Advances in Anatomic Pathology

Vol. 10, No. 1, pp. 8–26

© 2003 Lippincott Williams & Wilkins, Inc., Philadelphia

Review Article

Bone Marrow Biopsy: Interpretive Guidelines For the

Surgical Pathologist

James D. Cotelingam

Department of Pathology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, U.S.A.

Summary: Ideally, the bone marrow core biopsy should be reviewed with knowledge
of the clinical history, complete blood count, and findings in the peripheral blood and
bone marrow aspirate smears. However, for a variety of reasons, the pathologist may
receive the core biopsy and aspirate clot section without all of this information.
Although this approach is not optimal, a great deal of valuable information can be
generated from these specimens. Over the past 20 years, there has been considerable
progress in the fields of flow cytometric analysis, immunohistochemistry, and mo-
lecular diagnostic studies that can be performed on smears or extracted DNA from
paraffin embedded tissue. These modalities have augmented and refined diagnostic
criteria formerly ascertained by light microscopy, cytochemistry, and cytogenetics.
This is particularly true of some myeloid and lymphoreticular neoplasms where a
collaborative and multidisciplinary approach to the diagnosis has become necessary.
Despite this growing complexity and dependence on newer methodologies, the tradi-
tional role of histopathology in evaluating the bone marrow biopsy remains as impor-
tant as it has been in the past. In this review, we focus on contemporary practices and
expectations for interpreting bone marrow biopsies and clot sections. Key Words:
Bone marrow core biopsy—Immunohistochemistry—Fluorescence in situ hybridiza-
tion—Polymerase chain reaction.

INTRODUCTION tainment from one medical facility to another, Anatomic

Assessment of changes in the bone marrow is an im-
portant prerequisite for the care and stratification of pa-
tients with disease of the hematopoietic system. Located
within the labyrinth of the intertrabecular and medullary
spaces of bone, this highly specialized organ with com-
plex hematopoietic and immunologic functions provides
an excellent substrate for pathologic investigation in-
cluding the staging of nonhematopoietic neoplasms and
the monitoring of response to therapy.
Due to variations in logistical detail, organizational
experience, billing practices, and attempts at cost con-
Pathology Services often receive only the core biopsy
and clot section, while other components of the bone
marrow specimen are submitted elsewhere for evalua-
tion. Despite this fragmented and unsatisfactory ap-
proach to total specimen interpretation, the surgical pa-
thologist can ascertain considerable clinically relevant
pathologic detail by supplementing traditional histopa-
thology on paraffin embedded tissue (PET) with state of
the art immunohistochemistry (IHC) and molecular di-
agnostic studies.

Address correspondence and reprint requests to Dr. James D.
Cotelingam, Department of Pathology, Louisiana State University
Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71330.
The opinions published herein are the private views of the author and
do not reflect the official position of the Louisiana State University
Health Science Center.
ROLE OF THE BONE MARROW BIOPSY IN
PATIENT CARE
Ever since the role of the bone marrow in hematopoi-
esis was described in the German literature by Neumann

8
 BONE MARROW BIOPSY
(1) and Bizzozero (2) in 1868, and the first biopsy was
performed by Mosler (3) in 1876, there have been re-
markable improvements in the instrumentation and tech-
niques of specimen acquisition, analysis, and interpreta-
tion.
Before the paper by Turkel and Bethel (4) in 1943,
pathologic reports were based primarily on the micro-
scopic features of aspirated smears stained with Ro-
manowsky dyes. Subsequently, however, there has been
increasing appreciation that besides providing correla-
tion with the cytologic features of the aspirate, the core
biopsy offered a reliable means to quantitate cellularity
and evaluate architectural detail in situ (5). Additionally,
the core biopsy enables assessment of fibrosis, the iden-
tification of focal lesions (as in lymphoma, myeloma,
metastatic tumor, and granulomata), and is a repository
of material for immunohistochemical and molecular di-
agnostic testing. Furthermore, the biopsy provides an op-
portunity to report on the condition of bony trabeculae,
blood vessels, and other nonhematopoietic stromal and
cellular components of the intertrabecular space (5,6).
In our experience, medical facilities that support speci-
men acquisition, analysis, and interpretation by an orga-
nized and interactive team of health care professionals
including medical technologists, allied scientists, clini-
cians, and pathologists working in concert, offer the ad-
vantage of conforming to operational guidelines and
standards that cater to the needs of all specialties within
a healthcare facility at minimum cost and patient dis-
comfort.
To maximize yield, it is recommended that before
specimen procurement, the clinical picture be correlated
with the complete blood count (CBC) appearances of the
peripheral blood smear and other existing laboratory data
to anticipate which specimen components of the bone
marrow are likely to yield information most valuable to
the case under study. Such an ideal scenario is, however,
the exception rather than the rule, and in most cases, the
surgical pathologist has little control over the events an-
tecedent to receiving slides on a bone marrow specimen
for sign out.
INDICATIONS FOR BONE
MARROW ANALYSIS
● To explain a decrease in the formed elements of the
blood as in anemia, leukopenia, thrombocytopenia,
and myelodysplasia.
● To determine the causes of increased formed elements
of the blood as in unexplained sustained leukocytosis,
erythrocytosis, thrombocytosis, the myeloproliferative
disorders, and the leukemias.
9
● To explain abnormal morphologic changes observed
in the peripheral blood, such as tear drop erythrocytes,
rouleaux, myeloid and lymphocytic immaturity, and
leukoerythroblastosis.
● To assess marrow cellularity and to monitor the prog-
ress of therapy.
● To determine the adequacy and location of stainable
bone marrow iron.
● To evaluate for bone marrow involvement by meta-
static disease, lymphoma, plasma cell dyscrasia, my-
elofibrosis, and mast cell disease.
● As part of the workup for fever of unknown origin, to
assess for bone marrow involvement in infections,
granulomatous disorders, and in patients with unex-
plained adenopathy and hepatosplenomegaly.
● To obtain cellular bone marrow for cytochemistry,
flow cytometry, immunohistochemistry, molecular
genetics, cytogenetics, microbial cultures, electron mi-
croscopy, and tissue culture.
● To evaluate for bone marrow involvement in sus-
pected storage and collagen vascular disorders.
● To define the etiology of unexplained osteosclerosis
and other abnormalities of trabecular bone detected by
radiologic studies.
PREPARATION OF BONE MARROW FOR
HISTOPATHOLOGIC EXAMINATION
Information on the types of biopsy needles, and guide-
lines for acquisition of the aspirate and core biopsy are
well documented in the literature (7–10). It is important
that personnel obtaining bone marrow biopsies are fa-
miliar with the range of tests possible on each specimen
component, and are aware that bilateral core biopsies are
recommended for staging malignant lymphomas and
metastatic carcinoma, and by some for the diagnosis of
multiple myeloma at initial work-up.
The need to establish high expectations for quality
histologic preparations cannot be overemphasized. In
fact, the cardinal sin of misdiagnosis frequently results
from erroneous interpretation of inadequate or poorly
processed material.
Methodologies for processing the bone marrow core
and clot section vary considerably with institutional poli-
cies and philosophical expectations. In practice, routine
sections should be ready for interpretation within 24
hours after specimens are placed on the tissue processor.
The choices of fixative, decalcifying agent, and stains
vary from one institution to the other. A selected few,
which are in general use, are described below.
Fixation of the core biopsy and clot section may be
achieved with a zinc formalin fixative such as B-plus Fix
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
10
(BBC, Stanwood, WA), B-5, or neutral buffered forma-
lin. Thereafter, the specimen should be decalcified in a
10% aqueous solution of nitric acid, Redecal (a 12.5%
aqueous solution of hydrochloric acid in EDTA, Stat Lab
Medical Products Inc., Lewisville, TX) or RDO (APB
Engineering Products Corporation, Plainfield, IL), an-
other proprietary solution of hydrochloric acid in a coal
tar base ensuring good histologic sections, without dam-
age to the microtome knife. Decalcification results in the
leaching out of some storage iron from the core biopsy,
and nitric acid and hydrochloric acid have been reported
to diminish the acid fastness of mycobacteria (11,12)
resulting in false negative results. Acid fastness is how-
ever retained when decalcification is in formic acid-
sodium citrate or citric acid buffer (12). Therefore, these
are the decalcifying agents of choice when the need to
demonstrate mycobacteria can be anticipated. Combina-
tion fixative/decalcification preparations in use are Zen-
ker’s solution (13), Surgipath Decalcifier (a formic-acid
formalin mixture, Surgipath Medical Industries, Rich-
mond, IL), and Decal Plus (an aqueous solution of for-
malin, formic acid, and methanol, Stat Lab Medical
products, Inc. Lewisville, TX). An advantage of Zenk-
er’s solution and B-5 is a mordanting effect that en-
hances the tinctorial properties of the Giemsa and hema-
toxylin and eosin (H & E) stains. Additionally, glacial
acetic acid, the decalcifying component in Zenker’s so-
lution counteracts the cell shrinkage resulting from fixa-
tion. Metallic fixatives such as Zenker’s and B-5 degrade
DNA and impair subsequent molecular diagnostic test-
ing. This limitation is circumvented by fixation in a zinc-
formalin fixative such as B-plus Fix. It is noteworthy that
the manufacturer’s specified ratio of specimen volume to
fixative/decalcifying agent and treatment times be
closely followed to achieve optimum results.
Clot sections do not need to be decalcified. Bone dust
and small fragments of bony trabeculae that are occa-
sionally aspirated when acquisition of the core biopsy
precedes that of the aspirate, can usually be cut through
without decalcification. Agar embedding techniques (14)
for processing the clot section, plastic embedding (15,16)
of the undecalcified core and electron microscopy (16–
20) of aspirated material are described in the literature;
however, these techniques are not widely used for rou-
tine purposes.
Ideally, histologic sections of the core and clot section
should be cut at 4 micron. In addition to routine hema-
toxylin-eosin stained sections, other stains of value in-
clude iron (preferably performed on the nondecalcified
aspirate clot section), reticulin, periodic acid-Schiff stain
(PAS), and Giemsa. Although difficult to perform, a
well-done Giemsa preparation can be very helpful. This
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
stain imports a purple hue to the cytoplasm of plasma
cells, prominently highlights the metachromatic granules
of mast cells and basophils, and enhances the tinctorial
properties of neutrophilic and eosinophilic granules. Ad-
ditional immunohistochemical stains may be necessary,
and are further discussed below.
Samples for molecular studies require special han-
dling. For instance, lesions for assessment by fluores-
cence in-situ hybridization (FISH) may need to be local-
ized for the benefit of personnel in the molecular diag-
nostic laboratory. Paraffin sections for FISH are
submitted on Superfrost Plus glass slides (Fisher Scien-
tific, Pittsburgh, PA). For the polymerase chain reaction
(PCR), scrolls of paraffin embedded tissue are deparaf-
finized before DNA isolation in accordance with local
policies and practices.
EXPECTED DIAGNOSTIC YIELD FROM
COMPONENTS OF THE BONE
MARROW SPECIMEN
Not every item in the preceding list of indications
prompting bone marrow analysis can be resolved by ex-
amination of the core biopsy and clot section. Further-
more, the optimum yield of diagnostic information from
individual components of a bone marrow specimen in-
nately vary, and often reflect the type of disorder being
investigated (21). In general, the aspirate and touch
preparations provide qualitative cytologic detail, while
the core biopsy and clot section provide quantitative in-
formation. Because the surgical pathologist frequently
receives only PET, it is important to identify the expec-
tations and limitations of the diagnostic yield from such
material. These are enumerated and compared to those
from the aspirate and touch preparations in Table 1
(5,6,21–36), and are further discussed below.
INTERPRETATION OF PARAFFIN EMBEDDED
TISSUE AND DATA INTEGRATION
For most anatomic pathologists, a bone marrow
sample is often one among a number of surgicals in a run
requiring interpretation and sign-out. Although the pa-
tients name, age, and gender are part of the standard
biographic template, information concerning the clinical
picture, CBC, peripheral blood film, and bone marrow
aspirate are often absent or inadequate, and need to be
procured to ensure a meaningful interpretation. The
guidelines used in evaluating a bone marrow specimen
are understandably parochial. However, most observers
integrate the microscopic features of the specimen with
the ancillary data listed in Table 1 into a synopsis, un-
 BONE MARROW BIOPSY 11

