may

FIg. 5.19 Relractoryanaemia Wl1tJ excess b1asts-1(RAEB-1J. Bone rnatrOWsmear. The malJ.l'e ~ I'Ihsc.
show nuclear hypolobulabon (pseudo Pelger-Hll8I nuclei) and cytoplasmic hypograrnunty.

show d yserythropoiesis including the

presence of ab no rmally lobulated nuclei
and internucl ear bridging, Granulopoiesis
is frequently incr eased and shows var iable deg rees of dys p lasia. This is cha racterized primarily by sma ll size neutrophils
with nuclear hypo lo bation (pseudo
Pelq er-Hoe t nucl ei) or nucl ear hype rsegme ntation , c ytop lasm ic hypogranularity
and/or pseudo Chediak-Higashi g ranules.
Megakaryopoiesis is va riable in quantity
b ut is frequentl y no rma! to increased. The
megakaryocyt es often show a tend enc y to
c luster. Oysmegakaryopoiesis is a lmost
inva riably present and is usually cha racterized by the p rese nce of a bnormal
forms predomin antly of small size, incl ud ing micromegakaryocytes 122261. Howeve r, megakaryocytes of all sizes as well
as for ms wi th multip le widely-separated
nuclei can also occur. The BM biopsy
shows alte ration of the normal tnstctopography. Both erythropoiesis and
megakaryopoiesis appear frequently dis located towards the paratrabecular areas
that are normally predominantly occupied
by granulopoietic cells.
In a minority of cases the BM appears

normocellular or hvpocenuar. RAEBcases

with hypocellular 8M represent only a
small proportion of ca ses of hypoplasbC
MOS, since most of these cases do rd
show an increased numbe r of blasts ana
belong to the g roup of refractory cvtooere
with unilineage dys plas ia (RCUD) or less
common ly to refractory c yto penia witn
mu ltilineage dy sp lasia (RCMDl , The 8M
bio psy ca n be very useful in documenting
the presence of an exc ess of blasts perticula rly in cases w ith subo ptimal aspirate
smears such as those assoc iated wim a
hypocellular and/or fib rotic BM. Blastsi1
AAEB of ten tend to form cell clusters II
aggregates that are usually located a~
'rom bone trabeculae and vascular snc
teres. a histologic find ing formerly referred
to as abnormal localization of immature
precursors (AlIP). Immunohistochemical
staining for C034 may be particularty
helpful in their identification.
RAEB wilh fibrosis (RAEB-F):
In about 15% of patients with MOS, ee
BM stews a sign ificant d eg ree of re\lCl.irl
fibrosis . Such cases have been termed
MDS WIth fibrosis (MDS-F) (1246. 1400/.

MyelOdysplastiC syndromes

Since myelQfibrosis can be seen also in

cases otmerapv -rerateo MOS, myelop roliferative neoplasms, and, rarely, in reactive dyshaematopoietic con ditions (e9
HIVrelated myelopathy) these conditions
need to be excluded. Because of the lack
of consensus on the degree of fibr osis
necessary to characterize a case as
MDS-F, it is stilt unclear whether fibrosis
represents an indepe ndent prognostic
parame ter 12083 1. The cur rent wo rking
definiloo of MOS-F requires diffuse coarse
reticulin fibrosis with or without coocomilant
collagenizalion , associated with dysplasia
in at least two cell lineage s 12083, 23121.
Most of the cases def ined as MOS F
belong to the RAEB category (RAEB-F),
The presence of an excess of blasts in
these cases ca n usually be demonstrated
using immunohistoch emistry. particularly
for CD34. The BM smears are usually
inadequate. A cha ract eristic finding in
RAEB-F is an increased number 01meg akeryccv tes with a spectrum of cell size
(including micromeg akaryocytes) and a
high degree of dysplasia 112461. Cases of
RAEBF may morpholog ically over lap
acute paomveiosts with myelofibrosis
(APMF) previously referred to as acute
(malignant) myelofibrosis. APMF is d isne t from RAEB-F by its abrupt onset with
'ever and bone pa in 11651 , 22251.

Irrmunoph enotype
Flow cytometry in RAEB often shows
increased numbers 01 cells pos itive for
precursor ce ll assoc iated antigens CD34
and/or C0 117. These cell s are usually
positive for C038. HLA-DR and myeloidassoc iated antigens CD13 and/or CD33 .
Asynchronous expression of granulocytic
maturation antigens CD1S, C011b and/or
COOS can be seen in the blast population.
Aberrant expression 01C07 on blast cells
is seen in 20% 01 cases and C056 is
present in 10% of cases . while exp ression
of other lymphoid markers is rare {1210.
In tiss ue sec tions, C034 immunoh istochemistry may be used to co nfirm the
presence of an increased number of
blasts; it allows the apprec iation of their
arrangement into clusters or agg regates,
a cha rac teristic finding seen in most of
the cases of RAEB 120501. Antibodies
such as C061 or C042b can aid in the
identification of micromegakaryocytes
and other small dysplastic forms. wh ich
are particu larly numerous in cases of
RAEB-F 11246, 22261_

Postulated cell of origin

Haematopoietic stem ce ll.
Prognosi s and pl'edictive factors
Refractory anaemia with excess blasts is
usually char acterized by prog ressive BM
failure with increasing cytopenias. Approximately 25% of cases 01 RAEB-l and
33% of pat ients with RAEB-2 progress to
AML; the remainder succu mb to the
sequelae 01 BM failure. The median survival
is approximalely 16 months for RAEB-1
and 9 months for RAEB-2 17811. CD7
exp ression has been assocrateo with
poo r prognosis {16231.
RAEB-2 patients with 5- 19% blasts in the
PB have a median survival of 3 months
similar to that of myelodysplasia-related
AML 121 t 41 , In contrast, cases defined as
AAEB-2 based only on the presence of
Auer rods . have a prognosis which is
similar to that seen in cases of RAEB-2
with 2-4% periphe ral blasts (median survival. 12 months) 121141.

A variable percentage of cases of RAEB
(30- 50%) have clonal c ytogenetic abnormal ities, including +8 , -5, de l(5q ). -7.
del(7q) and del(2Oq). Complex karyotypes may also be observed 17821.

Refractory anaemia with excess blasts


Myelodysplastic syndrome with

isolated del(5q)

RP. Hasse rjian

MM LeBeau
AF. li st
J.M . Bennett
J . Thiele


Mveiccvsoiasnc syndrome with isolated
del(Sq) is a myelodysplastic syndrome
(MDS) cnaractertzeo by anaemia with or
without other cvtopenrasand/or thrombocytos is and in which the sole cytogenetic
abnormality is del(Sq), Myeloblasts conprise <5% of nucleated bone marrow (8M)
cells and < 1% 01 pe ripheral blood (PSI
leukocytes and Auer rods are absent.

MyeIodyspIastic syndrome with 5Q deletion
(Sq- syndrome) .
MDS with isolated del(Sq) occurs more
oflen In women, with a median age 0167

Pres umed loss of a tumou r suppressor
ge ne in the d eleted regioo . Possible ca ndi dates include the early g rowth respo nse
1 (EGR 1) and c -ceterm (CTNNA I) genes
and as-vet-untcennted genets) in 5q32
1256, 1075, 1324). The RPS14 gene that
encodes a ribosomal protein has been
propo sed as a can didate in the Sq- syndrome, raising the possib ility that a defect
in ribosomal p rotein func tion ca uses that
di sorder 1256. 635 , 1075. 1324 1.
Sites of involvement
Blood and bone ma rrow,
The most common symptoms are usually
related to anaemia. whic h is often severe
and usually macrocytic. Thromboc ytosis is
present in one third 10 one half of patients.
while rnromcoocytopenle is uncommon
{794, 14171.

non-lobated and hypolobated nuclei. In

contrast, dysplasia in the erythroid and
myeloid lineages is uncommon 1257.
794}. The term "Sq- synd rome - has been
used to desi gnate a subset 01 cases with
macrocytic anaemia. normal or eleva ted
platelet count and BM erythroid hypoplasia
1257,23621. The number of blasts in the
BM is <5% and in the PB is < 1%.
The sole cytogene tic abnormality involves
an interstitial deletion 01 chromosome 5;
the size of the del etion and the breakpoints
are variabl e, but ba nd s q 31 q33 are
invariab ly deleted . If any ad ditional c ytoge netic ab nor mality is p resent (With the
exception of a loss of the Y chromosome),
the case should not be p laced in this cateqoey 11 has bee n recen tly reported that a
small subset of patients with isolated del(Sq)
m ay show a concomitant JAK2 V617F
mutation. Until more data are collected for
such cases and their clinical behaviour and
respon se to therapy such as lenalidomide
are clarified. it is prud ent to classify lhem as
MDS with isolated de~5q) (rather than in the
MDS/MPN category) and to note the presence of the JAK2V617F in the diagnosis

The BM is usually hypercellular or normacellular and frequently exhibits erythroid
hypoplasia 123621. Meg akaryoc ytes are
increased in number and are normal to
sfil.:t1tIy decreased in size withconspicuwsIy

MyelodysplastJc Syndromes

Postulated cel l of origin

Haernatoootetrc stern cell . FISH analysis
has confi rme d p resence of the del{Sq)
abnormality in differentiating erythroid.
myeloid. and megakaryocytic cells, but

generally not in mature lymphoid cells

Prognosis and predictive fact ors

This disease is associated with a rrecen

survival of 145 months, with transformatioo
to acute myeloid leukaemia occurring II
<10% of patients 17941. Patients with
del(Sq) associated with other chrorTlOSlmll
abnormalities or with excess blasts have
an inferior survival and are excluded frOOI
this diagnosis 17941. Recently. the thali a;
mide analogue lena fidomide has been
shown to benefit MDS patients with isolated
del(Sq) as well as d el(5q) with additional
cytogenetic ab normalities. Transfusion
inde pendence was achieved in two thirds
of p atients and was c losely linked to
suppression of the abno rmal clone (795,


Myelodysplastic syndrome,

Myelodysplastic syndrome. unclassifiable
(MDS-U ) is a subtype 01 MDS which init~1y lacks findings appropriate for classi-

fication into any other MDS category

Three possible situations which qualify
patents tor inclusion in this category are
listed under -morp hology.


AD Brunning
I. Baumann

R.P. Hasserpan



There are no specific morphological lindiogs. The diagnosis of myerocvsplasnc

syndrome, unctasslnabie. can be made in
the followi ng instances:

1. Patients with the findings 01 refractory

cytopenia with unilineage dysplasia
(RCUO) or refractory cytopenia with rn.Jltilineage dysplasia (RCMD) but with 1%
blasts in the P8 qualify for MDS-U 111651.

Uyelodysplastic syndrome, NOS.

The incidence of mvetodvscrasuc 5YO-

2. Cases of MOO with tXlihneage dySplasia

which are associated with pancytopenia.
In contrast. the RCUD category only allows
for a single cytopenia or bi-cytoperna .

cone. uoctassmame. is unknown.

Sites of irwotvement
The peripheral blood (PB) and bone mal1'C1W
(8M) are the principal sites of involvement.

Clinical featu res

Patients present with symptoms similar 10

n ose seen in the other myetcovsprasnc


3 . Patients with persistent cvtooemats)

with 1% or fewer blasts in the blood and
fewer than 5% in the BM , unequivocal
dysplasia (Table 5.03) in less than 10% of
the cells in one or more myeloid lineages.
and who have cytogenetic abnormalities
considered as presumptive evidence 01 MOO
(Table 5.04) are p laced in this category
MDS-U p atients should be carefully
fo llowed for evid enc e of evolution to a
more specific MDS type.

See Table 5 .04.

Postu lated cell of origin
Haematopoietic stem ce ll.

Prognosis and predic tive factors

If characteristics of a specific subtype of
MDS develop later in the course 01 the
disease , the case should be reclassified
accordingly. In cases diagnosed as MOS.
U. it is unknown both the percentage 01
patients which translorm to acute myeloid
leukaemia as we ll as the disease survival .
Cases with features otherwise consistent
WIth a diagnosis 01 RCUD Of ACMO. but in
which 1% blasts are detected in the peripheral blood, have been shown to have a
prognosis which is intermediate between
ACUO (or ACMO) and that of refractory
anaemia with excess blasts (AAEB)

11 1651.

Myelodysptasttc syndrome. unclaSSiflable


Chi ldhood myelodysplastic syndrome

Myelodysplastic syndrome CMOS) is very

UflCOrTlfl"lOf1 in children, accounting lor less

than 5% of all haematcooenc neoplasms
in patients less than 14 years of age
(Table 5 .06) 1908. 910 , 1595A, 2079AI .
The de novo or primary form of MDS in
children should be distinguished from
cases of "secondary MOS that follow
congenital or acquired bone marrow (8M)
failure syndromes and from therapy
related MDS that tollows cytotoxic therapy
tora previous neoplastic or rco-reootastc
condi tion. Furthermore. although MOS
associated with Down syndrome has
been reported to account lor 20-25% 01

cases of childhood MDS in the past

{2079AI, this disorder is now considered
as a unique biologic entity synonymous
with Down syndrome-related myeloid
leu kaemia and cnstmct from other cases
of chil dhood MDS (See Chapter 6).
Many of the morphologic. immonophenotypic and genetic features observed in MDS
in adults are also seen in ch ildhood forms
of the d isea se b ut the re are some signific ant d ifferen c es reported , part ic ularly in
pat ients who do not have increased
blasts in the ir pe ripheral blood (PB) or
Table 5.06 Ir.cKIence of haematoklgical malignancies in
children 0 - 14 years, Combined data from Dtlnmark.
1980-1991 and British Columbia 1982-1996(907, 908}.

% Incidence'







Myebd leuk.aemia of OS
















ALl. acute IyrnpIlobIaSbC leukaemia; AML. acute

myeloid leukaemia; MOS, ~SbC s)'l'klrome;
JMML,;.wetiIe m~ leukaemia: CUl .
etworic myelogenous leukaemia. PII. poIytytllaeITia
vera; El essenbal ttvorrtlocyII'I
, Exdudng Down 5)'I'ome (OS)
I per n-.on poptAalJon peryear


Myelodysplastic syndromes

BM. For example, the subtypes 01 refractory

anaemia with ring stoeroblaets and MDS
associated with isolated del (Sq) chromosomal abnormality are exceedingly rare in
chil dren 11595A1. Isolated anaemia, which
is the major presenting rnamtestatton of
refractory anaemia (RA) in adults, is unCOlTIllOO in chil d ren, wto are more likely
to present with neutropenia and thrombocytopenia 1908, 11091. In addition, hypocellularity of the BM is more commonly
observed in childhood MDS than in older
patients. Therefore, some chi ldren have
findings that do not readily fit into the "low
grade" MDS categories. To address these
differences, a provisional entity, refractory
cytopenia of childhood (RCC) is introduced and defined below.
For ch ildren with MOS in whom there are
2-19% blasts in the PB or 5-19% blasts in
the BM . the same criteria utilized for adults
with refrac tory anaem ia with excess blasts
(RA EB) should be ap pl ied . Cu rrently, in
contrast to adult MOS, the re are no availab le stu di es that have investigated the
prognos1ic sig nific ance of distinguishing
RAEB-1 and RAEB-2 in chil dren, bu t it is
rec ommended th at this distinc tion be
made for future investiga tion. Children with
RAEB generally have relativ ely stable PB
co unts for weeks or months , Some cases
d iagnosed in children as ac ute myeloid
leukaem ia (AML) with 20-29% blasts in the
PB and/or BM that have myelodysp lasiarelated c hang es. includ ing cases w ith
myelodysp lasia-related c ytogenetic abnormalities (See Cha pte r 6 ) may also
have slowly progressive d isease. These
c ases, co ns idered as refract ory anaemia
with exce ss blasts in transformation in the
French-Amer ican -British cooperative classification. may lack the cli nical features of
acute leukaemia and be have more like
MOS than A ML 19081. thus follow-up PB
an d BM studies are often necessary to
measure the pace of the d isease in such
c ases. Children who present with a PB
and/or BM disorder associated with
t(8;21)(q22;q22), inv( 16)(p13.1q22) or
t( 16; 16XP13. 1;q22) or t( 15;17Xq22;q 12)
should be considered to have A ML regardless of the blast count

I. Bau mann
C,M. Niemeyer
J .M , Bennett
K. Shannon

~IQ .

5J l


marrow smear showing abnormal nuclear IctUabcwl d

an twyttYopoietIc precursor eel alld a smaI megaQ"rocyle WItIl a IJi.lobed 1IUdeus,

Refractory cytopenia of childhood (RCC)

Refractory cytopenia of childhoocl (RCC}1S
a mveioovsotastc syndrome (MDSl char
by persistent cytopenia with <5%
blasts in the BM and <2% bla sts in the PB
{908) . Although the pre sence of dysplasia
is required for the d iagnosis, the cytological
evaluation of dysplasia by itself const itutes
only one aspect of the morpho logical diagnosis of RCC , The evaluation of an adeq uate BM trep hine biop sy specimen is
indi spensable for the d iagnosis 01 RCe in
c hildren, About 75% of ch ildren with RCe
show co nsi de rable hypocellularity 01 the
BM 117841. Conseq uently, it may be very
cha llengin g to d ifferentia te hypocellular
RCC from other BM failure disorders, especially from acquired aplas tic anaere
and inherited BM failure disorders. Down
syndrome-related myeloid neoplasms are
excluded from this diagnosis. The WHO
Working Group assigned RCC to a groop
of provisional entities.


ICD-{) code


Refractory anaemia of childhood.


RCC is the most corrmon subtype 01 MDS

in childhood accounting for about 50%ct




. I ....~




ire cases 11704, 1784 /. II is diagnosed in

all age groups and affects boys and gi rls

with equal frequency 111091.

Stes of involvement
Blood and 8 M are alw ays affected. Gen efally. spleen. liver and lymph nod es are
rot sites of initial ma nifestation .

Clinical features
The most common symptoms are malaise,
bleeding , fever and infection /1109). lym-

The classica l p ictu re of RCC is a PB
sme ar that shows red blood cell
antsopolknocytosts and macrocytosis.
Anisochromia may be present. Platelets
often di splay anisocytosis and occasionally g iant p late lets can be de tected.
Neutrope nia wit h pseudc -Pelg er-t-luet
nuclei and/or hypogranularity of neutrophil

Table 5.07 Minimal diagnostic criteria for reffactory cytopenia of childhood.

phadenopathy secondary to local or

systemic infec tion may be present, but
hepatosple nomegaly is ge nerally not a
feature of RCe , In up to 20% of p atients,
eocjrucal signs Of symptoms are reported

11 109/. Congenital abnormalities of different organ systems may be present.

Three Quarters of patients have a platelet
count be low 150 x10 9/L. whi le anaemia
with a haemoglobin concentration 01less
than 10 g/d L is noted in aboul half of the
affected children 111091. Mac roc ytosis of
fed cells evaluated accord ing to the
patient's age is seen in mos t The wh ite
blood count is generally decreased with
severe neutropenia not ed in about 25 %

11 1091.
The etiology is unknown in most cases.

c ytop lasm may be note d . Blasts are

absent or account for less than 2% of the
white blood cells .
On 8M aspirate smears dysplastic
changes should be present in two ditlerent
myeloid cell lineages, or exceed 10% in
one sing le cell line (Table 5.07). Erythroid
abnormalities inc lude nuc lear budding ,
mcmnucreanty karyorrhexis , internuclear
bridg ing. cytoplasmic granules and macr0cvnc Changes . Cells of granulocytic lineage ma y extubtt hyposegmentation with
p seud o-Pelqer-Huet nuclei . hypo-fagranularity of the cyt oplasm , mac rocytic (giant)
bands and cyt oplasmic-nuclear maturation
asynchrony. Myeloblasts account lex" fewer
than 5% of the 8M cells. Megakaryocytes
are usua lly absent or very low in nt.rn ber.
The detection of micromegakaryocytes is
a strong ind icator 0 1 RCC . Ring sioerobla sts are not fou nd .
In RCC with norma- Of hypercetlular 8M
specimens there is slight to moderate
inc rease of erythropoiesis with accumulation o f immature precursor cells. mainly
proerymrootaste. Increased numbers of
mitose s indicate ineffective erythropo ies is. Granu lopoies is appea rs slightly
10 moderately decrease d and ce lls of
granulocytic lineag e are loo sely scattered. Blasts ac count for less than 5% of
the 8 M cells , and C034 staining on the
biopsy is useful for verification of the blast
percentage. Megaka ryoc ytes may be nor
ma l, decreased Of incre ase d in number
and display dys plasia with non-lob ulated
nuclei. abnorma lly sep arated nucl ear

Bone marrow

Bone marrow




Dyspl astic changes'

andlor megaloblastoid
changes in at least 10%
of ery\tlroid PfeoJ~

Dysplasbc changes" in at
18ast 10%of granulocytic

precursors and neutrophils:


in variable numbers

A lew dusttl'Sof at least20

erythroid precursors.

No minimal diagnostic cmeria



Stoll in maturatiOn with

irnrl'lJnohistoctlemistry is
obIigab')' (COOl , CD41 ).
oltlerdysplasti: cIIange5t
ill variable I1lSI1bers

increased numbers of

lncmased I1UIT'tlers of mitoses.
Peripheral blood

Dysplastic changes'
nat I8ast10%of neutrophis;



AbnormaII'IIdear lobulation, mutIirKIdear oeh. I'lUdear bfidge$.

r Pseu:Io-PeIger-HlJiit eels. tlypo-or agrardanly, IJ'if'l b8rlds (In cases of severe neutropenia lI's crilena may nol
be fuIIiIed ).
f Megakaryocytes of vanabIe see WIttl $&p8r31ed nuclei orround
emude refraclofy C)'IOPel'Iia of chitJlood.

IlI,dei.Theabsence of megakyIX:yIes


Childhood myeocvsotasuc svocrore


bbl, 5.08
Comparison Of rnlIIphologicaI cnlefiaaI hypoplastic refracby cytopeoiaof childhood and aplasticanaemia inchildhood
R,1ractofy cytopenil of childhood

--- -_d_

lbIe . C)'tc*lgy

Pattry dcstrtluIion
lell shift



Agranuiabon ofcytoplasm

Ni.dear<ytoplasmlc malurabondefects

Marked dea8ase
Dysplastic manges



May be increased focally

or dispersed

May be increased

C034+ cells


MulI ~e

separated nuclei

Small round nuclei

Aplastic lNemia in childhood

BoN tIJafJDW' ISpI(BIe ~


l.Icting or single smaI bcus

WlIh Ie5slhat110cels W11tl

lICkflg or Y8IY lew eels, WIthool.

dysplasia or megalobIastlid change

I.JIc:UIg or ~ decrease,
Y8IY lewsmalloci 'NIth maturation

l.adUng orY8IY few, no dysplastlc


May be increased bcally Of

C034+ cells

No increase

lobes and charact eristic micromegaKaryocytes. There is no incr ease in reticulin

The majority of patients with RCC show a
marked decrease of 8 M cellularity, down
10 5-10% o f the normal age matched
veroe. The morphologic findings are similar to those observed in the normally
cellular Of hypercetlular cases. Immature
erythroid precursors form one or several
islands consisting 01 at least 10 cells . This
patchy pattern of evtreoooests is usually
accompanied by sparsely distributed
granulopoiesis. MegaKaryocytes are sig.
nilicantly decreased or absent. Although
micromeqakaryocvtes may be rare or not
always found, they should be searched
lor carefully as they are impo rtan t in

May be increased

Myelodysplastic syndromes

establis hing the diagnosis, Multiple sections prepared from the biopsy may be
helpful in roermtcanoo of abnormal rneqakarvocytes and immunohistochemistry to
identify mictomegakaryocytes is obligatory.
Fatty tissue between the areas of haematopoiesis can mimic aplastic anaemia
(Table 5.08). Thereforeat least two biopsies
at least two weeks apart are recommended to facil itate the detection of
representative 8M spaces containing foci
of erythropoiesis.

Differential di agnosi s
In children, a variety 01 non-haematological
d isord ers such as viral mtecuons. nutritional deficiencies and metabolic diseases
can give rise to secondary myelodysplasia,

thereby mimicking RCC (Table 5.09). In

the absence of a cytogenetic marker the
clinical course of cases suspected lX
RCC has to be carefully evaluated before
a clear-cut diagnosis can be made. rte
haematological differential diagnosis ....
ciuoes acquired aplastic anaemia. riter
ited 8M failure diseases and paroxysrral
nocturnal haemoglobinuria (PNH). In ceotrast to RCe. acquired aplastic aneere
presents with adipocytosis of the 8M
spaces with few scattered myeloid cells
there are no erythroid islands wllh
increased numbers of immature erythroblas ts, no granulocytic dysplasia and no
micromegakaryocytes (Table 5.08). CO'\<
trary to wnat is sometimes reported in adUls
with aplastic anaemia, at presentation
acquired aplastic an aemia of childhood
does not have mega loblastic features; IQl.
lowing immunosuppressive therapy, the
histological pattern of acquired apiasic
anaemia can no longer be separated fnm
tha t observed in RCC. The inherited au
failure oeoroers such as Fanconi ereera
ovskeratosrs conqemta . ShwachmarDiamond syndrome, amegakaryocytC
thrombocytopenia or pancytopenia
radioulnar synostosis show overlap
morphological features with ACC, They
have to be excluded by medical hisl~
phySical exemoanoo and the appropraale
laboratory and molecular studies belen
a definite diagnosis of RCC can be made
The clinical picture of PNH is rare in C/"Ml(j.
hood. although PNH clones in the absence of naemoivsts or thrombosis may
be observed in children with RCe 122921
The relation between RCe with two (It"
mo re dysplastic lineag es and retractor
cy topen ia with mu llilineag e dysplasia
(RCMD) has not vet been evaluated,
Currently il is recommended that children
who otherwise fit the criteria for RCMD be
considered as RCC until such studies
cla rify whether the number 01 lineages
involved is an important prococsc
discriminator in childhood MOS.
Mlcromegakaryocytes can be missec
easily in H&E stained 8M trephine biopsy
sectcos but can be more readily aweciated by the expression 01 platelet g/y(
proteins like C061 (glycoprotein lila), C04I
(glycoprotein lib/lila) or von Willebrancl
factor. Myeloblasts do not account ta
more than 5% of the 8 M cells , and oetectton of 5% or more CD34, mvetooeroe
dase, lysozyme and CD 117 positive biaS!

cells may lnc ncate progression to high

grade MOS. Clusters of myeloblas ts are
-ot seen in ACC.

The genetic changes predisposing to
!.lOS in childhood remain largely obscure.
The presumed underlying mechanism
may also give rise 10 subtle phenotypic
abnormalihes noted in many children with
MOS. Monosomy 7 is the most common
cytogenetic abnormality /1 109, 1704,
17841 . Other cytogenetic abnormalities
IlChJding complex karyotypes may also
be observed. Most cases of ACC show a
rnmal karyotype irrespective 01 8M eelltarrty. There is no difference in morpholOgy between cases with Of without
-oonosomy 7.
PtlstuIated cell of origin
saematopoenc stem celt with multihneage potential ,
Prognosis and pred ictiv e factors
(aryotype is the most important factor
'or progression 10 advanced MOS. Patents with monosomy 7 have a sign ificantly higher probability of progression
f an patients with other chromosomal abrcmannes or normal karyotype 111091.

Table 5.09
Dfsofders which maypresent witll morp hoj ogic.a lleal~ res indisbnguishable from refractory cytopenia ofct1ildhood,

Infectioos (e.g, c:ytomeo;lalovirus, herpes Wuses. parvovirus 819, YiscerailelsnmaniasiS)

Vrtamin detiOeocy (e,g.deficiency of vitamin B12,Iolale, Yilamln E)

Metabolic: disorders (e.g, mevalonatemase delk:iency)

Rhel.maliC disease
A.utoirmuIe I)mphoproIIferative dISOrders (e,g, FAS deftciency)
Mllochondrial deleloos (Pear9on S)YIdrome)
~ bone marrow laikJre disorders(e,g Fanconi anaema. dyskeratosis congeniIa, 5hwactmam-Oiarnond

syndrome , amegakaryocyIit~,1hrorTtlocytope WI1h absent radii, radioulnar syMSlO$lS.

Sedtel syndrome)
P~nochrnaI ~ (PM-I)
~ apIasbc anaemia

dlmg haemalologicall'llCOYllfy

Spontaneous disappearance of monosomy 7 and cytopenia has been reported

in infants, but remains a rare event I t3801.
In contrast to mooosomy 7, patients with
trisomy 8 Of norma l karyotype may experiencea long stablecourseof their disease,
Currently, haematopoietic stem ce ll transplantation (HSCT) is the only cu rative
therapy and is the treatment of choice for
patients with monosomy 7 or complex
karyotypes early in the course of their disease . In view of a low transplant-related
mortality HSCT can also be recorsrenoed
for pa tients with other karyotypes if a SUIt
able donor is available /1784 . 21041.

An expectant approach with careful observation may be reasonab le for patients

in the absence of transfusion requirements.
severe cytopenia Of infections. Because
early 8M failure can at least in part be mediated by t-een immunosuppression of
baenatoooese. irrmunosuppressive therapy can be a successful therapy strategy
for improving outlook in some children
with ACC 12033, 24711 .

Childhood myelodysplastlc syndrome


Acute Myeloid Leukaemia and
Related Precursor Neoplasms

Acute myefoid leukaemia with recurrent genetic abnormalities

Acute myeloid leukaemia with myelodysplasia-related changes

lllerapy-related myeloid neoplasms

Acute myeloid leukaemia, not otherwise specified
Myeloid sarcoma
Myeloid proliferations related to Down syndrome
Blastic plasmacytoid dendritic cell neoplasm

Acute myeloid leukaemia

with recurrent genetic abnormal ities

AML with balanced

This group is characterized by recurrent
genetic abnormalities of prognostIC significance. The most commonty identified are
balanced abnormalities: 1(8;21)(q22:q22),
inv( 16)(p 13. l q22) or I(16:16)(p 13 .' ;q 22),
1(15;17}(q22;q12) and 1(9.11 )(p22;q23)
1306. 72 1, 848 , 20361 . Each 01 these
structural ch romosome rearrangements

creates a fusion gene encoding a chimaeric protein that is required. but usually

not sufficient. for leukaemogenesis 120631.

Many of these d isease groups have charac teristic morphological and immunop henotyp ic features 1651. The categories
of acu te mye loid leukaemia (AML) with
1(8 :2 1)(q22:q22), iov( 16 )(p 13. 1q22) or
1(16:16)(p 13 .1;q 22 ) or l(lS;17)(q22:q 12)

are considered as acute reukaermas

without rega rd to blast cell cou nt. It is not
yet c lear if all c ases with t(9; 11Xp22;q23) ,
t(6 ;9)(p 23 ;q34 ). inv(3 )(q2 1q26,2), t(3;3)
(q 21;q26 2) or t( 1;22)(p 13;q 13 ) shoul d be
c ate go rize d as AMl when the blast cell
count is <20%. Many of the trans loca tions
are dete cted by AT-PCA whic h has a
higher sensitivity (1x 10"5) than c ytogenetic
analysis (1x 10-2 ) . Cases of therapy- related
AMUmyel odyspla st ic syndrom e (MD S)
may also have the balanced transloc ations
and invers ions that are d escribed in this
section, but the se should be diagnosed
as therapy-re lated AMUMDS with th e
associated g enetic abnormality noted.

Acute myeloid leukaemia with

t(8;21)(q22;q22); RUNX1
Def inition
Acu te myeloid leukaemia. with t(8 ;2 1)
(q22;q22); RUNX 1-RUNX7 T1 is an AMl
gene rally showing maturation in the neutrophil lineage.




D .A, Arber
R D , Brunning
M .M. le Beau
B , Falini


Vard ima~

J. Thiele
CD. Bloomfield

The t(8 ;2 1)(q 22;q 22 ) is found in -5% of
cases of AMl and in 10% 01 the prior acute
myeloblast ic le ukaemia with matu ration
(M2) c ategory of the French -AmericanBritish cl assification. It occurs predominantly in younger pat ients .
Cli nical featu res
Tumour manifestations , such as myeloid
sarconas. may be present at presentation .
In such cases the initial bone marrow (BM)
aspiration may show a mis leading low
number of b last cells. but should be
diagnosed as AMl despite a b last percentage in the BM of <20,
Morphology and cytochemistry
The co mmon morphological features inc lude th e presenc e of large blasts with
abundant basophilic cytoplasm, often
containing nume rous azuroph ilic granules
and perinuclear clearing or bots . A few
b lasts in many cases show ve ry large
gra nules (pseu do-Chedrak-Hiqashi gran ules), sug gestin g abnormal fusion . Auer
rods are freq uently found and appear as a
sing le long and sharp rod with tap ered
e nds; they may be de tect ed in mature
neutrophns. In addition to the large bla st
c ells , some smalle r bla sts, pred om inantly
in the peripheral blood (PBj, may be found.
Promyeroc vtes, myeiocytes and mature
neutroph ils with var iab le dy sp lasia are
present in the BM. These ce lls may show
abnormal nuc lea r seg mentation (e.q.
pse uoo-Pelqer-Hoet nuc lei) and/or cy toplas mic staining ab nor malities, including
homogeneous pink colo ured c ytoplas m in
neutrophil s. Dyspl asia of othe r Cell lines,
however, is uncommon. Eosinoph il precutsees are frequently increased. but they do not
exhibit the cytological or cytoc hemical ab normalities charac teristic of AMl associated
with ab nor ma lities of c hromosome 16:
basop hils and/or mast cells are sometimes
present in exce ss. A monocytiC component
is usually minimal or absent. Erythrob lasts
and meg akaryocytes are morphologically
normal. Rare c ases with a BM blast percentage <20 occur, These should be
cl assifi ed as AMl and not as MOS.

Acute rnyelord leukaemia and related p recursor neo plasms

FIg. lOl /IoI/IIl myeloid IeUlaen'ia Wlltl .8 11XQ22:Q22'

Bone marrow tllasts s/'lowirlg abl.n:lant pUr

qtIpIasm WIlh ~deari'1g em Wge~


Fig. 6.02 Myeloid sarcoma Biopsy of an orbitaIl'I'IaSl

from a child w;th AML with a ~ a;21)(q22;q22). There in
precursors scattered in !he preOominat1l lNs1
poplI lation.


Immunop henotype
Most cases of AMl with the (8;21 )(q22;q22)
transloc ation d isp lay a characteristc
imm uno phenotype with a subpopulatioo
of blas t cells show ing hig h intensity expression of CD 34, together with HLA-DR,
myercoeroxidase (MPO) and CD13. bJ
relatively weak expression of CD33j114Q,
17751. There are usually sig ns of granulocyt ic differen tiation with subpopuianonsd
cells showing granulocytic rnaiuranco
demonstrated b y CD15 and/or COO
expression . Sometimes po pulations cI
blasts showing matu ration asynchrony
are present (e .g . co-expressing COOt
and CD15 ). These leukaemias frequen
express the lymphoid marke rs CD19 and
PAX5, and may express cvtoptasrre
CD79a 1996, 1155. 2236} . Some cases
are terminal deoxynucleotidyf transferase
(TdT) posi tive ; however, TdT exoresscoe

generally weak. C056 is expresse d in a

fraction of cases and may have adverse
prognostic significance {1231

The genes for both reteroosreoc components of core bindll)Q lactor (CBF), RUNX I
(atso known as AML 1or CBFA) aOO CBFB
ere involved in rearrangements associated
WIth acute reukaemes {20631. The t(8 ;21)
(Q22;q 22 ) involves the RUNXI gene, which
encodes core- bi ndin g factor subunit
alpha and the RUNX 1T1(ETO) gene {608,
1294, 17331. The RUNX1 -RUNX1T1 fusion transcri p t is consistently detected in
patients with 1(8;21)(q 22;q 22) AML. The
CBF transcripti on factor is essential for
baematopolests. and tr ansformation by
RUNX 1-RUNX 1T1 likely results from transcriptional repression of normal RUNX1
target genes via abe rrant recr uitm ent of
nuclear transcription al co- repressor complexes. Over 70% 01pati ents show aooiIIQll3I chromosome abnormalities: e.q. loss
rJa sex chromosome or d el(9q ) with loss
rJ 9Q22. Secondary cooperating mutations
rJ KRAS or NRAS are common (30%) in
caedtamc CBFassociated leukaemias
~l. Mutations of KIT occur in 20-25%
01 cases (16961.
Postulated nor mal cout erpart
Myeloid stem cell wilh predominant reunophil differentiation.
Prognosis and predictive factors
Acu te myelo id leukaemia with t(8;21)
(q22;q22) is usually associated with a


Acute myeloid leukaemia with

inv(16)(pI3.1q22) or
t(16;16)(pI3.1;q22); CBFB
Ac ute myeloid leu kaemia with inv(16)
(p1 3.1q22) or t(16: 16)(p13,1:q22); CBFBMYH11 is an AML that usually shows
monocytic and gra nuloc ytic differentiation
and characteristically abnormal eosinophil
component in the BM {1258. 1393, 20631.
ICD-O code


Acute myeloid leukaemia with abnormal
marrow-eosoconns .

