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Hematology Unit 9 (Bone Marrow) Flashcards

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1
Q

What is the purpose of bone marrow?

A

Hematopoiesis - makes 6 billion cells/kg/day in adults

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2
Q

What happens to bone marrow as we age?

A

At birth, nearly all bones contain red marrow.

As we age, fat cells begin to replace red marrow in the appendicular skeleton.

Red marrow is then limited to only the axial skeleton in late adolescence.

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3
Q

Adipocytes occupy ~____% of red marrow space in 30-70 y/o.

A

50%

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4
Q

BM puncture is PROHIBITED in patients with ___________

A

coagulopathies

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5
Q

Why would a BM exam be ordered on a patient?

A
  • Neoplasia diagnosis/staging
  • BM failure causing cytopenias
  • Metabolic disorders
  • Infections
  • Monitoring of treatment
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6
Q

What are the 2 parts of a BM specimen and how are they different?

A

Aspirate: liquid portion; obtained by BM aspiration and allows for identification of types/proportions of cells and look for morphologic variance

Core biopsy: solid portion; obtained by trephine biopsy and demonstrates bone marrow architecture and estimates cellularity

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7
Q

What is the most commonly used site for a BM collection? What other sites may be collected from, for adults and why?

A

`Posterior superior iliac crest of the pelvis - most common

Other sites:
- Anterior superior iliac crest of the pelvis (for patients who can only lie supine)
- Sternum (aspirate only)
- Spinous process of vertebrae/ribs (rare)

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8
Q

What areas on the body can a BM specimen be collected in children?

A

Posterior superior iliac crest most common

Anterior medial surface of the tibia, can only get aspirate

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9
Q

BRIEFLY list the steps of a BM biopsy/aspiration procedure

A
  • Palpate body site
  • Local anesthetic injected
  • Needle inserted and rotated to core through bone
  • Core biopsy removed
  • Touch preps of biopsy made
  • Aspiration of liquid
  • BM smears made
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10
Q

Advantages of a BM aspirate smear

A

Fast
No need for decalcification
Quantitation of cell type
Material for ancillary studies

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11
Q

Advantages of a BM core biopsy

A

Can analyze cells AND stroma
Represents all cells
Explains dry taps

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12
Q

Disadvantages of a BM aspirate smear

A

May not represent all cells
Dry tap may occur
Doesn’t represent architecture
Inability to analyze stroma

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13
Q

Disadvantages of a BM core biopsy

A

Slow processing
Decalcification required and preludes ancillary studies
Inability to perform quantitative diff count

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14
Q

What is a direct aspirate smear?

A

Made similarly to periph. blood smears (wedge technique)
Bony spicules = good and allows for more cells (do not crush them)

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15
Q

What is a crush smear?

A

Bony spicules placed on slide and crushed by another slide; superior to wedge prep method for morphological exam

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16
Q

What is a buffy coat smear? Why would you use this technique?

A

EDTA aspirate transferred to narrow-bore tube and centrifuged, ME and plasma layers are aspirated and smears are prepared using crush smear technique
- Useful when there is hypocellular marrow

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17
Q

What is a touch prep smear?

A

Made from core biopsy specimen; biopsy is repeatedly touched to a slide and is valuable when the specimen is clotted or there is a dry tap

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18
Q

What is the normal stain to use on a bone marrow specimen?

A

Wright or Wright-Giemsa stains

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19
Q

What is the purpose of the Prussian blue stain for bone marrow specimens?

A

Used to estimate marrow storage iron or iron metabolism abnormalities
Highlights presence of ring sideroblasts

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20
Q

What does MPO stain allow for detection of in BM specimens?

A

Detects myeloid cells

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21
Q

What does SBB stain allow for detection of in BM specimens?

A

Detects myeloid cells

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22
Q

What does PAS stain allow for detection of in BM specimens?

A

Detects lymphocytic cells and certain abnormal erythroid cells

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23
Q

What do esterase stains allow for detection of in BM specimens?

A

Distinguish myeloid from monocytic maturation stages

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24
Q

What does TRAP stain allow for detection of in BM specimens?