TABLE 1. Summary of differences between aspirated and paraffin embedded bone marrow samples
Component/parameter Aspirate Touch preps of clot/biopsy Clot section Core biopsy
Fat:Cell ratio Unsuitable for estimation Recommended specimens for estimation
Myeloid: Erythroid ratio Calculated from a Count differentials Working approximation possible
differential count correlate with those
of the aspirate
Myelopoiesis Stages of maturation accurately classifiable Normal myeloblasts and promyelocytes cannot
be discriminated; however,stages thereafter,
ALIP and AML blasts may be
Erythroid component Stages of maturation can be accurately designated Identifiable, but stages cannot be specifically
classified
Megakaryocytopoiesis Stages of maturation accurately classifiable Normal megakaryoblasts not identifiable, stages
thereafter classifiable generically as
megakaryocytes
Lymphocytes Small and scattered Normal lymphocytes can be differentiated from
NRBC, T/B phenotypes can be designated by IHC
Plasma cells Readily identified Can be designated in H/E stained sections,
readily enumerated in IHC preps
Metastatic tumor Appearances characteristic of cell type Identifiable and quantifiable.
Reticulin Not quantifiable Quantifiable
Collagen Not quantifiable Quantifiable
Granulomata Seldom observed, cannot be ruled out from these Specimen components of choice to
specimen components evaluate for granulomata
Iron stores Quantitation reliable, Quantitation unreliable, Quantitation reliable, Quantitation and
best for identification RSB identifiable RSB may be dentification
of RSB identified of RSB unreliable
Monocytes/Macrophages Monocytes, sea blue histocytes and other pathologic Monocytes not identifiable, tingible body
forms can be designated, and confirmed by macrophages and pathologic forms identifiable,
cytochemistry confirmation possible with IHC
Stromal space and mesenchyme Accurate assessment not possible Can be identified Best specimen
component
to assess
Arterial/Venous Structures Capillaries may be seen Not observed Seldom apparent Routinely observed
Marrow sinusoids Not observed Normally apparent,
dilated in
fibrosing states
Trabecular bone Not part of specimen Present, may offer
diagnostic
information
Cytochemistry Specimen of choice Can be performed Selected preparations feasible
Flow cytometry Specimen of choice Not possible Possible by vortex disaggregation of unfixed material
Immunohistochemistry Possible Specimen components of choice
Molecular Diagnostics Possible
Cytogenetics Specimen of choice Not possible Feasible on vortex disaggregated material

ALIP, Abnormally located immature precursors; AML, Acute myeloid leukemia; RSB, Ring sideroblasts; NRBC, Nucleated red blood cells; IHC,
Immunohistochemistry.

derscored by a diagnostic line and a comment, if neces- ● The fat:cell ratio.

sary. To ensure that no aspect of the examination is in- ● The myeloid:erythroid ratio.
advertently omitted, and to standardize reports, a check- ● A description of the hematopoietic cell lines (i.e., my-
list (5) such as the one below is recommended: elopoiesis, erythropoiesis, and megakaryocytopoiesis).

Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003

12
● A quantitation and description of lymphocytes and
plasma cells.
● Evaluation of stainable iron.
● Exclusion or description and quantitation of neoplastic
infiltrates such as blast forms, lymphoma, myeloma,
and metastatic tumor.
● Exclusion or description of infections and granuloma-
tous changes.
● Exclusion or description of fibrosis.
● A statement, if necessary, to cover any miscellaneous
abnormality observed in the macrophage system, bone
marrow stroma, vascular structures, and trabecular
bone.
● A concluding comment integrating the above with the
results of any corroborating cytochemical, flow cyto-
metric, immunohistochemical, molecular diagnostic,
cytogenetic, or other contributing studies.
THE FAT:CELL RATIO
It is the best to evaluate marrow cellularity and the
fat:cell ratio from the core biopsy. Although less reliable,
these may also be assessed from clot sections with mul-
tiple marrow particles. Variations in the ratio of fat to
cell in the bone marrow are an important index of bone
marrow activity. At birth and during early childhood, the
bone marrow is 100% cellular and virtually devoid of fat.
By the end of the first decade, the overall fat:cell ratio is
approximately 10:90, and in adults (Fig. 1), it varies
between 30:70 and 70:30 with increasing age. Slight
physiologic variations of the ratio from one microscopic
field to another are not uncommon and review of the
slide with a scanning objective can enable definition of
an overall ratio. Beyond the seventh decade, bone mar-
row fat may be expected to increase by approximately
10% with each passing decade (37–39). Despite this in-
creasing hypocellularity, the CBC remains within physi-
ologic limits. However, in the presence of otherwise un-
explained cytopenia, a fat content of greater than 70%
reflects hypoplasia. Quantitation of the latter is usually
expressed as mild, moderate, or severe.
The word “aplasia” is derived from Greek (40), and
connotes total fatty replacement of the bone marrow.
Aplasia may be generalized or focal (spotty). The de-
creased cellularity within the stromal space that results
from chemotherapeutic induction of acute leukemia (Fig.
2), serous fat atrophy (Fig. 3), hypoproliferative states,
and fibrosis are not accompanied by increased bone mar-
row fat. Therefore, these are examples of hypocellularity
rather than true aplasia. Under these circumstances, it is
considered more meaningful to report a ratio incorporat-
ing the relationships of fat, cell, and stroma. Accurate
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
evaluation of the fat:cell ratio is possible only on paraffin
embedded tissue, and areas with stromal hemorrhage,
dropout, and aspiration artifact should be excluded. In
cases with unexplained aplasia without peripheral blood
cytopenia, it is advisable to recommend a contralateral
core biopsy to rule out sampling error.
QUANTITATION OF CELLULAR
COMPONENTS IN THE BONE MARROW
Differential counts of cellular elements in the bone
marrow are traditionally expressed in percentile figures
(6,27,41–50). Included herein are blast forms, myelo-
monocytic, erythroid, megakaryocytic, plasma cellular,
and lymphoid cell lines. Macrophages, stromal cells, os-
teoclasts, osteoblasts, fat cells, and metastatic tumor cells
are excluded. The “hematopoietic” compartment is com-
prised of all myelomonocytic, erythroid, and megakaryo-
cytic elements. All other forms are classified as “nonhe-
matopoietic.” Quantitation of the extent of involvement
by tumor does convey meaning, and should be expressed
as a percentage of the involved marrow space or total
marrow cellularity.
MYELOID:ERYTHROID RATIO
At birth, the myeloid:erythroid (M:E) ratio is approxi-
mately 1.5:1. The myeloid (granulocytic) component
gradually increases and peaks at approximately 6:1 by
the end of the first week of life (51). Thereafter, values
plateau at a physiologic range of 2.5:1 to 4:1, with little
variation throughout life (6,20,51). Increase in either
component is reported as myeloid/erythroid “predomi-
nant” in the presence of a normal fat:cell ratio, and “hy-
perplasia” when the cellularity of the bone marrow ex-
ceeds 70%. While an M:E ratio can be calculated from a
500 cell count down to a decimal point in the aspirate,
paraffin embedded tissue provides only a coarse approxi-
mation of the same. However, paraffin embedded tissue
has the advantage of providing an overview of this ratio
in situ, and in different areas of the specimen. Also,
eliminated herein is any bias that may be manifest in
particle-depleted smears of sinusoidal blood. It is best to
read M:E ratios on core biopsies, away from paratrabecu-
lar areas, which are normally myeloid predominant. Be-
cause of their characteristic cytologic features, the my-
eloid component beyond the promyelocyte stage can be
readily designated with a 40 x objective, right up to the
neutrophil, eosinophil, and mast cell stage. Similarly,
nucleated erythroid elements beyond the early normo-
blast stage can be differentiated from lymphocytes by
their round, dense, and pyknotic nuclei. In contrast to
 BONE MARROW BIOPSY 13