Either inv(1 6)(p 13.1q22) or t(16 ;16)
(p13. 1;q22) is found in 5-8% of all cases
of AM L. They can occur in all age grou ps
but are found predom inantl y in younger

Fig. 6.04 Acu1e myeloid leukaemia with associated

inv(16Kp13.1q22). AbnonnaI eosi~ . one VIlth Large
basophiliccoloured granules. aAl present

Clinical features
Myeloid sarco mas may be p resent at
initial diagnosis or at relapse and may
c onstitute the only evidence of relapse in
some patient s.
Morpholog y and cytochemistry
In these cases. in addition to the usual
morphological featu res of acute myelomonocytic leukaemia, the 8M shows a
variable number of eosinophils (usually increased. but soretrres <5%) at all stages
01 rretoratco without significant maturation
arrest. The mos t striking aboomantee involve the immature eosinophilic granules.
mainly evident at the promyelocyte and
myelocyte stages . The abnormalities are
usually not p resent at later stages of
eosi nophil maturation . The eosinophilic
granules are often larger than mose normally pr esent in immature eosmocnus.
p urp le-violet in colo ur, and in some cells
are so dense that they obscure the cell



goo d response to ch emotherapy and a

high com pl ete remission rate with longterm d isease-free surv ival when treated
with high dose cytaratnne in the consolidation phase 1228. 8481. Some factors
appear to adversely affect prognosis
including C056 expression aOO the presence of KfTmutations 1123. 16961.



inv (16)


Fig. 1.03 Acute myeloid leukaemia with inv(16)(pt 3.1q22). A The inversion 16 results from breakage and rejoining of bands 16p13.1 and 1&;22. G-banded normal (nI)
linrTIosome 16 and irW(16) are shown. B Dual rolor ftUOfllSC6OC6 in situhybridizalion: !he 5' regll)llof CBFB is labeled in red; !he3' regionin pen Anonnal ettromosome 16 has
~ 5'and 3' regions ~ 10 e<lch otherresultiog in a siogle yellowOf oveOappiog IlldIgreen signals, The invefsion 16splits theCBFB locus resulting in separale red andgreen
sigla/$. 80Itl interphase ooIIs have one normal 16etvomosome andoneinv(16),

Acu te myeloid leukaemia with recurrent genet ic abnormalities

11 1

morpho~y. The mature eosinophils may

occasionally show nuc lear hyposegmenlal ion . The naphthol-ASD-chloroacelale
esterase reaction. which is normally
negative in eosinophils, is charactenstically
faintly pos.tive in these abnormal eosmophils. Such a reaction is 001 seen in eoerophils 01 AML with the 1(8;21)(q22;q22).
Auer rod s may be observed in myeloblas ts. At least 3% of the blasts show
mveioperoxioase (MPO) reac tivity. The
monob lasts and promonocvtes usually
show non-s peci fic esterase reactivity,
although it may be weak er than expected
or even abs ent in some c ases. In ad dition
10the predominant monocytic and eosinoph il compo nents, the neutroph ils in the
8M are usua lly sparse, with a de cr eased
number of matu re neutrc phils . The PB is
not different from other cases of ac ute
mveromonccvnc leu kaemi a; eosinoobus
are not usua lly increased. but an occasional case has been rep orted with abnormal and increased eosi nophils in the
PB. While the major ity of cases 0'
inv( l6)(p13.1Q22) have been identified as
having abnormal eosinophils, in some
cases they are rare and d iffic ult to lind .
Occasooar cases with this genetic abnormality lack the eosinophilia or show
cxty myeloid mansatcn wilhoul a I"ro"lOCytic
CCJITlX)IlE!lll or only rro-ocvtc d ifferentiation.
Not infrequently, the blast percentage is only
at the threshold level 0120%or oc:casionally
lower. Cases with inv( l6)(p13.1 q22) or
t(16; 16):( p l3. l ;q22) and less than 20%
8 M blasts should be di ag nosed as AML.
The BM treph ine biop sy is usually hyperce llular, but may occasionally be normoce llular.

Most of these leukaemias are c haracte rized by a complex immunop henotype with
the presenc e of multiple b last populations:
immature b lasts with high CD34 and
CD l 17 expression and pop ulations d ifferentiating toward s gran ulocytic (CD13,
CD33. CD l5. CD65. MPO positive) and
monocytic (CD 14. CD4. CDl 1b.
CD64. CD36 and lysozyme positive) lineages Mat urat ion async hron y is often
seen. Co-expression 01CD2 with myeloid
mark ers has been frequently documented
but It is not specmc for this di agnosis.


The inv( 16)( p 13, 1q22) foun d in the vas t
major ity of this subtype and the less common t(16; 16)(p13, 1:q22) both resu lt in the

fusio n of the CBFB gene at 16q22 to the

MYH 11 ge ne at 16p 13.1 120061. MYH11
codes for a smooth muscle myosin heavy
chain 15061. The CBFB gene codes for
the core binding factor (CBF) beta subunit, a heterodimeric transcription tactoe
known to bind the enhancers of t-een
rece ptor (TCR). Cylokine genes, and other
genes. The CBFB subunit heterodimerises
with CBFA, the gene product of RUNXl,
one of the genes involved in AMl with
t(8;21 )(q22;q22). Occasionally cytological
features of AM l with abnormal eosropnns
may be pr esent without karyotypic ev id ence of a c hromosome 16 abno rmality,
the CBFB-MYH 11 being neverthe less
demonstrated by molecular genetic studies
(1533 , 1882) By co nventional cytogenetic
ana lys is, the inv(1 6)(p1 3,lq22l/t(16:16)
(p1 3 ,1;q22) is a sub tle rearra ng ement
that may be over looked when metaphase
pr epa rations are suboptimal. Thu s, at
dia gnosis, the use 01 FISH an d RT-PeR
methods may be necessary to document
the genetic alte ration . Secondary cytogenetic abnormalities occur in approximately
40% of cases, with +22, +8 (10 -15%
each), and del(7q) or +21(-5%) most
commonly observed 113901. Trisomy 22 is
fairty specific for inv( l6XPl3.lq22) patients.
being very rarely detected with other primary aberrations in AM l. whe reas +8 is
commonly seen in patients with other prtmary aberrations. Rare cases of A ML and
chronic myelogenous leukaem ia with both
inv(16 )(p 13 ,1q22) and t(9:22)(q34:q1 l.2)
have be en reported, an d this findi ng in
ch ronic myelog enous leukaemia is usually
assoc iated with accelerated or blast phase
of the disease 12454 J Mutations of KIT
occ ur in approximately 30% of cases 116961.

Acute promyelocytic leukBemia

with t(15;17)(q22;qI2);
Acute promyelocytic leukaemia (API. or
AML with t(15 ;17)(q22;q12)J is an AMLII
which abnormal promyelocytes predcmnate. 8cttl hypergrarUar'or "l'ypil:3" APLcnl
microgranular (hypogranular) types emt
ICD-O code


AM l with 1( 15;17)(q22;qt2).
Ac ute promyeloc yte leukaemia comprises
5-8% of AMl {20 78 1. The disease can
occur at any age b ut pati ents are predom inantly adul ts in mid-life.
Clin ical featur es
Typical and rricrograrlAar API.. are lrequerty
associated with disseminated inlravasoJa'
coagulation (DIG) . In microgranular API..
unlike typical API.., the leukocyte COlJ'lt IS
very high, with a rapid doubling time

Postulated normal counterpart

Haemetcooienc stem cell w ith potential to

differentiate into g ranuloc ytic and monocytic lineages .

Prognosis and predictive factors

Clinical studies have shown that pa tients
with AMl with inv(16)(p13 .1q22) or 1(16;16)
(p13.1;q22) achieve longer complete
remissions when treated with high dose
cytarabine in the consolidation phase
1848, 15301. j-owever. older patients have
d ec rea sed survival and tho se with KIT
mutat ion s have a higher risk of relapse
and worse survival 1546. 16961. Patients
with +22 as a secondary abnormality have
bee n reported to have improved ou tcom e
11390. 196 21.

Acute mye loid leukaemia and related precu rsor neoplasms

Fig. '.05 Acute promyeIocybc leukaema. A ~
~ type n bone marrow smear. Theft we IM'i
abnormal prornyelocyles wilhITIense amq:hIc,.....
lam. Sewr1lI ollhe promyeIocyles oontaillUl-.all
Auef rods(Iaggot oeIs). B M~ vWrt. 1'1 Ptripheral bloocI smear. There are several abnclmll
promyelocy!es 'Mthlobl,Jlaled. almostc:eretlnbm ru:Il
The cytoplasm coolains numerous small alI.tllPl*
granules: other ~Is appear sparsely ganlMr.



d .~15 )




1(15 ;17XQ22;Q12)

~ U16 AcuIe prorll)'8locybc Ieuilaen'U WIIh 1(15;11Mq22;q12), A The D'lslocabon 15;11 t'&SUts from br9akage a'ld r-.nion of bands 15q22 a'ld 11q12. G-bMded normallnl) 15
111 17 dY\::Jnc:lsanes (Ieft.l a'ldthe derivatNe ldetl 151n:l11 reslAng from ee IransIocation are sIlOWl'I on hi fil1C. BOuaIlDorl'unscence" sill hybtidiZ.alion M1h probes Pf.C.
l'~ iIl'lll RARA(17ql2) derroostrate the presence of a Pl.UWtA.lusion ~ from the 15;11 transIoca1o'l. Eactlof hi fw'ee IlBphase eels has one sep;nte red (PK)
J9W. (W'II sepataIe ween (RARA) sigIaI, In:l one \'dOw or~ ~greet1 si!r.aI ronsislenl..,1Il1tle pttl5etIC8 of a PMJRARA gene Iusioo.

IbphoIogy and cytochemistry

The nuclear size and shape in the aboorrrel promyelocytes of hypergranular APL
ere irregular and greatly variable; they are
::tten kidney-shaped or bilobed . The cytoplasm is marked by densely-packed or
even coalescent large granules, staining
:Yight pink, red or purple in Romanowsky
stains. The cytoplasmic granules may be
solarge andior numerous that they totally
rescore the nuclear cytoplasmic margin .
In some cells. the cytoplasm is filled with
Ire dust-like granules. Characteristic cells
containing bundles of Auer rods ("faggot
cells") randomly dis tributed in the cytoplasm are present in most cases, Myeloblasts with sing le Auer rod s may also be
Observed, A uer rod s in hyper gr anu lar
APL are usually large r than in other types
rJ. AML and they may have a c haracteristic
rrorpholog y at the ultras truct ural leve l
'.vith a hexagonal arrangement of tubular
structures with a specific period ici ty of
aeoroxrnaterv 250 mm in contrast to the
6-20 lamina r periodicity of Auer rods in
erertypes of AML. The MPO reaction is
always strongly positive in all the
exaernc oromyeiocvtes . with the reaction product covering the entire cytoplasm
l"Id often the nucleus . The non -specific
esterase reaction is weakly positive in ao;>rQximately 25% of cases. Only occaSJOnaI obvious leukaemic prooweiocvtes
may be observed in the PB.
Cases of rracrcqranurar (hypogranular)
A.PI. arecharacterized by distinct morphoQJicaI features such as apparent paucity
CJ absence of granules. and predomiI'lafltly bilobed nuclear shape 18111.

The apparent hypogranular cytoplasm

relates to the submicroscopic size of the
azurophilic granules. This may cause c0nfusion with acute monocytic leukaemia on
Romanowsky stained smears; however, a
small number of the abnormal promyelocvtes showing clearly visible granules
and/or bundles of A uer rods (faggot cells)
can be identified in many cases. The
leukoc yte count is frequently markedly
elevated in the microgranular variant of
APL with numerous abnormal mcroqranular promy elocytes in con trast to typical
APL. The MPO reaction is strongly pos itive
contrasting w ith the wea k or negative reaction in monocytes. Abnormal promveocytes
w ith deep ly baso ph ilic cy toplasm have
been de sc ribe d ma inly in the rela pse
phase in patients who have be en p reviou sly treated w it h al l-tran s rettnoic acid
(ATRA), The 8M biop sy is usual ly hypercel lular, The abnormal promyelocyt es have
relatively abu ndant c ytoplasm with nume rous g ranul es: occasionally Aue r rods may
be identified in well-prepared specimens.
The nuclei are freq uently convoluted
Acute p rom vetoc vtrc leukaemia with the
t( 15 ;17)(q22;q 12) (hypergranular or "typical" variant) is characterized by low
expression or absence of HLADR. CD34.
leukocyte integrins CD11a, CD 11band
CD18. a homogeneous, bright expression
of CD33, and heterogeneous expression
of CD13_ Many cases show expression
of CD117, although sometimes weak .
The granulocytic differentiation markers
C015 and COO5 are negative Of only

weakly expressed 11654. 1678} and CD64

expression is common. In cases with
microgranular morphology or cera Iran.
scr ipt of the PML-RARA fusion gene there
is frequent expression of CD34 and C02,
at least on a fraction of cells 16531. Ap proximately 20% of APl cases express
C056. which has been associated with a
worse outcome 16901 Using enrourocvtoChemis try, antibodies against the PML
gene product show a characteristic nuclear multigranular pattern with nucleolar
exclusion, in contrast to the speckled relatively large nuclear bodies seen in normal
oromverocvtes or blas ts from other types
of AML (6621.
Genetic s
In ad d ition to its thera pe utic imp act, the
sensi tivity of APL cells to ATRA has led to
the d iscovery that the retinoic acid receptor
alpha (RARA) gene on 17q12 fuses with a
nuclear regulatory fac tor gene on 15q22

Fig. 1.07 Aone promyeIocytic Ieukaema. Bone IIIiWTtIW

biopsy. Abnormal prorrt)'eIotyIe wilIl abl.ndal'll hyper.
gran,Aated cytlpIasm. Thenudei are genefaIylWId tI
oval. SewlraI of !tie nudei llfll lfregU;w and I!YagrIaled

Acute myeloid leukaemia With reconenr genetic ebroerrautes


the p rognosti c signific ance of FLT3-JTO

mutations in this di sease remains unc lear
/690 , 1199 1.

Fig.6.08 PM!. anI1bod'y n aaM promyeIocybc Ieukaen'Ia

showing a etlaractetistic Ill.Ideaf mufbgrnular paltem
\MIll ru:leoIar exclusion.

(o ronvelocvnc leukaemia Of PML gene)

giving rise to a PML-RARA fusion gene
produCII506, 529 . 14521. Rare cases 01
APt. lacking the classic t(15:17)(q22;q 12)
on routine cytoqenenc studies have been
described with complex variant transiocations involving both chromosomes 15
and 17 with an additional chromosome Of
with submicroscopic insertion of RARA
into PML leading to the expression of the
PML -RAR4 transcript ; these latter cases are
considered as cryptic Of masked t(15 ;17)
(Q22;q12) /6471. Mor pho log ic al analysis
shows no major d ifferences be tween the
t( 15;17)(q 22 ;q 12) positive group and the
PML -RA RA positive p atients wi thout
t( 15; 17)(q22;Q12) , Secondary cytogenetic
abnormalities are noted in - 40% of c ases .
with +8 being the mos t frequen t (10- 15%).
Mutatio ns involving FLT3, including internal tand em duplic ation (ITO) and tyrosine
kinase doma in mutations (TKO) oc cur in
34-45% of A PL. FLT3-l TO mutation s are
mo st co mmon and a re associated with a
high er white b lood ce ll co unt. mlcrocranurar b last ce ll mo rph olog y and involvement of the bcr3 b reakp oint at PML 1318,
747 ,1 199).
Postulated normal counterpart
Myeloid stem ce ll with potential to d ifferent iate to granulocytic lineage.
Prog nosis and pred ictive fac tors
Ac ute promyetocyttc leukaemi a ha s a
p artic ular sensi tivi ty to treat ment w ith
ATRA. which acts as a dilferentiating ag ent
1342. 2 152/. The prognosis in APt.. treat ed
optimally With ATRA and an anlhrac ycl ine
is more favou rab le than lor any other AML
cytogenetic subtype. and cases of relapsed
or refractory APt. show a generally good
respo nse with arsenic tr ioxide th era py
1607.6851. Expression of CD56 is associ ated with a less faVlJU(able prognosis while

Variant RARA transl ocations

in acut e leukaem ia
A sub set of c ases. often with mor phological fealures resembling acute ~
cvtc leukaemia. show variant nensocetcos
involv ing RARA . These variant fusion partners inc lud e ZB TB 16 (previously known
as pr omv eiocvtrc leukaemia zinc finger
gene or PLZF) at l 1q23; the nuclear matrix assoc iated g ene (NUMA 1) at l 1q 13;
the nuc leophosmin gene (NPM1)at5q35
and STATSB at 17q l 1.2 124881.
Some c ases with vari ant transiocanons
we re initially reported as having APL
morphology 119141. However. the t(l l ;l7)
(q23;Q12); ZBTB16-RARA subgroup shc1ws
some morphological d ifferenc es with a
predominance of cells with reg ular nuclei,
many granules . usual absence ot Auer
rod s. an increased number of Pelg eroid
neutroph ils and strong MPO activity {19141 .
The initial cases of APL associated With
t(5 ;17)(q35 ;q1 2) had a p redom inant population of hypergran ular promyeiocvtes
and a minor population of hypogranular
promyelocytes; Auer rods were not oennteo
by ligh t m ic rosc op y 147 6 1. Some acute
promyelocytic leukaemia variants. incl ud ing t( 11; 17)(q 23;q1 2) w ith ZBTB16-RARA
and cases wit h S TAT5B RA RA fusion s are
res istant to ATAA 114521, A PL with the
t(5 :17)(q35;q 12 ) appears to resp on d to
ATRA {1452].
Cases with these va riant transroc atlons
should be d iagn osed as AML w ith a
va riant RARA transloc ation.

Acute myeloid leukaemIa with

t(9;II)(p22;q23); MLLT3MLL
Ac ute myeloid leuk aemia with t(9; 11)
(p22;q23): MLLT3-MLL is usually associated w ith monocytic featu res .

ICD-O code

present in 9-12% of paed iatric and 2%rJ

adult AML 1306 . 721 1.

Patients may pr esent with d isseminaled
intravascular coagulation. They mayhave
extramedullary myeloid (monocytic) serco
mas and/or tissue infiltration (gingiva, skn~
Morphology and cylochem;Sby
There is a strong association between
acute monocytic and myelomooocytlc
leukaemias and t(9; 11)(p22;q23). altho.ql
occasionally the t(9 ;11) is detected i'l At.(
with Of without maturation. MonobIaSlS
and promonocytes typically predominale
Monoblasts are large cells . with abt.r1ci<rf
cytoplasm which can be moderately to.,.
tensely basophilic and may shcwt
pod lormabon. Scattered fine azurophilo:
granules and vacuoles may be preset
The rrooobasts usually have round BJCIl'i
With del icate lacy chromatin, and one f1
more large prominen t nucleoli. Prorcoo
cvtes have a more irregular and delicat~
convoluted nuclear configuration; the evtr
plasm is usually less basop hilic ana
sometimes more obviously granulated,
with occasional large azurophilic grarUe!
and vacuoles. Monoblasts and proro-o
cvtes usually show strong positive f'lCJl'
specific esterase reactions. The rrcocoass
ofte n lack MPO reactivity.


Immu nophenotype
Cases 01 AML with the t(9: 11)(p22;q23) ir1
c hild ren are associated with strong
exp ression 0 1 CD33, CD65 , CD4 and
HLA-DA, while exp ression at CD 13, CD34
and CD 14 is usually low /491 1.
Most AML c ases w ith 11q23 abnormalities
express the NG2 homologue (encoded by
CSPG4j, a c hond roitin sulfate molecule
reacting with the Mab 7.1124561. MostacU:
AM l case s w ith 11q 23 ab normalities
exp ress some marke rs 01 monocac
differentiation including CD14, CD4, COlle
CO l lc. CD64. CD36 and lysozyme, v.tIire
variable expression of imma ture markers
suc h as CD34 and CD1 17 and of CD56
has been reported {154 11.


Ac ute myeloid leukaem ia . 11q23 abnorma lities.

The t(9;11)(p22;q23) may occur at any
age. but is morecomnor I in child ren. being

Acute myeloid leukaemia and related precursor neoplasms

Molec ular studies have iden tified a t1t.rna'I

homologue of the Drosophila trithorax
gene design ated MLL (HRX), that results
in a fusion gene in translocations invo/Vllg
11q231 1141. The MLL p rotein is a histl)1!!
mettwnransterase that assembles in pro.
tein complexes tha t reg ulate g ene Iran.

scription via ctuomato remodel ing. The

~9:11)(p22:Q23) involving MLLT3 (AF9 ) is
toe most common MLL translocation in
AML and appears to represent a distinct
enhty. Secondary cytogenetic abnormalities
are common with t(9:11) (p22:Q23). with
+8 most commonly observed, but do not
appear to influence survival [306, 15311.
Postulated normal cou nterpart
aaenaiopoeuc stem cell with multiJineage

Prognosis and pred ictive factors
Acute myeloid leukaemia with the
. 9:11XP22;Q23) has an intermediate sur.....aI and one that is supefior to AML with
e:tner l1Q23 translocations 11531. 18911.
Cases with the t(9: 11) and <20% blasts
II'IJSt be monitored closely fOf development of more definite evidence of AML.
'fi1riant MLL translocations
in acute leukaemia
C>ief 80 different translocalions involving
MLL are now described in adult and
paediatric acute leukaemia, with over 50
eensiccato n partner genes now cnaraclenzed 11 470. 20081. rrensiccetcoe involving MLLT2(AF4). resuitmq predominantly
n acute lymphoblastic leukaemia (ALL).
end MLLT3(AF9). resuhing predominan tly
n AML, are the most common. Other MLL
eensccauons that commonly result in AML
rcuoe the MLLT1(ENL). MLLTIO (AF1O),
MLLT4 (AF6) and ELL as partner genes,
Other than the ML L-ELL fusion resulting
Irom the t(1 1:19)(q23:p13,1), which is
res often associated with only AML,
these fusions occ ur pr edom inantly in
AML, but may be seen in ALL as well. Up
10 one third of MLL transiocauons in AML
ee not detectable on co nventional karyotype analysis , and FISH or other
molecular stud ies may be necessary to
dentify these variant translocations 120081.
AML with these fusions usually have
myelomonocytic or monoblastic rro rpnobgic and immunophenotypic features
While in the p ast all of these translocali:lns were encompassed by the category
rj AML with 11q23 abnormalities. the diagnosis should now specify the specific
abnormality and should be limited to
cases with 11q23 balanced translocations
fI'o'OIving MLL. For example. a case of
AMl with an MLL-ENL fusion would be
dl8gnosed as acute myeloid leukaemia
dh ~11 ,19)(q23;p13.3): MLL-ENL.
40Jte myeloid leukaemia with cytogenetic

Fig. 6.09 AML (monoblaslic) WIth t(9;1'Xp22;q23). Bone marrow smears A 5evefall'l'lOl'lllblasts. some WIth very
allur'l<Ia1l cytoplasm and h myelopeloxidase,..1iYe azurophilic granules are present B Non-speciflc esterllse
reacbon showing I1lensely poslIiYe IrOlOblasts,



Fig. 6.'0 Mt. (1TIOI'I:ltyIic) \Mlh 1(9;11)(p22;q23}. Bone tJWI(M ~ A ThenlarelilMlt8llfOIObIasts and ~
with very pale cytor*lsm containing numerous fine anrophiic ~_ The promonocyles have delicate rudear lolds.
B Noo-speci1ic esterase S\aII"I_ The pn::monocytes are intensely reactive.

abnormalities associated with prior therapy or myelodysplasia. such as t(2; 11)

(p2 1;q23) or t( 11:16)(Q23:p 13.3), should
be diagnosed as therapy- related AML or
AMl with myelodysplasia- related changes
(See Cha pter on therapy-related myeloid

Clinical features
Acute myeloid leukaemia with t(6:9)
(p23 ;Q34) usually presents with anaemia
and thrombocytopenia, and often with
pancytopenia, In adults, the presen ting
white blood cell count is gener ally lower
than other AML types with a median white
blood cell count of 12x1()9/L 120351,

Acute myeloid leukaemia with

t(6;9)(p23;q34); DEK-NUP214

Morphology and cytoche mistry

The BM blasts of AML with t(6:9XP23:q34)
may have morphologic and cytochemical
features of any FAB subtype of AML other
than acu te promyelocytic leukaemia and
ac ute megakaryoblas tic leukaemia. with
AML with maturation and acute mveromonocytic leukaemia the most common
128, 1676,20351_ Auer rods are present in
approximate ly one third of cases, Blasts
are myeloperoxidase positive and may be
positive or nega tive for non-specific esterase . Therefore , there are no features
specific to the blast cell population in this
entity Marrow and PB basophilia. defined
as >2% , is generally uncommon in AML
but is seen in 44-62% of cases of AML with
t(6;9)(p23:q34). In addition. most cases
""'" evidence oIgarL<ocybc and _
dysplasia. with megakaryocytic dysplasia
possibly less common. Ring siderooiaere

Acu te myeloid leukaemia with the 1(6 :9)
(p23:q34); DEK-NUP214 is an AML with
or without monocytic features that is often
associated with basophilia and multilineage dysplasia {17 14, 20351 .
The provisional code proposed for the
fourth edition of IGO-D is 986513.
The t(6:9Xp23;q34) is detected in 0.7-1 .8%
of AML, and occurs in both children and
adul ts with a median age 01 13 years in
childhood and 35 years in adults 1306.

Acute myeloid leukaemia wIth recurrent genetic eoocereetes


a re presen t in a subset of cases, The per-

centage of 8M blasts is variable. and

some cases may present wi th less than
20% bl asts.
The blasts have a non-specific myeloid
immunophenolype with consistent expression of myeloperoxidase. CD13,CD33.
C038 and HLA-DA 128, 1676,20351 . Most

cases also express CDl17. CD34 and

C0 15 while a subset 01 cases express the
monocyte-associated marker CD64 and
approximately hall are terminal oeoxvoodeotidy1 transferase (TefT) positive . Other
Iymp/loid antigen expression is Ul'lCOlTITlOl1 .
Gene tics
The 1(6:9)(p23:q34) results in a fusion 01
DEK on chromosome 6 with NUP214 (CAN)
on chromosome 9. The resulting nocieoporin fusion protein ac ts as an aberrant
transcription factor as well as altering nuclear transport by binding to soluble transport factors 119491. The 1(6:9) is the sole

clonal karyotypic abnormality in the vast

majori ty of cases, but some patients will
have the t(6:9)(p23:q34) in association with
a complex karyotype 120351. FLT3-lTO
mutations are very common in AMl with
t(6;9)(p23;q34) occurring in 69% of paediatric cases and 78% of adult cases
11676. 20351. Fl.T3-TKO mutations appear
to be uncommon in this entity.

Postulated normal count erpart

Haematopoietic stem cell with mullilineage
Prognos is and predictive factors
Acute myeloid leukaemia with t(6:9)
(p23;q34) in both ad ults and children has
a generally poor prognosis. similar to other
AMl with unfavourable cytogenetic abnorm alities . Elevated white blood cell
counts are most predictive of shorter
overall survival and increased 8M blasts
are assoc iated with shorter disease-free
survival. Based on limited data. allogeneic
stem cell transp lantation may be associated with better overall survival compared
to patients with no stem cen vansptantatoo 12035ICases with t(6;9XP23:Q34) and
<20% blasts must be monitored closely
for development of more definite evidence
of AML.

Acute myeloid leukaemia

with inv(3)(q21q26.2) or
/(3;3)(q2/;q26.2); RPN/EVIt
Acute myeloid leukaemia with inv(3)
(021026.2) '" 1(3;3Xo21;q26.2); (RPrvI-EVII)
is an AML that may present de novo or
arise from a prior MOS. It is often associated with normal or elevate d PB platelet
coun ts and has increased atyp ical BM
meoakarvcc vtes with mono- or bi-lobated
nuclei and assoc iated multil ineage dysplasia (225, 1983,2 131).
ICO-O code
The provisional code propo sed for the
fourth edition of ICD-O is 986913.
Acute myeloid leukaemia with inv(3)
(q21q26.2) or t(3:3)(q21;q26.2) represents
1- 2% of all AML 1306 . 20361. It occurs
most commonly in adults with no sex
predilect ion.

Fig.S." AML. with t(6:9)(p23:Q3-t). The blasts are

adn...ed with dyspIastlc erythroid precursors and

Clinical features
Patients most co mmonly present with
anaemia and a normal preteret count .
although marked thrombocythaemia
occurs in 7-22% of patients 1845.19831.
Patients may present de novo or have a
prior MOS. A subset of patients present
with hepalosptencmegaty. but "",,",,deropathy is UllCOI' llllOlI11983. 2C04, 21891.

scallered ~ (centre. '9ll).


Acute myelOid leukaemia and related orecursoe neoplasms

Morphology and cytochemistry

Periphe ral bloo d chan ges may include
hypog ranular neutrophils with a pseudoPetcer-Hcet anomaly, with or without
assoc iated peripheral blasts. Red eel
abnormalities are usually mild withOOt
teardrop cells. Giant and hypogranulat
platelets are common and bare megakaryocyte nuclei may be present 12251. The
8M blasts of AML with inv(3)(q2 1q26.2l cr
t(3 :3) (q2 1:q26.2) may have morphologic
and cytochemical features of any FAa
SUbtype of AML other than acute promyeIlr
cytic leukaemia with acute myebd
Ieukaertia without maturation. acute myeIomonocytic leukaemia and acute mega.
karyobIastic leukaemia morphologies rn:lSl
cornrnon 1715. 19831. A subset of cases
has less than 20% blast cens at the tiTle
of diagnosis. including cases with fsallles
of chronic myelornonocytic leukaemia
Multihneage dysplasia of non-blast eel
BM elements is a frequent finding WII/1
atypical megakaryocytes most cQlTllTlCll
1715. 1054. 19831. Megakaryocytes may
be normal or increased in number WI
many small
IJm) monoIobed a
bilobed forms. but other dysplastic mega.
karsocvtc forms may also occur. Dysplasia
of maturing erythroid cells and neutroptws
is also corrrnon . Marrow eosooonss. teso
phils and/or mast cells may be increased
The BM biopsy shows increased sma
hyr:x>lobated megakaryocytes. Bone marnJo\!
cellularity is variable with some cases presenting as hypoc ellular AML Marrow
fibrosis is variable.


Immunophenotypic studies of AML with
inv(3)(q21q26.2) or t(3:3}(q21:q26.2) are
limited. The blast cells generally express
C0 13. C033. HLA-OR. CD34 and C03S
Blast cells of some cases also abe rranf
express C07 and a subset may express
meg akaryocytic markers such as CQ4t
and C06 1. Abe rrant expr ession of lym.
photo markers other than C07 appears
uncommon [20041.
A variety of abnoemauties of the long arm
of chromosome 3 occur in myeloid rnalo(t
nances. with inv(3)(q21q26.2) and t(3:31
(q21 ;q26.2) being the most common. The
abnormalities involve the oncogene EVIl
at 3q26.2 . or its longer form MOS1-EV!
and RPN7 at 3Q21 APN1 may act as <WI
enhancer of EVIl expression resulting
increased cell proliferation , and impaireo

cell differentia.lion: it induces naen etoooreticcell transformati on ( 1236, 1609, 21251 .

Other cytog enetic aberrations involving
3q26.2, such as t(3:2 1)(q26.2:q 22) res~tting in an EVI1-RUNX 1 fusion and usually seen in therapy-related disease, are
not included in this disease ca tegory.
Secondary karyoty pic a bnormalities are
common with inv(3)(q21 q26.2) and t(3;3)
(Q21;q26.2) with monosomy 7 most common, occu rring in approximately half of
cases, followed by 5q deletions and com"'" ...",.",..1 1963/. These abroonalrties
may precede the development of the
3q262 abnormality 116091.
Patents with AMl with inv(3)(q21q26.2)
3:3Xq2 1;q26.2) show overexpression
d EV/1 and GATA2, bulthese fIndings do
ro appear to be specific for the genetic
aonormality 11236,16091 .
Patients with chronic myelogenous leu-.aemia may acquire inv(3)(q21q26.2) or
(3:3kq21;q26.2), and such a finding usually
portends accelera ted or blast pha se of
!heir disease , Cases with both t(9 :22)
(Q34;q11.2) and inv(3 )(q 21q 26.2) or t(3;3 )
(q21;q26.2) are best considered as ag g-essive phases 0 1 ch ronic myelogenous
leukaemia. rather than AMl with inv(3)
(q2tq26.2) or t(3;3)( q2 1;q26.2).
PosllJlated normal counterpart
tiaematopoietic stem cell with multilineage
Prognosis and predictive factors
AML with inv{3)(q 2 1q26 .2) or t(3;3)
(q21:q26.2) is an aggressive di sease with
sort survival 171 5 , 1834, 1983 1. Two patients with AMl with inv(3)(q2 1q 26.2) were
reported to show a response to a rsen ic
trioxide with thalidomid e, w ith one act uevi'19 complete rem ission 11 824 j , Cas es
lI,ttl inv(3)(q2 1q2 6 ,2) or t(3:3)(q 21;q2 6 .2)
and <20% bla sts must be mo nitore d
ClOSely for development of more d efinite
evidence of AMl.

Acute myeloid leukaemia

(megakaryoblast/c) with
~ 1;22)(p I 3;q I 3); RBMI5-MKL 1

ICD-O code
The p rovisional cod e prop o sed fo r the
fourth edition of ICD-D is 991 1/3,
The t(1; 22)( p13:q 13) is an uncommon
abnormality in A Ml, repr esenting < 1% of
all c ases. It most commonty occurs in
infants without Down syn d rome, with a
female pred ominance .
Clinical features
Acute mye lo id leukaemia with t( 1;22 )
(p13;q13) is a de novo AMl restricted to
inf ants and young chi ldren (3 yea rs or
less) with most cases occurring in the first
6 months of life (median, 4 months). The
'last rnajonty of cases present with
marked organomegaly, especially hepatosplenomegaly. Patients alsohaveanaemia,
and usually have throm bocytope nia and
a moderat ely eleva ted white blood cell
Morphology and cytochemistry
The PB and BM blasts 01AML with t( 1;22 )
(p13;q 13) are similar to those of acute
megakaryoblastic leukaemia of AM l, NOS.
Small and large megakaryo blasts may be
p resent and they may be admixed with
more mor ph olo gically und iffe rent iated
b last ce lls with a high nuclear-cytoplasmic
ratio resembling ivmorobrasts. The megakarvobtasts are usually of medium 10 large
size ( 12- 18 urn) with a round, sligh tly irrequrar Of indented nucleus with fine reticular ch romatin and one to three nucl eoli.
The cytopl asm is ba sophilic , often ag ranular, and may show d istinct ble b s o r
pseudopod formati on. Mic romeg akaryocvtes are common , but d yspl astic features of gra nu locytic and eryth roid c ells
are not usually p resent The 8 M biopsy is
usually normocellular to hyperce llular with
retic ulin and co llage nou s fib rosis usually
presen t. Cases may show a stromal pattern o f BM infiltration mimicking a metastatic tumour 120 5, 341 1. Cy toc hemical
stains for Sudan black B (SBB) and MPO
are cons istently negative in the megakaryob lasts. A subset of cases will have less
then 20% BM bla sts. but a low blast cell
count due to difficu lties aspira ting BM secon dary to fibrosis sho uld be excluded .

Fig. 6.12 AML WIth irlV(J)(Q21 q26.2). Bone marrowaspAte wrlhincreased blasts and atypica, rncnJIobaIed

marker CD42 (g lycoprotein Ib) is less frequently present. The myeloid~associated

markers CD 13 and CD33 may be positive.
CD34 , the pan-leukocyte marker C045,
and HLA-DA are often negative; CD36 is
Characteristically pos itive . Blasts are negative With MPO antibodies. lymphoid
markers and terminal deoxynucleotidyl
trans ferase (TdT) are not expressed, Cytop lasmic exp ression of CD4 1 or COBt is
more specific and sensitive than surface
staining ; the higher specificity is due to
possible adherence of p late lets to b last
cells in othe r types of AML, which may be
misin terpreted as positive staining by flow

Patients sho uld have karyotypic evidence
of t(1 ;22)(p1 3 ;q13) or molecul ar genetic
evidence of a RBMI5-MKL 1fusion, In most
cases, t( 1:22)(p 13;q 13) occurs as the sole
karyotyp ic ab normality, This trans locat ion
resu lts in a fusion of RNA-b inding motif
protem-rs (RBM1S) (also known as OTT)
and megakaryoc yte Ieukaemia- t (MKL 1)
(also known as MAL) (1352 ). RBMIS enco des RNA recognition motifs and aspen
par alog and ortholog C-terminal (SPOC)
domain , whi le MKL 1 encodes a DNAbin d ing motif involved in chromatin organization. The fusion gene may modul ate
chromatin orga nization . HD X-ind uced differenti ation and extrace llular sig naling
pathways 11461}.
Postu lated normal counterpart
Myeloid stem cell with predominant megakaryocytic d ifferentiation .

,' cute myeloid leukaemia with t( 1;22)
(p13;q 13); RBM15-MKL 1 is an AMl genEJaJy showing maturation in the megakaryocyte lineage.


The megakaryoblasts express one or more

of the platelet g lycoproteins: CD41 (glycoprotein lIb/l lla ), and/or COO1 (glycoprotein
ilia). The more matu re platelet-associated

Prognosis and predictive factors

Although early report s suggested a poor
prognosis for AM l with t( 1;22)(p13; q 13)
1205.34 11. more recent studies have found
the patients to respond well to intensive

Acute myelotd leukaemia WIth recurrent genetic abnormalities


AML chemothe rapy with long disease-free

survival 16201. Cases wi th the t(1;22)
(p13;Q 13) an d <20% blasts on aspirate
smears should be correlated withthe biopsy
to excjooe 8M fibrosis as a cause of a
falsely low b last cell count. 11 this is exc luded, these pat ients must be monitor ed
closely for d evelopment of more definite
evide nce of AML, such as the pres enc e
of extramec ouary di sea se or myeloid sarco ma,

AML with gene mutations

In add ition to translocations and inversions,
specific gene mutations also occur in AML.
They include frequent mu tations of fmsrelated tyros ine kinase 3 (FLT3), nucleophosmin (NPM 1) and . less corrmonly,
mutations of the CEBPA gene (encoding
the CCAAT/enhancer bi nding protein -c).
KIT, MLL. WT1 , NRAS and KRAS. Alone or
in com bination, mutations of FLT3, NPMI
and CEBPA have been reported in patients
with AML with a normal karyotype where
they have prognostic significance in the
co nte xt of most cu rrent therapies . althoug h they may be seen in pat ients with
ab normal karyotypes as well 115321,
FLT3, loc ated at 13Q1 2, encodes a tyrosine kinase rec ep tor that is involved in
haematopoietic stem cell differentiation
and proliferation. FLT3 is expressed on
these progenitor cells as w ell as on the
b last cells in most cases of AML. FLT3
mutations may occur with any AML type
(20-40% of all cases) and in MOS, but
a re mo st com mon in AML with 1(6 ;9)
(p23;q34 ), acute promy elocytic leukaemi a
and AML with a norm al karyotype 11184,
2035 1, The two primary typ es of FLT3 mutations a re intern al tandem duplications
(FLT3-ITO) within the lu xtamemb rane doma in (75 - 80%) and mutations affecting
codons 835 or 836 01 the second tyrosine

kinase domain (TKO) (20-35%). 'vVhile FLT3

mutations may occur in association with
recurrent cytogenetic abnormalities, such
as t(6;9XP23 ;Q34) and t( 15;17){Q22;Q12),
they may also occur with other so-called
cooperating mutations. FLT3-HOmul ations
are associated with an adve rse outcome,
b ut the sig nificance of the less common
FLT3- TKO mutations remains c ontroversial
1117, 1447,2396 1. Detection of FLT3-lTO
is important be cause th e prognosis of
most cytogeneti cally normal AML subtypes
correlates with the presence or ab sence
of this muta tio n KIT, loca ted at 4Q11-12,
is a mem be r of the type III tyrosine kinase
family and encodes a 145-kO transmembrane glycoprotein. Gain-of-function mutations of KIT occur in a variety of d iseases,
including g astrointestinal stromal tumours.
germ cel l tumours , mastocytosis and AML
Mutations of KI Thave been shown to have
prog nostic signifICance among AML with
t(8;2 1)(Q22 ;Q22) and inv( 16Xp13.1 Q22)1
t(16;16)( p 13.1;Q22), in which mey are associ ated with a poo r prognosis 11696 1.
These KITmutations most common ly occur
within exoo 8 and 17. To date, WT1 rrotat cos
have been shown to co nfer a poor prog nosis in AML patients with a rormat karyotype 11 696A I, but there is less compelling
evi de nce of p rognostic significance for
the less freq uent mutations of MLL, NRAS
and KRAS . Molecular studies have shown
tMtthe MLL gene is rea rrang ed more freQuently than is revea led by conventional
cytogenetic studies. A partial tand em dup lic ation of MLL has been reported in
5- 10% of ad ults Wi th a norma l kary otype
[313,6031 and in patients with isolated trisom y 11[3141. Its adv erse prog nostic significance in patients with a normal karyotype
is reported to be e liminated in pati ent s
rec eiv ing an auto logous stem ce ll tran sp lant in first rem ission 123951.
NPM1 mutations occur in about one third
01 adul t AML an d CEBPA mutations in

Acute myeloid leukaerTlla and related precursor neoplasms

6-15% of all AML. NPM 1 mu tations are

typically heterozygous and the leukaema
cells retain a wild-type allele [6671. They
usually oc cur at axon 12 01 the NPMr
gene 16661 but rarely involve exon 9 a t1
11 About 40 mutation variants ha...e
been described 16671. the most COf1Yl"O'l
being mutation A, a TCTG tenanucreotoa
dupl ica tio n at posi tions 956 to 959, which
accounts lor 70-80% of ad ult AML wltn
NPMI mut ation , Ind ep end ent of type,
NPM 1 mutat ions g enerate common ejeatrons at the C-terminus of NPM t
leukaemic mutants, i.e. re plac ement o!
tryp tophan (s) at position 288 and 290Mld
cre ation of a nuclear export signal (NESl
motif, which mediates aberrant localization of NPM to the cytoplasm 16671.
CEBPA (CCAAT/enhancer-bind ing pro.
teo-c) mutations occur only in AMl <W'C
are usually baneic mutations . The normal
ge ne encodes a transcription factor Illvolved in control 01 proli feration and dd
ferent iatio n of myeloi d p roge nitors. Whi'e
mutations may occ ur throughout the whole
gene sequen ce , tw o general c ategories
of mutat ion occur: out-of-frame insertions
and deletions in the Nterm inal regioo art
in-f rame insertio ns and de let ions in t'le
C-terminal reg ion. Mutations of NPM I ere
CEBPA are freq uently observed in At.l
with a normal karyotype an d , in the absence of FLT3-lTO, are associated wma
favourable prognosis 1216, 602 , 19711
2198 ,23311. In view of the freque ncy :;
Ihese mutations. the ir prognostic sigMcance. and their association with certan
morpho logic and clinical features , it has
bee n sug gested that they may ident~'
uniqu e subse ts of AML. Therefore, tIW
new provision al entities, AML with mutated
NPM 1 and AML with mutated CEBPA are
proposed. These have been giv en provisio nal status bec ause they have beer
on ly rec ently described and more sfudt
is requi red to confirm these categories as



Tillie &.01

Moleculaf geneticalteratioos allectlrtg dir1ical outcome of AML patients in specific qtogeoeUc groups.



KiT mutabon$





Wlth KITmutatons (especially ecse ill 8loo17) lXIIf4)8red 'Mtt1
{233A., 2Q09A,
CIRandRI Slgoificantly higher fof peteots wilh KITmutaloons compared Wlth patients with wild.fype KIT{310A, 1696}
EfS signlf!canny shorter forpabents with KITmutatons (especialy eese n e.oo 17) ~red IIIilh pall8/1ts with w~ KIT(233A.


OS si!1liflCalltly shortef I'tlr patents WIth KITmuta!lorls (espec:iaIyIhOs8 ill elOfl 17)compared wrltJ pabents wr01 wiId-4ype KlT{233A..
31QA. 1969A. 2009A}
No Slgf1fflcanl dllJerence 111 0$ bereeen patients IIIilh -"' wilhOul KITmutatl(lllS {1696}



ilw(16)(p131q22)1 RR'IIIOfSe lor patients wrltJ KlTmutatioos 111 el M 8 COIf4lilred WIlt1 patients \\'III'l wid-type KrTf33Ml
t(16.16)(p13,1;q22) CIR hIglMlI' and OS '/II'OIWfor pabents WIth KIT rrotations 11 elOfll1 c:unpared wr01 PI1ients with wid-typeKIT{1696}
No Sigr*ant dillereooe in EfS , RI, RFS and OS between pabentS withand 'Mlhoul KJTrnuIatols (2~ 31 0A)


......... .

CRa and DFS ~ shor1erfor pabenl$ WIth Fl.T3-lTD comparedwith palienls 'IIIClOlIl A.TJ.lTD {193A., 216. 736A 2394A)
EfS SiglWanty sI'o18r lor patents WIth fLT3-fTO comperedwotll palienl$ 'IlIltI'loIA A.TJ.lTD (2338)
OS~, sIlcrterlor patlents wotll A.T3-ITO c:unpared withpalients wrlholA FLTJ.lTD {193A. 216. 736Ai
No SIgI'ificart dIIetence in OS b8t'ween palietn WI!! a'ld witlCUfLT3-lTD(2338, ~
OfS .-.:I OS sqv6c:llIy shorter b patients Wlth FlT3-lTO and no 8~ rJno-l)1:Ie FlTJaIele ~ 'MiD'! ~ W!IhOut
FlTJ.lTD (m4A)

RJJ.m)MII t'1)




::lflAli mutabCW'lS


OFS sagnficantty shorter for patienls wit! FLT3-TKD ll'I'IPB!t:Id Mlh petlenls WIth wild-type FlTJ*'es (23961


CRD (but not OS) SignlfIcal1Uy srorter for patletlts WIlt1 AILL-PTD compnd with peli8nlsWIVlout ULL-PTD (313. 603)
Noli&renoe in OFS cnl
between patlenIswiIhand ntW AoIl-PTD recero'rlg I'IS8nSre treamenllIW*1g a**lgous SCT {2395l


kaizalion 01



CRD and OS ~ longer or patients WIll1 CEBPA mulabalsa:mpared wrlh patients with~ CEBFl4. genes {216, 731}
NoSigMIcant diIIereoce in OSbetweeI'l patienls 'lWilh and withOut CEBFl4. mulalions f233B}
EFSsignlflcanUy shorter forpatJeflts with CEBPA rnutaliolls compared Willi patients 'IIIIh wid-type CEBPA genes f2338}
CRrate of pabellts WIth cytopIaSlTic Iocaizaboll of NPM not 19'1ifical'lUy I)/Ieren! from CRrateof pabenls WJ\ll nudearIocaJiZatiOn of
NPM in l,I'Iivariable analysis. Cyloplasri; IocaIzabon 01 NPM wasan intIepen(lenllaYOUr3ble prognosbc Iador for CR achievement in
mulbvBl1a!e Iogislic-regres&Oll model inckIding WBC. age, NPM localizatIOn and FLTJ mutations {666}


CRrate Sigoificantly betterlor patents wrtI1 NPM1 mulatiOns lhal'llor palienls W1lh wi:l-type NPMl geoes {1970}
~ Sigl'lilical'll dillerel1C8 il'lCRrates between patiarllswith arid witt10ut NPMI mutations {139A. 233B}
DFSaodRFS sigl1lfical'l~y lorIQeffor peeems willi NPM1 mlllabor1$ compared wtlhpatients W1lh wild.fype NPMl genes {602, 219l1}
~ sigMicaol diflerel1C8 fnRFS between pabenls withandWithout NPM1 mutatiorls {139A. 2338. 1970}
EFSsigniflCilnlty ooget' 101' patients with NPM1 mlltatforls compared withpatients with wild-twa NPMl genes {1970}
~ Significam dillerel'lC8 in EFSbetween patents withandwitr.out NPMl mutatiOflS {139A, 233B}
Nosignificant dillerence in OSteween patients withandwithout NPM l rl'llItations {139A, 233B. 602, 1970, 2198}


CRrales, EfS, RFS, DfS andOSsignificantly better lot patients with NPMf mutations wholackFLT3-ITD compared withpatients wittl
NPMl mu tations andFLTJ-iTD or thosewith wildtype NPMI gelleS withor without FLTJ-ITD NPMl mutations do notseem to significantly alleet poorprognosis of patients with FLTJ-ITO {B02, 1970, 2198)
Nosignificant dillereoces in EFSand 05 between patents with NPMl mutations andnoFLTJ-ITD compared with patients with NPMf
mutations andFLTJ-ITD arid those with wild-type NPMl genes with or without FLTJ-ITD {139A/



Failureto achieve a CRwith standard induction chemotherapy lor patients With WTl mutations andFLTJ-ITD {2120Ai,
OFS andOSsignificantly shorter forpati$nts with WTl mutallons compared With pabents Wltt'l wiIdtype WTI alleles {1696A}



CRrateandrate01 primary resistant disease significantly WOfSelor patients withhigh e~pression oflhe BAALC gene in blood
compared willi patients withlow eJqlreSSiOn of the BAALC gene{1358}
No significant diflereooe in CRratesbe\Weel'I patieols withhigh aodpaLenls With lowe.pressiOn 01 the BAALCgeoe {l 35A, 216}
DFS, EFS. RR and OSsignificat1Uy WOfSeaooCIR significantly htgher for patients With high elpression of lhe BAALCgeoe 11 blood
compared 'Mth pabents withIoYt eqJre'SSlon oIth8 BAALCgeoe {1J5A.. 1356, 216}


CRrates, EFS, CIA, andOS SIgnificantly worse lor PlltJents widllligtl e~ioo oIlhe ERG gene in blood compared withpalieols wrlt1
lowe~oflt18 ERG gene{1J9OA, 139OB}


OS and RFS significantly shorter and RR higher for pallenl$ WIth high e~ of the MN f genecompared WIth pabents withIoYt
elp(8SSion altha ",NI gene (9J7A)

'ftIl mutations


lblIiIcI by[) Mn\z8k from MrOzek and Bloomtiekl {1531A).-.d MrOzek et Ill, {1532} WIth pemlI$SiDn.
EFS ...... SUl\'lYII: RFS, ralapse-frM Sl.fVival: OS, ova-aI surYi'IaI; CIA, eurnulative inl:icIence of relapse, RI. relapse inQdence: OFS, d1seas&4ree SUI'YMl; RR.fisk of
. . .. FL1J.ITO .,.,. tandem duplalllOll of the FLngene, FLT.HKD,1IkJtlOOns 11 the tyrOSII18 kinase domiIIo offhll FLDgene, CRO. compIeIe remission dIntioo ; AIU.n ,pnal llwldemduplicabon of118 AIU gene: SCT. stem cellrWlsplanta1ior CR. ~ I'eITissIon; ". NMnal kar)'otype,

Acute myeloid leukaemia with reclKrent genetIC abnQIrnaliltes

11 9

disease. entities rather than prognostic

teeters . A small number of AML will show
both NPMl and CEBPA mu tations. which
would no t fit well into the proposed classification structure. In addition, the prognostic signi ficance 01 the chromosome
aberrations reported to occur in 5-15% of
AML with NPM 1 or CEBPA mutations is

not yet clear. There fore. the presence of

any of the recu rrent nanstoc ations or inversions should be identified in any AML
d iagnosis . In ad d ition , because of the adverse prognos tic impact of FLT3mutations
in AML with NPMI mutations. mutation
analysis 01 FLT3 should always be performed with NPM1 and CEBPA

These mutations are not de tectable by

cytogene tic an alysis and are usually
detected by PeR. Detec tion of cytoplasrri:
NPM by immunohistochemistry coretaes
well wi th the molecular m ethod [6641. btl
similar immunohistochemical surrogate
tests are not currently available lor aI
known mutations.

Acute myeloid leukaemia

with mutated NPM,
Acute myeloid leukaemia with rnnaied
NPM 7 carries mutations that usually f'\o
valve exon 12 of the NPMf gene AbetraW
cytoplasmic expression of nucleophosrTrl
(NPM) is a surrogate marker of this gefIe
mutation 16661. This AML type IreqJef1l,
has myeIomonocytic or rrooocstc feall.Jes
and typically presents de novo in ~
adults with a normal karyotype.
The WHO Working Group ass igned !his
lesion 10 a group of provisional ennnee



Fig. 6.101 Acute myeloid leukaemia with NPAlt mutations and myelomonocytic features. A Bone marrow biopsy
showing complete teplacemel'l1 by large blaSCs With abuooanl cytoplasm and IoIded nuclei. B l elillaemic cells are
CD34-negalive. C l eukaeJTllC eels show aberrant cyloplasrric expression of rkJdeopilosrr'Wfl (NPM). D EXpt"ession of
C231nodeolin is restricted to Itle nucleus.
CEB~ +5 _ ~

CEBPA+lo\C.L-PTD+ 1.2%

FLJ'3.TKD+/KL PTD+ 0 .8%

FlJ'3.TKD+ 2."%

Fl T3-lTO+IMLlP"TO+ 2."%
FlT3-lTO+ 8 .1%
NPM'+lFLJ'3.TKD+/ } O "

NPM'+tf:;Un;::;: }o.,,%
NPMl+IFLT.J-TKD+/ } , _

-" ,.

NPAI, +,Fl n.rTO+l } , ' "

NPtrI1+,f=LT.J-m)+/ } , ' "


NPM1+.<:ESPJIl,+ 3. ~

Fig. 6.15 Pie dlaf\ based on 2"6 pabent$ analyZed tor Itle Ilf99l!I'lC8 01 mutations in Itle NPUI and CEBPA genes.
FLT3-ITD. FLT3-TKD and AIU.-PTD. E.actI seclof nIc3les the peI'C8flIllge 01 pabenIs harbotmg one Of ITOOl 0I1he
ab'emenliOlllld muIabons. WT rocates pabef\tS WlIh only ~ alleles01 genes tes1ed. FromIkozek (If 11I.(1532)
lnlltdapled!ram 00IVlllf (If Ill. (602}.


Acute myelOid leukaemia and related precursor neoplasms

Acute myeloid leukaemia wilh cytooasrc

nucreopnosrsn (NPMc+ AML) .


NPM1 mutation is one of the most COOlTOl

recur ring genetic lesions in AML [283,
602.666.667.2198.2331 1. Prevalence
increases wit h age, occurring in 2-8%ci
c hil dhood AM L an d 27% -35% of adLJII
AML. NPMI mutat ions occur in 45- 64%ci
adult AML w ith a nor mal kar yotype 1283
351, 439, 666.2 198, 2331). This disease
appears 10 show a fem ale pr ed ominance

Clinical featu res

Acute myeloid leukaemia with NPMl
mutation usually pre sents without a history of a MDS or MPN {6661. Patients otten
exhibit anaemia and thrombocytopenia.
b ut onen have high er whi te blood cell and
platelet coun ts tha n other AML types
16021. Patients may show extramedullary
involvement. the most frequently affected
sites be ing gingiva, lymph nodes and Skm.
Morphology and cytochemistry
There is a strong association betweee
acute myelomonocytic and acute rrceocytic leukaemia and NPMI mutation {666
6671: notably. 80-90% of acute rTIOf()o
cvtc leokaerntas show NPMl mctetce,


However, N.PM1 mutations are also detected in AML with and without ma turation
and in acute erythroid leukaemia. A subset
01 cases shows multilineage dysplasia.
These cases usually have a norm al
~aryotype and the blast cells are CD34
negative. The 8 M biopsy is usually
markedly nvcerceuutar. Bone ma rrow
blast percentages are generally higher in
AML with muta ted NPM1 than in other
acute myeloid reukaermes with a normal


The diagnosis relies on the identific ation

~ the genet ic lesion by molecular tech!1IQUE!S and/or imm unohistoc he mic al

detection in paraffin sectoos of aberrant

cytoplasmic expression of NPM 16671.
mronostaining with antiNPM antibodies
reveals involvement of two or IT'K)(e 8M
lineages (myeloid . monocytic . erythroid.
megakaryoc ytic ) in the vast majority of
ML Wlltl NPMl mutation 116981. The vanab~ lty of 8M cell types showing NPM 1
rrutations accounts for the wide rrorprological spec trum of this leukaemia.
Immunopheno type
In addition to myel oid an tigen s (CD13,

Fig. 6.16 W*eage IMIlvement in AAlt. WItl'l NPM1 mutabons. A Bone m<mlW biopsy. Massive replac:eITetlt by
myeloid blasts wittl maturalJon; !here are also megakaryocyles and occasional irTIrn<I~ erylhnlid eels (iIfl'OIW).
8 The same case as (A). Myeloid blasts (double arrtIlltS). rnegakarrocyles and mnaIu'e er)1tWOiCI eels (iIfl'OIW) sI'lOW
abemml cytr;lpIasri: po$l ~vity lor NPt.I (blue ). Immature erythroid eels (arrow) Ill! doubIe--slained lor gIytophonn
(brown) andNPM(bkJe~ C Bone marrow biopsy. UinmaIydilIenlnbaled llaIte myeIold leukaemia wrlh NPM1 rllIlaborls,
occasional immature g~ erythroid cells are present 0 The same caseas (C). Myeloid bIasls and
imrnatIR erythroid eels (amlW) showcytoplasmic eKl)feSSion of NPM.

CD33. MPO), the blasts in AML with

NPM I mutalion frequently express markers

01 monocytic differen tiation , incl uding
C0 14, CD 11b and the macrophagerestricted CD68. The roost striking inYnunophenotypic featu re 01 AML wi th NPM 1
mutation, which is independent of the
degree of maturation of leukaemic cetls,
is the lack of expression of CD3 4 (666).
By immunohistoch emistry on p araffin
sections, antibod ies aga inst NPM show
f e characteristic abe rrant exp ression of
the protein in the c yto plas m of leuk aem ic
cells(6661. In co ntrast, positivity for C23/
nucleolin (another major nucleolar protein)
isrestricted to the nucleus of leukaemic
cells. Immunohistoc hemical detection of
caoorasrnic NPM is predictive of NPM I
euatoos 16641. since the mutations c ause
critical changes in the structu re of NPM
native protein (c haracteristically located
'" the nucleolus), leading to its inc rease d
export tram the nucleus and aberrant
accumulation in the cytoplasm.

, 2

NPM1 gMfe ~





.. -iF .. -..::::::JI



.. . \ . _' '''.

. .cc ~ ' .' . u ~. r '. . . c '

N "

N "



N. . .,

c ' . t t

.aoc U
'. eOT
............. . ....... c .C<. e ~


' c


u.u ,

E _ 8ognol (NEll)


_ . . - - . s . - lNt-'i


M ur.redNPM

04 .

..-----.-=- -....,

WI~ryp. NPM

" ." 04" .' .'

c '
' . .
co CTe'TT""ee ' . '





leul<aemle protein


, II I

. T. _

Acute myeloid leukaemia with NPMl
ITkrtation is usually associated with a normal karyotype . however. 5- 15% of AML
W!ttl NPMt mutation show chromosomal
aberrations 1666, 667J, inc lud ing +8 and
de/(9q) 121961. NPMt m..rtabons are usually

Fig. 6.17 AclJte myebd leukaerria with NPM1 "'-IlaIions. Mutations usualy 0lXIS at exon 12 of tlle NPAlI gene. The
irs! i:lenlified NPU1rIlIlabons (A" F)Ill! shown (666}. MiDtIon A1$fie most hqI.Jenl acaulbng lcr 70-80'10 01 cases.
AI rn.Jtabllns feSUIt in a:mnon changes at fie e.tllmwu (COOH) 01 fie WlJd.type NPM protein. These dlanges (asl!lnst
in the NPM nwtated proIeIn) c:onsisl of replacement of ~s) aI posibon 288 and 290 and aeation d I ~
export sqJaI (NES) motil. whiCtllre boIh responsible lor the inc:reased nuclear eJPl and abemIrlt t')'lcIpliIsrrC
aca.oTUabon of !he NPM 1TlJIlwits.

Acute myelOId leukaemia With recurrent genetic abnormalities



POCO 000 1




NPMt-IFl r:J.fI'D-I










, r_ _

Acute myeloid leukaemia

with mutated CEBPA

NPM r-tFl rJ.,lTO"'"


C NPM""'/FL T34TD-o




CE8I'A -

favou rab le prog nosis to AML with a chromosomal aberration or with multilineage
d ysp lasia.

0 _


!: -



CEBPA rrc tanons occur in 6-15% 01 de

Postula ted normal counterpart

Haenatopoenc stern cell 113941


9861 /3




T_ _

Fig. 6.18 Prcq10sis ofAML paltents. A,B ThegenotypesNPM' -JFL1J-lTlY'" and CEBA<I'" arelaYCUable progllOSOC
markers. C.DUnivariate donor IWSUSno-donof analysis onreepse-rree survival 01 AML with normal karyolype in fi~
compleIe remission. acttII'ding III g&IlOtype. The donor group defifled by !he availability01 a HLA-maIched larrily
donor comprising a maId'! in toe loci HlA-A, HLAB and HLA-DR C Results in AML with li!VOUfab~ genotype
NPMf"'lFlTJ-lTO""; (0) !he results in AMl wilt! adverse gerotypes FLT3-/1D"" and NPI,/1"ICEBPA"JFLTJ.lTO"";
OnIyAML withactYerse gel'lOtypes (0) benefit from allogeneic stem celIlransptanlalion. From Sd1lenk RF 1:/1aI. {1962AJ

mutuallyexclusive of the recurrent genetic

abnormalities tha t define the AML entities
desc ribed in the p rec eding sec tion 16651
and with par tial tandem duplicat ions of
MLL and CEBPA muta tions, although concurrence of these abnormalities with
mutated NPMI have been reported 1602,
2198 1. Ab out 40% of AML with NPM1
mut ations a lso ca rry FLT3-ITD (6661.
NPMl mutations ap pear to precede FLT3ITO and these Ieukaermas are mo re
genet ically stetne during disease evolution
1439, 21981. AML wilhcytoplasmic mutated
NPM1 shows a di sti nct ge ne expression
p rofile characterized by up- reg ula tion of
HOX genes 119. 233 11 that di ffers from
th at of other AML typ es. inc lud ing AML
with MLL rearrangement 11539).

Acute myeloid leuk aemi a with rnctaiec
CEBPA usually meets criteria for AML
maturat ion or AML without maturation, bul
some cases may sho w myel ornonocyliC
or monobtastic features. This leekaema
usually presents de novo.
The WHO Working Group ass igned ~
lesion 10 a group of provisional entities

Prognosis and predictive factors

Acute mye loid leukaemia with mutated
NPM1 typ ically shows a good response to
induction the rapy 1666 ) Acute myelo id
leukaemia with mutated NPMI and a normal
karyotype, in the abse nce of a FLT3-ITD
mutation. has a characteristica lly favourable
p rognosis {283 , 60 2, 1970 , 2198 , 2331 1.
The coexistenc e of FLT3ITD mutations is
associated with a poorer prog nosis. b ut
Ihese patients still appear to have an improved prognosis c ompa red to AML that
is NPM1 negative and FLT3-ITD positive
17461. Younger ind ivid uals with AML and a
norma l karyotype exhi biting the genotype
NPM 1 mutated!FLT3-lTD negat ive show a
prog nosis that is comparable to that of
AML with t(8 ;21)(q22;q22) or inv(16)
(p 13.1q22) and may possibly be exemp ted
from allog ene ic stem cell transplantation
in first complete remission 16021. It is not
known whether a NPM1 mutated;flT3-lTD
nega tive genotype also confers a

Acute myelotd leukaemIa and related precursor neoplasms

novo AML and in 15-18% of AML W1:tl

norma l karyotypes 1216, 737, 12801. rtee
are no apparent age or sex d ifferences
between CEBPA mutated and l"IOI"HTUIale:!
AML [20401
Clinical features
Acute myelo id leukaemia with metered
CEBPA tends to have higher haemogkbn
levels . lower p latelet counts. lower lactae
dehydrogenase leve ls and higher PB
bl ast cell co unts when c ompared to
CEBPA non-mutated AML. This leukaemia
type also has a lower frequency of 1ymphadenopathy and myeloid sarcoma 1216,

Morphology and cyt ochemistry
There are no distinctive morpholog ic leatures ot AML with normal karyotype an~
CEBPA mutations. but the vast majority d
cases have features of either AML withoJ
Of with maturation Less commonl y. cases
have monocytic o r mveromonocvtc leatures. Three percent or more of the blasts
are myelope roxid ase or Sud an black B
positive, and most cases are non-specific
este rase neg ative.

Immu nophenotype
Leukaemic blasts usually express one (J
more of the myeloid-associated antigens.
CD13. CD33, CD65, C01 1b , and COIS
There is usually ex pression of HLA[)A
and CD34 on the majority of blasts
Monoc ytic markers such as C014 anc
C064 are usu ally absent. C07 is preset
in 50-73% of cases, while expression It

CD56 or otner lymphoid antigens is

uncommon 1216. 13081.

Postu lated normal co unterpa rt

Haematopoietic stem cell.

Seventy percent of A ML with CEBPA
mutation have a normal karyotype .
Fl.T3-lTD mutations occur in 22-33% of

Acu te myeloid leukaem ia with a normal
karyotype and CEBPA mutation is associated with a favourab le prognosis. similar
to that of A ML with inv(16)(p13.1q22)


or t(8:2 1)(q22;q22). The significance of

FLT3-lTO on the prognosis of this group (s
currently unclear. with small studies suggesting either no impact or a negative impact on prognosis 1737, 17801. Although
uncommon , the prognostic significance of
A ML with CEBPA mutations and other
chromosomal aberrations remains unclear.

Acute myeloid leukaemia With recurrent genetic abncemanoes


Acute myeloid leukaemia with

myelodysplasia-related changes

R D . Brunning
A .Orazi

Acute myeloid leukaemia (AML) with
myelo dysplasia-rela ted changes is an
acute leukaemia with 20% or more periphe ral blood (PB) or bone marrow (8M)
blasts with morphological features of
myelodysplasia or a prior history 01 a
myelodysplastic synd rome (MDS) or
myelodysplastic/myeloproliferative neoplasm (MDSlMPN), or MOS-related cvtogenetic abnormalities, and absence of
the specific genetic abnormalities of AMl
with recurrent genetic abnormalities. Patients should not have a history of prior
cytotoxic or radiation ther apy tor an unrelated d isease . Therefore , there are three
possible reasons for assig ning cases to
this subtype: AML arising from previous
MDS or MO S/M PN ; A ML w ith an MOSrelated cytogenetic abnormality; and AMl
with multilineage dysplasia. A given case
may be assig ned to this subtype for one,
two or alt three reasons (Table 6.02).

morphology, dysplasia must be present in

at least 50% 01 the ce lls in at least two 8M
ce ll lines. Dysq raoulo poresis is characterized by neutrophils with hypograOlJa'
cytoplasm, hyposegmented nuclei (pseLti>
Petqer-Huet anomaly) or bizarrely segmented nuclei . In some cases, these
features may be more readily identiliedoo
PB tha n BM smears. ()yseryItlropoiesls IS
characterized by megaloblastosis, karprhexis and nuclear irregularity, lragTllll1ahan or multinucleation. Ring sideroblasts,
cytoplasmic vacuoles and periodic acidSchiff (PAS) positivity are addlt~
features of cvsevtnroooesrs. Dysmegakaryo poiesis is characterized by microme gaka ryocytes and normal sized r:J
larg e megakaryocytes with non-lobulated
or multiple nuclei. Dy sp lastic megakaryo.
cvtes may be more readily appreciated n
sections than smears 169, 7421.
cases wiU not have sufficient
cell 8 M elements 10 adequately assessb
multilineage dysplasia or have sufficietw;
non-blast cells but do not meel the crilera
described above for a morphologic
nosis of AML with multilineage dysplasia
These cases are diagnosed as AML
mveiodvsptasta-retated changes by ee
detection of MD&-related cytogenetic aDnormalities anellor by a prior history ofMDS.

ICD-O code


Acute myeloid leukaemia with multilineage

Epi d emiology
This ca tegory of AML with mveiccysptasiarelated cha nges occurs mainly in elderly
pat ients an d is rare in chi ld ren 1913,
12691. Although the d efinition 01 rnultitineage dysplasia is variable in the literature ,
this category appears to represent
24-35% 01 all cases of AML 169, 869 ,
1493 , 2465).
Clinical leatures
Patients with AML with myeiooysprasiarelated changes often present with severe
pancytopenia. Some cases with 20-29%
blasts, especially those arising from MDS
or in ch ildhood , may be slowly progressive.
These cases, w ith relative ly sta b le PB
co unts for weeks or months, co nsidered
refrac to ry anaemia with exc ess b lasts in
transformation in the Frenc h-A mer icanBritish Cooperative Group ctassmcauon.
may behave clinically in a manner more
similar 10 MDS than 10 A Ml.

and cyt """,,",stry

Most, but not all cases in this category of

AML have morphological evidence 01
muniuneaoe dysplasia which must be
assessed on well -stained smears 01 PB
and BM. To classify an AM L as having
mve covsoasta-retateo changes based on

BJ. Barn


JW VardllTal
MoM. LeBeau
P.L Greertlefg


Fig. 6.19 Acute myeloid le~~ with myelodysptasia-felated changes (murtilillllage dysplasia). The marrow aspirate shows numefOlJS I9"8nulaf blasts as wei as actIuII:
hypogrardar neutrophiIs with dul1lled nucleardWomatin and erytt'ftid preanors \MttI irreQlAar nuclear am..n. AA small. l'lypoIobated rnegakaryotyIe is IQS80I al lhe txb.
BAIigher magOOicaIion 01 anoltl8fcase showing rl'ICIre irregIJar nuclearfeatures 01 eryIhroi:I l)"eanors and ~ wiIhcbnped IIUd&ar etwomatn


Acute myelOtd leukaemia and related precursor neoplasms

Immunophenotyping results are variable
dueto the heterogenei ty of the underlying
genetic changes, In cases with aberralions
01 chromosomes5 and 7. a high incidence
oICD34, terminal deoxynucleotidyl trans!erase (Td T), and CD7 expression has
been reported 123241. In cases with anieceoent MOS. CD34+ cells frequently
const itute only a suboopuraton of blasts
m may have a stem-cell related immunopheootype with low expression of CD38
M"dkx HLA-DA. Blasts often exp ress pan myeloid markers (CD13. CD33). The re is
'Tequently aberrant expression 01 CD56
and CD7 116231. The maturing myeloid
cells may show patterns of antigen excesson differing from thOSe seen in nQ{mal myeloid development, and there may
ee alterations in the light scatter properDeS of maturing cells, particularly neutrotfWs, There is an increased incidence of
'TUlKinJg resistanceglycoprOlein (MOO-1)
expressiOn in the blast cells 11206, 1268,

t(2;1 1)(p 21;q23 ), if not associated with

prior cytoto xic therapy, should be classified
in this group rath er than as a variant
translocation of 11q23 ,
Cases of AML with multilineag e dysplasia
may carry NPMI and/or FLT3 muta tions
[23561. Most NPMI mutated cases would
be expected 10 have a normal karyotype,
CD34-negative blasts and no history of
prior MDS 120151. However, the presence
of an MDS-associated karyotypic abrormality should take diagnostic precedence
over the detection of an NPMI or CEBPA
mutation for classification purposes until
the significance of such rare genet ic c0mbinations is clarified . In patients wIth AML
with multilineage dysplasia and a nQ{mal
karyotype. information regarding the mu
tational status of NPMI, CEBPA and FLT3
may provide important prognostic informauon. and the presence of these mutations should be noted along with the
diagnosis of AML with myelodysplasiarelated changes (multilineage dysplasia)



Chromosome abnormalities are similar to

Differential d iag nosis

The principal differential d iagnoses are
refractory anaemia with excess blasts ,
acute erythroid leukaemia, acute megakaryo blaslic leukae mia and the other categories of AML. not otherwise specified
(NOS). Caref ul b last cell counts. adnerence to the diag nostic criteria for morphological dys pl asia and evaluation for
MDS re lated c ytogenetic abnormal ities
shou ld resolve most cases, with this ca tego ry having priority over the purety morpholog ic ca teg ories of AML , NOS, For
exam ple, a ca se with >20% 8 M myeio blasts, multilinea ge dy spla sia, ove r 50%
BM erythroid precursors and monosomy 7
should be c onsidered as AML with
myelod ysplasi a-reiated c hanges rathe r
than acu te e rythroid leukaemia, Simila rly,
a case with over 20% 8 M megakaryoblasts and multilineage d ysplasia would
be considered AML with myelod ysp lasiarelated changes (megakaryoblastic type),

bose found in MDS and often involve

gain or loss of major segments 01certain
chromosomes with complex karyotypes
and -7/del(7q) and -5/del(5q) being most
ccmmon 11 269 , 1530 , 1641J, Additional
abnormalities that are considered sufficient for inclusion in this ca tegory are
given in Table 6.03, While trisomy 8 and
del(20Q) are also common in MOS, these
ffJdingsare not co nside red to be d iseasespecific and are not, by themselves, sufficient to co nside r a case as AM L with
myelodysplasia-related c hanges, Similarly,
bss of the Y ch romosome is a nonspecific find ing in o lder men and should
oo! be consi dered sufficient for c yto[Ie!1etic evidence of this d isease ca tegory
Balarced translocations are less common
in tnis disorde r, but when they occur are
of:en franslocations involving 5q32-33,
Tile t(3;5)(q25 ;q 34 ) is associated with
rrOtilineage dysplasia and a younger age
al presentation than most other cases in
tis disease group 1661. In addition, AML
W1h inv(3)(q2 1q26.2), t(3;3)(q21 ;q26 .2) or
W#l t(6;9)(p23:q34) may show evidence of
rru/tilineage dysplasia, but these are now
:ecognized as distinct entities in the AML
'MIll recurrent genetic abnormalities
goup and should be classified as such .
'*'wever, cases with the specific 11q23
wrangements. t(11 ;16)(q23;p13,3) and

Postulated normal counterpart

Multipotent haematcooreuc stem cell.
Prog nosis and pred ictive fact ors
Acute mye loid leukaemia with myelodysplastic features generally has a poor
prognosis with a lowe r rate of ach ieving
complete remission than other AML types
169. 742 , 1269 , 1493 , 24651. While the re
are no overall prognostic differences

Table 6.02 Criteria lor the diagnosis of AML with

~ 20%

blood Of mam;lW blasts

Anyof !tie Ioi:lwing
PreW:lus hislDry of myeIodysplaslic syndrome
MyeIodysj::QsbC syndrome--relaled L)'IogenetIc
abnormalrty (seeTable6.03)
Mullilineaga dysplasia



?nor cytlItWc therapy lor an I.MlIaIed disease

RlICllfTing ~ abIllllT1lahl)' as descnbed
in AMl-Mlh reamlOI genetic abroomIakbes.

CytlgenetJc abnorr!\alIbes suIIicienI m

<iII(p'105e AM.. will myelodyspIasia-leatLRs wnen
~ PB or8M blasts are presett.

Table 6.03

('.oorpe. ~ '

UnbtIIItdd aMoonaiilies



~ l1q)'l l1p)



&tI1l11Ud abnoonaiities
t1:11 ;t 6)(q23;p13,3)"
t1:311 )(q26.2;q22.1)"'
t1:1:3)(p36.3:q2t ,1)
t(5;1)(q33:qtl .2)

' >3 unrelated abnomlalities, none of which are

includedin theAML withrecurrent genetic abnormalities subgroup: such casesshould be dassjfied
in the aPPfClPriate cytoger.etic group.
0' These abl'lormalities most commonly occur in
tnerapy-ffllated diseaseand lherapy-relatedAML

should be excluded before u~ng these abnormalilin asevidence lor a diagnosjs of AML with
myeiodysplaSlB-related features.

between cases with and without prior

MDS 1691. recognition of cases with prior
MDS and relatively low blast counts may
identify cases with less clinically aggres sive disease. Some cases with prior MDS
and 20-29% 8M blasts, considered
refractory anaemia with excess blasts in
transformation in the French-AmericanBritish Cooperative Group ctess'ucatcn.