FIG. 1. Normocellular bone marrow biopsy. The fat:cell ratio is estimated at 60:40; H&E section (original magnification x 100).
FIG. 2. Adequate chemotherapeutic induction. Core biopsy from a patient with AML-M2 at day 14; H&E section (original magnification x 400).
FIG. 3. Serous fat atrophy. Deposits of acid mucopolysaccharide are located between fat cells. Core biopsy. (A) H&E section. (B) Alcian blue stain
(original magnification x 400).
FIG. 4. Normal M:E ratio. A PAS section of the core biopsy with an M:E ratio of approximately 4:1. Intensity of PAS activity increases with
granulocytic maturation. Erythroid precursors have deeply hematoxyphilic nuclei (original magnification x 400).
FIG. 5. Acute myeloid leukemia (AML-MO). Clot section at diagnosis. Most normal hematopoietic cells in the stromal space are replaced by the
leukemic infiltrate; H&E section (original magnification x 400).
FIG. 6. Chronic myeloid leukemia, accelerated phase. Core biopsy. Myeloblasts are less than 20% of marrow cellularity. Myeloperoxidase
immunostain (original magnification x 400).
FIG. 7. Myelodysplasia. Two morphologic features observed in core biopsies. (A) Abnormal localization of immature myeloid precursors, H&E
section (Courtesy of Dr. Kathryn Foucar). (B) Myeloblasts in stromal space estimated at less than 20% of marrow cellularity; H&E section (original
magnification x 400).
FIG. 8. Megaloblastic anemia. Note megaloblastic proliferation with interspersed myeloid component including giant metamyelocytes; H&E section
(original magnification x 400).
FIG. 9. Erythroleukemia, AML-M6B. (A) Blast forms in an H&E section. (B) Blast forms immunostained by the immunoperoxidase technique for
hemoglobin A (original magnification x 400) (Courtesy of Dr. Harold Schumacher).
FIG. 10. Dysplastic megakaryocytes including micromegakaryocytic forms from a patient with myelodysplasia. (A) H&E section. (B) FVIII RA
immunostain (original magnification x 400).
FIG. 11. Essential thrombocythemia. Core biopsy demonstrating increased megakaryocytic endoreduplication and abutment; H&E section (original
magnification x 400).
FIG. 12. Follicular lymphoma (grade I). Core biopsy. Tumor was located in paratrabecular and intertrabecular areas. (A) H&E section. (B) BCL2
preparation (original magnification x 400).
14
appearances in H & E preparations, cells of myeloid and
erythroid lineage are easier to recognize in Giemsa and
PAS stains (Fig. 4), and can be designated with certainty
on myeloperoxidase (MPX) and hemoglobin peroxidase
(HbPX) preparations of paraffin embedded tissue. It is
noteworthy that monocytes and lymphocytes (also re-
ferred to as nongranulocytes), plasma cells, and mega-
karyocytes are not included in the M:E ratio.
MYELOID SERIES
The myeloid component of the bone marrow arises
from self-replicating stem cells, which also gives rise to
the monocytic, erythroid, and megakaryocytic cell lines.
Data on the physiologic range of myeloid precursors and
mature forms in the bone marrow (Table 2)(41–43) have
been derived from aspirate preparations where the cyto-
logic features of each cell type are readily appreciated
under an oil immersion lens. Even though quantitation of
similar information on PET is in contrast largely subjec-
tive, and unlike aspirate counts lacks mathematical pre-
cision, it does have clinical utility.
In our experience, normal myeloblasts and promyelo-
cytes are not readily differentiated from pronormoblasts
and early normoblasts in PET with a high dry objective.
However, mature forms beyond the promyelocyte stage
and pathologic shifts in compartment size as in myeloid
hyperplasia, the myelodysplastic syndromes (MDS), the
acute myeloid leukemias (AML) AML-MO (Fig. 5)
through M6A, some of the myeloproliferative disorders,
and chronic leukemias of myeloid origin are readily dif-
ferentiated. Confirmation of myeloid lineage in PET may
be achieved by specific esterase (Leder), MPX (Fig. 6)
and other immunostains (28–31,52–55); and a mono-
cytic lineage may be supported by the identification of
CD68, lysozyme, alpha-1-antitrypsin, and alpha-1-
antichymotrypsin activity in AML-M4, AML-M5 and
chronic myelomonocytic leukemia (CMML)(56). Le-
TABLE 2. Types of myeloid elements and their normal
range in the bone marrow
Cell type
Myeloblasts
Promyelocytes
Myelocytes (neutrophilic)
Metamyelocytes
Band Forms
Neutrophils
Myelocytes (eosinophilic)
Band
Mature
Monocytes/macrophages
Basophils
Mast Cells
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
sions of mast cell lineage can be specifically confirmed
with mast cell tryptase and CD117 (C-Kit) preparations
(57–60), and TdT activity may be apparent in cases of
acute mixed lineage leukemia (61,62). Although the cy-
tologic features of blast forms in AML on PET are not
specific for the subtypes of AML according to the FAB
(French-American-British) scheme, cases of AML-M3,
AML-M4, and AML-M5B do tend to have “monocyt-
oid” nuclei. Also, minimal myeloid differentiation is ob-
served in AML-M2, and an abnormal eosinophil com-
ponent is apparent in AML-M4EO. Abnormal localiza-
tion of immature myeloid precursors (ALIP) (Fig. 7) in
the intertrabecular space is a feature of myelodysplasia
(63–65). Increased expression of PCNA antigen and
CD34 activity by immunostaining on PET serve to dis-
tinguish hypoplastic myelodysplastic syndromes from
acquired aplastic anemia, where these parameters are de-
creased (66). While immunostaining with CD34 is of
value in identifying immature populations of leukemic
cells, it does not distinguish between a myeloid and a
lymphoid lineage. Without incorporating data generated
from examination of the aspirate, cytochemistry, flow
cytometry, cytogenetics, and molecular diagnostic stud-
ies, it may be impossible to classify myeloid, and mixed
lineage lesions, according to the recent recommendations
of the Society for Hematopathology and World Health
Organization (WHO) expert committee (67–69).
In cases where no aspirate is available due to a dry tap,
vortex disaggregation of leukemic cells from the unfixed
core biopsy and clot can serve as a resource of material
for cytogenetics and flow cytometry. With the introduc-
tion of newer generations of therapy such as Myelotarg
(70) (formerly known as CMA-676), which is specifi-
cally directed against the CD33 epitope in AML, and
STI571, (71,72) which targets and inhibits bcr-abl tyro-
sine kinase in chronic myeloid leukemia (CML), there is
a growing expectation that laboratory identification of
such loci will become available as part of the diagnostic
armamentarium. Furthermore, it has now become appar-
ent that in patients with CML on STI571, despite micro-
scopic restoration of marrow cellularity with normal M:E
Range ratios, bcr-abl fusion persists (72) and may be demon-
0% to 2% strated by FISH on the core biopsy and clot section
2% to 5% (Table 3). This technology is therefore certain to influ-
9% to 16% ence therapeutic protocols for STI571 in the future. Ac-
7% to 23%
8% to 15% cording to the WHO expert panel and the Society for
4% to 10% Hematopathology, the threshold for transition of blast
0% to 2% counts from myelodysplastic syndrome (MDS) (Fig. 7)
0% to 2%
0% to 2% to AML is set at 20% with the exception of lesions that
0% to 3% include a t(8;21) chromosomal abnormality (67,68,73).
0% to 1% Despite lower blast counts, this entity, which would have
0% to 2%
been formerly classified as MDS, is now, because of a
 BONE MARROW BIOPSY 15

TABLE 3. Lineage specific molecular cytogenetic probes* currently in use to identify myeloid lesions by fluorescence in situ
hybridization (FISH) on core biopsies of bone marrow
FISH Signal color
Disease Locus Chromosome abnormality Green Orange Yellow
AML-M0/M1,MDS EGR1 5q Deletions-interstitial (5q31) 5p15.2 (control) 5q31-EGR1 N/A
AML-M0/M1, MDS CSF1R 5q Deletions-telomeric(5q33-q34) 5p15.2 (control) 5q33-CSF1R N/A
AML-MDS D20S108 (20q12) Deletions in 20q N/A 20q12 N/A
AML/MDS D7S486 (7q31) Deletions in 7q, i(7q) Alpha-satellite 7 D7S486 (7q) N/A
(7p11.1-q11.1)
AML/MDS 8p11.1-q11.1 Trisomy 8 N/A Alpha-satellite 8 N/A
(8p11.1-q11.1)
AML-M2 AML1/ETO t(8;21)(q22;q22) 8q-ETO (CBFA2T1) 21q-AML1 (RUNX1) 8;21 Fusion signal
AML-M3 (variant) RAR␣ t(11;17)(q23;q21) and related X/RARA Abnormal-1 green Abnormal-1 orange Dual color (normal)
(split signal) (split signal)
AML-M3 PML/RAR␣ t(15;17)(q22;q21.1) 17q-RARA 15q-PML 15;17 Fusion signal
AML-M4EO CBF␤ inv(16)(p13q22) and t(16;16)(p13;q22) Abnormal-1 green Abnormal-1 orange Dual color (normal)
(split signal) (split signal)
AML-M5 and Mixed lineage MLL(ALL-1, HRX) 11q23 rearrangements- Abnormal-1 green Abnormal-1 orange Dual color (normal)
t(4;11)(q21;q23),t(9;11)(p22;q23), (split signal) (split signal)
t(11;19)(q23;p13) and variants
CML BCR/ABL t(9;22)(q34;q11.2) 22q-BCR 9q-ABL 9;22 Fusion signal

* Vysis Inc. Downers Grove, IL.

Tabulated by Mary L. Nordberg PhD.

superior long-term outlook in adults, diagnosed and
treated earlier in its natural history as AML (69,73). The
supportive role of molecular diagnostic studies, some of
which are now available on PET (Table 3), is therefore of
paramount importance. Additionally, it is noteworthy
that the malignant progranulocytes of AML-M3 be in-
cluded in the total blast count, as should the myeloblasts
of erythroleukemia AML-M6A (74,75) (traditional
erythroleukemia of the FAB classification).
ERYTHROID SERIES
The erythroid component of the bone marrow nor-
mally comprises between 15% and 37% of a differential
cell (6,42,43,52) count that includes granulocytes, mega-
karyocytes, lymphocytes, and plasma cells. Maturing
erythroid precursors include pronormoblasts, early nor-
moblasts, intermediate normoblasts, and late normo-
blasts. Of these, pronormoblasts and early normoblasts
cannot always be distinguished with certainty from my-
eloblasts and promyelocytes in PET with a high dry ob-
jective. However, later stages of erythroid maturation
with their characteristic round, dense and deeply baso-
philic nuclei can be easily identified, and distinguished
from interspersed lymphocytes. In circumstances where
this distinction poses a problem, IHC identification of
erythroid precursors with an HbPX immunostain is de-
finitive. This technology is also invaluable in confirming
the absence of erythroid precursors in cases of total red
cell aplasia. Under normal circumstances and in regen-
erative states, clones of normoblasts tend to cluster in the
intertrabecular space. However, in florid megaloblastic
hyperplasia (Fig. 8), marrow cellularity may be diffuse
and resemble the neoplastic proliferations of acute leu-
kemia and large cell lymphoma (LCL). Unlike these con-
ditions however, myeloid elements including giant meta-
myelocytes are interspersed between megaloblasts. Un-
der these circumstances, correlation of biopsy findings
with other laboratory data such as the appearances of the
aspirate, CBC, serum LDH, folate, and B12 can be in-
valuable. Arrested erythroid maturation, giant pronormo-
blasts, and intranuclear inclusions are manifestations of
parvovirus B19 infection (76). Herein, viral material can
be positively identified by in situ hybridization (ISH) in
PET. Multinucleated erythroid precursors may be ob-
served in CDA (77), where additional confirmatory he-
matological testing such as the Ham and Sugar Water
tests become necessary. In cases of AML-M6B (74,75,
78), bizarre multinuclearity of leukemic erythroid pre-
cursors may be a prominent feature and lineage identity
can be established with HbPX immunostaining (Fig. 9)
on PET (79). In such cases, neoplastic pronormoblasts
should be included with myeloblasts in the overall blast
count, and in keeping with the recommendations of the
Society of Hematopathology and WHO, cases with a
blast count under 20% be classified as myelodysplasia,
and those above as acute leukemia. Vortex disaggrega-
tion of cellular material from the unfixed core biopsy for
flow cytometric, cytogenetic, and molecular diagnostic
studies can be an invaluable adjunct in patients with a
dry tap (34).
MEGAKARYOCYTES
Megakaryocytes are the largest of the hematopoietic
cells, and comprise between 0.5% and 2.0% of all nucle-
ated marrow elements (6,52,80). The earliest cell of

Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003

16
megakaryocytic lineage discernable microscopically is
the megakaryoblast, a mononucleated cell with scant
deeply basophilic cytoplasm rich in RNA. Megakaryo-
blasts are slightly larger than myeloblasts and pronormo-
blasts, from which they are not readily distinguished in
PET with a high dry objective. Subsequent stages of
maturation are characterized by increased cell size, pro-
gressive nuclear lobulation (endoreduplication), loss of
cytoplasmic basophilia, and increase in “cotton candy”
like granules. Normal megakaryocytes are randomly dis-
tributed among other hematopoietic cells, occasionally
reveal mature hematopoietic cells within their cytoplasm
(emperipolesis), and only seldom make physical contact
with other megakaryocytes. Because megakaryocytes
normally comprise about 1:200 nucleated marrow cells,
increase in the megakaryocytic compartment as in idio-
pathic thrombocytopenic purpura and other reactive
states can be readily appreciated with a low power ob-
jective. Megakaryocytes are PAS positive, and in PET,
megakaryoblasts and megakaryocytes are FVIII related-
antigen (von Willebrand factor), FXIII, CD41, and CD61
positive by immunohistochemistry (81,82,83). This tech-
nology is invaluable in establishing lineage identity in
acute megakaryocytic leukemia (AML M-7), where blast
forms may be indistinguishable from those of some other
forms of AML on H & E stains of PET (84,85). Immu-
nohistochemistry also helps in the identification of dys-
morphic, dysplastic, and micromegakaryocytic forms
that may be observed in the myeloproliferative and my-
elodysplastic disorders (Fig. 10). It is noteworthy that
megakaryocytes abut, cluster, sheet out, and reveal in-
creased endoreduplication in essential thrombocythemia
(Fig. 11). These features may be variably present in the
other myeloproliferative disorders, but are less pro-
nounced. Increased numbers of mature mononuclear
megakaryocytic forms may be observed in chronic my-
eloid leukemia and the 5q− syndrome (86–89), and loss
of nuclear lobulation with development of small discrete
nuclei (“pawn ball” forms) may be apparent in myelo-
dysplasia on H&E sections in PET.
LYMPHOCYTES AND
LYMPHORETICULAR LESIONS
In the bone marrow of normal adults, lymphocytes are
small, randomly interspersed between hematopoietic
cells, and comprise between 8% and 24% of all nucleated
elements (44–47). The ratio of T-cells to B-cells is ap-
proximately 3:1, and the CD4:CD8 ratio is approxi-
mately 2:1. In pediatric samples, the total lymphocyte
count is higher, and normal values up to 40% may be
observed (90). Labeled antibodies are now available
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
commercially, facilitating the evaluation of lymphocyte
subsets in PET by IHC. Beyond the third decade, benign
nonparatrabecular lymphoid aggregates may be observed
and rarely may contain reactive germinal centers (91). In
aspirate smears, it is not uncommon to observe benign
polyclonal lymphoid aggregates as a monolayer of ma-
ture lymphocytes.
In PET, monoclonal lymphoid infiltrates are usually
characteristic of involvement by a chronic lymphoid leu-
kemia (5) or a low or intermediate grade nonHodgkin
lymphoma. Rarely, follicle center cell lymphoma (FCL)
first presents within the bone marrow in patients with
cytopenia but without organomegaly or adenopathy. The
aspirate smears in these patients are commonly negative
(92) but paratrabecular aggregates diagnostic of lym-
phoma are found in the core (Fig. 12) and are CD20 and
BCL2 positive (93). Such infiltrates may be accompa-
nied by some reactive CD3-positive T-cells. In patients
with treated FCL, minimal residual (and occasionally
intertrabecular) deposits of tumor can be identified by
similar IHC procedures. This may correlate with the
presence of a combined CD19, CD10, and BCL2 popu-
lation of lymphocytes on flow cytometric analysis. Large
cell lymphoma has appearances in the bone marrow
comparable to those seen in node-based biopsies (Fig.
13). The presence of BCL6 activity in LCL serves to
distinguish this lesion from blastic mantle cell lym-
phoma.
Hodgkin lymphoma in the bone marrow (Fig. 14) is
associated with fibrosis, accounting for the rarity with
which Reed-Sternberg cells are observed in aspirate
preparations (94–98). As with the nonHodgkin lympho-
mas, bilateral core biopsies are recommended for staging
of Hodgkin lymphoma (21). The true identity of mono-
nuclear Reed-Sternberg cells in the bone marrow can be
established with antibodies specific for CD15 and CD30
and other related immunostains (69).
In cases of bone marrow involvement by acute lym-
phoblastic leukemia (Fig. 15) and the high-grade
lymphomas (i.e., lymphoblastic lymphoma and Burkitt
lymphoma) (Fig. 15), the pattern of infiltration is invari-
ably interstitial and diffuse (6). Correlation of the mor-
phology with immunophenotypic, cytochemical, and cy-
togenetic data is invaluable (99–101). The identification
of a minimal residual population of acute lymphoblastic
leukemia (ALL) in PET can be achieved by immuno-
staining for CD34 (Fig. 16), TdT, CD20, CD3, CD45RO,
and additionally with molecular diagnostic studies for
IgH, TCR gene rearrangement, and the identification of
abnormal genetic loci by PCR or FISH (Table 4). Also of
great importance is the distinction of acute lymphoblastic
leukemia from hematogones (102). The latter are B-
 BONE MARROW BIOPSY 17

FIG. 13. Large cell lymphoma. Core biopsy. Diffuse involvement of the intertrabecular space. (A) H&E section. (B) CD20 preparation (original
magnification x 400).
FIG. 14. Hodgkin lymphoma. Core biopsy. Note solitary Reed-Sternberg cell and fibrosis (original magnification x 400).
FIG. 15. Acute lymphoblastic leukemia (A) and Burkitt lymphoma (B). H&E stained sections of core biopsies (original magnification x 400).
FIG. 16. Relapsed acute lymphoblastic leukemia. Clot section; CD34 immunostain (original magnification x 400).
FIG. 17. Chronic lymphocytic leukemia. Core biopsy. Interstitial pattern of infiltration. (A) H&E section and Wäldenstrom macroglobulinemia.
Core biopsy. Note Dutcher body. (B) PAS section (original magnification x 400).
FIG. 18. Adult T-cell leukemia/lymphoma. Core biopsy. Note erosion of bony trabecula adjacent to tumor; H&E section (original magnification
x 400).
FIG. 19. Anaplastic myeloma. Core biopsy; H&E section (original magnification x 400).
FIG. 20. Anaplastic myeloma. Core biopsy with kappa light chain restriction; Kappa immunostain (original magnification x 400).
FIG. 21. Metastatic carcinoma of breast. Core biopsy; H&E section (original magnification x 400).
FIG. 22. Kaposi sarcoma. Core biopsy; H&E section (original magnification x 400).
FIG. 23. Reticulin and collagen fibrosis in bone marrow core biopsies. (A) Gordon and Sweet’s reticulin stain with markedly increased reticulin.
(B) H&E section with total effacement of hematopoietic tissue by collagenous fibrosis. (C) Trichrome stain demonstrating total collagenous fibrosis
(original magnification x 400).
FIG. 24. Granulomatous changes in core biopsy of bone marrow. (A) H&E stain of epithelioid granuloma from patient infected with Mycobacterium
tuberculosis. (B) H&E stain of “ring granuloma” in patient with Q-fever (original magnification x 400).

Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003

18 J. D. COTELINGAM

TABLE 4. Lineage specific molecular cytogenetic probes* currently in use to identify lymphoid lesions by fluorescence in situ
hybridization(FISH) on core biopsies of bone marrow
FISH signal color
Chromosome
Disease Locus abnormality Green Orange Yellow
ALL TEL(ETV6)/AML1 t(12;21)(p13;q22) TEL AML1 t(12;21) Fusion
ALL BCR/ABL t(9;22)(q34;q11.2) BCR ABL 9;22 Fusion
ALL p16 del(9)(p21) Alpha-satellite 9 p16 N/A
(9p11.1-q11.1)
Burkitt Leukemia/ MYC t(8;14), t(2;8), t(8;22) Abnormal-1 green Abnormal-1 orange Dual color (normal)
Lymphoma (split signal) (split signal)
Burkitt Leukemia/ IgH/MYC t(8;14)(q24;q32) IgH MYC 8;14 Fusion signal
Lymphoma
Mantle cell lymphoma IgH/CCND1 t(11;14)(q13;q32) IgH CCND1 11;14 Fusion signal
Follicle center cell IgH/BCL2 t(14;18)(q32;q21) IgH BCL2 14;18 Fusion signal
lymphoma
Extranodal marginal zone D3Z1 +3 N/A Alpha-satellite 3 N/A
B-cell lymphoma of (3p11.1-q11.1)
mucosa-associated
lymphoid tissue (MALT
lymphoma)
Large cell lymphoma BCL6 t(?;3q27) Abnormal-1 green Abnormal-1 orange Dual color (normal)
(split signal) (split signal)
CLL, Multiple myeloma p53 del(17)(p13.1) N/A p53 N/A
CLL, Multiple myeloma D12Z3 +12 N/A Alpha-satellite 12 N/A
(12p11.1-q11.1)
CLL, Multiple myeloma RB1 del(13)(q14.3) N/A RB1 N/A
B-cell lymphoproliferative IgH t(?;14q32) Abnormal-1 green Abnormal-1 orange Dual color (normal)
disorders, including nodal (split signal) (split signal)
marginal zone B-cell
lymphoma and monocytoid
B-celllymphoma
Anaplastic large cell ALK1 t(2;5)(p23.2;q35), Abnormal-1 Abnormal- 1 orange Dual color (normal)
lymphoma# (t2;?) variants green(split signal) (split signal)

* Vysis Inc. Downers Grove, IL.

# Most T-cell monoclonalities are best determined by alternate molecular genetic techniques.
Tabulated by Mary L. Nordberg, PhD.

lymphocytic precursors that express CD10, CD19, and
TdT, variably express CD20, usually do not appear in the
peripheral blood, lack sIg, do not reveal any cytogenetic
or molecular abnormality, and show a characteristic pat-
tern of antigen expression in flow cytometry histograms.
Hematogones cannot be positively differentiated from
lymphocytes and lymphoblasts on PET. The list of locus
probes that may specifically identify the molecular basis
of lymphoid lesions in PET (Table 4) is growing. While
it is unnecessary to apply such technology to cases where
histologic appearances and the corroboratory data sup-
port a diagnosis, these molecular genetic probes are in-
valuable when such data is either sparse or unavailable.
By complimenting light microscopy with the modali-
ties mentioned in Table 4, this differential and the fea-
tures characteristic of the indolent and intermediate
grade lesions, i.e., chronic lymphocytic leukemia (Fig.
17), Waldenström’s macroglobulinemia (Fig. 17), pro-
lymphocytic leukemia, hairy cell leukemia, malignant
lymphoma-leukemic phase, splenic lymphoma with vil-
lous lymphocytes, follicular lymphoma, mantle cell lym-
phoma, margin cell lymphoma, malignant lymphoma
originating from mucosa associated lymphoid tissue
(MALT), LCL, malignant lymphoma with intravascular
infiltration, T-cell rich B-cell lymphoma, adult T-cell
leukemia/lymphoma (Fig. 18), large granular lympho-
cyte disorders, peripheral T-cell lymphoma, mycosis
fungoides, anaplastic large cell lymphoma, and hepato-
splenic gamma/delta T-cell lymphoma can now be de-
finitively ascertained (103–132). However, because of
deficiencies in standardization and the known false nega-
tive and false positive rate for PCR-based immunoglob-
ulin gene and T-cell receptor assays to determine clonal-
ity, it seems unlikely that PCR will replace microscopy
to detect lymphoreticular lesions of the bone marrow in
the near future (133–135).
PLASMA CELLS
Plasma cells are absent in the bone marrow at birth,
but begin to appear during the first few years of infancy.
In the adult, plasma cells are rare, polyclonal, comprise
3% to 6% of all nucleated cells, and are occasionally
perivascular in distribution. The normal ratio of kappa:

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 BONE MARROW BIOPSY
lambda light chain producing cells is approximately 4:1
as evaluated by flow cytometry and IHC (136). Plasma
cells characteristically reveal intracytoplasmic immuno-
globulin and are CD38 and CD138 positive and CD20
negative. Increased numbers of polyclonal plasma cells
are observed in reactive states. However, when immu-
noglobulin light chain restriction is observed, a plasma
cell dyscrasia such as monoclonal gammopathy of unde-
termined significance (MGUS) or multiple myeloma
(Fig. 19) should be considered (136). In such cases,
plasma cells often cluster and demonstrate cytologic
atypia and light chain restriction on kappa and lambda
immunostains in PET (Fig. 20). Several locus probes for
the prognostication of multiple myeloma in PET are now
available (Table 4). However, these may be of practical
value only in controversial or research settings.
Correlation of plasma cell counts with clinical, radio-
logic, and biochemical parameters is of considerable
value. In patients with abnormal lymphoplasmacytic in-
filtrates, Waldenströms macroglobulinemia, heavy chain
disease, and amyloidosis additionally enter the differen-
tial diagnosis (107,108,137). Plasma cells may occasion-
ally reveal flame-like cytoplasmic transformation, bi-
nuclearity, and crystalline inclusions (Snapper-Schneid
bodies), features that are better appreciated on aspirate
smears (138–140). These changes may be observed in
both benign and malignant plasma cells. Because the
lesions of multiple myeloma are focal in the bone mar-
row, some authorities recommend bilateral core biopsies
at the time of initial investigation.
METASTATIC DISEASE
A large number of epithelial (Fig. 21) and mesenchy-
mal (Fig. 22) tumors metastasize to the bone marrow
(141,142). There is, however, considerable institutional,
biologic, and specimen related variation in the incidence
of these lesions. Tumors that commonly metastasize to
the bone marrow include carcinomas of the breast, pros-
tate, lung, and gastrointestinal tract in adults, and neuro-
blastoma in children. Metastatic tumor deposits in the
bone marrow may be detected in one or all of the speci-
men components submitted for review (21). Occasion-
ally, tumor deposits in the core biopsy are necrotic. Nev-
ertheless, tumor cells variably retain their protein epit-
opes and their true nature may be confirmed by their IHC
profile. Based on the architectural and cytologic pattern
of the tumor in question, a recommended battery of IHC
stains should include but not be limited to cytokeratin,
epithelial membrane antigen, carcinoembryonic antigen,
alpha-fetoprotein, prostate specific antigen, prostatic
acid phosphatase, HMB-45, S-100, leukocyte common
antigen (CD45), chromogranin, synaptophysin, CD99,
19
neuron-specific enolase, Leu-7, smooth muscle actin,
desmin, vimentin, and FVIII related-antigen (143–146).
Semiquantitation of tumor burden as a percentage of
bone marrow cellularity or medullary space involved
conveys additional meaning in the pathologic report.
RETICULIN AND COLLAGEN
PROLIFERATION
Normally, a delicate filigree of reticulin (type III col-
lagen) is found to pervade the stroma of the bone mar-
row, encircle fat cells and vascular structures, and sepa-
rate cellular bone marrow from adjoining bony trabecu-
lae. In core biopsy and aspirate clot sections, reticulin
can be demonstrated with a good Wilder or Jones stain,
and is reported as normal or increased. The latter may be
graded as mild, moderate, or marked (Fig. 23). Reticulin
proliferation is usually antecedent to collagen (type I
collagen) deposition. The latter may be suspected by its
coarse fiber pattern in H&E sections (Fig. 23), but should
be confirmed with a trichrome (Fig. 23) or other collagen
stain. Because of its inaspirable nature, collagen fibrosis
is not accurately quantifiable in aspirate clot sections and
should be evaluated only in the core biopsy.
Myelofibrosis may be acute or chronic, and idiopathic
or secondary to myeloproliferative, lymphoproliferative,
metastatic, or granulomatous disease (147–150). Slowly
progressive fibrosis, as evident in the early stages of
agnogenic myeloid metaplasia and established polycy-
themia vera, causes sinusoids in the bone marrow to
permanently dilate and develop intravascular hematopoi-
esis. These changes may also be observed in the other
myeloproliferative disorders. In contrast, rapidly pro-
gressive fibrosis replaces hematopoietic tissue, vascular
elements, stroma, and fat, resulting in obliteration of the
marrow space.
Grading of bone marrow reticulin and collagen may be
quantitated according to the Bauermeister Scale (151)
(Table 5). The limits of normality lie between grades 0
and 2.
TABLE 5. The Bauermeister scale for grading bone
marrow reticulin and collagen
Grade Morphologic features
0 No reticulin fibers demonstrable.
1 Occasional fine individual fibers and foci of a fine fiber
network.
2 Fine fiber network throughout most of the section. No coarse
fibers present.
3 Diffuse fiber network with scattered thick coarse fibers. No
mature collagen present.
4 Diffuse and often coarse fiber network with areas of
collagenization.
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20
INFECTIONS AND
GRANULOMATOUS CHANGES
A wide range of infections localize to the bone mar-
row (152), and may result in an inflammatory, necrotiz-
ing, or granulomatous response. Intact granulomas are
seldom observed in aspirate preparations, and their pres-
ence cannot be excluded if the aspirate is the only speci-
men available for evaluation. Granulomatous changes
(Fig. 24) may be specific or nonspecific (150,153), and
are best defined in the core biopsy and clot section. It is
necessary to work up all epithelioid granulomas with
acid fast and fungus stains, and correlate changes with
the results of microbial cultures (154). In immunocom-
promised patients, well-defined granulomas may fail to
develop. Under these circumstances, proliferation of mi-
crobial-laden macrophages (as in Mycobacterium
avium–intracellulare infection) may be evident (155)
(Fig. 25). The most frequently encountered granuloma in
clinical practice is the nonspecific lipid granuloma (156).
The latter are not associated with hematologic disease,
and do not require work up with microbial stains. It is
noteworthy that the amastigote forms of leishmaniasis
and the intranuclear viral inclusions of cytomegalovirus
(Fig. 26), herpes simplex and parvovirus B19 infection
(Fig. 27) are readily detected with a high dry lens and
may be confirmed by in situ hybridization if necessary
(157).
STAINABLE IRON STORES
Quantitation of stainable iron in the bone marrow is
most accurately interpreted in Prussian blue preparations
of the aspirate smear and clot section. The choice be-
tween manual and automated stains (BioGenex Labora-
tories, San Ramon, CA) is largely parochial and work-
load related. Decalcification, a prerequisite for prepara-
tion of the core biopsy, results in leaching out of some
storage iron. Despite this drawback, evaluation of iron in
the core biopsy is informative in cases where the aspirate
and clot sections were not procured or are dilute and
devoid of particles. Assessment on a scale of 0 to 4 plus
is both simple and reproducible (158,159). In this scale,
stainable iron is designated as follows: 0 ⳱ absent, 1 ⳱
trace/decreased, 2 to 3 ⳱ adequate, and 4 ⳱ increased
(Fig. 28). In the bone marrow, elemental iron can be
visualized in several compartments, including the cyto-
plasm of macrophages, in developing normoblasts (sid-
eroblasts), and as free hemosiderin deposits within the
bone marrow stroma. Reports should include descrip-
tions of both the quantity and the location of iron, and
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
also the results of a search for pathologic sideroblasts
including ring forms.
DISORDERS OF THE MACROPHAGE SYSTEM
Normally, monocytes and macrophages comprise up
to 3% of cellular elements in the marrow (Table 2). In
H&E stained sections of PET, monocytes cannot be posi-
tively identified. Nevertheless, by immunostaining for
CD68, lysozyme, alpha-1-antitrypsin, and alpha-1-
antichymotripsin, infiltrates of this lineage, as in AML-
M4, AML-M5, and CMML, can be designated (56). Oc-
casional tingible body macrophages can be encountered
in cellular marrow, and do not connote a pathologic pro-
cess. However, an abnormal macrophage component
may be observed in Gaucher disease (160) (Fig. 29),
CML (161,162) (pseudo-Gaucher cells), the hemophago-
cytic syndromes (163), oxalosis (164–166) (Fig. 30),
with thorotrast deposits (167) (Figure 31), sea-blue his-
tocytosis, and in the acquired and inherited lipidosis
(168). In each of these conditions, correlation with the
clinical picture and related laboratory data is invaluable.
STROMAL AND VASCULAR ABNORMALITIES
Stromal cells and the mesenchyme of the extracellular
matrix are located between fat cells, and surround both
nonhematopoietic and hematopoietic tissue (169). The
latter are decreased in hypoproliferative states, and are
virtually effaced by chemotherapy, an index of adequate
therapeutic induction in acute leukemia. Replacement of
hematopoietic tissue by mucopolysaccharide with com-
mensurate atrophy of fat cells is observed in serous fat
atrophy (170). Herein, the mucopolysaccharide can be
delineated with an Alcian Blue stain (Fig.3). It is impor-
tant that the patterns of aplasia, serous fat atrophy, and
adequate therapeutic induction of the acute leukemias be
so designated.
Nutrient arteries, veins, and intervening sinusoids are
also located in the stromal compartment. Lesions that
affect larger vessels, which may be incidentally ob-
served, are those of amyloid infiltration (171) (Fig. 32),
vasculitis, (172) and thrombotic thrombocytopenic pur-
pura (TTP) (6). It is noteworthy that sinusoidal dilatation
is associated with increased stromal reticulin and colla-
gen as in the cellular phase of agnogenic myeloid meta-
plasia, and is occasionally accompanied by intrasinusoi-
dal hematopoiesis (6,173,174) (Fig. 33).
DISORDERS OF TRABECULAR BONE
Although a core biopsy may have been procured to
evaluate hematologic disease, the bony component of
 BONE MARROW BIOPSY 21

FIG. 25. Mycobacterium avium-intracellulare in the core biopsy of a terminal patient with the acquired immunodeficiency syndrome. (A) H&E
section with marked histiocytic proliferation. (B) Fite stain with numerous acid-fast bacteria within histiocytes (original magnification x 400).
FIG. 26. Cytomegalovirus inclusion. Core biopsy in patient with acquired immunodeficiency syndrome. Nature of inclusion serologically and
immunohistochemically confirmed; H&E section (original magnification x 400) (Courtesy of Dr. Diana Veillon).
FIG. 27. Parvovirus B19 inclusions in early erythroid precursors. Core biopsy. Patient with acquired immunodeficiency syndrome. Nature of
inclusions confirmed by serology and in-situ hybridization; H&E section (original magnification x 400).
FIG. 28. Increased (4+) iron stores. Core biopsy. Patient with anemia of chronic disease; Prussian blue stain (original magnification x 400).
FIG. 29. Gaucher disease. Core biopsy; H&E section (original magnification x 400).
FIG. 30. Oxalosis. Core biopsy; H&E section (original magnification x 400) (Courtesy of Dr. Richard Brunning).
FIG. 31. Thorotrast deposits. Core biopsy; H&E section (original magnification x 400).
FIG. 32. Amyloid deposits. Core biopsy. (A) Congo-red preparation. (B) Birefringent appearances of amyloid with polarized light (original
magnification x 400).
FIG. 33. Intrasinusoidal hematopoiesis. Core biopsy. Patient with agnogenic myeloid metaplasia; H&E stain (original magnification x 400).
FIG. 34. Increased osteoblastic activity in the vicinity of metastatic carcinoma of the prostate. Core biopsy; H&E section (original magnification
x 400).
FIG. 35. Renal osteodystrophy. Core biopsy; H&E section (original magnification x 400).
FIG. 36. Paget disease. Core biopsy; H&E section (original magnification x 400) (Courtesy of Dr. Tuyethoa Vinh).

Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003

22
this specimen should be routinely assessed. It has been
estimated that the volume of cortical and trabecular bone
in an iliac crest bone biopsy comprises greater than 20%
of the specimen (175); and despite physiologic variances
related to gender, race, and age, the mean trabecular
width is approximately 200 microns (175,176). Cancel-
lous bone of the iliac crest is in dynamic equilibrium
with the rest of the skeleton, and offers protection to the
tissues within the labyrinthine marrow space. Trabecular
bone is lamellar, and is variably bordered by a slender
osteoid seam. Osteoblasts (Fig. 34) and osteoclasts are
located along the margins of trabeculae. These cells ef-
fectively maintain the structural and physiologic integ-
rity of bone when dispersed in a ratio of approximately
100:1. Variations in this ratio along with changes in the
structure of trabecular bone may be observed in previous
biopsy sites, renal osteodystrophy (177,178) (Fig. 35),
osteopenia, osteomalacia, (179) osteoporosis, (180)
Paget disease, (181) (Fig. 36) and osteopetrosis (182).
These lesions should be appropriately described and des-
ignated in the pathology report.
SUMMARY
Reporting takes many forms, and is understandably
parochial. Whatever the choice, accuracy, clarity, brev-
ity, and timeliness are paramount. A summary comment
following the microscopic description and diagnostic
line which ties together other ancillary aspirate related,
cytochemical, flow cytometric, molecular diagnostic,
and other clinicopathologic data gleaned during the work
up conveys depth to the report. This is invaluable for
purposes of prognostication, teaching, coding, retrieval,
and research in keeping with local needs and philoso-
phies. It is our practice to promptly appraise clinical
personnel by telephone of lesions and changes that are
unexpected or have immediate therapeutic impact. This
brings excellence in communication and service and also
keeps the pathologist abreast of clinical events.
ACKNOWLEDGMENT
The author thanks Ms. Bettie Crisler for secretarial
support.
REFERENCES
1. Neumann E. Uber die Bedetung des Knochenmarks fur die Blut-
building. Centralblatt Med Wiss 1868;6:689.
2. Bizzozero G. Sulla fungione ematopoietica del midollo delle
ossa. Zentralbl Med Wissensch 1868;6:885.
3. Mosler F. Klinische Symptome und Therapie der Medullalären
Leukemi. Berl Klin Wochenschr 1876;13:233.
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
J. D. COTELINGAM
4. Turkel H, Bethell FH. Biopsy of bone marrow performed by a
new and simple instrument. J Lab Clin Med 1943;28:1246–1251.
5. Cotelingam JD. Bone marrow interpretation: the science and the
art. Pathol Case Rev 2000;5:239–251.
6. Foucar K. Bone Marrow Pathology. 2nd ed. Chicago: American
Society of Clinical Pathologists Press; 2001.
7. McFarland W, Damashek W. Biopsy of the bone marrow with the
Vim-Silverman needle. JAMA 1958;166:1464–1466.
8. Jamshidi K, Swaim WR. Bone marrow biopsy with unaltered
architecture. A new biopsy device. J Lab Clin Med 1971;77:
2335–2342.
9. Islam A. Bone marrow biopsy needle with core securing device.
J Clin Pathol 1982;35:359–364.
10. MananTM bone marrow/aspiration needle MD TechR [package
insert]. Gainsville, FL: Medical Device Technologies, Inc.; 1998.
11. Anderson G, Coup AJ. Effects of decalcifying agents on the
staining of Mycobacterium tuberculosis. J Clin Pathol 1975;28:
744–745.
12. Wong FTS, Wu PC. The influence of decalcifying fluids on the
demonstration of Mycobacterium tuberculosis in paraffin sec-
tions. Med Lab Sciences 1979;36:153–157.
13. Krause JR. Zenker-glacial acidic acid treatment of bone marrow
biopsies. In: Bone Marrow Biopsy. New York: Churchhill Liv-
ingston; 1981;209.
14. Arber DA, Johnson RM, Rainer PA, et al. The bone marrow agar
section: a morphologic and immunohistochemical evaluation.
Mod Pathol 1993;6:592–598.
15. Islam A. Proposal for a classification of acute myeloid leukemia
based on plastic embedded bone marrow biopsy sections. Leuk
Res 1993;17:421–427.
16. Burns WA, Yook CR. Plastic sections and ultrastructural tech-
niques in the evaluation of bone marrow pathology. Hematol
Oncol Clin North Am 1988;2:525–536.
17. Breton-Gorius J, Reyes F. Ultrastructure of human bone marrow
cell maturation. Int Rev Cytol 1976;46:251–321.
18. Ghadially FN. Ultrastruct Pathol of the Cell and Matrix. 3rd ed.
Boston: Butterworths; 1988.
19. Zucker-Franklin D, Greaves MF, Grossi CE, Marmont AM. Atlas
of Blood Cells. 2nd ed. Philadelphia: Lea & Febiger; 1988.
20. Wickramasinghe SN. Bone marrow. In: Histology for Patholo-
gists. 2nd ed. Philadelphia: Lippincott-Raven; 1997:707–742.
21. Barekman CL, Fair KP, Cotelingam JD. Comparative utility of
diagnostic bone marrow components: a 10-year study. Am J
Hematol 1997;56:37–41.
22. Aboul-Nasr R, Estey EH, Kantarjian HM, et al. Comparison of
touch imprints with aspirate smears for evaluating bone marrow
specimens. Am J Clin Pathol 1999;111:753–758.
23. Custer RP. An Atlas of the Blood and Bone Marrow. 2nd ed.
Philadelphia: WB Saunders; 1974.
24. Beckstead JH. The bone marrow biopsy: a diagnostic strategy.
Arch Pathol Lab Med 1986;110:175–179.
25. Brynes RK, McKenna RW, Sundberg RD. Bone marrow aspira-
tion and trephine biopsy: an approach to a thorough study. Am J
Clin Pathol 1987;70:753–759.
26. Hyun BH, Gulati GL, Ashton JK. Bone marrow examination:
techniques and interpretation. Hematol Oncol Clin N Am 1988;
2:513–523.
27. Naeim F. Atlas of Bone Marrow and Blood Pathology. Philadel-
phia: WB Saunders; 2001.
28. Li C-Y, Yam LT. Cytochemistry and immunohistochemistry in
hematologic diagnosis. Hematol Oncol Clin North Am 1994;8:
665–681.
29. Pileri SA, Roncador G, Ceccarelli C, et al. Immunohistochemistry
of bone-marrow biopsy. Leuk Lymphoma 1997;26 (Suppl
1):69–75.
30. Erber WN, Willis JI, Hoffman GJ. An enhanced immunohisto-
chemical method for staining bone marrow trephine sections. J
Clin Pathol 1997;50:389–393.
31. van der Valk P, Mullink H, Huijens PC, et al. Immunohistochem-
 BONE MARROW BIOPSY
istry in bone marrow diagnosis. Value of a panel of monoclonal
antibodies on routinely processed bone marrow biopsies. Am J
Surg Pathol 1989;13:97–106.
32. D’Onofrio G, Zini G, Tommasi M, et al. Automated analysis of
bone marrow: routine implementation and differences from pe-
ripheral blood. Lab Hematol 1998;4:71–79.
33. Fan G, Alvares C, Ismail S, et al. Quantitative and qualitative
bone marrow analysis by the Cell-Dyn 4000 Hematologic Ana-
lyzer. Mod Pathol 1999;12:190A.
34. Vos JA, Simurdak JH, Davis BJ, et al. Vortex disaggregation for
flow cytometry: a tissue preserving method. Mod Pathol 1999;
12:147A.
35. McCoy J, Keren DF. Current practices in clinical flow cytometry:
a practice survey by the American Society of Clinical Patholo-
gists. Am J Clin Pathol 1999;111:156–160.
36. Willman CL. Acute leukemias: a paradigm for the integration of
new technologies in diagnosis and classification. Mod Pathol
1999;12:218–228.
37. Hartsock R, Smith EB, Petty CS. Normal variations with aging in
the amount of hematopoietic tissue in bone marrow from the
anterior iliac crest. Am J Clin Pathol 1965;43:326–331.
38. Gruppo RA, Lampkin BC, Granger S. Bone marrow cellularity
determination: comparison of the biopsy, aspirate, and buffy coat.
Blood 1977;49:29–31.
39. Fong TP, Okafor LA, Schmitz TH, et al. An evaluation of cellu-
larity in various types of bone marrow specimens. Am J Clin
Pathol 1979;72:812–816.
40. Vaquez MH, Aubertin C. L’anémie pernicieuse d’après concep-
tions actuelles. Bull Mem Soc Med Hop Paris 1904;21:288.
41. Osgood EE, Seaman AJ. The cellular composition of bone mar-
row as obtained by sternal puncture. Physiol Rev 1939;24:105–
114.
42. Wickramasinghe SN. Normal hematopoiesis. Cellular composi-
tion of normal bone marrow. In: Blood and Bone Marrow. Sys-
temic Pathology. 3rd ed. Edinburgh: Churchill Livingstone;
1991;70.
43. Perkins SL. Examination of blood and bone marrow. In: Lee GR,
Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers GM, eds.
Wintrobe’s Clinical Hematology. 10th ed. Baltimore: Williams &
Wilkins; 1999:1;9.
44. Clark P, Normansell DE, Innes DJ, et al. Lymphocyte subsets in
normal bone marrow. Blood 1986;67:1600–1606.
45. Horny HP, Wehrmann M, Griesser H, et al. Investigation of bone
marrow lymphocyte subsets in normal, reactive, and neoplastic
states using paraffin-embedded biopsy specimens. Am J Clin
Pathol 1993;99:142–149.
46. O’Donnell LR, Alder SL, Balis UJ, et al. Immunohistochemical
reference ranges for B lymphocytes in bone marrow biopsy par-
affin sections. Am J Clin Pathol 1995;104:517–523.
47. Algino KM, Thomason RW, King DE, et al. CD20 (Pan-B cell
antigen) expression on bone marrow derived T-cells. Am J Clin
Pathol 1996;106:78–81.
48. Sternberg PA, Hill RJ. Platelets and megakaryocytes. In: Lee GR,
Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers GM, eds.
Wintrobe’s Clinical Hematology. 10th ed. Baltimore: Williams &
Wilkins; 1999:1;615–660.
49. Wolf BC, Brady K, O’Murchadha MT, et al. An evaluation of
immunohistologic stains for immunoglobulin light chains in bone
marrow biopsies in benign and malignant plasma cell prolifera-
tions. Am J Clin Pathol 1990;94:742–746.
50. Harada H, Asaoku H, Kuramoto A, et al. Phenotypic difference of
normal plasma cells from mature myeloma cells. Blood 1993;81:
2658–2663.
51. Oski FA, Naiman JL. The bone marrow. In: Oski FA, Naiman JL,
eds. Hematologic Problems in the Newborn. 3rd ed. Philadelphia:
WB Saunders Co; 1982;20.
52. Naeim F. Pathology of Bone Marrow. 2nd ed. Baltimore: Wil-
liams & Wilkins; 1997.
23
53. Pinkus GS, Pinkus JL. Myeloperoxidase: a specific marker for
myeloid cells in paraffin sections. Mod Pathol 1991;4:733–741.
54. Horny HP, Campbell M, Steinke B, et al. Acute myeloid leuke-
mia: immunohistochemical findings in paraffin-embedded bone
marrow specimens. Hum Pathol 1990;21:648–655.
55. Dunphy CH, Polski JM, Evans HL, et al. Evaluation of bone
marrow specimens with acute myelogenous leukemia for CD34,
CD15, CD117, and myeloperoxidase. Arch Pathol Lab Med
2001;125:1063–1069.
56. Warnke RA, Pulford KA, Pallesen G, et al. Diagnosis of myelo-
monocytic and macrophage neoplasms in routinely processed tis-
sue biopsies with monoclonal antibody KP1. Am J Pathol 1989;
135:1089–1095.
57. Horny HP, Parwaresch MR, Lennert K. Bone marrow findings in