Acute myeloid leukaemia WIth myelodysplaSIa-related changes


may behave in a manner rrore similar to

MOO than ome AML. These cases . as well
as cases with myelodysplasia and just
under 20% blasts, require regular monitoring of PB counts and 8M morpholOgy
lor changes suggesting disease progression to overt AML.
Although AMl with mu ltilineage dysplasia
is generally associated with a poor prog
nests. several studies have not found
morphology to be a significant parameter
when using multi-variant analysis thaI also
incorporates the results of cytogenetic
analysis, high risk cytogenetic abnormalities being more significantly associated
with prognosis {869, 2356, 24651. Therefore, mUltilineage dy splasia should b e
conside red as a po ssible indicator of high
risk cy togenetic abnormalities, bu t in the
abse nce of such abnorma lities. may not
be important. In such c ases, fluorescence
in situ hybrid ization (FISH) stu dies for
MO$-related abnormalities may be useful.
It is cu rren tly unclear whe ther a NPM1
posl livefFLT3-negative genotype in AMl
with multilineage dysplasia confers the
same good prognosis as in other AMl
with NPM, mutations. Cases of AML with
multilineage dysplasia and NPM1 metanone usually do not have adverse cytogenetic findings or a history of prior MOS
120151. However. the clinical impact of
mutation status versus the presence of
multumeaqe dysplasia requi res more
investiga tion. Therefore, it is not yet clear
how cases of AML with multilineag e dysp lasia without prior MOS or MOSrelated
cytogenetic abno rmalities and with an
NPM1 mu tation or a CEBPA m utation
should be c lassified . How ever, as noted





v.... ,,""' .......

Fig. 6.20 Survival curve lor cases of acu te myeloidleukae mia with adverse cytogenetic find ings in the "tRC-AMl IO
trial Reproduced from Grimwade Det al. {MB}.

above, at this time cases of AMl with

MOS-related cytogenetic findings and
one of these mutations should be diaqnosed as AMl wi th myelodysplasiarelated changes as well as noting the
mutation detected.
Diagnostic term inology
Because there are different pathways to a
diagnosis of AML with myelodysplasiarelated changes, which upon further
study may have clinical differences, it is
recommended that the reason(s) for
dia gnosing a case as such be included in
the di agnosis. For example , a c ase di agnosed solel y on mo rphology would be
considered "AMl with myelodyspla siarelated changes (rnultitineage dysplasia)":
a case arising from p reviou sly diag nosed

Acu te myeloid leukaemia and related p recursor neoplasms

MOS without assoc iated dysplasia idl!f$the lime 01 AMl diagnosis woUd
be considered ~ AMl with myelodysplasaarelated changes (following prevos
MOSt; and a case with prior MOS. dysplastic features and monosomy 7 WCllil
be considered "AMl with rnyeIoctyspIase
related Changes (fotleJ'oNing previous
MDS-associated cytogenetic a~
and muttilineage dysplasia). Cases
NPM1, CEPBA and/or FLT3 mutatll)'lS
should also indicate the mutation hndrYJ
(r.e. "AMl with mverocvsotasta-reraiec
changes (multilineage dysplasia) aM
NPM1 mutation"). Finally, because ollhe
possible cli nical heterogeneity of cases
with low blast cell cou nts (20-29%), tt:E
b last count should be cl early stated in t~
repo rt.

ueo at

Therapy -related myeloid neoplasms

Inis category include s therapy -rela ted
acute mye loid le ukaemia (IAML). rnyelodysplastic synd rome (I -M DS ) and m yelodysplastic/myelop ro life rative neoplasm s
(t-MDS/MPN) occurring as late compliea'ons 01 cytotoxic chemotherapy an d/or
-adtatlOn therapy adminis tered lor a pr ior
'lPIastic or non-neoplastic disorder. AIh:lu'Jh some patients may be d iagnosed
nnpt'dogicatty as 1-"'-105, t-MDS/MPN ()(
~AML according to the number 01b lasts
present. all of these therap y-related neoplasms are bes t considered together as a
IIlJque clinical syn d rome . Exc luded fro m
mig categor y is tran sfor mati on of MPN
srce it is etten no t possible to determine
if !his is disease evolution or therap yrelated.


Therapy-related acute myeloid

ielJ:.aemia. NOS.

Therapy-related t-AMl.../t-MDS and t-AMLJ
l.MDS!MPN ac count fo r 10 - 20% of a ll
cases of AML, MDS and MDS/M PN 11278,
1433, 1536 1. The incidence among paieras treated w ith c ytotoxic agents varie s
ElC cording to the underlying di sease and
fe treatment strategy. Any ag e group
rray be affected b ut the risk associated
lIllh alkylating agent or rad iation therapy
jjerlefally increases with age whereas the
rsillor those treated with topoisornerase II
II'hbIlors is similar ac ross all ages 1651,


Therapy-related neoplasms are thou ght to
bethe conseq uence of mutational eve nts
mceo by cytotoxic ther apy, Som e indiOOualsmay have a heritable predis position
due topolymorphism s in genes that affect
drug metabolism or DNA -repair rnecha ~sms. but for most cases the und erlying
08thOgenesis rema ins uncertain 11899 1.
Cy1oIoxic agents commonly imp licated
ire istec in the Table 6.04 . Although other

JW. Vardiman
DA Arber
RD. Bruming
RA Larson

E. Malutes
I. Baumann
J Thiele

the rap ies such as hydroxycarbamid e

(hyd roxyu rea), rad ioisotop es, L-aeo araqinase and naematcootetrc growth teeters
have been sugg ested to be reukae mogenic, their pr imary role in thera py-related
haema tologic neoplasms. if any. is not
clear. Characteristic clinical, morphologic
and genetic features often relate to the
previous ther apy received .

Sites of involvement
Peripheral b lood (PB) and bone ma rrow
(BM) are the princip le sites of involvement .
Clinical features
Near ly an equal number of patient s give a
history of treatment fo r a p revious baematologi cal ma lignancy as for a non -haematolog ical solid tumo ur. How ever. 5 - 20 % of
patients are reported to have rece ived cytotoxic therapy lor a rco-oecoasrc disease.
A smlar num ber develop a therapy-related
myeloid neoplasm afte r high dose
chemotherapy and autologous haematoporenc stem cell transplant for a prev i.
ously treated malignancy 11 433. 20411 .
Two subsets of t-AMlIt-MDS and t-A MU
t-MDS/MPN are generally recognized ,
The most common occurs 5- 10 years
afte r exposure to alkylating agents an d/or
ioniz ing rad iation. Patien ts often pr esent
with t-MDS and ev idence of 8 M failure
with one or mul tiple cyto penias, although
a minority will present with tMDS/MPN or
with overt t-AML This c ate go ry is com mon ly associated with unbalanced loss of
genetic material . often in volv ing chromosomes 5 and/or 7 . The second category
of t-A ML/t-MDS and t-A ML/t-MDSIMPN
encompasses 20-30% of patients. has a
latency period of about 1- 5 years, and
follows neannent with agents thai inte ract
With DNA tcoosorerase II (topoisornerase
II inhibitors). Most patient s in this subset
do not have a mveioovsotasnc p hase bu t
pre sen t initia lly with ove rt acute leukaem ia
tha t is ofte n assoc iated with a bal anced
cororoscrat translocation 1651, 1716, 20411,
A lthough it may b e useful to c onsid er
t-A MlIt- MDS and t-A MU t-MDSIMPN
as being alkylating agent and/or rad iationrelated or as top:lisctnerase II irtlibitor-related.

Fig. 6.21 Therapy.retaled AML with t(9;11)(p22;q23).

This pabenl deYeloped 1-AMl. 1essltlanone yearfoIow.
ing instilulion oIlherapy lor osteosartoma. The therapy
included both alkylabl'lQ agentS and ~ II inhibilorn.

in practice many p atients have rec eived

polychemotherapy that includes both
classes of drug s an d the boundary between the two categories is not always
sharp 120411.

The majority of patients present WIth
t-AMlIt-MDS associated with multllineage
dysplasia . Commonly, but not invariably
in such c ases, a history of p rior therapy
with alkylat ing agents and /or rad iation
therapy is elic ited and cytog enetic studies rev eal abno rmal ities of c hromosomes
5 and/or 7, o r a comp lex karyotype , Nevert heless, dysplasia may be seen in some
c ases wit h balanced tran siocauons as
well. The P8 shows one or more cvtopemas . Anaemia is almost always present
and red cell morphology is cha racterized
in most cases by macrocytosis and poikik::x:ytosis, Dysplastic changes in the neutn>
p hils include abnormal nuclear lobation,
particularly hypolobatoo, and cytoplasmic
hypogranulation . Baso philia is freq uently
present 11 4721. The 8M may be hyper.
ce llul ar, no rmcceuurar or twpoc euuiar.
and slight to mark ed 8M fibrosis occurs
in approximately 15% of c ases. Dysgranulcpoiesis and dy serythropo iesis are pre sent in mos t patients , Ring siderobla sts are
rep orted in up to 60% of cases and in
some c ases exceed 15% of the erythroid
precu rsors. Meg akaryoc ytes ....ary in nurnTherapy-related myeloid neoplasms


00 O __
000 0 00 00.p~ . _
o 0000000 &0 , _

000 00 0

10.Q 0 0 000
~ 00 0

00 .


0 00

00 0 1
A O OO. O O O_O..~O!?C .

Fig.6.22 Thefapy-relaled MDSlAML This 42-year-old man was lrealed withABVD therapy lor dassical Hodglin IymJ:tloma but retapsed 161T1OflthS laterandwas!Jven 9vage
chemolt1erapy and radiolt1erapy, Two years later he presented W11t1 pancytopenia in l!le PB(A), a BM asprate (8) and BM tMopsy (C) st'lowtld ilCteased bass and mullili1eaile
dysplaSia. A complex karyotype Jnduded lossof d1romosomes 5 and7.

ber but dysp lastic fo rms of variable size

with rnooo- or hypolobated or widely separated nuclei are seen in the ma;orlty of
ca ses 11472, 164 71- The percenteae 01
b lasts also varies but in patients presenting with a rnyelodysplastic pha se a lmost
50% will have less than 5 % 8 M b lasts
11472, 2026J About 5% of pat ients have
features of MDS/M PN, suc h as c hronic
mveromooocvnc leukaemia 120261. Althou gh patient s presentmq With rnyeiodyspl asia and cvtoperaas may be
desi gnated as l-Moo or t-AMl depending
on their mo rphology an d b la st counts.
suc h subclassification may lack clinical
sig nifica nce 120261.
In 20-30% of c ases, the first man ifestation
of therapy-re late d mye loi d neoplasm is
ov ert acut e leu kaemia without a preceding myelodysplastic phase , Often , but not
invariably , these cases follow toposomerase II inhibitor tnerapy. The majority of
the cases are associated with balanc ed
rec urren t c hromosomal transtocanons
that frequently involve 11q 23 (MLL) or
21q 22 (RUNX1) , and hav e morphology
that resembles de novo ac ute leukaemi a

associated wi th these chromosomal

abnormalities 136. 1886 . 2034 1although a
lew cases may pr esen t as MDS or have
dysplastic teatures as well . Many cases
fall in the categories of acute monoblaslic
leukaemi a or mverononocvtc leukaemia.
but ca ses with granuloc ytic d ifferentiation
al so occur Case s mo rph ologi ca lly (and
cytogenet ica lly) identical to those observed in all of the subtypes of AMl
With rec urring cytogenetic abnormalities
have been descri be d , inc luding acute
pronverocvnc leuk aem ia , Such cases
should be designated as t-AMl with the
ap propriate cytogenetic abnormality indi c ated. e.q. t-AML with t(9; 11)(p2 1;q23 ).
Cases of lymphoblastic leukaemia (All )
also occur in this group , usually associ ated
with a t(4 ; t 1)(q2 1;q 23) c hromosomal
abnormality 11022,19841.
There are no specific immunophenotypic
findings in tAMUMDS ()( in t-AMljt-MDS/
MPN. lmmunophenotypi ng stud ies reflect
the heter og eneity of the und erly ing morph olog y and often show c hanges similar

....kylating agents
Melphalan. cydophosphamide , nitrogen mustard, cI*lrafnbldl. MuIIM, carboplalin. eisplabn ,

dacarbazirle, procarbazine.carmustine. mitomycin C .lh~epa,lomus ~ne. etc.


large fields IfIcIuding active bone marrow


aMIl inhibiton

EIOpOSide. 1eoipO!iiOe. dolOf\ban, d8ulorIbcin.lIWJ.dnlrorle, arnsacrnt. acIIrom';an

"TCJP(lI5OlTIeIaS IIirlhbIr:Jts may abo be associated WIltIIherapy-related ~ leukaemia


Anilmetaboilles: thiopurines, ITl)'tOI)Ilenolate, fludarabine

An titublJlin agents(usuallyin comblnenco withother agents):vincristine, vinblastine, virdesine, paditaxet,



Acute myeloid leukaerrua and rela ted precursor neoplasms

to their de novo counterpa rts 1681. Blasts

are generally CD34+ and express panmye loid markers (CD 13, CD33), There 1$
freq uent aberrant expression of CD56
and lor the lym phoi d- associated marker
CD7 . The ma turing myeloid cells may
show patterns of antigen expr ession that
diff er from that see n in norm al myeloid
development. and there may be alterations
in the light sc alier properties of maturing
cells. particularly reutropnus .
The leukaemic cells of ove r 90% eX
patients with t-AMUt-MDS show an
abn ormal kary ot yp e , The cy tog enetic
abn or ma lities often co rre late with the
laten t pe riod be tween the initial l herapy
and the onset 01 the leukaemic disorder
and With the pre vious cytotoxic therapy
11254.1433,1716, 1886,20411. Approximately 70% of patients harbour ureaanced chromosomal aberrations. mainly
whole o r oaruat loss of ch romosomes 5
and /or 7, that are often assoc iated wit!l
one o r more ad d itional ch romosomal
abnormalities [e .g . d el(13q ), del(2OQl,
d el( 11q ), del(3p), -17, -18 , -2 1, +8} in a
complex karyotype. These changes are
usually associated with a long latent period . a preceding myelodysplashc phase
or t-A Ml with dysplastic features, and
alkylating agen t and/or rad iation therapy
The remaining 20 -30% of patients have
balanc ed c hromosomal transloc aticns
that invo lve rearrang ements of 11Q23
[including us,11)(p22:q23l and t( 11 :19)
(q23 ;p13l] . 2 1q22 [inc lud ing
(q22;q22) and 1(3;21)(q26.2:q22.1)] and
other abnormalities such as 1(15;17)
(q22;q12) and inv (16)( p 13q22) , The balanc ed transtocano ns are generally associ ated with a short latenc y period, most
often present as ove rt AMl without a
pr ec ed ing mverocvsptasnc phase. and

are associated with prior toootsomerase

II inhibitor therapy.
Postulated normal counterpart
Haematopoietic stem c ell.
Prognosis and predictive factors
The prognosis 01t-AML./l-MOS and t-AMU
\-MDS/MPN is generally poor. although it
is strongly influenced by the associated
karyotypic abnormality as well as the
comorbidity of the underlying malignancy
or disease for which cytotoxic therapy
wasl'itialyrequired. CNeratl, 5-year SlJVivaI

of less than 10% is commonly reported .

Cases assoc iated with abno rmalities of
chromo some 5 and/or 7 and a com ple x
karyotype ha ve a particularly poo r outcome. with a median survival time ot less
than one year regard less 0 1 whether they
pre sent as overt acute leukaemia or as
t-MOS 11472, 20261. In contrast to de novo
MOS, some report s have suggested that
neither the blast percentage nor subclassification have a significant impact on
clinical outcome, and the designation of
t-AMUt-MOS or t-AMUt-MDS/MPN may
be more appropriate 11472. 20261. Patients

with balanced translocations genera lly

have a be tter prognosis, but. except for
those with t(15;17)(q22;q 12) and inv(16)
(p 13.1q22) or t( 16;16)(p 13.1;q22). median survival times are shorter than for
their de novo count erparts 136. 227 , 1886.

2034 .20411 .
It shou ld be noted that occ asional patients assigned to the category of therapyrelated myeloid neoplasms represent
coincidental disease and would be expected to behave like other de novo

Therapy-related myeloid neoplasms


Acute myeloid leukaemia,

not otherwise specified

The c ategory of ac ute myeloid leukaemia,

not otherwise spec ified (AML. NOS) enco mpasses those cas es that do not fulfil
criteria lor inclusion in one of the p revi ously desc ribed groups with rec urrent
genetic abnormalities, myelodysplasia-relate d c hanges or tha i are therapy-related .
These tumours are fell 10 be derived from
haematopoietic stem cells . The clinical
relevanc e of some subgroups 01 AML.
NOS is of q uestionable significance 169.
21531 bu t they are reta ined in the cl assi fication because they define criteria for the
d iagnosis 01 A ML ac ross a diverse morpholog ic spectrum and include the unique
d iagnostic criteria for ervmroreukaemra.
Mutation ana lysis and cytoge netic studies are rec ommend ed for c ases in this
ca tegory and may offer more prognostic
sig nificanc e than the morphologic subtypes. The pr imar y basis for subclassification within this category is the
morphological and cylochemical/immunophenotypic features of the leukaemic cells
that indicale !he major lineages involved
and the degree of maturation. The de fining cntenon for AML is 20% or mo re
mveioorasts in the peripheral b lood (PBl
or bo ne marrow (BM): the promonocytes
in AML wiltl monocytic di fferentiation are
consi dered blast equiva lents, The cl assification of acute eryt hroid leukaem ia is
uniqu e and is based on the percent ag e
of abnorma l eryth roblasts for pu re ery throid leukaemia and the percen tage of
myeloblasts among non-erythroid cells for
the eryt hroid/myeloid type. It is rec ommended that the blast percentage in the
BM be determined from a 500 cell
differentia! count using an acceptable
Roma nowsky stain . In the PB, tne differential shoul d include 200 leukoc ytes: If
Ihere is a marked leukopeni a, b ufty coa t
smears can be used , Should an aspi rate
smear not be obtainable due to BM fibrosis
and if the b lasts exp ress CD34, immun ohistochemical detection of CD34 on b iopsy
sec tions may p rovide valuab le information and may allow the diagn osis of AML
if the 20% b last threshold is me l. The
major crite ria required for this c ategory
are based on examination of BM aspirates,


D.A. Arber

R D. Brunning

L. Peterson
J. Thiele
M.M. Le Beau

A. Porwil

PB smears , and 8 M trep hine b iopsies,

The recommendation s for cl as sif ic ation
are applicable only to specimens obtained
prior to chemoth erapy. It should be noted
tha t most of the epidemiolo gic data cited
for each AMl, NOS entity has been
lar gely g athered from studies using the
p rior FAB classi fication scheme, and may
not directly apply to series of patients
classi fied by the WHO sys tem, in which
most patients will be classified into other,
more specific entities , and fOf which sufficient epid emiologic d ata is not yet available.

Acute myeloId leukaemia with

minimal differentiation
Ac ute myeloid leukaemia with minimal
differentiatioo is an AML with no evidence
0 1 myeloi d differentiation by morphology
and light mic roscopy cytochemistry. The
myeloid nature 0 1 the bl asts is demonstrated by immunological markers and/Of
ult ras tructural studies including ultrastructural cytochemistry. Imm unop henotypi ng studies are essential in all cases to
distingui sh this disease from acute lym phoblastic leukaemia (ALL) ,
ICD -O code


These cases comprise <5% of cases of
AML. The disease may occur at any age,
bu t most patients are ei ther intants or
older adul ts.
Clinical features
Patients wiltl AML, minimally differentiated
usually present with evidence of BM failure
With anaemia, ltl rombocytopenia and neutropenia. There may be leukoc ytosis with
a mark edly inc reased number of b lasts,
Morphology and cytoc hemistry
The blasts are usually of medium size with
dispersed nucl ear chromatin, round or
slightly ind ented nuc lei with one or two
nucl eoli . The cytoplasm is agranular with

Acute myelold leukaemia and related precursor neoplasms


f ig. 6.23 AcuIe myeloblastiC leukaemia. minirnaI"

enlJated. A&nI 1I8TOW sme. The blasts wary II Silt.
ilITICV1t d ~ and prorrWlen(;e d ru:id. ThM
ate no QfferenlIabng lealU'8$. B Bone man'OW sedioIl
TIis lxlne marrow is COl,lpIetely replaced by tusts..,.
Olf 11l1lerenbalJng I8alures.

a varying degree of basophilia Less frequently, the blasts are small with more
cond ensed chroma tin, inconspicuous
nucleoli and sca nty cytoplasm resemb ling lymp hoblasts. The c ytochemical
reactions for myeloperoxid ase (MPO),
Sudan Black B (SBB) and naphthol-ASDctnoroacetete esterase (CAE) are neqetive 3% positive blasts): a naphthyl
acetate and butyrate es terases are negative or may sbow a noo-specmc weak C1
local reaction distinct from that 01 rT"IOOl>
cvtrc cells 1186, 1084, 1880 1. In some
unusual cases of AML with minimal ditter
ennanon there may be a residual norma
population of maturing neutroo nue. These
c ases ma y resemb le AML with maturenon. but are distingui shed by the absence
of MPO or SBB positivity in the b lasts and
the abse nce of Auer rods, The BM sections are usually markedly hvoerceuuie
with poorly differentiated blasts. With sensitive ultrastructural studies, MPO, CAE
ac tivity may be demonstrated in sma

granules. endoplasmic reticulum, Goigi

area and/or nuclear membranes.

1",,,,,,,OP" 011Otype
Most cases express earty, heernetoooetcassociated antigens (such as CD34,
CD38 and HLA-DR) and lack antigens
associated with myeloid and monocyti c
maturation. such as CD 11b. C01S , CD14,
CD64 and CD65 Biasi ce lls usually express CD13 and/or CO l 17 while expression of CD33 is found in approximately
60% of cases, Blasts are negative tor Band T-assoc iated cytoplasmic lymphoid
markers cCD3, cCD79a and cCD22 .
MPO is neg ative by cytochemistry. but
may be positive in a fraction 01 blasts by
flow cytometry Of immunohistochemistry.
Nuclear terminal oeoxvnocieonoyttransterase (Td T) is positive in approximately

50% of cases. Expression of CO? has

been reported in approximately 40% of
cases, while expression of o ther membfane,lympood-associated markers is rare.
Genetic s
No unique chromosomal abnormality has
been identi fied in AM L with minimal differentiation. The most co mmon abnormalities previously reported are complex
karyotypes and unbalanced abnormalities, such as -5/del(Sq), -7/del(7q), +8
and del( 11ql , but the presence of some
01 these abnormalities would now pl ace
the case in the category of AML with
myelodysplasia-related changes. Mutations of RUNX 7 (AML 7) occur in 27% of
cases and 16-22% of cases have FLT3
Differential diagnosis
The differential diagnosis incl udes ALL,
acute megakaryoblas!ic leukaemia, mixed
phenotype acute leukaemi a and more
rarely. the leukaemic phase of large cell
lymphoma. Immunophenotyping studi es
are essential to dis tinguish these condi-

Acute myeloid leukaemia
without maturation
Acute myeloid leukaem ia without maturation is characterized by a high percentage o! 8M b la.''-.ts l~I,~\1 $~":li~ic.5\'71
evidence of maturation to more matur e
neutrophils. Blasts constitute ~% of the
roo-erythroi d cells. The myeloid nature of

Fill.6.2" Acute myeloid leukaem ia without maturation. Bone marrow smear. AThecellsarepredominanlty myelobIasts:
OCC3S;onal myeloblasts contain azllrophilic grarlules or Aller rods. There is rIO e'o'i Oenc41 01 maturation beyornllhe
myeloblast stage. B Myeloperoxidase reaction showing OOmertlUSmyeIoblasls with strong peroxidase reactivity. There
areseYeraI peroxidase negative tfYlhroid precursors ifl the centre.

the blasts is demonstrated by MPO or

S8B (3% or more of blasts) posi tivity
and/or Auer rod s.
ICD-O oode


Epidem iology
Acu te myeloid leukaemia without maturation comprises 5- 10% of cases of AML. It
may occu r at any age but the majority of
patients are ad ults; the median age is approximately 46 years.
Clinical features
The patients usually present with evidence of 8M failure with anaemia, thrombocytopenia and neutropenia, There may be
a leukocytosis with marke dly increased
Morphology and cytochemistry
Some cases of AML without maturation
are characterized by obv cos mveicorasts.
some of which have azurophilic granulation
and/or unequivocal Auer rods. In other
cases, the blasts resemble Iymphob lasts
and lack azurophilic granules: MPO and
SBB positi vity are present in a varia ble
number of bl asts , but always in at least
3% . The 8M biopsy sections are usually
markedly nvperceuutar although rormocellular or nvooceuuiar cases may occur.
Acute myeloid leukaemia without maturation usually presents with a popu lation of
blasts expressing MPO and one Of more
of myel oid -associated antigens suc h as
C0 13, C033 and C0 117. C0 34 and HLAOR are positive in approximately 70% of


r,~q'6' , ~ ~%'l '~\~' ,';\7 ex~<%'S\iJ'l'i'

of markers assoc iated with granu locytic

matu ration such as C0 15 and C065 or
rrcnocync mark ers such as C0 14 and

C064. C0 11b is expressed in a fraction

of cases. Blasts are negative for B- and Tassociated cytoplasmic lymphoid markers: cC03. cC079a and cCD22 . CD7 is
foond in -30% of cases , while expression
of other membrane , lymphoid-associated
markers such as C02, C0 4, CD 19 and
C056 has been described in 10- 20% of
There is no demonstrated association between AML without maturation and specific recurrent chromosomal abnormalities.
The immunoglObulin heavy chain gene
and T-eel! receptor chain genes. in most
cases , are in a germline configuration.
Differential diagnosis
The differential diagnosis includes ALL in
cases with blast cells lack ing granules or
having a low percentage at MPO-positive
blasts, and AML with maturation in cases
with a higher percentag e of MPD-positive

Acute myeloid leukaemia

with maturation
Defin ition

Acu te myeloid leukaemia with maturation

is cha racterized by the presence of ~
blasts in the BM or PB and evidence of
maturation (~10% matUringcells of neutrophil lineage); cells of monocyte lineage
com prise <20% of BM cells.
ICO-D cod e



Acute myeloid leukaemia with maturation

com prises approximately 10% of cases 01
AML (691. It occurs in all age groups;

Acute myeloid leukaemia. not otherwise specified


expression of HLA-OR, CD34 and/or

CDl 17, which may be present only in a
fract ion of blasts. Monoc ytic ma rkers
such as CD 14 and CD64 are usually ab sent. CD7 is present in 20-30% of cases.
while exp ression of CD56, C02, CD19
and CD4 is uncommon (- 10% of cases) .

Nts l'I'Iylllod leulo:BMilI Wllh mlll.ralD'" Booe

marrow &ITlNf. kl ~ tJ !he myeIobIa$l$. lhere 8111
sewraI more malure nevtrophIs; one neutrophI has a
psetJdo Pelger-HIJill Ikldeus.

20% of patients are <25 years of age and

40% are ~ years of age 120781.

O inical features
Patients often present with symp toms r
elated to anaemia, thrombocytopenia and
neutropeni a. The white blood cell coun t is
variable as is the number of blasts.
_ o g y and cytochemisOy
Blasts with and without azurophilic granu
larion are present. Auer rods are frequently
present. Promyelocytes , mveiocvtes and
mature neutroph ils com prise at least 10%
of the BM cells; variable degre es of d ysplasia are frequently present. Eosinophil
precur sors are frequ ently increased but
do not exhibit the c ytolo gical or cytochemic al abnormalities ch aracteristic of
the eosinophils in acute myelomonocyti c
leukaemia. associated with inv(16)(p13,l q22).
Basophils and/or mast ce lls are some times increased . The BM biopsy is usually
hyoe rceuular.

Immunophenotyp e
l eukaemic blasts in AML with maturation
usually express one or more of the
myeloid-associated antigens, C0 13,C033,
C065, C0 11b and C01 S. There is often


There is no demonstrated association between AM L with maturation and specific
recurrent chromosomal abnormalities.
Differential diagnosis
The differential diagnosis includes retractOf'y anaemia with excess blasts in cases
with a low bl ast percentage, AML withOut
maturation when the percentage of blasts
is high, and acute myelomonocytiC
leukaemia in cases with increased monocvtes.

Acute myelomonocytic
Acute myelomonocytic leukaemia is an
acu te leukaemia characterized by the
proliferation of both neutrophil and monocyte precu rsors, The PB or BM has ~20%
blasts (including prorronocvtes): neutrophils and their precu rsors and monocytes
and their precur sors eac h comprise at
least 20% of BM cells, This arbitrary minimal limit of 20% monocyt es and their
precu rsors disting uishes acute myelomonoc ytic leukaemia from cases of AML
with or without maturation in which some
monocyte s may be present. A high number (usually ~5x 1 09/L) of monocytic cells
may be present in the PB,
ICD-O code

Acute myeloid IeukaEtnlla and related precursor neoplasms


Ep id em iology
Acute myelomonocytic leukaemia c0mprises 5- 10% of cases of AML. uoccca n
all age groups but is more corrrnoo in ddEJ
individuals; the median age is 50 years,
There is a maleJemaIe ratio of 1.4:1 120781.
Clinical features
Patients typically present with anaerre
and thrombocytopenia, fever and fatigue
The white blood cell coun t may be high
with numerous blasts and promonocytes

Morphology and cytoct>erT;sOy

The monoblasts are large cells, wm
abundant cytoplasm which can be m0derately to intensely basophilic and may
show pseudopod formation. Scaneeo
fine ezurconmc granules and vacuoles
may be present. The monoblasts usuaJy
have round nuclei with delicate lacy ceemann and one or more large prominert
nucleoli. Promonocytes have a more irregular and delicately convoluted nucIe<r
con figura tion : the cytoplasm is usua~
less basophilic and sometimes more oIr
viously granulated , with occasional large
azurophilic granules and vacuoles. Monocvtes and promooocvtes ma y not always
be readi ly distingui shab le in routinely
staine d BM smears. The PB typically
shows an incre ase in monocytes. whlch
are often more mature than those in the
BM. The monocytic component may be
more evident in the PB than in the 8M, N.
least 3% of the blasts should show MPO
positivity. The monoblasts, promonocytes,
and monocytes are typically non-soecnc
esterase (NSE) positive, although in some
cases reactivity may be weak or absent. I
the cells meet morphologic criteria IO'
monocytes. absence of NSE does not exclude the diag nosis. Double staining IO'
NSE and CAE or MPO may show dual
pos itive cells ,

f'll. 6..27 Acute myeIomonocytIe 1eI*aen'ia.
A BIoocI smear. myeloblast monoblast al'ld prormnocytes. B Bone marrow smeaf. MyelobIas1s.1ld smnIlOOre mallJ'e mooocyte5
rdudir9 prornonocytes, C Nm-specific esterase reactionon bone marrow smear. 5eYetaI NSE positi'Ie eels819 presert. The l'ICIl'Hll8dII1 eels 8111 ~ myeIcitlIasls
m~ preaJ ~.

These ieusaemras generally show several
populations of blasts variably expressing
myeloid antigens C013. CD33, COO5 and
CD15, One of the b last populatio ns is
usually also positive for some markers

find ing s and perc ent of mo nocyt ic cells.

The differential d iagn osis with c hron ic
myelo monoc ytic leukaemia is c ritical and
rel ies on the p ro per id entific ation of
p romo noc ytes.

characteristic of monocytic d iffer entiation

such as CD 14, CD4, C0 11b, COl le,

CD54.CD36, macrophage-restricted CD68

(PGM1), CD l63 and lysozyme. In pa rticular. co-exp ressio n of CD15 and strong
C064 is characteristic of monocytiC di lferentiatoo. There is often also a popctam ol irrmature blasts tha i express CD34
<rdIor COll]. Most cases are positive for
~-DR. approximately 30% for CD7 ,
illtlile expression 01 othe r fvmpnoc-assoCiated markers is rare.

Myeloid-assoc iated , non-s oecrnc cytogenetic abnormalities, e.g. +8, are present in the majority of the cases.
Differential diagn osis
The major d iffe renti al d iagnoses inc lude
AML with matu ration , acut e mo noc ytic
leukaemia and c hronic mvelomonocync
leukaemia. The distinction from the other
Mi L types is based on the cytochemical

n;. 6.21

Acute monoblastic and

monocytic leukaemia
Def inition
Acute monoblastic leukaemia and acute
monocytic leukaemia are myeloid
leukaemias in which 80% or rrcre of the
leukaemic cells are of monocytic linea ge
incl udi ng monoblasts, prorooocvtes and
monocytes : a minor neutrophil component,
<20%, may be present. Acute monobIastic
leukaem ia
an d
ac ute
mo nocyti c
leukaemia are d istingu ished by the
relative proportion s of mono blasts and
p romo noc ytes. In ac ute monobreettc
leukaem ia, the major ity of the monocytic
c ells are monob lasts (typ ica lly ~80 % ) , In
acu te monocytic leukaem ia, the majority
of the mo nocyti c c ells are crornonocvtes.
ICD-O cod e


A Acute monoblaslic leukaemia, Bone marrow biopsy showing complete replacement by a ~lation of

llrge blasts wilh abundant cytoplasm. The nuclei aregeneraly rOI.Ild to oval: occasional nuclei are di&lol1ed
<TIO'lOCytiC leukaemia Bone marrow sedion . The nudea!'IoIds in the promonocyles arepfOmineol.

8 Acute

Ep idem io log y
Acut e monob lastic leukaemia com prises
<5% of cases of AML. 11 may oc cur at any
age bu t is most co mmon in young individuals, Extramed uliary lesions may occur.
Acute mo noc ytic leu kaemi a comprises
<5% of cases 01 AML : the mare.ternare
ratio is 1.8:1. It is more common in ad ults
(median. 49 years) 120781.
Clinical features
Bleed ing d isorders are common presenting featu res . Extramedullary masses .
cutaneous and gingival inlit1ration. and
c entral nervous system (eNS) involvement are common.
Morphology and cytochemistry
Monoblasts are large cells , with abundant
cytop lasm which c an be moderately 10
intensely baso philic an d may show
pseudop od formation. Scattered fine
az urop hilic g ranules and va cuo les may
be present. The monob lasts usually have
round nuc lei with delicate lacy c hromatin,
and one o r more large prom inent nucl eoli , Promonocytes have a more irregular
and delicately con voluted nuc lear con fig uration; the cytoplas m is usually less ba sophilic and sometimes more obv iously
g ranulated , with occasional large azurep hilic g ranules an d vacuoles. Auer rod s
are rare in acute mono blastic leukaemia
and. when present, are usu ally in ce lls
ident ifiable as myeloblasts. Haemophagocytosis (eryttrophagocytosis) may be 0bserved and suggests an associated
t(8;16)(p11 .2:P13.3) chromosomal abnormali ty 120 791. Haemoph agocytosis wilh
an associated t(8 :16)(pll.2:p 13.3) may
also be observed in AML with maturation .
The monobtasts and p rornonoc ytes usually show intense non-sp eci fic este rase
activity in mos t cas es, In up to 10-20% of
ca ses of acute monooasnc leukaemia, the

Acute myeloid leukaemia, not otherwise spec ified


can be dis tinguished with well-stained

smears . The differential diagnosis with
chronic myetomonccytc leukaemia is critical and relies on the proper identification
of promonocytes and their inclusion as
blast equivalents. The abnormal promyebcvtes in APL are intensely MPO and CAE
pos itive whereas the monocy tes are
weakly reactive or negative.
Fig. 6.29 Acute monocytic leukaemia, testcclar infiltralion Al ow magnification of a biopsy ot a testis from a patienl
with acute monocytic leukaemia. There is extensive expansion and infiltrationof tile space between the seminiferous
tubu les. 8 ThemonocyIic cells nave relati ~e ly abundant cytoplasm and ~ery dispersed chroma tin.

non-specific esterase reaction is negative

or very weakly positive. In some of these ,
immunophenotyping may be necessary
to estab lish monocytic diffe rentiation ,
Monoblasts are typically MPO negative;
promonocvtes may show some scattered
MPO positivity. The BM biopsy in acute
monobtastrc leukaemia is usually hypercellular with a predominant population of
large, poorly d ifferentiated blasts with
abundant cytop lasm, Nucleoli may be
prominent. The prornonccytes in acute
monocytic leukaemia show nuclea r lobulation. The extramedul lary lesion may be
predominantly of monoblasts or prornonocvtes or an admixture of two cell types.
Immunop henotype
By flow cytomet ry these leukaemias variably express myeloid antigens C013,
C033 (often very bright), C015 and
C065. There is gene rally exp ression of at
least two markers characteristic of monocytic differentiation such as C014 , C04,
C011 b, C011c , C064, C068, C036 and
lysozyme, C034 is pos itive only in 30% of
cases, while C0117 is more often expressed, Almost all cases are positive for
HLA-OR. MPO may be exp ressed in
acute monocytic leukaemia and less often
in monoblastic leukaemia. Abe rrant expression 01 C07 and/or C056 is found in
25-40% of cases. By immunohistochemistry
in paraffin-embedded 8 M biopsy specimens and in extramed ullary myeloid
(monobtast'c) sarcomas , MPO, CAE are
typica lly negative but may be weakly positive. Lysozyme is often positive, but is relatively non-specific. Macrophage-specific
CD68 and C0163are oftenpositiveand appear to be morespecific for monocyticdifferentiation.


Myeloid-assoc iated, non-specif ic cytoge netic abno rmalities are present in the majority of the cases. The t(8;16)(p 11.2;p13.3)
may be associated with acute monocyt ic
leukaemia or acute myelomonocytic
leukaemia and , in the majority of cases, is
associated with haemophagocytosis by
leukaemic cells, particularly erythrophagocytos is and coagulopathy 12079).
Differential diagnosis
The major differential diagnosis of acute
moncorastrc leukaemia incl udes AML
without maturation , AML minimally differentiated and acute megakaryoblastic
leukaemia. Extramedullary myeloid (monablastic) sarcomas may be confused with
malignant lymphoma or soft tissue sarcomas. Occasi onal cases resemble prolvmphocytic leukaemia; they are readi ly
distinguished by immunophenotypic analysis and cytoch emistry. The major differential diagnosis of acute monocytic
leukaemia inc ludes ch ronic mvelomonocytic leukaemia, acu te myelomonocytic
leukaemia and microgranu lar acute
promyelocyt ic leukaemia (APL). These

Acute erythroid leukaemia

Acute erythroid leukaemias are acute
leukaemias that are charac terized by a
predominant erythro id popu lation. Twa
subtypes are recognized based on the
presence or absence of a significant
myeloid (granu locytic) component:
Erytnroleukaernia (eryth roid/myeloid) is
def ined by the presen ce in the 8M of
~ 50% erythroid precursors in the entire
nucleated cel l popula tion and <::20%
myeloblasts in the non-erythroid cell population, i.e. the myeloblasts are calculated
as a percen t of the non-erythroid cells.
Pure erythroid leukaemia represents a
neoplastic proliferation of immature cells
(undifferentiated or proerythroblastic in
appearance) committed exclusivelytothe
erythroid lineage (2:80% of BM cells) with
no evidence 01 a significant myeloblastic
componen t 1753).
ICD-O code


Erytnroleukaernia (erythroid/mye loid) is
predominantly a disease of adults (20781.
It compr ises <5% of cases of AML. Pure
erythroid leukaemia is extremely rare and
can occ ur at any age, including childhood


Fig. 6.30 Acute erythrcleukaemia. erythroid/myeloid. BOlle marrow smear. A Myeloblasls and erythroid precursors
with dyserythropoietic changes are present. B Bone marrow smear Perocc acid-Schiff reaction. There are se~eraI
erythroid precu rsors atvaryingstagesof maturation wilh PAS-positi~ cytoplasm. The more immature precursors Mile
a coarsely granu laril10bular reaction; thelater stage precursors havea diffuse cytoplasmic positi~Fty.

Acute myeloid leukaemia and related precursor neoplasms


,... .

Fig. 6.31 Acute erythroid leukaemia, erythroid/myeloid.

Bone marrow biopsy, There is a population of erythrokl
precursors and myeloblasts refi ecting the duallineage
proliferation. A binucleate megakaryocyte is present.

Clinical features
The clinica l features of the eryth roid
leukaemias are not unique but profound
anaemia and circulating erythrob lasts
are common, Erythroreukaernia (erythroid!
myeloid) may present de novo or evolve
from MDS or, less common ly, from chronic
myeloproliferative neop lasms (MPN),
Morphology and c ytoc hemistry
Erythroleukaemia (erythroid/myeloid)
All maturation stages of the erythroid precursors may be present, frequently with a
shift to immatu rity. The erythroid precursors are dy splastic with meparobras torc
nuclei and/or bi- or multinucleated forms ;
the cytoplasm in the more immature ce lls
frequently contains poo rly dema rcated
vacuoles, which may coa lesce , Large
multinucleated erythroid cells may be
present. The rnveioorasta are of med ium
size, often con taining a few cytoplasmic
granules and occasionally Auer rods and
aresimilar to the mveiobrasts in AML with
and without maturation. Dysplastic changes
of maturing neutrophils and megakaryocytes are common, The iron stain may
show ring siderob lasts and the perio dic
acid-8ch iff (PAS) stain may be positive in
re erythroid precursors either in a globular or diffuse p attern. The MPO, CAE and
SBS stains may be positive in the myeloblasts. The 8 M biop sy in erythroid!
myeloid leukaemia is usually hypercelluar. There may be prominent mega karyocytic dysplasia.
Pure erythroid leukaemia
The undifferentiated form of pure erythroid leukaemia is usually ch aracterized
by the presence 01 medium to large size
erythroblasts usua lly with round nucl ei,
fine chromatin and one or more nuc leoli

Fig.6.32 Pure erythroid leukaemia. Bone marrow smear

with numeroos very immafure erythroid precursors; these
cells have cytoplasmic vacuoles which occa sionally

Immunoph enotype
Erythrole ukaemia (erythroid/myeloid)
The erythroblas ts in ervtbroieokaemia
generally lack myeloid-assoc iated markers and are negativ e with anti-MPO; they
react with antibodies to haemog lobin A
and glycophorin, but the more immature
ce lls may be negative. An aberrantly low
expression of CD71 may be present. The
immunophenotype of the myeloid population usually co rresponds to that 01 AML
without differentiation or AML with minimal


(proerythroblast): the cytoplasm is deeply

basoph ilic, often agranular and frequently
con tains poor ly demarcated vac uoles
which are often PAS-posi tive, Occasionally the blasts are smaller and resemb le
the Iymphob lasts of ALL. The ce lls are
nega tive for MPO and SBB; they show reacti vity with a -naphthyl acetate esterase,
ac id phosphatase and PAS, the latter usually in a block-like staining pattern, In the
BM biops ies of pure acute erythroid
leukaemia the ce lls appea r undifferentiated.

Pure erythroid leukaemia

The more differentiated forms can be detected by the expressio n of glycophorin
and haemoglobin A and absence of MPQ
and other myeloid markers; the blasts are
often negat ive for HLA-DR and CD34, but
may be pos itive for CD117. The more immature forms are usually negative for glycophor in or this is only weakly expressed
in a minority of blasts. Other markers such
as ca rbon ic anhydrase 1, Gero antibody
against the Gerbich blood group or CD36
are usually pos itive as they detect
erythroid progeni tors at earlier stages of
differentiation. However, CD36 is not specific for ervtbrobrasts and may be

Fig.6.33 Pure erythroid leukaemia,Bone marrow section, A Apredominant population of veryimmature erythroid precursors , some of which aremuRilobated (arrow). B The immature erythroid precursors and mrtotic figures showpositivity fof glycophorin A.

Fig.6.34 Pure erythroid leukaemia. A Bone marrow smear shows fourabnormal ptcerythrcblasts. The erythroblasts
are large withfinely dispersed chromatin. prominent nucleoliand cytoplasmic vacuoles, some ofwhfch are coalescent.
B The cytoplasm of the proerythroblasts shows intenseglobular PAS staining.

Acute myeloid leukaemia, not otherwise specified


expressed mo-ocvtes and mega karyocvtes. Antigens associated with me gakaryocytes (CD41 and CD6 1) are typically
negative, b ut may be partially expresse d
in some cases . Immunohistoc hemistry to
haemoglobin A or glycophorin may be
helpf ul in establishing cell origin in biopsy

There is no specific chromosome abnormality described in this type of AML.
Complex karyotypes with multiple structural abnormalities are com mo n, with
-5/del(Sq), -7/del(7q) and +8 the most
corrvnon 112821. However, cases with
-5/del(Sq), -7/del(7q) and/()( complex
chromosomal aonomaunes should be
classified as AML with myelodysplasiarelated changes if the other requirements
f()( that category are satisfied.

Differential d iag nosi s


be distinguished from refractory anaemia

with excess blasts (RAEB) , AML with
mye lodysplasia-related changes, AML
wi th ma turation with increased erythroid
precu rsors and reactive eryth roid hyperplasia follow ing therapy sx administration
of eryt hropoietin. A BM differential coun t
of all nuc lea ted cells should be pe rforme d. If the ove rall percentage of b last
cells is ~20% and muJlilineage dysplasia
is prese nt in ~50 % of the cells of two or
mo re lineages, a di agnosis of AMl with
myelodysplas ia- relate d c hanges should
be made . When there are <20% total
blasts an d the erythroid p rec ursors are
~ 50% of all cells, the di fferential co unt of
non-erythroid ce lls shou ld be ca lcu lated .
If blasts are ~20% of non-eryth roid ce lls ,
the di agn osis is erythro leukaemia (erythroid/myeloid ); if <20%, the d iagnosis is
usually MOS. The d ifferential diagnosis of
pure erythroid leukaemia inc lud es megaloblas tic anaemia due to vitamin B 12 or
folate de ficienc y. In eq uivoc al cases, a
trial of 81 2 o r folate thera py should be
Pure erythroid leukaemia without mo rphologic evidence of erythroid maturation
may be diffic ult to distinguish from othe r
type s of AML . particularly megakaryob lastic leukaemia, and also from ALL or
lymphoma lack of expression of lymphoid antigens will exclude the latter diagnoses. Distinction from megakaryoblastic
leukaemia is the most difficult: If the
immunophenotype is characteristic of

er ythroid pr ec ursors, a diagnosis can be

e stab lished , howeve r some cases are
am big uous and there may be cases with
concurrent erythroid-megakaryocytic involvemen t.
Prognosis and predictive factors
Erythroi d/myeloid leukaemia is generally
associated with an aggressive clinical
course. The morphologic find ing s may
evolve to a mo re predominant myeloblast
picture. Pure erythroid leukaemia is usually
associated with a rap id clinical course.

Acute megakaryoblastic
Acute megakaryoblastic leukaemia is an
acute leukaemia with 20% ()( more blasts
of which at least 50% are of megakaryocyte line age; however, this category
excludes cases of AML with myelodysplasia-related changes, AML with
t(1;22)(p13;q 13), inv(3)(q21q26.2), t(3;3)
(q21 ;q26.2) and Down syndrome-related
ICD-O code

99 10/3

Ep idemiology
Ac ute meg akaryo bl astic leukaemia occ urs in bo th adults an d children. This is
an unc ommon d isease compris ing <5%
of ca ses of AML .
Clinica l features
Patients present with cyto pe nias. often
thromb ocytop enia, although some may
have thrombocytosis. Dysplastic features
in th e neutroph ils, er ythroid precu rsors,
p late lets and me ga karyocytes may be
pres en t. Hep atosplenomeg aly is intre-

Acute myeloid leukaemi a and related precursor neoplasms

quent. An association between acute

meqekarvonrasnc leukaemia and mediastinal germ cell tumours has been ocserved in young adul t males 115941.

Morphology end cytochemistry

The megakaryobl asts are usually of
medium to large size (12-18 jJm) with a
round , slightly irregular or indented l'MJcieus with fine reticular chromatin andce
to three nucleoli . The cytoplasm is baseprune. often agranular, and may showdistinct blebs or pseudopod formation. In
some cases the blasts are predominaf1ty
small with a high nuclear-cytoplasmic
rato resembling Iymphoblasts; large and
small blasts may be present in the sere
patient. Occasionally, the blasts occur I'l
small clusters. Circulating micromegakaryocytes. megakaryoblastic fragments,
dysplastic large platelets and hypogralurar neutrophils may be present. Micromegakaryocytes are small cells with 1rx
2 round nuclei with condensed chromalfl
and matu re cytoplasm: these should rwx
be counted as blasts. In some patients,
because of extensive 8 M fib rosis restJ!.ing in a "dry tap ", the percent of 8M
blasts is estimated from the 8 M biopsy.
Imprints of the biopsy may also be uselul.
Although acu te megakaryoblastic leukaemia may be associate d with extensive
fibrosis, this is not an inva riant finding.
The histopathology of the b io psy vanes
from cases with a uniform population of
poor ly d ifferentiated blasts to a mixtureof
poorly differentiated blasts and maturing
dysplastic megakaryoc ytes; varying deg rees of reticulin fibrosis may be present.
Cytoc hemical stains for SBB, CAE and
MPQ are co nsistently negative in the
megaka ryob lasts ; the blasts may show
reac tivity with PAS and for ac id phosphatase and punctate or foc al nonspecific esterase reactivity.

_ B


fig.6.36 ACVle mega~ 1eI.*aenia. A Bone marrow smear. The two megaka-yoblasts are large ceHs with
GytlpIasmic pseudopod lonnatiOn: portIOnS of the cytqllasm are "zoned" with granular basoplliliC areas and dear
~_ Nucleoli cwelAl$lJ3ly ptCIII1nerL B Bone marrow smear reac:t8d wrth alllilOOy to CD61 (pIal9lel: gIycopro.., II). The eyklpIasm of the ITlI!9lkalyoblasls is in&enSeIy reactJYe

The meqakarvobtests express one or
'!'(Jfa of the platelet glycoproteins: CD41
19yooprotein 1Ib/llla). and/Of COOl (glycoprotein ilia). The more mature plateletassociated marker CD42 (glycoprotein Ib)
s less frequently present The myeloidassociated markers, CD13 and CD33.
'fay be positive. C034. lhe pan-Ieukocyte

marker CD45. and HLA-OR are often negalIVe. especially in children; CD36 is characteristically positive. Blasts are negative
with !he anti- MPO antibody and with other
markers 01 g ranulocytic differentia tion.

Lymphoid markers and TdT are not

expressed. but there may be aberrant
eqxesson of CD? Cytoplasmic expression of CD4 1 or C06 1 is more specific
and sensitive than surface staining, due
tl possible adherence of pl atelets to bl ast
,:ells, whic h ma y be m isi nte rp re ted as
positive sta ining by f low c ytometry In
cases with fibrosis, immuno phe no ty ping
011 BM trephine biopsies is particularly
mportant for di agn osis. M eg akary ocytes
and in some cas es rr eq ak arvo brast s can
te recognized by a positive reac tion w ith
antibod ies to von wmeorand's factor, the
platelet glycopro teins (CD6 1, CD 42b)
irld LAT (linker of activation of r -cenej the
eetecton of platelet glycop roteins is the
rest lineage specific but detection is
Ilighly dependent on procedures used for
ixation and decalcification.

There is no unique chromosomal aonorTe'rty associated with acute meqakarvoblastic leukaemia in adults . Complex
r.aryofypes typical of MD S, inv(3)
!:321(126.2) and t(3;3Xq21q26.2) can all
be associated with megakaryoblasticl
n!gak.aryOcytic differentiation 1507, 16371

but these cases are all assigned to other

categories of AML (See AML with recurrent
genetic abnormalities) ,
In young males with mediastinal germ cell
tumours and acute meqakarvobtasuc
leukaemia. several cytogenetic acoomauties have been observed of which i( 12p) is
Differential diagnosis
The differential diagnosis inc ludes minimally d ifferenti ated AML, AML with
myelodyspl asia-rela ted changes, acute
panmyelosis with myelofibrosis, ALL , pure
erythroid leukae mia and blastic transforma tion of chronic myelogenous leukaem ia
or rneqakarvobrasnc crisis of any MPN. In
the latter tw o conditions, there is usu all y
a history of a chronic phase an d splenom eg aly is an alm o st consta nt find ing.
Some metastatic tumours in the 8M, particularly in c hild ren , e.q alveo lar rhabdomy osarcoma , m ay resem ble acute
m eqak aryobla stic leukaemi a. In g en eral.
acute meqakarvoblastic leukaemia repr ese nts a p rol ifer at ion pr ed omi nan tly of
rne q ak arycbta sts. whe reas acut e p anm yelosis is c har acterized b y a trilineage
proliferation, i.e. granulocytes, megakaryocvtes and erythro id precursors. The distinction between acute megaka ryoblastic
leukaemia, ac ute pan myelosis with fibrosis
and AML with m yelodyspla sia-re lated
Changes is not always clear.
Prognosis and predictive fact ors
The prognosis 01 this category 01 acute
mecakarvobtasnc leukaemia is usually
poor when compared to other AML types
as well as in comparison to AML with
t( 1;22XP13;q 13) 1620 , 16371 and acute
megakaryoblastic leukaemia in Down
syn d rome,

Fill, 6,37 Acu1e megakaryoblastic 1e\Jkaen'ia. Bone

Il'\I'OW biopsy shows vi1uaRy ~ repIacemenl by

a popuIaIion 0/ blasts CI'ld weW1IerenhaIed megakaryo.

cya There is a n'WlOl" popJabon 0/8I)'IIVOid preanors,

Acute basophilic leukaemia

Defin ition
Acute basophilic leukaemia is an AML in
which the primary differentiation is to ba-

ICD-O cod e


Epidem iology
This is a very rare disease with a relatively
small number of reported c ases, comprising < 1% 01 all cases of AML.
Clinical fea tures
As in other acute reokaemras. patients
present with featu res related to 8 M failure
and mayor may not have c irculating
bl asts, In addition, cutaneous involvement, organomegaly, lytic les ions and
symptoms related to hy perhistam inemia
ma y be present.
Morphology and cytochemistry
The circulating PB and 8 M bla sts are of
medi um size with a high nuclear-eytoplasmic
ra tio, an oval, round or b ilobed nucleus
c harac terize d by disperse d chromatin
an d one to three p rom inent nucleo li. The
cytoplasm is moderately basophilic and
contains a varia ble numbe r of coarse basophilic granules wh ic h ar e positive in
me tachromatic stains; vacuolation of the
cytoplasm may be present. M ature basephi ls are usually sparse. Dysplastic tealures in the erythroid precursors may be
present. Electron microscopy shows that
the granules contain structures characteristic of basophil precursors; they contain
an electron-dense particulate substance,
are internally-bisected, e .g. have a theta
character, or contain crystalline ma terial
arranged in a pattern of scrolls or lamellae , the latter finding is more typical of

Acute myeloid !eukaerma, not orrerwse specified



ma st cells. ,Coe xistenc e of basop hil and

mast ce ll granules may be iden tified in the
same immature cells {17321. The mo st
charac teristic c ytochemi cal react ion is
metac hroma tic positivity with toluidi ne
blue. In addition. the blasts usually show
a diffuse pa ttern of staining wit h acid
p hosp hatase and . in some cases. PAS
posi tivity in b locks or lakes; the blasts are
often neg ative by light mic roscopy for
SBB, MPO. CAE and non-specmc esterase. The BM trephine biopsy shows diffuse replac ement by blast ce lls.
' rrm.Jnophenolype
Leukaemic blasts expre ss myeloid markers such as C0 13 arldJor C033, and are
usually positive for CD 123. C0 203c and
CD 11b. but negative for other monocytic
markers. Blasts may express CD34 and
in contras t to normal basophils may be
positive lor HLA-DR but are negative for
CD 117. Immunopheno typic detec tion of
abnormal mast cells expressing CD1 17.
mast cell tryptase and C0 25 will distinguish
mast cell leukaemia tram acute basophilic
leukaemi a. Usually blasts show exp res sion of COO. Some cases may be positive
for memb rane CD22 and /or Td T. Other
mem brane and cytop lasmic. Iymp hoidassoc iated markers are usually negative
11295.207 41.

F"Ii- 6.38 Acute ~ 1eINema . Bone marrow smear. A Blasts and irrmature basophiIs. The bascJpIj pUIs
vary from large roarsegraUes III smaI8rpUBs. B Bone marrow trepl1n8 biopsy. The bIa:sls /we pco1y~

Clinica l features
Patients pre sent acutel y with severe constitutional sympt oms including weakne ss
and fatigue ; fever and bone pain are also
frequently ob served. Pancytopenia is
alwa ys p resent. There is no or minimal
sp lenomeg aly. The clinical evolution is
usually rapidly progressive 122251.

Occasional neutrophil precusors inc::kJl:ilv

bla sts may be id entified . Dvsotastc
Changes in myeloid cells are frequent
Abnormal platelets may be noted . aoe
marrow aspiration is frequently uosocce ssful: either no 8M is obtained or ee
specimen is suboptimal. Bone marroe
biopsy supplemented with immunohis:o.
logy is required for diagnosis /2124.
2225 1. The 8 M b iopsy is hypercelljjw
and shows , within a diffusely fibrotIC
stroma . an increased p ronteratco of erythroid precu rsors. granulocyte precursors
and megakaryocytes (panmyelosis). wt'ich
is variable in terms of the relative prooction of each given component. Characteristic findings include foci of immature
baematcpolettc cells including blasts
associated with cons picuously dvsplastc
megak aryocyt es p redominately of smat
size with eosinophilic cytoplasm showing
variable d egrees of cytological atypia il'leluding the presence of hypolobulated cr
non-lobulated nuclei with dispersed crso
matin. Mic romegakaryoc ytes may be
present but should not be cou nted as
bla sts. The visib ility of the small meqakaryoc ytes may be ac centuated with the
PAS stain and immunohistochemistry
l 22251. The overall frequency of blasts ir
APMF marrows is uncertain. Based onBIll
biopsy, a median value of 22.5% was
found in a recent study /165 11. Mosl cases
have a range of 20-25%. The degreed
myelofib rosis is variable. In most patients
there is a marked increase in reticulir
fibres with coarse fibres; frank collageroo;
fibrosis is. however, uncommon.

_logy and cylochem;stty

The PB shows panc ytopenia whic h IS
usually marked . The red blood cells
show no or minimal aniso poiknoc v tosrs
and variab le macrocytosis; rare erythroblasts c an be seen b ut teardrop-shaped
c ells (d acryocytes) are not observed.

If sufficient 8 M specimen is obtained!o'
immunologic markers or circulating bIas:s
are p resent in the P8 . the c ells sh:)w
phenot yp ic heterogen eity, with va~
d egrees of expression of myeloid-aSSOCIated antigens . The blasts usually express

Prognosis and p redictive factors

Since this is a rare type of acute leu kaemia. there is little information on survival. The cases observed have genera lly
been associated with a poor prognosi s.

Acute panmyelosis with

Acute panmyelosis with myelofibrosis
(APMF) is an acute panmyeloid proliferation with inc reased bla sts and accompanying fibrosis of the 8 M {168, 2 1201 that
does not meet criteria for AML with
myelodysp lasia-related changes.
ICD-O code

Genetic s
There is no consistent chromosomal
abnormality identified in these cases.
AML with t(6:9)(p23;q 34) is speci fic ally
excluded as are cases associ ated with a
BCR-ABL 1 fusion gene.
Differential diagnosis
The d ifferential d iagnosis inc lud es bl ast
ph ase of MPN, other AML subtypes with
ba sophilia suc h as AML with t(6;9)
(p23:q 34), mast c ell leukaemia and , more
rare ly, a subtype of ALL with prominent
coarse granules. The clinical features and
cytogenetic pattern will distinguish cases
p resenting de novo from those resulting
'rom transformation of chronic my elogenous leukaemia and from other AML subtypes With basophilia. Immunologica l
markers will distinguish between granulated AlL and acute basophilic leukaemia
and light microsc op ic c ytochemist ry lo r
myelope roxidase and elect ron mlcroscopy will distinguish acute basophilic
leukaem ia from other leukaemias.


993 1/3

Acute (malignant) myelofibros is, acute
(malignant) myelosclerosis.
Epidem iology
Acute panmyelosrs with myelofib rosis is a
very rare form of AML APMF oc curs de
novo. It is primar ily a disease of adu lts but
has also been reported in children.

Acute myeloid leukaemia and related precursor neoplasms

the progenilotlearly precur sor-associated

market CD34 and one or more myeloid associated antigens: C013, C033 and
CD117 11651, 2 124, 2225 1. Myeloperoxidase is usually negative in the bla sts. In
some cases a proportion of immature
cells express erythroid antigens. Immunohistochemistry can facilitate the identi fication of the relative proport ions of the
various myeloid components on the
biopsy specimen and is g enerally used to
confirm the multiline age nature of the
proeteranon. This is usually d one by
employing a panel of antibodies which inclodes myeloperoxid ase, lysozyme , antimegakaryocytic markers (C06 1. C0 42b ,
C041 or anti-von Wil1ebrand 's fac tor) and
erytIYOid markers such as g tycophofin and
haemoglobin A. These confi rm the preseoce 01 parvnyelosis and allow exclusion
ci specific unilineage" -predominant proilerations.such as acute rnegakaryObtastic
~emia .

If sufficient specimen for cytogenetic
analysis is obt ained , me results are usually abnormal. The d etec tion of a com plex
karyotype, frequ ently Involving ch romosomes 5 and/or 7 [-51del(5q), -7/d el{7q)]
122251, means that the case is assigned
to AML with my elodysp lasia-related
changes, not to ac ute panmyelosis.
Differential diagnosis
The major di fferential diagnosis of APMF
includes other type s of AML with associated BM fibrosis including acute megakaryoblastic leukaem ia 116511. Usual ly
ess problematic is the di stinction from
primary myelofib rosis (PMF), po st-p olycythaemia vera myelofibrosis, post-essen~ a l lh rom boc yt h ae m i a myelofibrosis, and
eon other neopla sms that c an be encountered in a myelofib rotic BM such as
metastatic malig nancies with a de srnoplastlc stromal reaction . The distinction between AML. particularly c ases of AML with
myekxiysplasia-related changes with multi~neage dysplasia and myelofibrosis and
acute megakaryoblastic leukaemia with
myelofibrosis, and APMF may be difficu lt,

particularly if no specimen suitable for cytogeneti c analysis can be obtained.

If the proliferative process is predominantly
one cell type. i.e. myeloblasts, and there is
assoc iated myelofibrosis, the case should
be classified as AML with a specific subtype, e.g. AML-myelodysplasia-related .
and then desig nated with the qua lifying
phrase w ith mveronbrosrs". Acute megakaryoblastic leukaemia is assoc iated with
the presence of 2': 20% b lasts, of which at
least 50% are mega karyobla sts. In contrast, the b lasts of APMF are more heterogenous, poorly differentiated and express
CD34. The majority of blasts do not display
megakaryocytic reactivity, and the proliferative proces s involves all of the major BM
c ell lines.
Particul arly difficu lt is the di stinction between APMF and cases of MOS associated
with both an excess of blas ts and myelofibrosis (AAEB-F), since the latter cases c an
share roost of the morphological finding s
seen in APMF. Clin ica lly, APMF can be
separated from MOS by its more abrupt
onset with fever and bone pain. In APMF.

histology of the BM shows more numerous megakaryocytes and , on average, a

higher numb er of blas ts than what are
found in AAEB. Cases of AAEB-2-F. except for their usually less acute clinical
presentation , may be indisti nguishable
from APMF 116511. APMF is distinguished
from PMF by the more numerous blas t
ce lls in the former and the distinct cytological characteristics of the megakaryocy tes in the latter (See Chapter 2). The
presence of a metastatic malignancy or,
rarely a lymph oid disorder c an be excluded by studies with appropriate antibodies.
Postulated normal cou nterpart
Haematcpoie tlc stem cell. The fibroblastic
proli feration is secondary.
Prognosis and predictive fac tors
The disease is usually associated with poor
response to chemotherapy and usually
only a few months survival 1165 1, 21241 .

Acute myeloid leukaemia,


otherwise spec ified


Myeloid sarcoma

SA Pileri
A. Orazi
B. Falini

A myeloid sarcoma is a tumour mass consisting of myeloid blasts with or without
maturation occurring at an anatomical site
other than the bone marrow (BM) . Infiltrates of any site of the body by myeloid
blasts in leukaem ic patient s are rot cl as-

sified as myeloid sarcoma unless they

Sites of involvement
Almost every site of the body c an be involved , the skin, lymph node, ga strointestinal tract, bone, soft tissue and testis
be ing more frequently attectec 1663.
1742 1. In less than 10% of ca ses . myeloid
sarcoma presents at multiple anatomical
sites 1663, 17421.

proportion of c ases, it d isp lays rnyelomonocytic or pure monoblastic morphology 1663. 17421. Tumours with trilineage
haematopoies is Of predom inantly erythroid precursors or megakaryoblasts are
rare and may occu r in c onj unction W1tt1
transformation of MPN 117421.

Clinical featu res

Myeloid sarcoma ma y occur de novo: its
detection should be conside red as the
equivalent of a d iag nosi s of AM L. It may
precede or coinci de w ith AML or represent acute b lastic tran sfor ma tion of
myelodysplasti c syndromes (MDS), MPN
or MDS/MPN 1663, 17421.
Finally, myeloid sarcoma may also be the
initial manifes tation of relapse in a pa tient
with prev iously diagnosed AML, regard less
of blood or 8M findi ngs 1t7421.

On imp rints, cytochemical stains for

myelo pe roxid ase (MPO), naphthol-AS().
c hloroacetate esterase (CAE) and l'"Il;no
specific estera se (NSE) ma y assist in
d ifferentiating granukx::ytic lineage (Mfl()+,
CAE+) from rroooblasnc forms (NSf+~ In
addition , CAE reaction can be applied to
rout ine sec tions , although the results may
depend o n fixation and d eca lcifying

present with tumour ma sses in which the

tissue arch itecture is effaced

Extramedullary myeloid tumour; granulo-

cytic sarcoma : cmorona

There is a predilect ion for ma les and last
de cades ctute. The mare.t emaie ratio is
12 :1. The median ag e is 56 years (rang e.
1 month-89 yea rs) 1663 . 17421.

The same as for acute myeloid leukaemia
(AMl) and myelop roliferative neop lasm s



A myeloid sarcoma most c ommonly consists of myelobl asts with or w ithout features of promyeloc ytic or neut rophilic
maturation that pa rtially o r totally efface
the tissue arch itecture. In a sig nific ant

Acute myelotd leukaemia and related precursor neoplasms

On immunohistoc hemistry in paraffin sections, C D68 /KP1 is the most c ommonly
expressed marker, followed in decreasing
frequency by MPO , CD t 17, CD99 . CD6&'
PG-M t , lysozyme , CD34 , termin al deoxvnucreoncvt trans ferase (TdT ), CD56,
CD6t/lAT/von Willeb rand antigen, CD30,

glycophorin, .and C D4 117421 . Foc i of

plasmacytoid dendritic c ell differentiation
(C0 123 +) are occasionally observed in
cases carrying inv(16) 117421 . The combination at the above mentioned markers
allows the recognition of tumo urs with a
more immature mye loid pheno type, as
well as of c ases with mveromonccvtrc.
monoblastic, erythro id or megakaryocytic
differentiation. Exceptionally, aberran t antigenic expres sions are obs erved (cytokeratins. B- or T-cell marker s). Ca ses that
meet cntena for mixed phenotype AML
are not c lassified as my eloid sarcoma
(See Chapter 7). Flow cvtorenlc ana lysis
on cell suspensions revea ls posmvmes for
C0 13. C033. C0 117 and MPO in tumour s
with myeloid d ifferentiation. and for CD 14.
COl 63 and COll e in the monob las tic


Geneti cs
By FISH andlor c ytog enetics, c hromosomal aberrations are detec ted in ab out
55% of cases. They incl ud e rnonosomy 7,
trisomy 8, MLL-rear rangement. inv( 16).
trisomy 4, monosomy 16, 16q-,
2Oqand trisomy 11 {17421. About 16% of
cases carry evidence of NPM 1 mutations
as shown by aberrant cytopl asmic NPM
expre ssion 1663. 666/. The t(8;2 1Xq22;q22)
observed in paed iatric series seem s to be
less frequent in adu lthood 1' 742 , 19 781.


Differential d iag nosi s

The major d ifferential d iag nosis is with
mali gn ant lymphoma , The d iag nosis of
my elo id sar coma is valid ated by the
results of c ytochemical and /or immu nophenotypic analyses. These allow the
d istinction of myeloid sarcoma. from: 1ymphoblastic lymphoma, Burkitt lymphoma .
diffuse large B-cell lymphoma. small round

c ell tumours, part icu larly in child ren, and

blastic pl asmacyt oid dendritic cell neopla sm 11742/. These tumours must be
di stinguished from non-effa ci ng tissue
infiltrates by AML or MPN
Postu lated normal counterpart
Haernatopoietic stem c ell.
Prog nosis and predictive factors
The cli nic al be haviou r and respon se to
therapy seem not to be influenc ed by any
of the following factors: age , sex, anatomical site(s) involved . de novo presentation,
clinical history related to AMl. MDS or
MPN , histological fea tures. immunophenotype and cytogenetic find ing s
117421. Pat ients 'Nho undergo allogeneic
or aUIOOgous BM transp lantation seem to
have a hig her pr ob ab ility of prolonged
surviv al or cu re 1268. 17421.

MyelOId sarcoma


Myeloid proliferations related

to Down syndrome

Individuals with Down syndrome (OS)

have an inc reased risk of leukaemia compar ed to non-OS individ uals 1716. 23651.
The inc reased risk is variously estimated
at 10 to 100 Iold . The inc reased risk ex-

tend s into the adult years. In addition to

the increased Incidence, the ratio of acute
lymphoblastic leukaemia (A LL) to acute
myeloid leukaemia (AMl) in OS chil dren
less than 4 years of age is ap proximately
equal, 1.0 :1.2, compared 10 nonDS children in the same age group in which the
ratio is 4 :1 . There is an approximately 150
fold increase in AML in OS children less
than 5 years of age; 70% of the cases of
AM l in OS children less than 4 years of
age areacute megakaryoblaslic leukaemia
in con trast 10 the 3-6% incidence otttns
to m of leu kaemia in r"lOfl-DS child ren . The
acut e megakaryob lasl ic leukaemia whic h
occurs in OS children has somewhat
uniqu e morpho logic, imm unophenotypic,
mol ec ular and clinical characteristics
wh ich d ist ing uish it from other forms of
ac ute megakaryob lasli c leukaemia, inelud ing GATA 1 mutations 1635. 1362 J
These va riou s featu res serve as the rationale for the recog nition of this form of
leukaemia as a d istinct type in the WHO
c lassification, In add ition to the uniq ue
characteristics of the pred ominan t form of
AM L in OS ch ild ren less than 4 yea rs of
age , ap p roximately 10% of OS neonates
manifest a haema tolog ic di sorder refe rred
to as transient abnormal my elop o iesis or
trans ient myelop roliferative otsoroer wh ic h
may be morphologi ca lly ind isting uishab le
from the predominant form of AML in OS
child ren 127 1, 1409 1, This disorder resolves
sponta neously over a peri od of seve ral
weeks to 3 mo nths , In 20-30% of the affected cases. non-remi tting ac ute megakaryoblastic leu kaemi a su bs eq uently
develop s in t to 3 yea rs. It is important to
rec og nize that altho ugh the atore mennooeo d isorders have rec eived the most
attention in OS p atient s , they occur in a
specific age g rou p and other fo rms of
ac ute leukaemia, bo th ALL and AML. affec t OS individuals. The ove rall inc reased
risk for OS individuals includes all types.
The same approach lor characterizing the

I. Baum ann
C M, Niemeyer
AD. Brunning
O.A. Arber
A, Porwit

specific type of teukaemia in OS patients

m ust incl ude the same ca reful morpholoqic, lmmunoonenotvoic. cytogenetic
and mol ecular eval uation as in non-OS
individu als to ensure that appropriate
the rapy is administered 124891.

Transient abnormal
Transient abnormal myelopoiesis (TAM) is
a unique d isord er of Down syndrome (OS)
newborns that presents with clinical and
mo rphologic find ing s indistinguishable
from AML. The blasts have morphologic
and irrrnunologic features of megakaryocytic lineage.
The provisiona l code proposed for the
fourth edition ofICO-O is 9898/1.
Transient mye lopro liferative d isord er.
Epide miolog y
Trans ient abnormal myelopoi es is occurs
in approximately 10% of OS newborn s: it
uncommonly occ urs in phenotyp ica lly
normal neonates with trisomy 21 mosaic ism,
Clinical fe atures
At presen tation , thrombocytopenia is most
commo n; other c ytopeni as are less freq uently encoun tered, There may be a
ma rked leukoc ytosis and the pe rcentag e
of blasts in the per ipher al blood (PB ) may
exceed the blast pe rce ntage in the bon e
ma rrow (BM ). Hepatospl enomeg aly may
be present. Rarely, cl inical complications
incl ude ca rd iopulmonary failure. hyper.
viscosity. spl enic necrosis and p rogressive hepa tic fibrosis 15921. The proc ess in
the major ity of patients undergoes spontaneous remission Within the first three
months of life; a few chil dren experience
life th reaten ing or even fatal clinical complications.

Acute myeloid leukaenlla and related precursor neoplasms


Fig. 6.41 Blood 5me from a ore day-old Ilfanl ...

00rM'l synOrome and lransieot abnofmal ~
The PB contailed 55% f*Ists. C)1Jgenek studystx.:l
horny 21 as hi soleabnormality. The process ~
~1MIl" a period ofbJ" weeks.

Morphology and immunophenotype

The morphologic and immunophenotyplC
features of TAM are simila r to those of the
blasts in most cases of OS AML. Peripheral blood an d 8 M blasts ouen have
basophilic c yto plasm w ith coa rse besop hilic gra nules and cytoplasmic blebbing suggestive of meqakervobiasts.
Some patients have PB bas op hilia; eryth roid and meg akaryoc ytic dysplasia is
often present in the BM 127 11. Blasts in
TAM d isp lay a cha rac teristic immunoph enotype 11 25 11 . In most cases the
bl asts are positive fo r C034, CD56.
C0 117, CO t3, C D33, CD7 , CD4 dim,
C041, C0 42, TPO-R, lL-3R, C036, COOt,
C071, and a re negative for myeio pe rc
case. C0 15, C0 14 and g lyc oph orin A
The bl asts in approximately 30% of cases
are posi tive for HLA-DR.
Antibod ies to C04 1 and CD61 may be
p artic ularly useful in id entifying cells of
megakaryocytic lineage in immunohistologic prepa rations .
In ad dition to trisomy 2 1, ac quired GATAI
mutations are present in blast cells of TAM
1635,942,2347/. While gene eneysnoes
have suggested differences in expression
between AM L of OS an d TAM. these
findings have not yet been cootsrreo
1258, 1298, 1439/.

..:....."!;;.4 . ....," -'

FIg. 6.42 UyeIoid 1eukaerr'U associaled wilh Down syrdome in a two year-dd d*l. A Bone marrow smear. ThePB and8M smearsc:ontarled ITIJIbpIe blasts as ~_ loWry
ollie bIasls contained runetOUS coarse basoIlI*CI:lIcAnd gJarUes . wtidl were myeloperoxidase ~_ Cy!OgenetJC sludy et 1M bme showed trisomy 8 in ali:lIbDn kllrJsomy
21. B Bone marrow trephrle biopsy !rom !he same pabenl There aft! I'II.I'flef'OI. blasts and occasional megakaryocyles induding one with a IIOIHobated IllJl::llM. C An irTmJnl>
IJst*9C readJon WIth CD-61 antibody. There are r...metOUS readJng eels indtdng otMous megakatyocyles and sevetaI smaIer eels .

Prognostic and predictive factors

individuals beyond the neonatal period .

Although the d Isorder is characterized by

a high rate of spontaneous remission,
rco-nansent AML develops 1 103 years

There are no biok>gical differences in OS

individuals between myelodysplaSbC ~

later in 20-30% ot mese children 125031.

Indic ations lor chemotherapy in TAM are

not firmly established ,

Myeloid leukaemia associated

with Downsyndrome
Individuals with OS have a 50 fold increase in incidence of acute leukaemia
during the first 5 years of life compared to

non-OS individuals. Acute myeloid

leukaemia in OS is usually an acu te
megakaryoblaslic leukaemia, accounting
for 50% of cases of acute leukaemia in OS

drome (MOS) and overt AMl; therefore, a

comparable diagnost ic differentiation algorithm is not relevant and would have no
prognostic or therapeutic consequences.
Since this type of disease is unique to
ch ildren with OS the term myeloid
leukaemia of OS encompasses bOthMOS
and AML.
The provisional code proposed for the
fourth edition of ICo-O is 9898/3.
The great majority of children with OS with
myeloid leukaemia are under 5 years of
life. Abou t 1- 2% of ch ildren with OS will
develop AML dur ing the first 5 years of

Fig. 1.'3 SedicI'I d iWI atldl:ri'III ~ node In:lm eNd wrltl Ck:Jr,yrJ syncmne lnl ac:uIe megakar'yobl9sbc Ieo..*aerTia
The I'lXIe is ~ ~ by b8sls wifl occasicI'laI ~. sane d.n::n ae dyscllasIc.