systemic mastocytosis. Hum Pathol 1985;16:808–814.
58. Li WV, Kapadia SB, Sonmez-Alpan E, et al. Immunohistochem-
ical characterization of mast cell disease in paraffin sections using
tryptase, CD68, myeloperoxidase, lysozyme, and CD20 antibod-
ies. Mod Pathol 1996;9:982–988.
59. Horny HP, Sillaber C, Menke D, et al. Diagnostic utility of stain-
ing for tryptase in patients with mastocytosis. Am J Surg Pathol
1998;22:1132–1140.
60. Natkunam Y, Rouse RV. Utility of paraffin section immunohis-
tochemistry for C-KIT (CD117) in the differential diagnosis of
systemic mast cell disease involving the bone marrow. Am J Surg
Pathol 2000;24:81–91.
61. Hanson CA, Abaza M, Sheldon S, et al. Acute biphenotypic
leukemia: immunophenotype and cytogenetic analysis. Br J Hae-
matol 1993;84:49–60.
62. Gaffney RL, Lowrey MC, Sciotto CG. Acute lymphoblastic leu-
kemia relapsing as acute myelogenous leukemia: the role of the
mixed lineage leukemia (MLL) gene. ASCP Check Sample HP-
99, 1999.
63. Mangi MH, Salisbury JR, Mufti GJ. Abnormal localization of
immature precursors in the bone marrow of myelodysplastic syn-
dromes: current state of knowledge and future directions. Leuk
Res 1991;15:627–639.
64. Heaney ML, Golde DW. Myelodysplasia. N Engl J Med 1999;
340:1649–1660.
65. Reddey VB. Topics in bone marrow biopsy pathology: role of
marrow topography in myelodysplastic syndromes and evaluation
of posttreatment and postbone marrow transplant biopsies. Ann
Diagn Pathol 2001;5:110–120.
66. Orazi A, Albitar M, Heerema NA, et al. Hypoplastic myelodys-
plastic syndromes can be distinguished from acquired aplastic
anemia by CD34 and PCNA immunostaining of bone marrow
biopsy specimens. Am J Clin Pathol 1997;107:268–274.
67. Brunning R. The proposed WHO classification of MDS and
MDS-related acute leukemias. Mod Pathol 1999;12:102.
68. Vardiman JW. Myelodysplastic/myeloproliferative disorders.
Mod Pathol 1999;12:104–105.
69. Jaffe ES, Harris NL, Stein H, et al. Tumors of Hematopoietic and
Lymphoid Tissue (WHO Classification of Tumors: Pathology and
Genetics). Lyon: IARC Press; 2001.
70. van Der Valden VH, te Marvelde JG, Hoogeveen PG, et al. Tar-
geting of the CD33-calicheamicin immunoconjugate Myelotarg
(CMA-676) in acute myeloid leukemia: in vivo and in vitro satu-
ration internalization by leukemic and normal myeloid cells.
Blood 2001;97:3197–3204.
71. Druker BJ, Talpaz M, Resta D, et al. Efficacy and safety of a
specific inhibitor of the BCR-ABL tyrosine kinase in chronic
myeloid leukemia. N Eng J Med 2001;334:1031–1037.
72. Hasserjian RP, Boecklin F, Parker S, et al. ST1571 (Imatinib
Mesylate) reduces bone marrow cellularity and normalizes mor-
phologic features irrespective of cytogenetic response. Am J Clin
Pathol 2002;117:360–367.
73. Applebaum FR, Downing J, Willman C. The biology and therapy
of acute myelogenous leukemia. Molecular detection and moni-
toring of AML 1/ETO transcripts in AML with t(8;21). In: Kaus-
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
24 J. D. COTELINGAM
hansky K, McArthur JR, eds. Hematology Education Program,
American Society of Hematology. Seattle: Smith, Bucklin & As-
sociates; 1995;23–35.
74. Kowal-Vern A, Cotelingam JD, Schumacher HR. The prognostic
significance of pronormoblasts in acute leukemia. Am J Clin
Pathol 1992;98:34–40.
75. Mazzella FM, Cotelingam JD, Kowal-Vern A, et al. Proposed
WHO classification of acute myeloid leukemia and myelodys-
plastic syndromes. Mod Pathol 2000;13:101–102.
76. Strauchen JA. B19 Parvovirus infection. In: Diagnostic Histopa-
thology of the Bone Marrow. New York: Oxford University
Press; 1996;282–285.
77. Lee GR. Congenital dyserythropoietic anemias. In: Lee GR,
Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers GM, eds.
Wintrobe’s Clinical Hematology. 10th ed. Baltimore: Williams &
Wilkins; 1999:2;1489–1496.
78. Mazzela FM, Kowal-Vern A, Shrit A, et al. Erythroleukemia.
Evaluation of 48 cases with reference to classification, cell pro-
liferation, cytogenetics and prognosis. Am J Clin Pathol 1998;
110:590–598.
79. Crocker J, Gyde O, Jenkins R. Demonstration of normoblasts in
tissue sections by means of an immunohistochemical technique
for haemoglobin. J Clin Pathol 1984;37:1312–1313.
80. Sternberg PA. Hill RJ. Platelets and megakaryocytes. In: Lee GR,
Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers GM, eds.
Wintrobe’s Clinical Hematology. 10th ed. Baltimore: Williams &
Wilkins; 1999:1;615–660.
81. Innes DJ, Mills SE, Walker GK. Megakaryocytic leukemia: iden-
tification using antifactor VIII immunoperoxidase. Am J Clin
Pathol 1982;77:107–110.
82. Calapso P, Vitarelli E, Crisafulli C, et al. Immunocytochemical
detection of megakaryocytes by endothelial markers: a compara-
tive study. Pathologica 1992;84:215–223.
83. Chuang SS, Yung YC, Li CY. Von Willebrand factor is the most
reliable immunohistochemical marker for megakaryocytes of my-
elodysplastic syndrome and chronic myeloproliferative disorders.
Am J Clin Pathol 2000;113:506–511.
84. Huang MJ, Li CY, Nichols WL, et al. Acute leukemia with mega-
karyocytic differentiation: a study of 12 cases identified immu-
nocytochemically. Blood 1984;64:427–439.
85. San Miguel JF, Gonzalez M, Canizo MC, et al. Leukemias with
megakaryoblastic involvement: clinical, hematologic, and immu-
nologic characteristics. Blood 1988;72:402–407.
86. Ivanyi JL, Kiss A, Telek B, et al. Megakaryocyte markers in
myeloproliferative disorders. Acta Histochem 1993;95:79–88.
87. Jacobson S, Wadenvik H, Kutti J, et al. Low megakaryocyte
ploidy in Ph+ chronic myeloid leukemia measured by flow cy-
tometry. Am J Clin Pathol 1999;111:185–190.
88. Boultwood J, Lewis S, Waincoat JS. The 5q− syndrome. Blood
1994;84:3253–3260.
89. van den Berghe H, Michaux L. 5q−, twenty five years later:a
synopsis. Cancer Genet Cytogenet 1997;94:1–7.
90. Rosse C, Kraemer MJ, Dillon TL, et al. Bone marrow cell popu-
lations of normal infants: the predominance of lymphocytes. J
Lab Clin Med 1977;89:1225–1240.
91. Farhi DC. Germinal centers in bone marrow. Hematol Pathol
1989;3:133–136.
92. Lambertenghi-Deliliers G, Annaloro C, Soligo D, et al. Incidence
and histologic features of bone marrow involvement in malignant
lymphomas. Ann Hematol 1992;65:61–65.
93. Ben-Ezra JM, King BE, Harris AC, et al. Staining for Bcl-2
protein helps to distinguish benign from malignant lymphoid ag-
gregates in bone marrow biopsies. Mod Pathol 1994;7:560–564.
94. O’Carroll DI, McKenna RW, Brunning RD. Bone marrow mani-
festations of Hodgkin’s disease. Cancer 1976;38:1717–1728.
95. Bartl R, Frisch B, Burnhardt R, et al. Assessment of bone marrow
histology in Hodgkin’s disease: correlation with clinical factors.
Br J Haematol 1982;51:345–360.
96. Karcher DS. Clinically unsuspected Hodgkin disease presenting
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
initially in the bone marrow of patients infected with the human
immunodeficiency virus. Cancer 1993;71:1235–1238.
97. Naughton MJ, Hess JL, Zutter MM, et al. Bone marrow staging
in patients with nonHodgkin’s lymphoma. Is flow cytometry a
useful test? Cancer 1998;82:1154–1159.
98. Munker R, Hasencleaver D, Brosteanu O, et al. Bone marrow
involvement in Hodgkin’s disease: an analysis of 135 consecutive
cases. J Clin Oncol 1995;13:403–409.
99. Schumacher HR. Acute Leukemia: Difficult, Controversial and
Automated Analysis. Baltimore: Williams & Wilkins; 1997.
100. Orazi A, Cotton J, Cattoretti G, et al. Terminal deoxynucleotidyl
transferase staining in acute leukemia and normal bone marrow in
routinely processed paraffin sections. Am J Clin Pathol 1994;102:
640–645.
101. Kheiri SA, MacKerrell T, Bonagura VR, et al. Flow cytometry
with or without cytochemistry for the diagnosis of acute leuke-
mias. Cytometry 1998;34:82–86.
102. Davis RE, Longacre TA, Cornbleet PJ. Hematogones in the bone
marrow of adults. Immunophenotypic features, clinical settings
and differential diagnosis. Am J Clin Pathol 1994;102:202–211.
103. Foucar K. Chronic lymphoid leukemias and lymphoproliferative
disorders. Mod Pathol 1999;12:141–150.
104. Gala J-L, Guiot Y, Delannoy A, et al. Use of image analysis and
immunostaining of bone marrow trephine biopsy specimens to
quantify residual disease in patients with B-cell chronic lympho-
cytic leukemia. Mod Pathol 1999;12:391–399.
105. Shapiro JL, Miller ML, Pohlman B, et al. CD5− B-cell lympho-
proliferative disorders presenting in blood and bone marrow. A
clinicopathologic study of 40 patients. Am J Clin Pathol 1999;
111:477–487.
106. Tworek JA, Singleton TP, Schnitzer B, et al. Flow cytometric and
immunohistochemical analysis of small lymphocytic lymphoma,
mantle cell lymphoma, and plasmacytoid small lymphocytic lym-
phoma. Am J Clin Pathol 1998;110:582–589.
107. Andriko JA, Aguilera NS, Chu WS, et al. Waldenström’s mac-
roglobulinemia: a clinicopathologic study of 22 cases. Cancer
1997;80:1926–1935.
108. Owen RG, Barrans SL, Richards SJ, et al. Waldenströms macro-
globulinemia: development of diagnostic criteria and identifica-
tion of prognostic factors. Am J Clin Pathol 2001;116:420–428.
109. Schlette EJ, Buesco-Ramos CE, Medeiros LJ. B-cell prolympho-
cytic leukemia. Pathol Case Rev 2000;5:274–280.
110. Schumacher HR, Cotelingam JD. T-Prolymphocytic leukemia.
In: Chronic Leukemia: Approach to Diagnosis. New York: Igaku-
Shoin; 1993;269–280.
111. Hounieu H, Chittal SM, AL Saati T, et al. Hairy cell leukemia.
Diagnosis of bone marrow involvement in paraffin-embedded
sections with monoclonal antibody DBA 44. Am J Clin Pathol
1992;98:26–33.
112. Pittaluga S, Tierens A, Dodoo YL, et al. How reliable is histo-
logic examination of bone marrow trephine biopsy specimens for
the staging of nonHodgkin’s lymphoma? A study of hairy cell
leukemia and mantle cell lymphoma involvement of the bone
marrow trephine specimen by histologic immunohistochemical,
and polymerase chain reaction techniques. Am J Clin Pathol
1999;111:179–184.
113. Troussard X, Valensi F, Duchayne E, et al. Splenic lymphoma
with villous lymphocytes: clinical presentation, biology and prog-
nostic factors in a series of 100 patients. Br J Haematol 1996;
93:731–736.
114. McCluggage WG, Bharucha H, el-Agnaf M, et al. B-cell signet
ring cell lymphoma of bone marrow. J Clin Pathol 1995;48:275–
278.
115. Vasef MA, Medeiros LJ, Koo C, et al. Cyclin D1 immunohisto-
chemical staining is useful in distinguishing mantle cell lym-