Iile. Children with OS account lor - 20% of

all paediatric pat ients with AMUMOS
1271 .592.9081 _Myeloid leukaemia of OS
occ urs in 20-30% 01 children with a pr ior
history of TAM and the leukaemia usually
occ urs 1-3 years after TAM.

Sites of involvement
Blood and BM are the princip le sites of involvement . Extramedul lary involvement,
mainly of sp leen and liver, is almost always present.
Clinical features
The disorder manifests predominantly in
the first 3 years of life, The clinic al course
in children with tess than 20% blast cells
in the 8M appears to be relatively indolent and presents initially with a period of
thrombocytopenia. A preteokaemc phase
comparable to refractory cytopenia of
ch ildhood (RCG)generally preceeds MOS
with excess blasts or overt leukaemia.
In the pre-leukaemic phase. which can
last for several months, the disease has
the features of RCC (See Chapter 5) lacking a significant increase of blasts. Erythroid cells are macrocytic. Dysplastic
features may be more pronounced than in
primary refractory cytopen ia.
In cases of AML, blasts and occasionally
erythroid precursors are usually present
in the PB. Erythrocytes often show
con siderable anrscooikllocytoele. sometimes dacryocytes. The platelet count is
usually decreased and giant platelets
may be observed,
In the 8M aspirate, the morphology of the
leukaemic blasts shows particu lar features with round to slightly irregular nuclei
and a moderate amount of basophilic

MyefOid proliferatIOnsrelated to Down syndrome


c ytoplasm; cy topl asmic b lebs may be

present. The cytoplasm of a variable number of blasts co ntains coarse granules resembling b asoph ilic gra nules. The
granules are generally myeloperoxid ase
negalive. Erythroid p recursors often show
megaloblastic changes as well as dysp lastic forms, including bi- Of trinuc leated
cells and nuclear fragments. Dysgranuloporesrs may be present .
The 8M core may show a dense network
of reticulin fib res, making adequate 8M
aspi ration difficult or impossib le. Erythropoiesis may be increased in cases with a
low blast percentage and decreases with
disease progression. Maturing cells of
neutrophil lineage are usually decreased.
In cases WIth a dense blast cell infiltration
rare dysplastic megakaryocytes may be
seen. In other cases of acute megakaryootasnc leukaemia. megakaryocytes may
be markedly increased with clusters of
dysplastic small forms , micromegakaryocvtes and occasionally an increase in


Leukaemic blasts in acute megakaryocytic
leukaemia of OS display a similar immunoph enotype to blasts in TAM /125 11. In
mos t cases, the blasts are posi tive for
CD 11?, CD 13, CD33 , CD? , CD4 , CD42 .
TPO-R, IL-3R. CD36, CD4 1, CD61, CD7 1.
and are negative for myeloperoxidase,
C0 15. CD1 4 and glycophorin A. However, in con trast 10 TAM, CD34 is
neg ative in 50% of cases and approximately 30% of cases are negative for
CD56 and CD4 1. Leukaemic blasts in
other types of AML in OS display phenotypes corresponding to the particular
AML category
Antibodies to C041 and C061 may be
particularly useful in identIfying c ells of
megakaryocytic lineage in irrvnunohistologic preparations.

In addition to trisomy 21, senate rmtatcos
01 the ge ne encoding the transc npnon
factor GATA1 are considered pathognomonic of transient ab normal mveicooeeis

Acute myeloid leukaemia and related precursor neoplasms

of Down syndrome (TAM) or Mo S/AMl oi

OS 1835 . 942, 13621. Children above the
age of 5 with myeloid leukaemia may not
have GATA 1 mutations and such cases
should be consi de red as 'conventional"
MDS or AML. Trisomy 8 is a comrTlO'l
cytogenetic abnormality in myeloid
leukaemia of OS occurring in 13-44% at
patients 1908, 9181. Monosomy 7 is very
rare in Ds-associateo myeloid leukaemia
Postulated nonnal cou nterpart
Haematopoietic stem cell.

Prognostic and predictive factors

Clinical outcome for young children WlI!l
OS and myeloid leukaemia with GATAI
mutations is unique and is associated
with a better response to chemotherapy
and very favourable prognosis
to non-OS children with AML 112501. rte
children should be treated on DS-specrllc
protocols. Myeloid leukaemia in older OS
children with GATA' mutation has a
poorer prognosis comparable to AMl i'l
patients without OS {75 11.


Blastic plas macyto id dendritic cell


Blastic plasmacytoid dend ritic cell (BPDC)
recoesm is a clinically agg ressive tumour
defived from the precursors of otasrnacvklid dendritic cells (also known as pro tesSlOnaI type 1 interferon producing cells or
plasmacytoid morocvtes). with a high trecuencv of cut aneous and bo ne marrow
(8M) involvement and leukaemic d issemination.

ro<l code


Blasbc NK-celilymphoma 11039/. aqraniJaf CD4. natural kille r cell leukaemia
12771. blastic natural killer leukaemia/lympt'(ma \576 J, aaranurar CD4 +CD56+

reematooerrmc neoplasm 117361ltumour

This is a rare form of haem atologic neoplasm. without any known racial or ethnic
predilection. It has a male/fema le rano of
33:1; most patients are elderly, w ith a
eererecnan age at diagnosis of 61-67
years. but it can occ ur at any age , inCkldlngchildhood 1702. 920 ,1031 1.

There are c urrently no cl ues to the etrobgy 01 BPDC , bu t its association w ith
myelodysplasia in some cases may suqgeS! a related pathogenesis. There is no
association with Epstein-Ba rr virus (EBV) .

F. Pacchem
D.M. Jone s
T. Petrella

Sites of involvement
The d isease tends to involve mul tiple
sites . w ith a p redi lection for skin (almost
100% of cases). followed by 8 M and peripheral blood (PB) (60-90%). and lymph
nodes (40 -50%) 1920, 17351 .
Clinica l features
The pat ients usua lly present with asymptomatic solitary or multip le skin les ions
that c an be nod ules, pl aque s. o r b ruiselike areas, Reg ional lympha denopathy at
presentation is c ommon (20%); PB and
BM involvement can be minimal at pre sentation . but invaria bly develops w ith
progression of d isease . Cytopenias (especia lly thrombocytopenia) can occur at d iag nosis, and in a minority of cases can be
seve re, indic ating BM failure 1702, 920 1.
Follo wing initial respo nse to chemotherapy , re lapses invariab ly oc c ur, involv ing
skin alone. or skin associated with othe r
sites . includ ing soft tiss ues and the centrat nervous system. In most cases a fulminant leukaemic phase ult imately
develop s 1702 1.
About 10-20% of cases of BPOC are associated with or develop into a mveromonocytic leukaemia or acu te myeloid
leukaemia 1702, 920, 924 , 1142 . 1735 ,
18301 . Thes e second teukaermas can
evo lve from underl ying mye lodysplasia,
or appea r sud de nly upon prog ression or
relapse 1702, 924 ,1 1421
BPDC must be d istinguished from the
occasional association of a myeloid neoplasia (especially chronic myeIornonOCylic

leukaemia) with massive nod al or extranodal localization of plasmacytoid dendritic cells, in which the plasmacytoid
cells are rrnphoIogica/ly mature
and C056 negative 123351.


BPDC is usually characterize d by a dif fuse, monomorphous infiltrate of mediumsized blast ce lls with irreg ular nuclei, fine
c hromatin an d one to seve ral small nucleoli . The cytoplasm is usually scant and
appears grey-blue and ag ranu lar on
Giemsa stain . Mitoses are variable in
number. but rarely prominent; angiOlnvasion and coagulative necrosis are absent.
In cutaneous inlihrates, tumour c ells predominantly occupy the dermis, sparing
the ep ide rmis , but eventually extending to
subcutaneous lat. l ymp h nodes are diffusely involved in the interfollic ular areas
and medulla, with a leukaemic pa ttern of
infiltratio n .
Bo ne marrow b iop sy may show either a
mild interstitial infihrate only delectable by
immunophenotyping , or massive infiltration ; residual haeroatcooetc tissue may
exh ib it dysplast ic features, especially in
megakaryocytes 11735}. On PB and BM
smears tumour cells may show cytoplasmic
rmcrovacuoles localized along the cell
memb rane and p seudop od ia.
Cytochem istry
BPDC tumour cells are non-reactive lor
naphthol-butyrate esterase and perox idase cytochemic al react ions .

r.. .-" 8IastJC pIasmacyIoid llendnOC eel neoplasm.

"' '\;I''~CIoJii.

A Ski'I tI.I'I'lWfand plaques. B The inIiIlrate diftu$ety imoIYes !he demis andedends tl subc:Wnews fat. but spares lIle
1Pde!fM, CThe neoplasbc eels are mediI.m-sized. wiIh lineetwomatin and scanly cytoplasm. reminiscentof undlf!erentiated blasts,

Blastic p lasmacytoid den d rrtic ce ll neop lasm


Tumour cells express CD4, CD43, CD45RA
and CD56, as we ll as the plas mac ytoid
dendritic cell-assoc iated antigens CD123
(interleukin-3 a-chain receptor), BDCA-2/
CD303, TCU , CLA (cutaneous lymphocyte-associated antigen) and the interferon-a dependent molecu le MxA (92,
920,924 , 1735-1737, 1739, 1747, 1830,
22791. Rarely, the C056 antigen can be
negat ive, which does not rule out the diagnos is if CD4, CD123 and TCl 1 are
present. Tumours that share some but not
all immunophenotypic features of BPDC
may be better class ified as "acute
leukaemia of ambig uous lineage".
C068 (an antigen typical ly found on normal plasmacytoid dend ritic ce lls) is expressed in 50% of cases , in the form of
small cytoplasmic dots (1735 , 1739J.
Among lymphoid and myeloid-associa ted
antigens, CD7 and C033 are relatively
common ; and some cases have shown
expression of C02, CD36 and CD38 ,
while CD3 , CDS, CD13, CD16, CD19 ,
CD20, CD79a, LAT (linker for act ivation of
T cells) , lysozyme and myeloperoxioase
are regularly negative , Granzyme B,
which is reg ularly found in norma l plasmacytoid de ndritic cells , has bee n
demonstrated on flow immunophenotyping and mRNA analysis in BPDC [395 ,
820\. but it is most ly negative on tissue
sec tions, similarly to other cytoto xic
molecules such as oertonn and TIA 1,
Terminal deoxynucleotidyl transferase (TdT)
is expressed in about one third of cases ,
with pos itivity rang ing between 10% and
80% of cells; CD34 and CD117 are negative. EBV antigens or EBV-encoded small
nuclea r RNA (EBER) are not found.
Except for CD56 and TdT, the immunophenotype of BPOC largely overlaps with
that of plasmac yto id dendritic cells occu rring in reactive lymph nodes and tonsils [654}. Because other heematotoqic
neop lasms (such as acute myeloid
leukaemia, extranodal NK/T-eeil lymphoma,
nasal type and mature T-cell lymphomas),
with or without skin involvement, may express CD56 with or without CD4, an
extensive immunohistochemical and/or
genetic analysis is manda tory before a
definitive diagnosis of BPDC is made (92,
173,386,920, 1386).

gamma rearrangement 1920, 1735}. Two

thirds of patients with BPDC have an abnormal karyotype: specific chromosoma l
aberrations are lacking, but complex karyotypes are co mmon; six major recurrent
ch romosomal abno rma lities have been
recognized, including 5q21 or 5q34 (72%),
12p 13 (64%), 13q 13-21 (64%), sqza-qter
(50%), 15q (43%)and lossofchrornosome9
(28%) 11279, 1737, 18301. Gene expression

profiling and array-based comparativegenomic hybridization have shown recurrent

de letions of regions on chromosome 4
(4q3 4), 9 (9p 13-p11 and 9q12-q34) and
13 (13q 12-q31) that conta in several tumour suppressor genes with diminished
exp ression (RB 1, LATS2), while elevated
exp ression of the products of the OrtCGgenes HES6, RUNX2 and FLT3 is notassociated with genomic amplification (5781.


J-ceu and a-cen receptor ge nes are usually ge rmline {92, 1735, 1830}, except for
a few cases that showed T-cell receptor

Acute myeloid leukaemia and related precursor neoplasms

Postulated normal counterpart

The normal co unterpart is the p recursor
of the plasmacytoid den dritic cells .
Data on anligen 139 5. 396 . 820 , 920. 924.
1031 , 1051,1736, 1739.2279landchen"ll>
kine rec ep tor expression {18Sf, in vitro
functional assays {18S, 3961. gene e xpression profiling 15781. as well as on the
tumour-derived cell line CAL-l 11361 1all
point toward a derivation from the precursors of a special subset of dendritic cells,
!he plasma cytoid dendrit ic cells 1356,
857,20591 . These c ells are distinguished
by their p rod uction of high amounts of u Interferon in humans 1357l; in the pas t.
!hey have been defined with many different terms. such as lymphoblast, t-essocrated plasma cell , plasmacyt oid T-ce U
and plasmacytoid monocyte {6541 . The
i'nmunophenotypic heterogeneity with regards 10 TdT and the assoc iation with
myeloid disorders suqqests a multihneage po tential lor some cases 01 BPOC.

Prognosis and pred ictive factors

The c linical co urse is aggressive . with a
median survi val of 12-1 4 months . irrespective of the initial pa ttern of disease .
Most cases (80 - 90%) show an initial response 10 mulliagent chemotherapy, but
relapses with subsequent resistanc e to
drugs are regularly observed . Long-lasting remissions have been documented in
spor adic c ases, usua lly occurring In
young p atients who have been treated
with acute leukaemia-type induction therapy, followed by allogeneic stem cell
transplantation in first complete remission

192.920, 17351

Blastic plasmacytoid cencntc cell neoplasm


Acute Leukaemias of Ambiguous Lineage

Acute leukaemias of ambiguous lineage

Ac ute leukaemias of ambigUOlls line age

encompass those leukaemias that show
no clear evidenc e of differentiation a long
a singl e lineage. They include Ieukaemias
with no lineage-specific antigens (acute
und ifferentiated leukaemia. AUL) and
those w ith b lasts that express antigens of
more tha n one line age to such a degree
that it is not possi ble to assign the
\eukaefT'Wa to any o-e lineage with certainty
(mi xed phenotype acute ieukaermas .
MPAL). The latter can eithe r contain d isIinc t b last populations. each of a different
line ag e. or one population with multi ple
an tigen s 01di fferen t line ages on the same
cell s. or a com bin ation.
Historically, there has been confusion
both in the term ino log y and d efinitio n of
MPAL. The term ac ute b ilinea l (o r b ilineag e) leukaem ia ha s been ap plied to
leukaemias con taining separate po p cta.nons of b lasts of mo re than one lineage,
and the ter m b iphenotyp ic leukaemi a to
thos e co nta ining a sing le populat io n of
b lasts c oexpressing antigens of mo re
thanone lineage I885, l267, 1427 , 21 19},
although some times the ratter term also
encom passed blnneaueu kaemta. Here the
term mixed p henot yp e acute leukaem ia
applies to this g roup of lesions in general,
and , as d efined b elow, the mo re spec ific
terms B/my e lo id (B/MY) and T/mye lo id
(T/MY) leukaemia to refer to reu keemra s
c onta ining the two linea ges specified,
irres pec tive of whether one or mo re than
one po pulation of bl asts is seen .
Some well-d ef ined mye lo id leukaem ic
en tities may have irnrnunoonenorvplc
features that might suggest that they be
classified as Bimye loid (BlMY ) Of Tlmyeloid
(T/MY) leukaemras. However, MPAL, as
de fined here, exc ludes c ases that c an be
cl assified in another category, eithe r b y
genetic or clinical features. These speci fic ally inc lud e c ases with the rec urrent
acu te myeloi d leukaemia (AML)associetec uansiocenons 1(8;2 1), t( 15;17 ) or
inv( 16); the first of these especiall y freq uently exp resses muniple Bceu markers
/22361. In addition, cas es of leu kaemi a
with FGFR I mutations are not con side red
TIMY leuk aemias Cas es of c hronic


mye logenous leukaemi a (C ML) in b last

c risis, MDS-re lated AMl and therapyrelated AMl shou ld be cl assified pnma rily as suc h , even if they have a mixed
phe notype, with a secon dary notation that
they have a mixed phenoty pe .
The d iag nos is of amb ig uou s lineage
leukaem ias rests on irnmunophenotyping .
Flow cytometry is the preferr ed method
for establishing the d iagnosis, especially
when a d iagnosis of MPAl is de pen dent
upon demonstrating coexo ressoo of 1ymphoid and myeloid d ifferentiation antigens
on the same cell. Cases in which the d iag nosis rests on demonstration of two distinct leukaemic populations with a d ifferent
p henotype may also be established by
immunohistochemistry in tissue sections,
or with cytochemic al stains for myeloperoxid ase on smears c oupled with flow cvtomet ry to detec t a leukaemic B or T
lymphoid population.
The myel oid component of an MPAL c an
be rec ogn ized in one of three ways:
1) When ther e are two or more d istinct
pop ulations of leukaemic c ells, one of
whic h wo uld meet immu no pheno typic
c riteria for ac ute mye loid leukaem ia {with
the exception that this po p ulation need
not c omprise 20% of all nuc leated cel ls}
2} When there is a sing le population of
b lasts that by itself wou ld meet c riteria for
B acute lymphoblastic leukaemia (B-ALL)
or T acute lymphob lastic leukaemia (T-ALl)
and the blasts also expressmyeloperoxidase,

M ,J Borowitz
M ,-e , Bene
Nt.. Harris
A. Porwit
E. Mat ures

most freq uently show n by flow cvtomeuc

positivi ty, on b last c ells coexp ressing 1ymp hoid mar kers. The myeloid lineage anngens CD 13, CD33 and CD l 17 are no!
specific enough to allow identification cA
a mixed phenotype leukaemia.
3) When there is a single population ot
cells that by itself would meet criteria forB
Of T-All in which the blasts also show tXIequivocal evidence of monoblastic differen tiation: either d iffuse positivity !t;)
non-specific esterase or expression cA
more than one monocytic marker such as
CD 11c, CD 14, CD36, CD64 Of lysozyme
The first of these three ins tances wooId
previously have be en consid ered -bilineage leukaemia" while alternatives 2 and
3 represent wha t wou ld have been
termed "bi phenotypic leukaemia".
The t-een component of an MPAl is recognized by strong express ion of cvtop lasmic CD3, either on the ent ire blast
population, or on a sepa rate suo oc ouanon of leukaemic c ells. Surface CD3,
thOugh rare, also ind icat es T-cell lineage,
Expres sio n of cC D3 is bes t determined
by flow c ytometry using relatively brighl
fluo roph ores such as phyc oerythrin or er
lophyc oc yanin , and should be as bright
o r nea rly as br ight as that of norma l residual T ce lls p resent in the samp le. T-cell
linea ge can also be demonstrated by
CD3 expression on b lasts by immunohistoc hem istry on bone marrow biop sies,
thou gh it should be noted that polyvalent

Table 7.01 RllQuiremefils for assigrlingmore than onelineage toa Single ~asl populaton.

Myeloid lineage
~xidas.e (fbw cylomeIfy,

immunohislOChemistry or cytoChemistry)


Mi:Inocy1icdifterentiaticl'l (al least2 of lhe kllIowrng: NSE. CDlle , C014, CD64 ,~)

Cytoplasmic COO (!kM' cytomeIry wi1l'l antibodies 10COO epsilon etIatn: irnn~nolliStoehemistry USIIIg polydonaI
<W1b-C03 <W1tbody maydeled CD3zeta chain, wt\id'I is not T<:eII spec::ific)


SOOace COO (rare W1 mixed pIlenoIype lClJIe leUkaen'liasj

8 lineage (multiple antigens requnct )

Strong C019 wiltl a1ieas11 oftnefclowing strr.Tf/'I e~ . CD79a. C)1OpIasrrMc C022. COlO


Weak CD19withill least 2 oIlhe IoIowilg 5IfOn!lIY exp!&S:Sed: C079a, cyqMsmic C022.CD10

Acute ieckaenes of ambiguous lineage

T-cell antibodies used in immunohistochemistry also reac t with the zeta (~)
Chain of the
receptor present in the
cytoplasm of NK-c ells , an d are thus not
specific .
In contrast to w hat is d esc rib ed above
with mye loid and t -een lineages, no single marker is sufficie ntly specific to indicate B-cell differentiation with ce rtainty, so
that a constellation of find ing s is needed.
Been diffe rentiation can be recognized
v.tIen there is a distinct subpopulation of
cells that by itself meets criteria for B-ALL
When only one population of cells is present. then B-lineage assignment requi res
either 1) strong Co 19 exp ression coupled
with strong exp ression of at least one of
the follow ing antige ns : C01O, Co79a or
cCD22; or 2) weak CO 19 exp ression co upled with strong ex pression of at least two
of the following : C01O, Co79a and
cCD22. Rarely, a case may be ass igned
as B lineage even If C0 19 is negative,
though care must be taken when doing
this because of the relative lack of speci!iclty of C010 and Co79a.
Cases of MPAL based on one cri terion at
diagnosis (e.g. 'biph enotypi c leukaemia ")
may c hange ove r tim e or at relap se to the
other (" bilineage leuk aem ia"), o r vic e
versa. Also, following therapy, per sistent
disease or relap se may occur as eithe r
pure ALL o r AML. Some cases of wh at
'as been termed "lineage switch" 11684,
18251may reflect this phenomenon
Ambiguou s lineage leukaemias are rare
and account for less than 4% of atl cases
ol acute leukaemia. Many cases of w hat
have been rep o rted as undiffe rentiated
'eukaemia ca n b e d emon str ated to be
eokaemtas of un usua l lineag es, and
'TIany ca ses of what have been reported
as biphenotypic acu te leukaemias may in
tact represent acute lymphoid or myeloid
letJkaemias With cross-lineage ant igen
expression , so that the actual frequency
may even be lower, The se leukaerruas
occur both in children and adults but
-rore frequent ly in the latter, although
some su btypes of MPAL may be more
common in c hild ren 11145, 16711 .
Avariety of genetic lesions hav e been reported in am bigu ous lineage leukaemi as,
especially MPAL. Two of these , the t(9 :22 )
(Q34;q 1l ) BCR-ABL 7 translocation, and
sansrocanons associated with the MLL
gene occur frequently enough and are
associated with distinctive features that
lhey are considered as sep arate entities.



Acute undifferentiated

There are too few case s des cnbed to
know whether any consistent ge netic
lesions occur.

Ac ute undifferentiated leukaemia expresses no markers co nsidered specific
for e ithe r lym pho id or myeloid line ag e .
Before categorizing a leukaemia as undif ferentiated, it is necessary to perform irnmunophenotyp ing w ith a comprehensive
panel of monoclonal antibodies in order
to exclude leukaemias of unusual lineage s, such as those derived from myeloi d
Of p lasmac ytoid dendritic cell p rec ursors,
NK-c ell precursors, basophils or even
non-baernatocoietrc tumo urs

Prognosis and predictive factors

While anecdotal experience generally
considers these leukaemias to be of poor
prognosis , information is too scanty to
make any defin itive statements.

ICD-O c od e

(q34;q11.2); BCR-ABL1

980 1/3

Acute leukaemia, NOS; stem c ell acute
leu kaemia.
These leukaemfas are very rare , and
nothing subs tantial is known about the ir
Sites of involvement
Bon e ma rrow and b loo d . There a re too
few cases to know wh ether the re is a
predilect ion for othe r sites.
Clinical featu res
There are no features that distinguish this
from other ac ute ieukaemias.
The b lasts have no morp holog ic feature s
of myeloid d ifferentiation .
The blasts are negative for nweicoe ro xlcase and esterase.
These reukaemas typ ically express no
more than one membrane ma rker of any
given lineage. By definition , they lack the
T or my eloid lineag e specif ic ma rkers
cC 03 and MPO and do not expr ess Bce ll specific ma rkers such as cCD22,
cC079a or strong C0 19. They also lac k
specific features 01other lineages such
as megakaryocytes or p lasmacytoid denontrc ce lls. Blasts otten express HLA-oR.
CD34 , and/or C038 and may be posi tive
for terminal d eoxynuc leoti dyltransferase .

Postulated normal cou nterpart

Haematopo ietic stem cell.

Mixed phenotype acute

leukaemia with t(9;22)
This is a leukaemia meeting the criteria for
MPAL in which the blasts also have the
t(9 :22) tra nslocation or BCR-ABL 1 rearrangement. Some pat ients with chronic
myeloid leukaemia may develop or even
presen t with a mixed blast phase that
would meet criteria for MPAL, however
this d iagn osis should not be made in patients know n to have had CML.
ICD-O code
The provisional code proposed for the
fourth edition of ICo-o is 980613.

Epidem iology
Althoug h this is the most common recurrent genetic abnormality seen in mixed
p henotyp e ac ute leukae mia. it is a rare
leukaemia , prob ably accountin g for less
than 1% of ac ute leukaemias. It occurs in
bot h children an d ad ults , b ut is more
common in ad ults 1338 ,11 451.
Clinica l featu res
Patients present with features similar to
those of other patients with ac ute
leukaemia. Though there are not enough
da ta to be ce rtain , it is likely that they
present with high white b lood cell counts ,
similar to patients with Ph-s ALL.
Many cases show a dimorphi c blast
population , one resembling Iymphoblasts
and the OIher nwecotasrs. although some
cases have no d ist inguishing features
Cases generally do not show significant
myeloid maturation ; care shoold be taken
abou t making this diagnosis in a case of

Acute leokaernias of ambiguous lineage


Mixed phenotype acute
leukaemia with t(V;11q23);
MLL rearranged

Immunop henotype
In the majority of cases it is possib le 10
rec og nize a lymp hoblast popula tion With
a CD 19-positive , CDlO-negative B prec ursor (p ro-B) irnmuncphenotype , frequently positive for CD15. Expression 01
other B markers such as CD22 and
CD79a is often we ak. In addition to this,
cases also fulfi l criteria lor myel oid lineage as defined above, most comrnonly
via demonstration of a separate papUa.
tion of myeloid. and usually monobIaSIJC
leukaemic ce lls 1167 1. 237 11. Coexpessian of myeloperoxi d ase on Iymphold
blasts is rare. MLL translocations can also
produce T.ALL, so that it is thOOfeticaly
possible that T/myeloid Ieukaemias
oc cur, although these have not been
reported .



Fig.1 .01 ElJrnyeIoid I8ulalInN with 1(9.22Nq34;q11 2). Theblasts vary from smaI ~ iIppeWVlg bIasIs kl ~
blasts WIlh dispersed c:lVl:lmaIin, prorninefJl nudeoIi and a Il'llXlefllte ann.n of pale ~.

myeloid leukaemia with maturation that

also expresses lymphoid markers, because such a pattern may be seen in patients with blast phase 01CML.
The grea t majority 01 cases have bl asts
meeting c riteria tor 8 and myeloid line age,
as descr ibed above , though some cases
have T and myeloid b lasts . Triphenotypic
leukaemi a has also rarely been reported .

Genetic s
All cases have either the 1(9;22) detect ed
by classical karyotyp ing . or the BCR-ABL1
transloc ation d etect ed by FISH or PCR.
Many c ases have addit ional c ytogenetic
abno rmalities, and of ten have comp lex
kary olypes.

Postulated normal counterpart

Murnootent haematopoietic stern cell.
Ther e is no evidenc e thai this leukaem ia
derives from a di fferent cell from other
cas es of Ph+ acute leukaemia .
Progn osis and pred ict ive factors
This type of leukaemia has a poor orogno sis ; it a ppe ars to be worse than that
of other patients with MPAL {1 145 1, It is
not c lear whether the p rog nosis is wo rse
than that of patient s with Ph+ ALL, or if d iffere nt therapy can improve ou tcome.
There a re no known fact ors among pa tients with this leukaemia that c an p red ict
who w ill do better or worse. It wou ld be
expected that imatinib and related tyrosine kinase inhibitor s mig ht be useful in
the treat ment of this type 01 leukaemia;
how eve r. there are no data availa ble to
state this with ce rtainty.



This is a leukaemia meeting req uiremen ts

for mixed phenotype acute leukaemia in
which the b lasts also have a translocation
invo lv ing the MLL gene . Many cases of
A LL wi th MLL transiocauons express
myeloid-associated an tigens , bu t these
should not be considered MPA L unless
they meet the specilic c riteria noted above.
ICD-O code
The prov isiona l code p ropo sed for the
fourth ed ition of ICo-O is 980713.
This is a rare leu kaemia that is more common in child ren th an in adults . As with
AL L or A ML with MLL rearran gem ent s,
th is leukaemia is relatively more co mmon
in infancy 11 145 , 16711.
Clinical featu res
Patients present similarly to other patients
with acu te leukaemia. As with other ac ute
ieukaemras w ith MLL transtcceuons. hig h
wh ite blood cell counts are common .


All c ases have rearrangements of se

MLL gene, with the most corrmon partner
gene being AF4 an chromosome 4 bafld
q2 1 1338. 16 71 1. r ranstocanons t(9:111
and t(1 1;19 ) have also been reported
The rearrang ement may be detected
either by standard karyotyping or by FISH
with an MLL breakapan probe or, less
com monly, by Pe R. Cases w ith deletions
01 ch romosome 11Q23 detected by
karyo typing shoul d not be considered in
this ca tego ry. The MLL tra nsloc ation may
be the only lesion present or there may be
other seconda ry cytog enetic or rrolecular ab nomaunes althoug h no additiooal
g enetic lesions common to multiple cases
have been d escr ibed
Progn osis and p redi ct ive factors
This is a poor prognosis leukaemia 111 45,
237 11. Patients with B/myelo id leukaemia
with MLL translocations are often treated
di ffere ntly from patients d iagnosed witn
ALL with MLL transtocatlons . but there is
no evidence that this is nec essary or

Most commonl y these leukaemias display
a d imorph ic blast population , with one
population clearly resembling monoblasts
and the ot her resembling Iymphob lasts .
However. in other cases they may have no
d istinguishing features and appear only
as undiffe rentiated b last cells. Cases in
whi ch the e ntire blast po pulation is
monobtasnc are more likely to be A ML
with an MLL translocation.

'eokaenes of ambiguous lineage

Mixed phenotype acute

leukaemia, B/myeloid, NOS
This leukaemia mee ts c riteria for assign.
ment to both B an d myeloi d lineage as
described above. but in which the btass
lack the above-mentioned g enetic abrc-


ICD-O cod e _
The provisiona l code propo sed for the
ftxmh edition of ICD-O is 9808/3
This is a rare leukae mia , p rob abl y ac counting for ab out 1% 01 leukaemi as
overall. It can be seen bo th in ch ildre n
and adul ts bu t it is mo re common in

Clinical features

Immu noph enotype

Blas ts meet the criteria for both Bclymproto and myeloid lineage assignment
listed ab ove. Mveiooeroxioase-po sluve
rnyeloblasts or mon ob lasts commo nly
also express other mye loid -assoc iated
marker s includ ing CD 13, CD33 or CD 117.
Exp ression of more mature markers of Bcell lineage such as CD20 is rare but may
occur, particu larly when a sepa rate
population of B-cell lineag e is id entified
{23 71 I,

There are no uniq ue c linical features,


cases have blasts with no d istin-

(p.ishing features, morph060gicaJIy resembk'lg ALL, Of hav e dImorphic ocoutetcns

with one rese mbling Iymphobl asts and

ee other resembli ng myeloblasts.


5: .~"( -..

Most cases of B!myeloi d leukaemia have
c lonal c ytogenetic abnormalities. Ma ny
d ifferent lesions have been demonstrated. thou g h none is of such frequency
to sug g est specifici ty for this g roup of
leukaemias. lesions that have been seen
in more than a single case include de l(6p) ,

Postulated normal counterpart

Multipotentia l naematopoeuc stem cel l.
There is g rowing evidence of a poss ib le
relation ship be tween a-.cell and mye loid
d evelop ment suggesting either involvement 01a corrrnon precursor, or of a precu rsor of one lineage that has reactivated
a d.tte renueton program of the other
11 127, 12401
Prognosis and predictive factors
B/myeloid leukaemia is generally cons ide red a poor prog nosis leukaemia. Many
pat ients mee ting c riteria lor B/myeloid
leukaemia have the unfavourable ge netic
lesio ns and it has bee n sugg ested that
this ac cou nts for the ir poor prog nosis
11145 1. Whether ad verse cytog enet ic features entirely exp lains the poor outcome is
not definitively established 11267, 23711.

-- _ .

;: ..~ -.

12p 11.2 abnormalities, del (5q) , structural

ab normaliti es of 7, and numerical abnorma lities inc ludi ng near tetraploidy [338,
16711, Com ple x karyotyp es may be seen
There are insufficien t da ta in the literature
to sugg est that B/mye loid and T/myeloid
leukaemias have differ ent freque nc ies of
oeterent genetic lesions, once the t(9:22)
and MLL rearra ngements have been accounted for.


;. '
' I' :"'.: .


. ,

Mixedphenotype acute
leukaemia, T/myeloid, NOS

Def inition
This leukaemia meets c riteria for assign ment to both T and mye loid lineage as desc ribed above , but in which the blasts
lack the above men tioned genetic abnormalitie s.

COlO m e

ICD-O code
The provi siona l code proposed for the
fourth ed ition of ICD-O is 9809/3.

,, ;.


. :.~..
: C

of.,'" ''':-1 '' , Ii.,

. ~ )


Fig. 1.D2 FkIw L)'IOmetty in EIJmyeIoid 1euUemia. A C045 'IS Side scatter display ShoWlIlQa ma,a popuIaIlon of din
COt5+ !:*lsts. B ~ 1111 bloe. residual normal B cells red and rnyeIoperoxidas posIbYe c:eIls (ndudong boIh
tesls and I1ISiduaI nonnaI ceh)~ . aeTheIk:et ~ CD19 and C022 areslrOI9Y expressed on !he B Iym~ blasts. II"" CXlll1lIlable b!hal seen WIII'I residual nonnaI Ek:eIs (in red). 0 t.b;t of !he B-ceI blasts IaciMPO
..., many hJu!1l nol aI of !he ~ blasts are MPO posiIi'Ie. There is a smaIpopUabonof blasts eoexpmsing
1I1l9 rei MPO.

Epidemiolog y
This is a rare leukaem ia, probab ly ac co unting for less than 1% of leukaemias
overall. It can be seen both in c hildren
and ad ults . It may be relatively more Irequent in c hildren than is 8/myeloid acute
leuka emia .
C linical features
There are no unique clinica l features.

Acute leukaemias of ambiguous lineage


the t(9:22) and MLL rearrangements teve

been accounted lor.
Pos tulated normal counterpart

Mctnpot entrar haematopoietic stem cell.

There is growing evidence 01 a possible
relatio nship between T-c ell and myeloiO
development suggesting either irM:llverne1:
01 a common precursor, or of a Iymphoicl
precursor that has reactivated a myeloid
differentiation program 11 127, 12401.
PrognosiS and predic tive factors
Tfm ye loi d leukaemia is generally CQl'lSI'
dered a poor prognosis IeU<aema a/Ito..I;1l
data are limi ted on the outcome of trese
patients distinct from other MPAl pawns.
Patients with TtmyeIoid leukaemia teve I'l'A
been treated un iformly. although carrOnations of myeIoid-directed and IymptloiOdtrected therapy have been tried . and scm!
patients may respond to one or the OCher,

Mixed phenotype acute

leukaemia, NOS rare types

""""""Most cases have blasts with no cnstmguishing features. morphologically resembling ALL, or have dimorphic
populations. with one resembling lympboblasts and the other resembling myeio-

addition to cCD3, the

t-een com ponent


fre quently expresses othe r

ma rkers
including C07,CD5, and C02. Expression
of surface G03 may occur when a separate population of
line age is ioenu-


fied 123711.

b lasts.

Blasts meet the criteria for both T-lymphoid
and myeloid lineage assig nment listed
above. My eloper oxid ase-p ositiv e mvero-

blasts or monoblasl s com monly also ex

pr ess othe r m yeloid-associated ma rkers

including CD 13. CD33 or CD 117. In

Most cases have clonal chromosomal abnor ma lities , although no ne is of such frequency to sug gest specific ity fo r this
g roup ofleukaemias. There are insufficient
data in the literature to sug gest tha t B/MY
and T/ MY le uka emi as hav e d ifferent freque nc ies of d ifferent ge netic lesions, once

Fig. 7.001 ThnyeIoid 1euIlaenU. ThIn ill . dimlrphicpop.MtionaI blasts wilh many smaI~ ; larger blasts
alsoMoe high ~sm 1'lIlio. h manatin arid inalnspicuous rndeoL

Acute leukaemlas 01 ambigUOUS lineage

Some cases of leukaemia have been seen

in which leukaemic blasts show clear-cut
evidence of both T and B lineage commitment as defined above. This is a very
fare phenomenon, with a frequency that is
likely lower than what has been reported
in the literature. As strictly applied, the most
recent EGIL c rite ria for biphenotypic
leukaemia (scores hig he r tha n 2 in more
than one lineage), whic h assigned 2 points
to CD79a expression 153, 187) would
likely overest imate the inc idence of BIT
leukaemia bec au se CD79a can be detected in T-ALL 11 750). In assig ning B lineage to a case of T-cell leukaemia, CD79a
and CD 10 should not be considered as
evidence of B-celt d ifferentiation. There
have also been a few c ases with e~i
dence of trilineage (8, T and myeloid lineage) assignment. Overall ther e are too
few cases of either of the se to make any
specific statements about cl inical features, genetic lesions or prognosis.
To date, there have been no reports of B
or T/meg akary ocyt ic or B or Tferythro1eukaerJias. Because it has been suggested
that erythroid and megakaryocytic lineages
are the earliest to branch off from the
plur ipotent haematopoietic stem cell , lea...
ing progenitor cells w ith T, 8 and myeloid
potential 1111 , neoplasms of these corenations of lineages may not occur. If It'ey

do occur, it is possible that the definitions

used here might not detect all cases, as
these leukaem ias would not be expected
to express MPO .


, '.

-.. .. -


Other ambiguous lineage

Under some circumstances leukaemias
may express combinations of markers
that do not allow classification as either
AUL or MPAL as defined above. yet de Iinitive c lassific ation along a singl e lineage may be difficult. Examples of suc h
cases mig ht includ e cas es that express
J-ceu-assoctated but nol
markers suc h as C D7 and C OS without
cytoplasmic C03. along with myeloid-associated antigens such as C0 33 and
CD13 without mvetoperoeoase. Such
cases are best considered ac ute uncle ssiliable teukaemes. With more extended
panels containing newer, less commonly
used markers, such leukaemi as might be
able to be c lassified.

. .~.. _, , ...., . .. ,. ,

coe """"



Natural killer cel l tymphobIastic leukaemia!

.,',',- C


., ,....,
. . ..,.,
"Ii, ,..,.,
SS L..


This neoplasm has been very difficu lt to

define, and there is con siderable con fusion
inthe literature, Con tributing to the confusion is that many cases rep orted as NK
leukaemia because of the expression of
N-CAM (COS6) are now recognized to
represent cases of plasmacytoid dendritic
cell leukaemia 11735, 1736J. Similarly, the
entity at mye loid/NK-cell acu te leukaemia
11980, 2129J, whic h has been suggested
to be of prec ursor NK origin 11660) has a
primitive immunophenotype that cannot
be d istinguished from acu te myeloid
leukaemia w ith minimal different iation,
and until further evidence emerges these
should be considered as cases of AML.
Early in development, Nrc-celt progenitors
express no spe cifi c markers 17331 or ex pressmarkers that overlap with those seen
inT-cell All.., including C07. C02 and even
CDS and cytoplasmic C03 120701. so that
distinguishing between TALl..and NK -ce ll
tumours may be d ill icult. More mature but
rrore specific markers suc h as C016 are
rarely expressed in any acute leukaemia.
while some markers that m ight be c on sidered relatively more scecmc . but st ill
expressed on NK progenitor s. suc h as
CD94 or C0161 17331 are not commonly
tested. Some we ll c ha rac terized cases of
NK precursor tumours WIthlymphomatous






.. .'

. ,.~

. ..' .-


presentations that expressed NK -specilic

CD94 lA transcripts have been de scr ibed
113061. It is hoped that wider availability of
more specific NK markers includ ing panels
01 antiboclies against killer inrnunog lObuhnlike receptors (KIRs) will he lp c lanfy this
d isease. but until then th is is best coosrcereo a provisional ent ity. The diagnosis of
precursor NK lymphoblastic leukaemia}

lymp homa may be considered in a case

thai expresses C056 along with immature
T-associated markers such as COl and
C0 2 and eve n incl udi ng cCD3, provided
that it lacks B-eell and mye loid markers,
and IG receptor genes are in the
germline configuration\1128, 1174, t6601
and blast ic plasmacytoid oenonuc c ell
leukaemia has been excluded


Acute leukaemias 01 ambiguous lineage



Introduction and Overview

of the Classification
of the Lymphoid Neoplasms

Introduction and overview of

the classification of
the lymphoid neoplasms
Defini tio n
B c ell and liNK c ell neopl asm s are clonal
tum our s of matu re and immature B cel ls ,
T ce lls o r natural Killer (NK) c ells at various stages of differentiation , Because NK
ce lls are closely related . and share some

immunopheno typic and functional properties with T cells , these two classes of
neoplasms are considered together.
B-cell and T-cell neopla sms in many re-

spects appear to recapitulate stages 01

normal B-cell or t -een differentiation, so
tha t they c an be to some extent c lass ified
accord ing to the correspon d ing no rma l

staqe . However, some common B-cell

neo pl asms. e.q . hai ry celt leukaemi a, do
not c lea rly correspond to a no rmal B-cell

differentiation stage. Some neoplasms

may exhibit lineage heterogeneity. or

j lnnate immune system

E.S. Jaffe
N.L. Ha rris
H. Stein

E. Campo
SA Piler i
S.H. Swerdlow

even more rarely. lineage plasticity 11037 ,

13571, Thus, the normal co unterpa rt of the
neop lastic ce ll c anno t at this time be the
sal e basis for the c las sification.
Pathob iology of lymphoid neoplasms

and the normal immune system

The re are two major arms of the immune
system tha t d iffer, both in the nature of the
target and the type of the immune response, known as the innate and adaptive
immune responses , Ce lls of the innate
immune system represent a first line of
defense, a primitive response. Cells of the
inna te immune system inc lud e NK cells,
CD3+ CD5 6 + t-eens or NK -like t-eens.
and y6 T ce lls. These ce lls playa ro le in
b arrier defenses inv o lv ing mu cosal and
c utaneous immu nity. They d o no t need to

IAdaptive immune system I

yl T - . _ _


Toll like receptors

Not MHC Class II



on B + T cells

First line of defense with a

maJor role in banief immunity

Ag presentation to
T cells in
context of MHC

Immunological defense
cha racterized by specificity and memory

Fill, 1.01 There are I\lIO mainarms of tile immur.e system. the innate immur.e system, and the adaptive immuroe
system, Diagram shows respective roles 01 lymphocyte sutlpopulations in the innate and adaptive immuneresponses
NKcells, N K~ike Tcells, and yfo Tcellsfunction with othercell types including granulocytesand macropha ges asa first
Hna of defense. These cells havecytotoxicgran ules (shown in red) oontainingperIorin andgranzymes The inna teimmuoe system lacks specilidty and memory. In the adaptive invnuoe system, B 00115 andToeIIs r&COgnize anligeos (Ag)
lhrough specific rec:e~ , immunoglobulin (Ig) and !he T-eeII recepD" rompIex (TCR) respediwly, Antigen presenta,
tion to T eels must take pIac:e via anligen-presenling cells (APe) in lhe conlell of Ihe appropnale majorhlstoa::lmpatibihly c:omplex (MHC) ClassIIantigens. FiglIe R'I()Ijfied from {1035}.


Introduction and overview 01 the cassmcatoo 01 the lymphoid neoplasms

encounter an tigen in the context of the

major histoc ompatib ility co mplex (MHC),
and thus do no t require antig en presenting ce lls to ini tiate an immune response,
The adaptive immune sys tem is a more
sophisticated type of imm une response.
It is specific for a particular pathogen; two
key feature s of the adaptive immune response are specifici ty and memory This
con trasts with innate immune responses
whi ch are non- specific lor the target. and
do not req uire o r lead to immunological

B-eeli lymphomas: lymphocyte differenti

ation and function
Bccell neo plasms tend to mimic stages 01
normal B-cell d iffe rent iation , and the reo
semblance to normal c ell stages is a
ma jor basis for their classification and
Normal B-eeU d ifferentiation begins WIth
precursor B c ell s known as progenitor
B c eli sIB Iymphoblasts (b last ce lls thaI
are the precursors of the ent ire B-eell
line) , wh ich undergo irTYnunoglobuhn IDI
gene rearrangement and differentiate into
man se surface immunoglobulin (slg) pesitive (lgM+ IgO+) naive B cel ls via pre-8
cells with cytoplasmic ~ heavy chains and
imma tu re IgM+ B cells Naive B cells . that
are often CD5 + , are sma ll rest ing lymphocytes that c irculate in the peripheral blood
(PB) and also occupy pr ima ry lymphoid
foll icl es and follicle mantle zones (socalled recircula ting B cells) 11004A,
1152AI. Most cases 01 man tle c elilymphoma are thought to correspond to CDS
positive naive B cells 1994A I.
On encountering antigen that fits their 51.1'
face Ig rec eptors, naive B cells undergo
transformation, prolifera te, and ultimately
ma ture into an tibody-secreling plasma
cells and memory B cells. Translormed
cells formed from nerve B c ells that have
encountered antig en may ma ture d irectly
into plasma ce lls mat produce the early
IgM antibody respon se to antigen. T-cell
ind epend en t ma turation can take place
ou tside of the germinal centre 14241, It is
debated whether somatic hypermutatiOl"l
of the IGH@ genes occurs du ring this

Central lymphoid tissue

Precursor s-cene

Peripheral lymphoid tissue

Peripheral (mature) B-cells






.... AG



Memory B-cells
Marginal zone









Precursor B-cell neoplasms

B lymphoblastic

Pre-GC neoplasm
Mantle cell lymphoma

GC neoplasms
Follicular lymphoma
Burkill lymphoma
OLBGC. (some)
Hodgkin lymphoma

Post-GC neoplasms

Marginal zone & MAlT lymphomas

lymphoplasmacytic lymphoma
Plasma cell myeloma
Fig, auz Diagrammatic represenlatiooof ~II diflerentiatioo and relationship to major ~II neooasms. ~II neocasme correspond to stages of B-cell maturation, even ItIoogh
the precise cell counterparts are not known in all Instances. Precursor s-ceu nat mature in the bone marrow may undergo apcotose or develop intomature naive B-cells that, fol..
'(lw'ng e~sure to antigen and blast transformation, may deveiop into shOl1lived plasma cells or ent8l'thegerminal centre (GC) where somatichyp&mlulatiOn and heavy chain class
switchingoccur. Centroblasts, the transf()(ll16(j cells of the GC, either undergo apcotcsis or develop into centrocytes. Post-GC cells include both klng-lived plasm a cells and mem-


ory/marginal zone B-cells. Most B-cells areactivatedwithin the GC, butT-cell independent activation can take place ootsideof thegerminal centreandalsoprobably leads to memory type B-cells. Monocytoid B-cells, many of which lack somatic hyperm utatioo, are not illustrated.
Dl.BCl, diffuse large Bcell 'Ymphoma; CLUSll, chronic lymphocytic leukaemia/sma ll 'Ymphocytic lymphoma; MAlT, meccsa-essccated lymphoid tissue; AG. antigen; FDC, fojlic
u1W Oeooriticceli. Red bar. irmnurKlglobulinheavy cha in gene (IGH@) rearrangement;bluebar,immunoglobulinlightchaingene(IGl)rearrarJgem&nt; b1ad1 insertions in thered and
blue tersindK:ite !WI'Iatic hypermutation.

extratollicular maturation . Other antigenexposed B cells rniqrate into the ce ntre of

a primary follicle, proliferate, and fiJi the
follicular d endr itic cell (FOG) mesh work,
forming a germinal cenlre (l 325A, 1355AI.
Germinal centre centrobtasts express low
levels of slg. and also switch oH exp ression of BGL2 p rotein; thus . they and their
progeny are susceptible to death through
acootose ( 1828A1. Centrobtasrs express
COlO and BGlS protein. a nuclear tran scription factor that is expre ssed by bo th
centroblasts and centrocytes. BCL6 is not
expressed in naive B cells and is switched

off in memory B cells and plasma cells

11346 . 1760 1.
In the germinal centre, somatic hypermutation occu rs in the imm unoglobulin
heavy and ligh t chain variable (IGV)
region genes; these mutations may result
in a non-funct ional gene. or a gene tha t
produces antibody with lower or higher
affinity for antigen than the native IG
gene. Also in the germinal cen tre some
cells switch from IgM to rgG or Ig A production. Through these mechanisms, the
germinal centre reac tion gives rise to the
higher aHinity IgG or 19A antibodies 01the

late primary or secondary immune response 11 356 A I. The BCL6 gene also undergoes somatic mutation in the g erminal
cen tre, however, at a lower freq uency
than is seen in the IG genes l 1698A 1. Ongoing IGVregion gene mutation with intraclona l diversity is a hallmark of germinal
cent re cells. and bo th IGV reg ion gene
mutation and BCL6 mutation serve as
markers of cells that have been through
the germinal c entre. Most dilfuse large
B-cell neoplasms (DLBCL) are composed
01cells that at least in part resemble cantrobtasts and that have mutated IGV

Introduction and overview 01the classification of the lymphoid neoplasms


Table 8.01 Immuoophenotypic featuresof CO!M'!OIl mature B-<::el reooasme.




C0 10



















MALT lymphoma

f ollicubr

. t,


. ;.


' ,'

8-cIll lymphoma

. /.;.


. ;-











. /-"

, >90% 01 cases -: . /., >50% 01 cases -: 01., <50% 01 cases e:-, <l<ni. 01 cases IRF4IMUM1, inletfeton regu3a
and 311; - , DLBCl oIgerTTlInaI centre 8<eI type (GCB) elqlAlSS COlOand BCl6; " . DlBQ. 01 aclro'aIed 8<eI
type (ABC) aretypically posllMt lor IRF41MUM1; "'. some Dl8Cl are C05. ; NA. not applc:able; lPl,1yrnptooo

Iabng Iacb' 4:ANXA1 , AnneXll"lAl; PC, praIileratIon celllreS: " plasma eel c:ornponent po$IllYe;', some grades

p1asmacylic lymphoma; MIL, ITIlIrgmI zone I)mphoma; MeL nlall1le eeI~ .






naive 8

eeoee B

Antigen Independent

Memory B
(Marginal zooe)

Plasma cell

Antigen Dependent



[ CD20

n nnours.
Centrobrasts ma ture to centrocstes. and
these cene are seen predomina ntly in the
light zone of the ge rminal cen tre. Centrocvtes express slg that has an altered antibody combini ng site as compared WIth
that 01 their oroqenrtors. based both on
somatic mutations and hea vy chain class
Swit ching Cen trocytes with mutations thai
result in increased affini ty are rescued
from eocotose and they re-express Bel2
protein 11355A1. Throug h inleraction"";tn
surface molecules on FDC 's and t-cees.
such as CD23 and CD40 ligancL centrocytes swilch off BCL6 p rotein expression
1346, 17601. and oitterennate into either
memory B-eetts Of p lasma
1t 355AJ.
BCL6 and IAF4/M UM 1 are rec iprocally
exp ress ed , w ith IAF4/MU M l being positive in late cer nrocytes and plasma cells
166 1. t 9t4AI. IRF4/MUM 1 plays a critical
role in down-regulating BCL6 expresser
11914AI, Follicu lar lymphomas are 1lJTlCU'S
of g er minal c entre B-c etts (centrocytes
and centrobiasts) in wh ich the germinal
c entre celts fail 10 undergo apcorosts. in
most cases du e to a chromosomal rearran gement. t{14 :18), that prevent s the
normal switc hing off 01 BCL2 proten
expression, Centrccvtes usua lly preooninate ove r cen t roblas ts , and these neoplasms tend to be ind olent.
Post-germinal ce ntre memory Bccells cir
cu lat e in the PB and comprise at least
in the follic ular marginal
some of the
zone s of lymph nodes, spleen and mucos a-assoc iated lymphoid tissue (MALT).
Marginal zone e-cens of this co-roanmen t typ ica lly express pan-B antigens,
surfac e Ig M w ith only low level IgO and
lac k both COS and COlO 12064 A. 2293Bl.
produced in the ge rminal
c entre enter the PB and home 10 the bone
marrow (BM). They conran predom inantlY
IgG or IgA ; they lac k slg and CD20, bI.C
exp ress IRF4/ MUM 1, C D79a , C03B and
CD 138. Both memory B-eetl s and long.
lived p lasma cens have mutated IGV
reg ion genes , bu t d o not continue 10
undergo mutation . Posl-germinal centre
Beene reta in the ab ility to home to tissues
in wh ic h they have undergone antigen




fig.I.O] SChematic diagram showing pherlotype 0/8 ~ at ~ stages of mah.ra1ion. TOT is II feature of
earty Iyn1)hOid preanors, irdIclIng boIh Band T IyrrfJhobIasts. as wei as!he blasts in some cases of acu1ll myeloid
leukaemia. C079A and PAX5 appNI' allhe bme of heavy etlan ger-.e rearral'lQelTlelll. COlO is I'IOt e~ IA'ltIIIhe
stage of inIrrI.JllOgIobuIirlliljll chain gene (/GLJ I'8aITllflQE!I' TOT, Iermml ~ IransJerase; SHM, soma1lc~ ; Red t .,/GH@ ~ll blue bar./GL rearrarJgelTleflt; Pre-8CR. pre-8<eI receplor ~
sisIi1g 01 a IG heavy thaI'l and !he IIWfOgale io,tJl chail (YItIch is ~ d two lri;ed smaI pepIides VpreB llf'Id
45, represenled in ~J; BCR. B celIl'llOfII*;Irol rnetln 8 eels : Redbar and blue bar wiItl bladti'lser1DJs, fNIfIIIglId
IGH@ and IGl. QeIleS WIth somabc h~.

ge nes , consis tent with a derivation from

c ells that have been exposed to the qe minal centre. Burkitt lymphoma cells are
BCL6+ and have mu tated IGH genes,
and are Ihus also though l to correspond
to a g erminal cen tre b last celt. Both
Burk itt and DLBCL co rrespon d 10 prolferating c ells. and are cli nically aggressr.oe

Introduction and overv-ew 01 the ctess.tcauoo of the lymphoid neoplasms

stimulation, probably through su rface integrin exp ression, so that B-cells that
arise in MA LT tend to return the re, while
those that arise in lymph nodes will home
to nodal sues and BM p03AI . Marg inal
zone lymphomas of MALT. splenic . and
nodal types correspond to post germinal
centre, merTIOfY B cells of marginal zone
type thaI derive from and proliferate
specifically in extranoctal, splen ic or nodal

nssoes. Plasma cell myekma corespooos

to a 8M homi ng p lasma cell.
T-cell lymphomas : lymphocyte differen tia

tion and function

Tlymphoc ytes arise from a 8M prec ursor
that undergoes maturation and acqui sition
of function in the thymus g land . Antig en
specific T cells mature in the thymic co rtex,
Tcells recognizing selt-peptides are eliminated via eccotosrs. in a process med iated

Peripheral lymphoid tissue

Central lymphoid tissue

Precursor T-cene



.. ... .....


receptor. The 0.1\ and

structu re of the
"}'IS chains are each composed 01a variable (V) and const ant (C) po rtion. They
both are associated with the CD3 complex. which con tains 't- 0 and t chains.
NK-cells dO not have a complete 'r-cen
receptor com plex, ac tivated NK cells
exp ress the t and l; c hains of COO in the
cytoplasm. They express C02. COl , and
sometimes C DS. but not surfa ce COO.
They also typi cally express CD16 , CD56,
and variably COSl and contain cytoplasmic cytotoxic granule p roteins . NK-cells
kill th eir targets. through antibody depend ent cytotoxicity (ADCC) or a second
mechanism involving killer activating
rec ept ors and killer inhibi tory recept ors
, (KIRs). As NK-cells do not rearrange the
T-cell rec eptor genes, analysis of clonali ty
in NK -c ell prol ifera tions c an utilise antibod ies to the various KIR receptors ,

b y cortical e pithelial cells an d thymic

nurse cells. Co rtical thymocytes have an
imma lu re j-ceu phenotype . and express
termina l deoxynucleolidyl transferase
(TOTl. CO la . COO. CDS, and COl. CD3
is lirst expressed in !he cytoplasm, prior
10 complete t-een receptor gene rearrangement and export to the ce ll membrane. Cor tical thymoc ytes are initially
dou ble-negative lor bo th CD4 and CDS.
These ant igens are co-expressed in rnaluring mvmocytes. and later more mature
T-c ells express only CD 4 or CDS. These
varying sta ges 01 j-ceu matur ation are
ref lected in T lymphoblastic leu kaemia!
lymp homa (T-ALULBL).
Med ullary thymo cyt es have a ph enotype
similar to that of mature t-eens of the periph era l lymphoid o rga ns, There are two
classes of t-eens: o.~ t-eens and ~ T-c ells
12841. This d istin ct ion is b ase d on the

Peri heral mature T- and NK-cells



T-binI , . . "


~ ~f ~, -,------+-------?~ffl'

L~ ZT~'
T tvmphoblastic


Peripheral (mature) T-cell and NK-cell tymphomaslleukaemlas

Fig. ' .0<& Diagrammatic representation d T-cel drflerenbabal. T-<.:eI neopIastnscorrespond lCI dJflerent stages 01 mabntion. Lymphoid progenilClfs enteree thymus wherePfflCU'sorT-cees deYeIop intovaried typeS 01 naive T-ceis. The~ rnauationaI palhd natural kiIer cells andy6 T<.efls is not filly ~tood. Thea~ T<:eIsleave1he1l'Iyrrus where
\.p)n expl)Sl.Q 10 anligen they mayUI'ld9rgo b1asllranslormabon and developfurther intoC04+andCD8+ elledor andmemory T<ets, T regulalory eels en 1hemajortype 01 COol
eIIector T<ells. AnoIhllf speciIic type 01 eIJedor T<eIls is the IoIliculaf helperT-eel that is found in gernjnal centres. Upon anligetjc stimulabal, T-cel teSj)(Ilses may OCW" irJd&.
pendenl ollhe gemWoal ceoue. or in 1hecontext 01 a germinal centre reaction. FDC. Follicular dendritic cells: AG. antiQen.

Introduction and overview of the classifica tion of the lymp hoid neoplasms


Toll-like receptors playa role in ce ll-cel l

interac t ions and sig nal ing. They p laya
critical role in the rec og nition of infectious
agents, init iating signaling through NFKB.
While they func tion most prominently in innate immune respo nses, t hey also have a
role in the adaptive immune system
[ 1282AI
The lym phomas of the innate immune
sys tem are pr ed ominant ly extra nocal in
p rese ntation, mi rroring the d istrib ut ion of
the fun ction al componen ts of this system.
It is interesti ng that ma ny t-een and
NK-ce il lymp homas o bse rved commonly
in the paed iatr ic and youn g ad ult age
group are de rived from cells of the innate
immun e system {10351. These inc lude aggressive NK -c ell leu kaemia, systemic
EBV-positive t-een lymphoproliferat ive
disease (LPD) of ch ild hood. most heo atosp lenic t-een lymp homas, and y8 Teen
lymphomas affectin g cutaneous and
mucosal sites. Anaplastic larg e cel l lymphom a (ALC L) is the most comm on paedi atri c T-cell lymphom a , and also is of
cytotoxic origi n. However its normal cellular
co unte rpa rt, if o ne exists, is unkno wn.
y8 t-eens exp ress nei ther CD 4 nor COB,
and also usually lack CDS. A subpop ulation
expresses COB. They comprise less than


5% of all nor mal

and show a restricte d d istrib ution, being found mai nly in
the sp lenic red p ulp , intestinal ep ithelium,
and other epi the lial sites. It is notable that
these sites are mo re com monly affected
by yo T-cell lymphomas, w hich otherwise
are relatively rare 147, 241, 1303j. yO T-cells
hav e a restricte d range of antigen recognition, and repr esent a first line of de fense
against bacterial oeotroes, such as heat
shock proteins l2841. They are often involved
in respo nses to mycobac terial infec tions,
and in mucosal immunity
More rece ntly, the pattern of c ytolytic molecules has been investigated and co rrelated with both c ellular origin and
funct ion . For exa mp le, to da te five
g ranzymes have been demon strated in
human cel ls j 1984Aj. These enzymes are
simi lar in struct ure, but differ in their substrate speci fic ity and chromosomallocanons. G ranzyme M, a nove l me mber of
this family, has unus ual e nzyme specificity, preferring clea vage after meth ionine,
leuci ne or no rleuc ine. It has been sugg ested that this enzyme may p laya role
in the effector phase of innate immune responses . Its expre ssio n is rest ric ted to
NK-cells, CD3+ CD56 + t-eens. and yo
J-ceus, bu t it is absent in other cytotoxic





C0 3



CD4 +

Double +


=:lIl:B:l~)IIPeripheral T-eell lymphomas



Fig.8.05 Schematic diagram of T-<:ell maturation illustrating changes inantigenic expression. Tccell receptor (TCR)
genes (TRA@, TRB@, TRG@,TRD@) are shown schematicallywith solid red bars indicating absence ofrearrangement, and rearrangement ofrelevant TCR genes as additional black segments.The TRG@generearranges first, followed by TRB@ and TRD@ . up T cells delete the TRD@ gene during TRA@ gene rearrangement, as TRD@is
contained within the TRA@ locuson14q11.2. HOIVevef, yO Tcells may haverearranged TRB@genes,withoutassembly
ofa complete up TCR Productive rearrangement gives rise to two mainT-<:ell populations. ul3and yO. wiltlexpression ofltle relevantTCR complex on the cell membrane (shown as double red bars).

t-een subsets , Granzvme M is expressed

in bepatosorenrc T-cell lymp homas, cutaneous .,8 t-een lymphomas, and most
intestinal t-een lymphomas tested, linking
these neoplasms to the innate immune
system 11 1911.
T-cells of the adaptive immune system are
heterogeneous and functionally comp lex,
and inc lud e naive. effector (regulatory
and cy toto xic) , and memory t-eens. Interesting ly, t-een lymphomas of the adapt ive
immune system p resent pr imarily in
adu lts, and are mainly nodal in origin,
contrasting w ith the extranodal r -cenfym.
phomas of the innate immune system
/10351. CD4-positive T-cells are primarily
regulatory, acting via cytokine production
CD4-positive ce lls a re divided into two
maj or types, based on their cytokine
sec retion profiles, known as Th1, and Th2.
Th1 cells secrete inter leuk in {IL)-2 and
interferon t , bu t not IL4 . 5, or 6. In contraer , Th2 ce lls secrete IL4, 5, 6 , and 10
12841, Th 1 cel ls provide help mainly to
other t -eens and macropbaoes. whereas
Th2 ce lls provide help ma inly to Bcens.
in the prod uction of antibodies /2851.
CD4-positive T-cells can act to both help
and suppress immune responses, and
cons ist of mu ltiple sub po pu lations only
rece ntly recog nized .
Recen tly much has been learned about a
unique CD 4+ t-een subset found in the
normal germinal centre. These cells,
termed fo llicular T-helper ce lls (TFH), provide help to B-cells in the co ntext of the
ge rm inal centre reaction j63 1, 852.
1656A l . They have a unique p henotype.
exp ressing the germinal centre-associated
ma rkers BCL6 and COlO, norma lly found
TFH exp ress CD 4, CDS? PD
1, and p roduce the chernckine CXCL13
and its rece ptor CXCR5, CXCL 13 causes
ind uction and prolife ration of FOe;
CXCL 13 also facili tates the migr ation of 8
and T cel ls exp ressing CXCR5 into the
germina l cen tre. Recen t stud ies have
identified inc reased expression of CXCL13
in angioimmuno blastic T-cell lymphoma
{A ITL}, a finding that he lps to link tog ether
many of its c linica l and pathological teatures 163 1, 852. 1656A l . Notably AITL is
associ ated with polyclonal hype rpamma.
glo b ulinaem ia and expansion and prolif
eration of bot h B-ce lls and CD2 1+ FDC's
within the lymph node.
A CD 4+ T ce ll with very d ifferent properties
is the regulatory T cel l (Trag), w hich fuoctrons to shut off and sup press immune
responses 12043Aj . This cell is thoug ht to

Introduction and overview of the c lassification of the lymphoid neoplasms

Table a.o2



features 01 common manse T-cell arid NKoCeII reooasrns.




















ENKIT, Maul typt




Pmry cutMllOU .,6

T"", _














,'- .,- ,
.,- .,- .,- .,-



.. ..

.. ..








c, cytopla~ C03(01)'. restricled to C03&: " T<eII receptor 'l'6: 'IIi, a rJIfIOriIy of cases expresses the o;fI T-ceHreceptor. " cose is exprMSed in Iha moIlO1'lOI"phic t)1Itt of
EAR 0( Type II: " , EBVis Ibsenl in neoplastic cess. but is nearly always present in a subpopuIabon of backgrourld 8-ceIs; . , PTCl. OOS is 001 a Slrg\e disease, buI a hettrOgenttOUS group, andItlefelore, a vanety of imml.flOPhenotypic proftles canbe seen. A, a subset of PTC,l. NOS Ire 0&riVed !rom loIicuIar helper T-eels FH), and often express CDS7, COlO and BCl6: TPLl , T~ proIymphocytic leukaemia; T-LGl, T<eIIlarge gra1u!af lymphocyllC leukaemla; ATLl, adiJft T-<;8" leukaemia/lymphoma: AggNK,
aggressive NK-cel leukaemia, ENKIT-nasaltype. Mranodal NKfr-telllymphoma, nasa~lype; EATL, enteropathy-associated T-eelIlymphoma; HSTl. hepatosplenic T-ceH
lyrrloma: SPTCL, subcutanlC!JS panl'licu~tis-li ke T-een Iymptloma; MFISS, mycosis tungoides and sezary syndrome: primary cutaneous COJO+ lPD, primary cutaneous
CD30+ T-<;elI lymphoproll!erative disease, including primary cutaneousanaplasticT-cell lymphoma: AlLY. ang'oimmunoblestic T-ce~ lymphoma: PTLC, NOS, periphlfa! T-cell
lymphomas, nototherwise specified: ALCL, anaplastic large cel lymphoma. 00, granzyme B; Per, perforin,


play an imp ortant role in preven ting autoimmunity. Tregs exp ress high den sity
CD25, and the tran scription fact or
FOXP3, in com binatio n w ith C04, Adul t
T-cell leukaem ia/lymphoma (ATLL), ha s
been linked to Treg ce lls b ased on expression of both C025 and FoxP3 , and
this finding helps to explain the marked
m munosuppression associated with ATLL

Recent studi es have tried to relate the
pathological or c linical manifestati ons of
t -een lym phom as to c vtokme or onemokine expre ssion by the neoplastic cells, or
accompanying ac cessory cells w ithin the
lymph nod e . For exa mple. the hypercalcemia assoc iated with ATLL has be en
linked to sec retion of fact ors with osteoClast-activating ac tivity 1664, 13581. The
haemophagocytic synd rome seen in scme
T-cell and NK-celt ma ligna nc ies has bee n

associated wit h sec retion of both cy tokines and c herno kmes . in the selt ing
d efect ive cytolytic function (737 , 12761.
Geneti cs
Seve ral ma ture B-cell neopla sms have
characteristic genetic abn ormalities tha t
are impo rtant in determining their biologi c
features and can be useful in d ifferential
d iagnos is . These includ e the t( 11:14) in
mantle c etl lymphoma, t(14 :18) in follicu lar
lymphoma, 1(8 :14) and var iant s in Burkttt
Iymphana, and 1(11:18) in MALT lymphoma
1515 ,1 104, 12851. The 1(11;14) is seen in
both mantle c ell lymphoma and a fraction
of c ases of pla sma cell myeloma, but
mino r differences in the tra nslocation
exist , invol ving d ifferent portions of the
irnrronoglobu lin heavy chain gene (IGHO)
(1991. The most common paradig m tor
trans locations involving the IGHtlon 14q ,

is tha t a c ellula r proto-oncogene come s

under the influence of the IGH @p romo ter
For example, in follic ular lymphoma. the
overexpreeeton of BCL2 blocks apoptosrs
in germinal c entre Bccells. The t(11;1 8),
c ommon in MALT lymphoma, results in a
fusion ge ne , AP/2/MALTI 1574, 1837,
2 109AI. The expression of API2 inhibits
the act ivity of several caspases. The partner g ene , MALTI, act ivate s the NF",B
pathway, as do other nensrocatons found
in MALT lymp homa, suc h as t(1; 14) and
t(14 :18).
Only a few T-cell neoplasms have thus far
been associated With speci fic genetic
abnormali ties . Anap lastic larg e cell lymphoma, AU< +, is def ined by trensocercos
involving the ALK (anaplastic lymphoma
kinase) gene on ch romosome 5, (t(2;5)
and variants 1582 .12291). Hepat osoieoc
lym phoma is assoc iated with


Introduction and overview of the classification of the lymphoid neoplasms


Diffuse large B-cell 37%

Follicular 29%
WII... T l)rnp homa 9%
ManUe celll)rnphoma 7%

.CLLlSLL 12%
Primarymed large B-cell 3"A:
High Grade B. NOS 2.5%
Burkitt 0.8%

Splenic marginal zone 0.9%

Nodal marg inal zone 2%
l)rnphoplasmacylic 1.4%
Fig. 8.06 Relative frequencies of B-celilymphoma subtypes in adults. Significant differences exist in different geographicregions. However, dilluse large B-eelilymphoma(OlBCl) and~ I icular lymphoma are the most common subtypes irrespective of geographicor ethnic group. Note that these figures unoerasmate theincidence of CLUSLl, as
only patients presenting clinically with lymphoma were included, MCl , mantle 0011 lymphoma; ClUSlL, chronic lymphocytic Ieukaemialsmali lymphocytic lymphoma; PMLBCl , primary mediaslinal large B-celi lymphoma; SMZl, splenic
marginal zone lymphoma; NMZL, nodal marginal zooe lymphoma. Oala based on {51}.

isochromosome 7q . However, the molecular pathogenesis of most other T-cell and

NK-cell neoplasms remains to be defined,
Multiple othe r genetic tools have been
broug ht to bea r on the study of mature
lymphoid neoplasms, These include com parative genomic hybrid isation (CGH) ,
and the newer and more sens itive tech nique of array CG H, both of which can
identify areas of deletion or amp lification
within the genome \165-167}. Gene
exp ression microarrays can interro gate
the exp ression of thousands of genes at
the RNA level, helping to elucid ate pathways of activation and transformation 1509,
510,513,701, 1507, 1867, 1944}. Most
recently, studies have begun to explo re
changes at the epigenetic level that control
the expression of multiple genes {13141.
Principles of classification
The class ification of lymp hoid neoplasms
is based on utilisation of all available information to define disease entities 1898l.
Morphology and immunophenotype are
sufficient for the diagnosis of most lymphoid
neopl asms. However, no one antigenic
marker is specific for any neoplasm, and
a combination of morpholog ic features
and a pane l of antigen ic markers are
necessary for co rrect d iagnosis, Most
B-cell lymphomas have c haracteristic

immu nophenotypic profiles that are very

helpful in dia gnosis. However, immu ne
profiling is somewhat less helpful in the
subclassification of T-cell lymphomas.
In add ition, wh ile certain antigens are
commonly associated with specific disease entities, these assoc iations are not
entirely disease-specific. For example,
CD30 is a universal feature of ALCL, but
can be expressed in other T-cell and B-cell
lymphomas and classical Hodgkin lymphoma (CHL), Similarly, while CD56 is a
ch aracteristic feature of nasal NKff-cell
lymphom a, it can be seen in other T-cell
lymphomas, and in plasma cell neoplasms
1208,701,13251. Within a given disease
entity, variation in immunoph enotypic features can be seen For example, most
hepatosplenic 'teen lymphomas are of yi5
't-een phenotype, but some cases are of
aj3 derivat ion. Likewise, some follicular
lymphomas are CD1Q-negative. Additionally, the presence of an aberrant immunophenotype may suggest or help to confirm
a diagnosis of malignancy (10341 ,
While lineage is a defining feature of most
lymp hoid malignancies , in recent years
there has been a greater appreciation of
lineage plasticity within the haematopoietic
system, Lineage switch, or demonstration of
mUltiple lineages is most often encountered
in immature haematolymphoid neop lasms,

lntroduction and overview of the class ification of the lymphoid neoplasms

but also can be seen rarely in mature lymphomas l451A, 675A, 88DAI.
Genetic features are playing an increasing ly impo rtant role in the classification of
lymphoid malignancies, and for manyofth:l
small 8-celllymphomas and leukaemias,
recurren t genetic alterations have been
identi fied. However, the molecular pathogenes is of most T-cell and NK-ceillymphomas remains unknown,Genetic studies,
in pa rticu lar PCR stud ies of IGH@and
Teen recep tor (TCR) gene rearrangements and fluorescence insituhybridization
(FISH), are valuable diagnostic tools,both
for determinat ion of clonantv in 8-ce ll and
T-cell proliferations (aiding in the ditteren.
tial diagnosis with reactive hype rplasia),
and in identifying translocations associated with some disease entities,
The WHO class ification emphas izes the
impor tance of knowledge of clinical leateres, both for accu rate diagnosis, as well
as for the definition of some diseases,
such as margina l zone lymphoma of
MALT type versus noda l or splenic marginal zone lymp homa, mediastinal large
B-celilymphoma versus DLBCL, and roost
mature T-cell and NK-ce ll neoplasms.
Diagnosis of lymphoid neoplasms should
not take place in a vacuum , but in the
context of a complete cl inical btstorv
Lymphoid malignancies range in their
cl inical behaviour from low grade to high
grade, Howeve r, within anyone entity a
range in clin ical behaviour can be seen
Moreover, histological or clin ical proqressian is often encountered during a patient's clin ical co urse. For these reasons,
the WHO class ification does not attempt
to stratify lymphoid malignancies in terms
of grade . Both morphology and immunephenotype often change over time, asthe
lymphoid neoplasm unde rgoes clonal
evolution with the ecqutstion of additional
genetic changes , In addition, evolution
over time does not necessar ily lead tothe
develop ment of a more aggress ive lymphoma, For example, patients with DLBCL
can relapse with a more indo lent clonaity
related follicular lymphoma, Some of these
clonal evolutions can be unexpected and
not obv iously connected, such as the development of a plasmacytoma in a patient
with CHl [1042B).
Traditionally,classical Hodgkin lymphomas
(CHL) have been considered separately
from so-called "non-Hodgkin lymphomas'
However, with the recognition that CHL is
of B-cell lineage, grea ter overlap has
been app reciated between CHL and

many form s Qf Been ma lignancy. The 4th

edition of the WHO classifica tion reco gnizes these gr ey zones, and provides fo r
the recog nitio n of c ases tha t bridg e the
gap between the se various forms of lymphoma 12265).
Precursor lymp hoid neopl asms incl ud ing
B lymphob lastic leukaemia/ lympho ma
(B-ALL.JLBL) and T fyrnphoblastic leukaemia!
lymphoma (TA LLJLBL) are p rimarily d iseases of c hild ren. 75% of cas es occur in
children unde r six years of age Ap oroxrmately 85% of cases presenting as ALL
areof precur sor B-ce ll type. whereas lymphoblastic ma lig na nci es of precursor
T-cell type more often present as lymphoma, with med iastinal ma sses. A mal e
predominance is seen in lym ph ob lastic
malignanc ies of bot h B-c e ll and T-cel l
Mature s-een neoplasms comprise over
90% of lymph oid neoplasms worldwide
151, 791. They repr esent approximately
4% of new cancers each year. They are
more common in d evelop ed coun tries ,
particularly th e United States. Australia,
New Zealand and Weste rn Europe. The
most recent surve y from the Survei llance,
Epidemio log y and End Resu lts (SEER)
program in the United States indic ated an
incidence rate per 100 000 per sons per
yearof 33.65 for al l lymp ho id neop lasms,
26.13 for a-ce.r neoprasms. 1.79 for all Tcell neoplas ms, a nd 2.67 for Hodgkin
lymphoma 11525A). The most co mmon
types are foll ic ular lymp homa and
DLBCL, which tog ether mak e up more
than 60% 01 al l lymphomas excl usive of
Hodgkin lymp homa and plasma c ell
myeloma 137, 511. The inc idenc e of lymphomas. in pa rtic ular Been lymph omas,
is increasing worldwid e, with mo re than
280000 cases occurring ann ually each
year 121 12A) . The ind ivid ual a-cen neoplasms vary in their relative freq uenc y in
different parts of the world . Follic ular lymphoma is more common in th e United
Slates (35% of non-Hodgkin lymp homas)
and Western Europe, and is uncommon
in South America, Eastern Europe , Africa
and Asia. Burkitt lymp homa is ende mic in
equatorial Africa, where it is the most
common c hildhood mal ig nanc y. b ut it
comprises on ly 1-2% of lymphomas in
the United States and Wes tern Europe.
The med ian age for all types of mat ure Bcell neoplas ms is in the 6th and 7th
decades, b ut med ias tina l large B-c ell

c AduI T..::eI leukemlatlylT1jlhomll 9 no

. Al'IalUs lic I8fge cell lymphoma. Al K. e n.