phoma from other low grade B-cell neoplasms in bone marrow.
Am J Clin Pathol 1997;108:302–307.
116. Kent SA, Variakojis D, Peterson LC. Comparative study of mar-
 BONE MARROW BIOPSY
gin zone lymphoma involving bone marrow. Am J Clin Pathol
2002;117:698–708.
117. Traweek ST, Sheibani K. Monocytoid B-cell lymphoma with
bone marrow and peripheral blood involvement at presentation.
Am J Clin Pathol 1990;94:117–118.
118. Hodges GF, Lenhardt TM, Cotelingam JD. Bone marrow in-
volvement in large cell lymphoma. Prognostic implications of
discordant disease. Am J Clin Pathol 1994;101:305–311.
119. Jones D. Large B-cell lymphoma in the bone marrow. Pathol
Case Rev 2000;5:281–286.
120. Franco V. Florena AM, Campesi G. Intrasinusoidal bone marrow
infiltration: a possible hallmark of splenic lymphoma. Histopa-
thology 1996;29:571–575.
121. Tucker TJ, Bardales RH, Miranda RN. Intravascular lymphoma-
tosis with bone marrow involvement. Arch Pathol Lab Med 1999;
123:952–956.
122. Khalidi HS, Brynes RK, Browne P, et al. Intravascular large
B-cell lymphoma: the CD5 antigen is expressed by a subset of
cases. Mod Pathol 1998;11:983–988.
123. Estalilla OC, Koo CH, Brynes RK, et al. Intravascular large B-
cell lymphoma: a report of five cases initially diagnosed by bone
marrow biopsy. Am J Clin Pathol 1999;112:255.
124. Skinnider BF, Connors JM, Gascoyne RD. Bone marrow involve-
ment in T-cell rich B-cell lymphoma. Am J Clin Pathol 1997;
108:570–578.
125. Ogata M, Ogata Y, Kohno K, et al. Eosinophilia associated with
adult T-cell leukemia: role of interleukin-5 and granulocyte-
macrophage colony-stimulating factor. Am J Hematol 1995;59:
242–245.
126. Evans HL, Burks E, Viswantatha D, et al. Utility of immunohis-
tochemistry in bone marrow evaluation of T-lineage large granu-
lar lymphocyte leukemia. Hum Pathol 2000;31:1266–1273.
127. Hanson CA, Brunning RD, Gajl-Peczalska KJ, et al. Bone mar-
row manifestations of peripheral T-cell lymphoma. A study of 30
cases. Am J Clin Pathol 1986;86:449–460.
128. Gaulard P, Kanavaros P, Farcet JP, et al. Bone marrow histologic
and immunohistochemical findings in peripheral T-cell lym-
phoma: a study of 38 cases. Hum Pathol 1991;22:331–338.
129. Graham SJ, Sharpe RW, Steinberg SM, et al. The prognostic
implications of a bone marrow histopathologic classification sys-
tem in mycosis fungoides and the Sézary syndrome. Cancer
1993;72:726–734.
130. Salhany KE, Greer JP, Cousar JB, et al. Marrow involvement in
cutaneous T-cell lymphoma. Am J Clin Pathol 1989:92;747–754.
131. Fraga M, Brosset P, Schaifer D, et al. Bone marrow involvement
in anaplastic large cell lymphoma. Immunohistochemical detec-
tion of minimal disease and it’s prognostic significance. Am J
Clin Pathol 1995;103:82–89.
132. Vega F, Medeiros LJ, Bueso-Ramos C, et al. Hepatosplenic
gamma/delta T-cell lymphoma in bone marrow. A sinusoidal neo-
plasm with blastic cytologic features. Am J Clin Pathol 2001;
116:410–419.
133. Coad JE, Olson DJ, Christensen DR, et al. Correlation of PCR-
detected clonal gene rearrangements with bone marrow morphol-
ogy in patients with B-lineage lymphoma. Am J Surg Pathol
1997;21:1047–1056.
134. Medeiros LJ, Carr J. Overview of the role of molecular methods
in the diagnosis of malignant lymphoma. Arch Path Lab Med
1999;123:1189–1207.
135. Fader S, Kurzrock R, Estrov Z. Minimal residual disease in he-
matologic disorders. Arch Pathol Lab Med 1999;123:1030–1034.
136. Wolf BC, Brady K, O’Murchadha MT, et al. An evaluation of
immunohistologic stains for immunoglobulin light chains in bone
marrow biopsies in benign and malignant plasma cell prolifera-
tions. Am J Clin Pathol 1990;94:742–746.
137. Harada H, Asaoku H, Kuramoto A, et al. Phenotypic difference of
normal plasma cells from mature myeloma cells. Blood 1993;81:
2658–2663.
138. Thiry A, Delvenne P, Fontaine MA, et al. Comparison of bone
25
marrow sections, smears, and immunohistologic staining for im-
munoglobulin light chains in the diagnosis of benign and malig-
nant plasma cell proliferation. Histopathology 1993;22:423–428.
139. Snapper J, Schneid B. On the influence of stilbamidine upon
myeloma cells. Blood 1946;1:534–536.
140. Roberts GT, Khalil SH. Multiple myeloma with bone marrow
crystal deposition and marrow fibrosis. Ann Saudi Med 1998;18:
432–436.
141. Singh G, Krause JR, Breitfeld V. Bone marrow examination for
metastatic tumor: aspirate and biopsy. Cancer 1977;40:2317–
2321.
142. Jatoi A, Dallal GE, Nguyen PL. False negative rates of tumor
metastases in the histologic examination of bone marrow. Mod
Pathol 1999;12:29–32.
143. Mansi JL, Berger U, Wilson P, et al. Detection of tumor cells in
bone marrow of patients with prostatic carcinoma by immunocy-
tochemical techniques. J Urol 1988;139:545–548.
144. Lazda EJ, Berry PJ. Bone marrow metastasis in Ewing’s sarcoma
and peripheral primitive neuroectodermal tumor: an immunohis-
tochemical study. Pediatric & Developmental Pathol 1998;1:
125–130.
145. Mathieu MC, Friedman S, Bosq J, et al. Immunohistochemical
staining of bone marrow biopsies for detection of occult metas-
tasis in breast cancer. Breast Cancer Res Treat 1990;15:21–26.
146. Dabbs DJ. Diagnostic Immunohistochemistry. New York: Chur-
chill Livingstone; 2002.
147. Hruban RH, Kuhajda FP, Mann RB. Acute myelofibrosis. Immu-
nohistochemical study of four cases and comparison with acute
megakaryoblastic leukemia. Am J Clin Pathol 1987;88:578–588.
148. Rywlin AM. Myelofibrosis and osteosclerosis. In: Histopathol-
ogy of the Bone Marrow. Boston; Little Brown & Co.; 1976;153.
149. Burthem J, Cawley JC. Bone marrow fibrosis of hairy cell leu-
kemia is caused by synthesis and assembly of fibronectin matrix
by hairy cells. Blood 1994;15:479–504.
150. Bhargava V, Farhi DC. Bone marrow granulomas. Clinicopath-
ologic findings in 72 cases and review of the literature. Hematol
Pathol 1988;2:43–50.
151. Bauermeister DE. Quantitation of bone marrow reticulin: a nor-
mal range. Am J Clin Pathol 1971;56:24–31.
152. Diebold J, Molina T, Camilleri-Broët S, et al. Bone marrow mani-
festations of infectious and systemic diseases observed in bone
marrow trephine biopsy. Histopathology 2000;37:199–211.
153. Tefferi A, Li CY. Bone marrow granulomas associated with
chronic natural killer cell lymphocytosis. Am J Hematol 1997;54:
258–262.
154. Volk EE, Miller ML, Kirkley BA, et al. The diagnostic usefulness
of bone marrow cultures in patients with fever of unknown origin.
Am J Clin Pathol 1998;110:150–153.
155. Farhi DC, Mason III UG, Horsburgh Jr CR. The bone marrow in
disseminated MAI infection. Am J Clin Pathol 1985;83:463–468.
156. Rywlin AM, Ortega R. Lipid granulomas of the bone marrow. Am
J Clin Pathol 1972;57:457–462.
157. Conner DH, Chandler FW, Schwartz DA, et al. Pathology of
Infectious Disease. Stamford: Appleton and Lange; 1997:1;255.
158. Strauchen JA. Interpretation of iron stores in the bone marrow. In:
Diagnostic Histopathology of the Bone Marrow. Oxford: Oxford
University Press; 1996;16.
159. Rywlin AM. Bone marrow hemosiderin. In: Histopathology of
the Bone Marrow. Boston: Little Brown & Co.; 1976;53–58.
160. Rector JT, Cotelingam JD. Gaucher’s disease. ASCP Check Path
(Hematopathology) 1996; QAH 96–4.
161. Lee RE, Ellis LD. The storage cells of chronic myeloid leukemia.
Lab Invest 1971;24:261–264.
162. Ulirsch RC. Sea Blue histiocytes in chronic myeloid leukemia.
ASCP Check Sample 1985; H-4.
163. Brunning RD, McKenna RW. Infection associated hemophago-
cytic syndrome. In: Rosai J, Sobin LH, eds. Atlas of Tumor Pa-
thology, Bone Marrow. AFIP Fasicle. Washington DC; Armed
Forces Institute of Pathology; 1994;9:447–452.
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
26 J. D. COTELINGAM
164. McKenna RW, Dehner LP. Oxalosis: an unusual cause of my-
elophthisis in childhood. Am J Clin Pathol 1976;66:991–997.
165. Boquist L, Lindquist B, Ostberg Y, et al. Primary oxalosis. Am J
Med 1973;54:673–681.
166. Gherardi G, Poggi A, Sisca S, et al. Bone oxalosis and renal
osteodystrophy. Arch Pathol Lab Med 1980;104:105–111.
167. Graham SJ, Heaton RB, Garvin DF, Cotelingam JD. Whole body
pathologic analysis of a patient with thorotrast induced myelo-
dysplasia. Health Phys 1992;63:20–26.
168. Kolodny EH, Tenembaum AL. Bone marrow involvement in stor-
age diseases. In: Nathan DG, Orkin SH, eds. Nathan and Oski’s
Hematology of Infancy and Childhood. 4th ed. Philadelphia: WB
Saunders Co; 1992;1452–1492.
169. Wilkins BS, Jones DB. Immunophenotypic characterization of
stromal cells in aspirated human bone marrow samples. Exp He-
matol 1998;26:1061–1067.
170. Mehta K, Gascon P, Robboy S. The gelatinous bone marrow
(serous atrophy) in patients with AIDS, evidence of excess sul-
phated glycosaminoglycan. Arch Pathol Lab Med 1992;116:504–
508.
171. Wolf BC, Kumar A, Vera JC, et al. Bone marrow morphology
and immunology in systemic amyloidosis. Am J Clin Pathol
1986;86:84–88.
172. Rosenthal NS, Farhi DC. Bone marrow findings in connective
tissue disease. Am J Clin Pathol 1989;92:650–654.
173. Burkhardt R, Bartl R, Beil E, et al. Myelofibrosis-osteosclerosis
Advances in Anatomic Pathology, Vol. 10, No. 1, January, 2003
syndrome: a review of literature and histomorphology. Adv Biosci
1975;16:9–56.
174. Wolf BC, Neiman RS. Myelofibrosis with myeloid metaplasia:
pathophysiologic implications of the correlation between bone
marrow changes and progression of splenomegaly. Blood 1985;
65:803–809.
175. Vigorita VJ. The bone biopsy protocol for evaluating osteoporo-
sis and osteomalacia. Am J Surg Pathol 1984;8:925–930.
176. Frisch B, Bartl R. Biopsy Interpretation of Bone and Bone Mar-
row. London: Arnold-Oxford University Press; 1999;27.
177. Teitelbaum SL. Renal osteodystrophy. Human Pathol 1984;15:
306–323.
178. Wittels B. Renal osteodystrophy. In: Bennington JL, ed. Surgical
Pathology of Bone Marrow: Core Biopsy Diagnosis. Philadel-
phia: WB Saunders Co; 1985;133–136.
179. Bain BJ, Clark DM, Lampert IA. Osteomalacia. In: Bone Marrow
Pathology. London: Blackwell Scientific Publications; 1993;258–
259.
180. Becks JS, Nordin BEC. Histological assessment of osteoporosis
by the iliac crest biopsy. J Pathol Bacteriol 1960;80:391–397.
181. Frisch B, Lewis SM, Burkhardt R, et al. Paget’s disease of bone.
In: Biopsy Pathology of Bone and Bone Marrow. New York:
Raven Press; 1985;97–100.
182. Milgram JW, Jasty M. Osteopetrosis. A morphologic study of
twenty-one cases. J Bone Joint Surg Am 1982;64:912–929.