. Anaplas tic '-lie cel

lym~ AlK .


C P fim ary Cu!arlIIOUll Ala. 1.7%

c l.lnctall s<table PTCl 2.,5%

fig. 8.07 Relative frequenciesofmature T<elllymphoma subtypesinanadultpatient population. Significant differences

exist indifferent geographic regions. However. peripheralT<elllymphorna. not otherwise specified (NOS)and AITL are
two ofthemost common subtypes intemationally.' Notethatlhe category of enteropathy-type T<elilymhpoma (Erel )'
used inthisstudy was not eqllivalent toenteropathy-associatoo T<eII ~ (EATL)as deflood in this monograph. ErCL
was utilized largely asageneric category lor most T<ell lymphomas ifl'/Ol'ving theintestine. inclusive of EATL and )'0T-<:elI
lymphomas. Data courtesyofJ. Vase and The International PeripheralT-CellLymphoma Project (57A).

lym p homa has a med ian age of -35

year s. Of the mature B-cel l lymphomas ,
only Bu rkitll ymphoma an d DLBCL occur
with any sig nifica nt frequen cy in chi ldren .
Mo st type s have a mal e p redo minance
(52 -55%), but ma ntle cel l lymp homa has
a str iking ma le p redo minance (74%) ,
wh ile fema les pre dom inate in follic ular
lymp homa (58 %) and most partic ularly in
pr imar y me diastinal large B-ce ll lymphoma (66 %). Primary med iastinal large
B-c e ll lymphoma a nd cl assical Hodgkin
lymphoma of the nodular sclerosis subtype
have simi lar cl inica l p rofiles at presen tation , most commonly affecti ng ado lescent
an d young ad ult females. These common
clinical featu res first prompte d co nsrce ratton that these lymphomas might be related 11870, 1944, 2265)
O ne majo r known risk factor for mature
B-ce ll neop lasia appea rs to be an abnormal ity of the imm une sys tem, e ithe r immunod efic iency or autoimm une d isease.
Although evide nc e of immune system ab no rma lities a re lac king in most patients
with mature B-c ell neop lasms, immunodeficie nt p atients have a ma rkedl y inc rease d inc idence of a-cen neoplasia ,
partic ularly DLBCL and Burkitt lymphoma
(193,33 1. 1569 }. Major forms of immunod efic iency c urrently incl ud e infec tion with
the human immunode ficiency virus (HIV),
iatrog enic immunosuppression to preven t

allog raft rejection or graft versus host d isease (GVHD) and primary immun e defic ienc ies. Some autoimmune diseases are
also assoc iated with an inc reased risk of
lymphoma, pa rticu larly B-ce illymp homas
in patients with lympboepithelial sraraoentis or Hashimoto thyroiditis 11114, 11161.
Mutations in genes con trolling lymphoc yte epo ptosfs have been linked to a risk
for both autoimmu ne d isease and lymphoma (ma inly B-cell types). Patients with
the autoimmu ne Iymp hop roliferative syndrome. wh ich usua lly is ca used by
ge rmline muta tions in FAS, have an inc reased risk for a-cer lymp homas and
Hod gk in lymp homas 12108). Somatica lly
acquired FAS gene mutations also have
bee n reported in some spo rad ic B-cell
lymp homas, most co mmo nly marg inal
zone lymphomas 1855). Recen t stud ies
employing mo lecula r epidemiology have
identified pol ymorp hisms in a number of
immun ore g ulator y genes that appear to
impa ct both risk of lymphoma and prognosis within a patient cohort l359A.
1248A , 2358C) . Molec ular ep idemiology
is a relatively rec ent area of investigation
and more data will be accumulated in the
com ing yea rs. For example , a recent
stu dy foun d incre ased risk associated
with polymorph isms in certain drug
metabol izing enzymes 116A}.
Mature T-c ell and NK-c eil neoplasms are

Introd uction and overv iew of the c lassificat ion of the lymp hoid neoplasms


relatively uccorrmon. In a large international study that evaluated lymphoma

cases from the United States, Europe,
Asia and South Africa, T-cell and NK-cell
neoplasms acco unted for only 12% of all
non-Hodg kin lymphomas [51}, The most
com mon subtypes of mature t -een lymphomas are peripheral r-eef lymphoma,
not otherwise specified (NOS) (25.9%)
and angioimmunoblastic T-cell lymphoma
(AITL) (18.5%), respectively (57A}.
T-cell and NK-cell lymphomas show significant variations in incidenc e in different
geog raphical regions and racial populations In gene ral, "l-cell lymphomas are
more common in Asia [6161 . These differences result from both a true increased incidence , as well as a relative decrease in
the frequency of many B-cell lymphomas,
such as follicular lymphoma. One of the
main risk factors for T-ce ll lymphoma in
Japan is the virus, HTLV-1. In endem ic
regions of southwestern Japan, the seroprevalence of HTLV-1 is 8-10%. The cumulative life-time risk for the development
of adult r-cenieokaemlaavrrctoma (ATLL)
is 69%"for a seropos itive male and 2.9%
fora seropositive female [6831. Other regions
with a relatively high seropreveience for
HTLV-1 include the Caribbean basin. where
Blacks are primarily affected over other
racial groups {760f. Differences in viral
strain also may affect the incidence of the
disease [523,13451.
Another major factor influencing the inc idence of r-cea and NK-ceil lymphomas is
racial predisposi tion. EBV-associated NK
and T-cell neoplasms. including extranodal NKfT-cell lymphoma, nasal type, aggressive NK leukaem ia, and paediatric
EBV+ T-cell and NK-cell lymphomas are
much more common in Asians than they
are in other races {2n In Hong Kong,
nasal NKfT-cell lymphoma is one of the
more common subtypes, accou nting for
8% of cases By contrast, in Europe and
North America , it acco unts for less than
1% of all lymphomas. Other popu lations
at increased risk for this disease are individuals of Native American descent in
Central and South America , and Mexico
{40,3411. who are geneticall y related to
Asians [8921. Finally, enteropathy-associated J-ce!l lymphoma is most co mmon in
individuals of Welsh and Irish descent, who
share HLA haptotvpee that confer an
increased risk of gliadin allergy and suscep tibility to gluten-sensitive enteropathy
10 PTCL occu r with increased frequency

in the setting of immune supp ression,

especially following organ transp lantation, a finding that is not well understood
{758A, 1582Al The comb ination of two
factors, both immunosuppression and
ch ronic antigenic stimulation. appear to
increase risk. Hepatosptenic T-cell lymphomas are most com mon, but primary
cuta neous and mucosa-assoc iated T-cell
lymp homas have been rep orted as well
{3311. Recent data from the SEER prog ram indicate a modest inc rease in the
inci dence of t-ceu neop lasms in the
United States to 2.6 cases per 100000
persons pe r year, with the greatest
increase occu ring in the category of
cutaneous T-eeillym phoma (492A, 1525A).
Infectious agents have been shown to
contribute to the development of several
types of mature B-cell, T-cell and NK-cell
lymphomas. Epstein-Barr virus (EBV) is
present in nearly 100% of endemic Burkitt
lymphoma and in 15- 35% of sporad ic
and Hrv-assocrateo cases {877, 1780Al.
and it is involved in the pathogenesis of
many B-eelilymphomas arising in immunosuppressed or elde rly patients, including
many post-transp lant Iymphoproliferative
disorders, plasmablastic lymphoma and
EBV+ large B-ceillymphoma of the elderly. EBV is also associated with extranodal NKfT-cell lympho ma and two
paediatric t -een lymphomas. systemic
EBV+ t-een LPD of childhood and hydroavaccin iforme-like t-een lymp homa. The
exac t ca use of these EBV+ T-cell lymphomas of childhoo d is not clear. Risk
factors may be either high viral load at
presentation, or a defective immune response to the infect ion {179n Chronic
active EBV infect ion may precede the
deve lopment of some EBV+ t-een lymphomas {1094, 1797f.In cases associated
with chronic EBV infection, a polyclonal
process may be seen early in the course,
with progression to monoclonal EBV+ T-cell
lymphoma 11 094}.
Human herpesvirus-8 (HHV8) is found in
primary effusion lymphoma and the lymphomas associated with multicentric
Castleman d isease, mainly seen in HIVinfected patients {372). It is of interest that
the same virus ca uses a number of B-cell
Iymphoproliferative disorders whic h differ
in their cl inical manifestations {617A) .
Human T-ceil lymphoma/leukaemia virus
type 1 (HTLV1) is the causative agent of
adult T-cell lymphoma/leukaemia, and is

Introduction and overview of the classification of the lymphoid neop lasms

clona lly integrated into the genome of

transformed T-cells !2148). In this condition as in HHV8-associated disorders, a
spec trum of clinical behaviours are seen,
although most cases of ATLLare aggressive.
Hepatitis C virus has been implicated in
some cases of Iymphoplasmacytic lymphoma associated with type II cryoglobulinaemia. splenic marginal zone lymphoma,
noda l margina l zone lymphoma and
DLBCL 112A, 88A, 527A, 534A, 1073A,
1434, 1775A, 2506), The role of the virus
in tumour initiation is not clear. However, it
does not directly infect neoplastic
and appears to influence lymphoma
development through activa tion of a
B-cell immune response.
Bacteria, or at least immune responses to
bacter ial antigens, have also been implicated in the pathogenesis of MALT lymphoma. These include H. pylori in gastric
MALT lymphoma (998, 1587,2444,2445),
B. Burgdorferi in cutaneous MALT lymphoma in Europe {192), Chlamydia
psittaci. C. pneumoniae and C. trachomatis
in ocula r adne xal MALT lymphomas in
some geogra phic areas {394, 18981and
Campy lobac ter jejuni in intestinal MALT
lymphoma associated with alpha heavy
chain disease {1781, 1812f
Environmental exposures also have been
linked to a risk of developing B-ceil lymphoma. Epidemiolog ical studies have
implicated herbicide and pesticide usein
the development of follicular lymphoma
and DLBCL !460A, 903A) . Exposure to
hair dyes had been ident ified as a risk
factor in some olde r studies, but newer
dye formations have removed potential
carc inogens {2496AI.


The multipa rameter app roach to classification adopted by the WHO classification
has been validated in international studies as being high ly reproducible, and enhancing the interpretation of clinical and
translational studies. In addition, accurate
and precise class ification of diseaseentities facilitates the discovery of the molecular basis of lymphoid neoplasms in the
basic science laboratory151, 1034, 1525A1.




B lymphoblastic leukaemia/lymphoma,
not otherwise specified

Definiti on
B lymphoblastic leukaemia/lymphoblastic
lymphoma is a neoplasm of precursor
cells (lymphoblasts) corrmined to the Bcea
lineage. typically composed of small to
medium-sized blast cells with scant cytoplasm. moderately condensed to dispersed
chromatin and inconspicuous nucleoli,
involVing bone marrow (BM) and blood
(8 acute lymphoblastic leukaemia/ALL)
and occasionally presenting with primary
involvement 01 nodal or extranodal sites

(B lymphoblastIC IymphomallBl), By cooventon. the term tymphcma is used when

the process is confined 10 a mass lesion
with no or minimal ev idence of peripheral
blood (PB) and 8M invo lveme nt. With extensive 8M and PB involvement, lym phoblastic leukaemia is the appropriate term .
If the patient presents with a mass lesion
and Iymp hob lasts in the 8 M. the d istinc tion between leukaemia and lymphoma is
arbitrary 11 550 1. For many treatment protocols, a fig ure of 25% BM blasts is used
as the thresho ld for defi ning leukaemia .
In contrast to mye loid Ieokaemtas. there
is no ag reed-upon lower limi t for the
perc entag e of b lasts required to establish
a d iagn osis of lymphoblastic leukaemtas
In g eneral, the d iagn osis sho uld be
avo ide d when the re are few er than 20%
blasts, Presentations with low blast co unts
c an occur b ut are unc omm on; c urrently
there is no co m pe lling evidenc e that
failure to treat a pat ient whe n there are
fewer than 20% 8M Iymph ob lasts has an
ad verse effect on ou tcome,
The term B-ALL shoul d not be used to
indicate Burk itlleukaemia/lymphoma, in
spi te of its historica l assoc iation with tha t
lesion, Cases of BALU LBL with recu rrent
genetic abnormalities are considered
separately below
ICD-O code
The p rovisional code proposed for the
four th edition of ICO-O is 981 113
Epidemiolog y
Acute lymphoblastic leukaemia (AL L) is
primarily a d isease of children; 75% of
cases occur in c hild ren under six years of

Precursor lymphoid neoplasms

M .J, Borowi tz
J ,K ,C. Chan

age . The worldwi de incidence is estimated

at 1- 4.75/ 100 000 pe rsons pe r year
{18271. The estimated number of new
cases in the United States in 2000 is
approx imate ly 3200, with approximately
80-85% bein g of precursor B-cell phenotype {1845 , 20391.
B-lBL constitutes -10% 01 lymphoblastic
lymphomas. and the rema inder are of
"T lineage 12421 Ap proximately 64% 0198
cases reported in a literature review were
less than 18 years of age 113671. One report
indi cated a ma le predominance {13101.
Some transiccenons associated with
B-ALL have been detected in neonatal
specimens long befo re the onset of
leukaemia. and monozygotic twins with
concordant leukaemia frequently share
genetic abnormalities {832, 15t41 , suggesting a genetic cornponen tto at least
some c ases. Many of these trans locations
appear to be p rimary initiating events.

Sites of involvement
By definition, BM is involved in all cases
c lassi fied as B-AL L, and PB is usually
invol ved. Extramed ullary invo lvement is
frequent. with parti c ular pred ilect ion for
the c entral nervous system , lymph nod es,
spleen. liver and testis in males. The most
frequent sites of involvement in BL BL are
th e skin, soft tissue, bo ne and lymph
nodes 1202, 1310, 13671- Med iastinal
mass es are infreq uent {202, 1367, 19281.
Clinical features
Most patie nts with B-ALL presen t with
evidence and consequences of BM failure: throm bocytopenia and/or anaemia
and/or neutropenia, The leukocyte count
may be decr eased , norma l or markedly
elevated, Lymphadenopathy, hepatcmegaly
and splenomegaly a re frequent. Bone
pain and arIt1ralgias may be prominent. Patients with B-LB L without leukaemia are
usually asymptomatic , and most have limited stage disease. Head and neck presentations are particularly common,
especially in children. Marrow and PB involvement may be present . but the

Fig. 9.01 B lymphoblastic leukaemia, Bone rnarJOll

smear. A 5everal ~asls with a highIIlIdearIc't
lopiasmic ratiO and variably conoensed nudear dWl).
mallO, B B Iymphoblasls containing numerous eo<ne
azurophihc granules,

percentage ollymphoblasts in the 8M is

<25% 11310,13671 .
Mor phology
The Iymphoblasts in B-ALlA.BL in smear
and imp rint preparations vary from sma"
blasts with scant cytoplasm, condensed
nuclear ch romatin and indistinct nucleoli
to larger cells with moderate amounts
of light blue to blue-grey cytoplasm

occasionally v ac uolated . d ispersed nuclear chromatin and mult ip le variab ly

oronrent nucleoli. The nucl ei are round ,
tregUar or corwoIuted. Coarse azurophilic
granules are prese nt in some fvmoroblasts in approximately 10% of cases. In
some cases. the Iymphoblasts have a cytoPlasmic pseudopod (hand mirror cells)
In most cases the morphology of the Iympeootasts differs from that of no rmal
Be en precu rsors (haematog on es) with
which they may be confused . The latter
typically have even highe r oucieu s/cytoplasm (N/C) ratio s, mo re homogeneou s
chromatin and no discernible nucleoli,
In BM biopsies. the Iymp hoblasts in
B-ALL are relatively uniform in app earanc e
with round to oval, indented or co nvoluted
nuclei. Nuc leoli range from inco nsp icuous
to prominent. The c hromatin is fine ly
dispersed The number of mitotic figures
varies Lymphob lastic lym phoma is
generally charac terized by a di ffuse , o r
less comrT'lOflly, paracomca r pattern 01
involvement of lymph node or other
1JSSUe. A single-file pattern of infiltration of
sot! tissues is common. Mitotic figure s are
usually numerous and in some cases
\hefe may be a foca l "starry sky " pattern.
The morphologiC features of Band T lymphoblastIC proliferations a re inoisnngliShable.

Cy10chemistry seldom con trib utes to the

diagnosis of ALL lymphoblasts are
negative 'or nweiope roxio ase. Gran ule s,
Ifpresent, may stain light g rey with Sudan
Black-B staining bu t are less intense than
myeloblasts. lymphob lasts may show PAS

positivity, usua lly in the form of coarse

granules . Lymphob lasts may reac t with
non -specific esterase with a mutntocat
punctate or Galg i zone pattern that shows
variable inhibition with sodium fluoride .
The Iymphoblasts in B-AlLllBl a re almost always positive for the Been markers
CD 19, cytoplasmic CD79a and cytopla sm ic C022; wh ile none of these by
itself is spec ific , po sitivity in c om bination
or at high intensity strongly sup ports the
B lineag e. The Iymphoblasts are pos itive
for C01O, surface C022, C024, PAX5 and
TdT in most cases. while C020 and C034
expression is var iabl e: CD45 may be abse nt. The myelo id-associated antigens
C0 13 and CD33 may be expressed. and
the presence of these myeloid mar kers
doe s not exclude the diagnosis of B-ALL
In tissue sections, C 0 79a and PAX5 are
most frequ ent ly used to demon strate
B-cen different iation, but the former reac ts
with some cases of T-ALL and is not spec ific 19061. PAX5 is generally considered
the most sen sitive and speci fic ma rker for
B lineage in sections 122511but it is also
posi tive in cases 01 AML with t(8 :21) and
rarely in other AML 122851. Myeloperoxicase express ion in leukaemic cell s detected with anti-MPO antibodies excludes
this d iagnosis and wou ld ind icate either
acute mye loid leukaemia or B/mye loid
The degree of differentiation of a-uneace
Iymp hobl asts ha s cl inic al and g ene tic
co rrelates. In the earliest stage, so called
ea rly precursor B-ALl or p ro-B-ALl. the
blasts express CD19, cytop lasm ic C079a,

cytoplasmic C022 and nuc lear Td l ln the

inte rmedi ate stag e. so called common
ALL. the b lasts expre ss C01O. In the most
matur e precursor B d ifferentiation stag e,
so c alled pre-B-ALL. the blast s exp ress
c ytoplasmic ~ c hai ns (c -u ). Surface immunoglobulin is c harac teristica lly ab sent
alt hough its pre senc e does not exc lude
the pos sibil ity of B-AlLllBL (15841. provided that other immuno p henotypic teatures, morphology and c ytog enetics are
co nsistent With B-AlL. Although CO l O.
positivrty is seen both in B-ALl and in normal haematogones. the immunophenotype
of prec urso r B-AL l differs in alm ost all
cases from that seen in no rmal Been precu rsors, The tatter sho w a continuum of
expression of ma rkers of 8-cell maturation. includ ing surface Ig light c hain. and
d isp lay a reprod uc ible pattern of acqui sition and loss of normal antigens {14421.ln
con trast. c ases of B-A LL show patterns
that d iffer from normal with either overexpres sion o r uno erexpres sion of many
markers incl udi ng CO l O, CD45, CD38,
C058 or Td T, among others 1326. 401.
134 2. 23721. These crttererces c an be
very use ful in evalua tion of followup BM
specimens for minimal resid ual d isease,

Antigen recep tor genes
Near ly all cases of B-ALL have clonal OJ
rearrang eme nts of the IGH@gene. In ad d itio n, t-een recepto r gene rearr angeme nts may be see n in a sig nifican t
proportion of c ases (up to 70%) 122941so
that these rear rangements are not helpful
for lineag e assignmen t.

Ft;. 9.03 B~sbc lymphoma, A Skin, The ~Iic cells diffusely infiltrate the dermis -Mlh sparing of theepidermis. B Samecase aI h p magnification shows ~
SI.mU'ldW'9 a blood vessel.

8 lyrnp hobtastic leukaemiaJlymph orna. not otherwise speci fied




Fig. 9.04 IrIcnIased haemalcJlp'le$ A Bone marrow sedJon . B Bone marrow smear In::m an et;;rt year.Qd male.
showing tympnoid eels with I high nucIeaIlcyqJlasmicratio and hcm:lgeneou$ nudear dlromaW1; nucleoli . . not
observed or areindl$1lllCl These cells resemble!he ~ in All 01 dtilood.

Cytogenetic abnormalities and onrogenes

Cytogenetic abnormalities are seen in the
majority 01 cases of B-AlLABl; in many
cases they define specific entities with
unique phenotypic and prognostic features. These cases are considered separately Additional genetic lesions that are
not associated with these entities include
del(6Q), del(9p). del( 12p). though mese
do not have an impact on prognosis.
Some genetic lesions that may be
assoc iated with poo r prognosis include
the very rare 1(17;19); E2AHLF ALL and
the lonachromosonat amplification 01the
AML 1gene on chromosome 21 (iAMP21),
whic h ac cou nts for about 5% of cases of
All 11510]. The latter is being recognized
with increasing frequency with the increased


Precursor lymphoid neoplasms

use 01 FISH studies to detect TEL AML 1

translocations, because it can be detected with the same AML 1 probe.
Postulated normal counterpart
Depending upon the specific leukaemia ,
B-ALL arises in e ither a naematopoienc
stem cell or a B-ceU progenitor.
Prognosis and p red ictive factors
BALL has a good prognosis in ch ildren,
but it is less favourable in adults . In c hild ren, the ove rall complete remission rate
is >95% and in adults 60-85%. Approximately 80% of children with BALL appear
to be cured, while this fig ure is less than
50% for adults Mo re intensive therapy
makes a d ifference in c ure rates , and


9.05 B IympIw)I:lIask leukaerria. L~ rnje. The

neoplastiC eels infiIlrate cMlusely sparW1g IUmallaides

there is some evidence tor youngeradlAls

at least , that therapy with more intensive
"paediatric-type" regimens is associated
with better outcome 1233, 8721. Inlancy.
increasing age (> 10 years), higher white
blood cell count, slow response to initial
therapy as assessed by morphologic ex
emmanon 01P8 and/or 8M , and the presence 01 minimal residual disease after
the rapy are all associated with adverse
prognosis 1488, 679, 19 76 , 2023 , 2093.
22951. The presence of eNS disease at
diagnosis is associated with adverse out
come, and requi res specific therapy 14461.
The prognosis of B-LBL is also considered relatively favourable. and as with BALL appears better in ch ildren than accns


B lymphoblastic leukaemiallymphoma
with recurrent genetic abnormalities

This group of d iseases is c harac terized

by recurrent genetic ab normalities, in-

clud ing balanced translocations and

abnormalities involving ch romosomes,
Many ch romosomal abnormalities that are
non-rand omly associated w ith B acu te
tymphoblastic leukaemia (BALL) are not
inCluded as separate ent ities in this sectal. While inclusion or exclusion 01 a genetic -entity- is somewhat arbitrary, those
lesions that are specifically mentioned are
chosen because they are associated with
distinctive clin ical or phenotypic p ropertes. have important proqnosnc implie arcos.demonstrate omerevidence that they
ale biologicall y di stinct an d are generally
mutually exc lusive w ith other ent ities.

leukaemiallymphoma with
~9;22)(q34;q 11 2); BCRABLt

Aneoplasm of Iyrnphoblasts corrmitted to
lhe e -cen lineage in whic h the blasts
harbour a trans location be tween the BCR
gene on ch romosome 22 and the ABL 1
oncogene on ch romosome 9

ICD-O code
The provis ional co de prop osed for the
fourth ed ition of ICO-O is 98 12/3.
Epidemiology and cl inical features
Presenting features are generally similar
to those of other pat ient s w ith B-All.
BCR-ABL 1 associated ("Ph . -) All is
relatively more common in adults than
Children, accounting for about 25% of
adult All but only 2-4% of childhood
All. Most chil dren with Ph. B-All woul d
be consid ered "hig h risk " b y sta nd ard
age and white b lood ce ll (WBC) feat ures,
but there are otherwise no cha racteristic
docalf indings Though patients with t(9;22)
BAl l may have organ invo lvement. lymphomatous presentations are rare

and cytochemistry

There are no un ique mor phologic or

MoJ. Borowitz
J.K.C. Chan

cytochemic al feat ures that d istingui sh this

from other type s of ALl.
B-Al l wit h t(9;22 ) is typicall y C 01O .
C0 19. and TdT . There is more frequ ent
expression of myeloid -assoc iated anngens C0 13 and C033 19851: COl17 is
typically not expressed . C025 is highly
associated with t(9.22) B-All, at least in
adu lts 116791. Rare ca ses of t(9 :22) All
have a T precursor phenotype.
Genetic s
The t(9 :22) results from fusion of BCR at
22q l 1.2 and the cy to plas mic tyrosine
kinase gene ABL 1 at 9q3 4. w ith produ c tion ot a BCR-AB lfusion protein, In most
chi ld hood cases of Al l w ith the t(9 ;22), a
p1 90 kd BCR-ABU fusion p rotein is
produced. In ad ults, ab out o ne half of
cases of ALL w ith the t(9 .22) prod uc e the
p2 10 kd fus ion protein that is present in
chronic myelogenous leukaemia (C ML) .
and the rema inder prcouce the p190. No
de finite cl inical differences have been attribu ted to these two different gene produc ts. The t(9 ;22) may be associated with
other ge netic abnorm alities, inc lud ing
rare cas es that mig ht othe rwise c ause a
cas e to be plac ed in one 01 the other categories below, It is ge nerally conside red
that cl inica l features in suc h c ases are
governed by the p resenc e of the t(9:22) .

Fig. 9.06 Ttis bone marrow from ., iICkJIl WIth 119"22)

posIbve &-ALl is ~leIy replaced by tyrnp1ctlIasb.
Mitolic figl.l'eS areI'lUI'IlefOUS.

ad d ition to hig h-dose c hemotherapy has

been reported to imp rove early event-free
survival {19751.

B Lymphoblastic

leukaemiallymphoma with
t(v;11q23); MLL reafT8t1ged
A neoplasm ol lymphoblasts ccmm ined to
the B lineage that harbours a transl oca tion between the MLL g ene at band
t 1q23 and anyone 01 a large number of
differe nt fus ion pa rtne rs. Patien ts with
leukaemias that have dele tions of 11q23
w ithout MLL rear rangemen ts are not incl ud ed in trns group ,

Postulated normal counterpart

There is some suggestion that the c elt 01
origin of t(9 :22) ALL is more immature
than that of othe r B-All cases 14521.

ICD-O code
The p rovis iona l code proposed for the
fourt h ed ition
is 981313

Prognosis and pred ictive factors

In both c hild ren and adults , t(9 ;22 ) All
has the worst prognosis among pat ients
with All. Its hig her frequency in adu lt
All expl ains in pa rt but not completely
the relativ ely poorer outcome of ad ults
w ith All. In ch ild ren . the prese nce of
favourab le c linical features inc lud ing age.
white count and response to thera py, is
associated with somewhat better outcome
1771. althoug h prognosis is still cons idered
relatively poor . Treatment with imatinib in

Wh ile the specific et iology of leukaemia
with MLL transJocations is unknown . this
translocation may occur in utero. with a
sho rt latency between the transloca tion
and dev elopment of d isease , Evidence
for this inc lud es the fact that these
leu kaemias are frequ ent in very young
infants, as well as the fact that this translocation has been identified in neonatal
b lood spots of patients who subsequently
develop leukaemia {7451.


B lymphoblastic leukaemia/lymphoma With recu rrent genetic abnormalities


proteo-qryca n neural-glial antigen 2

(NG2) is also characteristically expressed
and is relatively, thoug h not absolutely,
spec ific.


Fig, 9.07 B tymphoblasbc le ukaemia~ym phom a with MLL reerrarqement FISHstudy usingan MLL breekapa rt probe.
The normal MU gene"MLL(11q23)"appears as ajuxtaposed red and green, Of sometirnas yellow signal, The trensJocatioo is demonstrated by separation of theredandgreen probes r MLLsp") (Cocrtesy of Or AJ carroll)

The MLL gene on chromosome 11Q23

has many fusion partners. The most cammon partner gene is AF4 on cnrorosore
4q 21. Othe r commo n partner genes
incl ude ENL on chromosome 19p13and
AF9 on chromosome 9p22. MLLENL
fusions are also co mmon in TALL and
fusions between MLL and AF9 are
more typ ica lly associated with myel()d
leukaemia. Leukaemias with MLL nanslocations are frequently associated with
overexpresston of FLT-3 l 801. Cases with
deletions of 11q23 are not included in this
group of leukaemias as they appear not
to share the same clinical, phenotypic or
prognostic features.

Prognosis and predictive factors

Leokaerreas with the MLLAF4 translocation have a poor prognosis. There is some
cont roversy as to whether reukeenee
with translocations other than the MLL-AF4
rearrangement have as poor a prcqross
as trcse that do , Infants with ML1. translocations, particularly those <6 monfhs ~
age, have a particularly poor prognosis

B Lymphoblastic
laukaemlaJlymphoma with

1(12;21)(p13;q22);TEL-AML 1
Flg.9 .08 B tymphoblastic leukaemialtymphoma with1(12;21) (p13:q22); TEUAML 1 (ETV&-RUNX1) FISH study using
a red probe against RUNX1 and a green probe against ETV6. The normal genes appear as isolated red or green
signals, wMe evcerce of the fusion gene (arrows) appears asa yelklwsignal, (Coortesy of Or. AJ carroll).

Epidemiology and clinical features

ALL with MLL rearrangements is the most
common leukaemia in infants < 1 year of
age . It is less common in older child ren
and inc reases with age into adulthood .
Typica lly pa tients with this leukaemia
present with very high white blood cell
counts, frequently> 100 OClO/J-J-L. There is
also a high freq uency of eNS involvement
at diagnosis. While organ involvement
may be seen , pure lymphomatous presentations are not typical.
Morphology and cytochemistry
There are no uniq ue morpholo gic or

Precursor lymphoid neoplasms

cytochemical features that distinguish this

from other types of ALL. In some cases of
leukaemtas with MLL rearrangements it
may be poss ible to recog nize distinc t
lymphoblastic and monoblastic popul ations , which can be confirmed by
immunoph enotyping; such cases should
be consid ered Blmyeloid leukaemias .
Irrrnu nophenotype
ALL with ML L transiocanons. and most
especially t(4;1 1) ALL typically have a
CD 19+, Cu tn-neqenve. CD24-neg ative
pro-B immunophenotype, also positive for
CD15l985, 169 11. The Chondroitin sulfate

A neoplasm of Iymphoblasts committed to
the B lineage with a translocation between
the TEL (ETV6) gene on chromosome 12
with the A ML 1 (RUNX 1)gene on ctecrcsome 12.
ICD-O code
The provisional code proposed for the
fourth edition ol lCD-O is 98 14/3.
Epidemiology and clinical features
This leukaemia is common in chiklren
accounting lor abou t 25% of cases ~
B-ALL It is not seen in infants and
decreases in frequency in older children
to the point that it is rare in adulthood.
Presenting features are generally similar
to those of other patients with ALL

Morphology-and cytochemi stry

There are no unique morphologic or

cytochemica l features that diSlinguish
this from ot her types of ALL.



Basts have a C019+ , C010+ phenotype
and are most often CD34+; other phenotypic features. includ ing near or complete
absence of COO, C020 and CD66c 1245,
533,9851. are relatively but not absolutely
specific. Myeloid-associated an tigens.
especially CD13, are frequently expressed,
but this does not indicate mixed phenotype acute leukaemia 11551.
The t(12;21)(p13;q22): ETV6-RUNX1 translocation results in the p rodu c tio n of a
fusion prote in that likely ac ts in a dominant negative fashion to interfere with
normal func tion of the transcri ption
factor RUNX1. This leukaemia appears to
possess a unique gene expression
signature 12469 1. The E1Y6-RUNX1 translOCahon is co nsid ered to be an ea rly
lesion in leukaemog enesis, as evidenced
by studies of neonatal blood spots that
have shown the presence of the translocation Il'l child ren who develop leukaemia
many years later 124001. There is evioeoce that the translocation is necessary
but not suHicient for the development of
leukaemia 12400 1.
Postulated normal counterpart
This leukaemia appears to d erive from a
Been progeni tor rather than from a
naematoooetrc stem cell 13441
Prognosis and predictive factors
B-Al l with the TELAML 1 transloc ation
hasa V8fY favourab le prog nosis with c ures
seen in >90% of c hildren, espec ially if they
have other favo ura ble risk factors. Relapses often occur muc h late r than those
at other types of ALL. Beca use this
translocation appears to occur as an early
event, it has been sug gested that some
laterelapses in fact de rive from pe rsistent
"preleukaemic clones that ha rbour the
lI'ansIocalion and unde rgo ad ditional
genetic events afte r the first leukaemic
cICIIe has been eliminated 17191 Ch ildren
"MIh this leukaem ia who also harbour adverse prognostic factors . such as ag e
ewer 10 years or high white count d o not
have as good a prognosis, b ut may still
lare better as a g roup than other
patients with these same adverse fac tors .



... ..



. .~







Fig. U9 Hyperdiploid ALL. G banded karyotwe stlowlng 55d'll'omosomes. indudlng trisomies of 4. 10 and 17and
kltrasomy 2t. Thefe are nostruc:llnl abnor'malitJes. (Courtesy of Dr. AJ carrol).

B Lymphoblastic leukaemia!
lymphoma with hyperdiploidy
Defi nition
A neoplasm of Iymphoblasts comm itted to
the B lineage whose b last s c ontain >50
and usually <66 c hromosomes, typically
withou t uansiocanons or other struc tural
a lterations . There is controversy as to
whet her specific c hromos omal ad ditions.
rather than the specific numbe r of c hromosom es. should be part of the def inition
1894. 1806,21231.
ICO-D code
The p rovisional co de pr op osed for the
fourth edit ion ofICDD is 981513.
Hype rdi ploi d ALL; high hyp erd iploid ALL :
ALL with favo urable trisom ies.


This le ukaemia is common in children ,

accounting for about 25% of c ases of
B-ALL It is not seen in infa nts, and
decreases in freq uenc y in older c hild ren
to the point that it is rare in adulthood.
Cli nical featur es
Presenting features are generally similar
to those of other pa tients with ALL.

cvtocremcet teatores that distinguish this

from other types of ALL.

Blasts are C0 19 +, C01O+ . and expre ss
other markers typi cal of B-ALL Most
c ases are C 0 34 + and C045 is often
ab sent 19851. Patients with T-ALL with
hyperdiploidy should not be considered
part of this group, though most such
patients have near tetrap loid karyotypes.
Genet ics
Hyperd iploid B-Al L contains a numerical
increase in chromosomes. usually without
struc tural abnormal ities . Extra co p ies of
c hromosomes a re non random. with
ch romosomes 21, X, 14 and 4 being the
most co mmo n and ch romosomes 1. 2
and 3 being the least of ten seen 19151.
Hyperd iploid B-AlL may be detec ted by
standard karyotyp ing , FISH or flow cvtomet ric DNA ind ex 11 40 11. Some ca ses
that appear as hyperdiploid ALL by standard karyotyping may in fact represent
hypodiploid ALL that has undergone
enooreouoncetco. doubling the number
of chromosomes. Specific chromosomes
that appear as trisomies may be more impo rtant to prognosis than the actual
number of chromosomes, with simultaneous trisomies 014. 10 and 17 carrying the
best prognosis 121231.

Morphology and c ytochemistry

There are no un iq ue morph o log ic or
B lym phob lastic leukaemia/lymphoma with recu rrent genetic abnorma lities


Prognosis and predictive factors

Hyperdiploid B-ALl has a very favourable
prognosis with cu res seen in >90% of
children. especially if their risk p rofi le is
favourab le Presence of adverse tee te rs.
such as ad vanced age or high white
count may ad versely affect the prognosis,
but patients may not fare as badly as otbers without this favourable abnormality.

B Lymphoblastic
leukaemiallymphoma with
hypodiploidy (HypodiploidALL)
A neop lasm of Iymp hob lasts committed to
the B lineag e whose blasts co ntain <46
chromosomes. A stricter definition of &