A

Hair cell leukemia

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25
What can we perform under low power examination of BM?
- Assess peripheral blood dilution - Locate bony spicules, aggregations of bone, and hematopoietic cells - Estimate cellularity - Search for tumor cells - Examine and estimate megakaryocytes
26
What can we perform under high power examination of BM?
- Observe maturation of nucleated cells - Perform a differential - Calculate M:E ratio
27
What is the estimated cellularity of children? 30-70 y/o? How do we estimate cellularity for >70 y/o?
Children = 80% 30-70 y/o = 50% > 70 y/o = subtract patient age from 100% and add +/- 10% (Ex. 75 y/o = 15-35%
28
Osteoblast vs osteoclast
Osteoblast = bone formation Osteoclast = bone resorption
29
What is the purpose of the H&E stain?
Used for the examination of core biopsy specimen when aspiration procedure yields a dry tap; assess cellularity but cannot perform a differential
30
What is the purpose of cytochemical studies on BM?
Diagnosis of leukemias/lymphomas
31
What is the purpose of cytogenetic studies on BM?
Diagnosis of acute leukemias via chromosomal abnormalities
32
What is the purpose of molecular studies on BM?
PCR for diagnostic point mutations
33
What is the purpose of FISH testing on BM?
Staining for diagnostic mutations
34
What is the purpose of flow cytometry testing on BM?
Immunophenotyping of malignant hematopoietic cells
35
What information may be included on a bone marrow examination report?
- Patient medical history and CBC results - Diagnostic narrative: Summary of the recorded BM findings and additional lab chemical, microbiologic, and immunoassay tests
36
Each tech counts _____ cells during a BM exam at RH.
250
37
What is meant by the term “bone marrow failure”?
Reduction/cessation of blood cell production affecting one or more cell lines (PLTs/WBCs/RBCs)
38
What is the result of bone marrow failure?
Pancytopenia
39
Name 6 potential causes of bone marrow failure
1. Destruction of HSCs through drugs/chemicals/radiation etc. 2. Premature senescence and apoptosis of HSCs due to genetic mutations 3. Ineffective hematopoiesis 4. Disruption of BM microenvironment 5. Decreased production of hematopoietic growth factors 6. Loss of normal hematopoietic tissue due to infiltration of marrow space with abnormal cells
40
What is the major form of BM failure?
Aplastic anemia
41
What are the characteristic features of aplastic anemia?
Pancytopenia Reticulocytopenia BM hypocellularity Depletion of HSCs
42
Name a few associations/causes of aplastic anemia
Idiopathic --> unknown Secondary --> drugs, chemicals, radiation (benzene/cytotoxic drugs) Viral infections --> EBV, HIV, parvovirus B19
43
Most cases of aplastic anemia are _________ (85%) and few are ________ (15%).
acquired; inherited/congenital
44
What is the PRIMARY cause of aplastic anemia?
Quantitative and qualitative deficiency of HSCs
45
What are some laboratory findings associated with aplastic anemia?
Decreased ANC HGB <10 Decreased retics Decreased neuts/monos/PLTs Macrocytic/normocytic RBCs Toxic granulation Increased iron and %TSAT Decreased CD55 and CD59 Decreased CD24 and CD14 Severe hypocellularity in BM
46
What is the most common of the inherited bone marrow failure syndromes?
Fanconi anemia
47
What is Fanconi anemia?
Inherited chromosome instability disorder characterized by aplastic anemia, physical abnormalities, and cancer susceptibility
48
What population is most affected by Fanconi anemia?
Ashkenazi Jewish and South African Afrikaner populations
49
What are the clinical findings of those with Fanconi anemia?
Thumb malformations Cafe-au-lait lesions on skin Short stature Increased cancer risk
50
What is the diagnostic test for Fanconi anemia?
Chromosomal breakage analysis; FA cells have increased fragility
51
Lab results of those with Fanconi anemia
Pancytopenia Reticulocytopenia Hypocellular bone marrow
52
What is the prognosis of someone with Fanconi anemia?
1/3 develop MDS and/or AML by 14 y/o 1/4 develop solid tumors by 26 y/o >90% develop BM failure by 40 y/o If it goes untreated, death by 20 y/o due to BM failure.
53
Treatment for Fanconi anemia
HSCT
54
What are the clinical findings of someone with Dyskeratosis Congenita?
- Mucocutaneous abnormalities (abnormal skin pigmentation, dystrophic nails, oral leukoplakia) - Increased cancer risk - Multisystem abnormalities - BM failure/pancytopenia
55
Genetics and pathophysiology of Dyskeratosis Congenita
DC chromosomes have very short telomeres leading to premature cell death and predisposition to cancer Mutation in one of at least 11 genes, most commonly a mutation of the DKCI gene on the X chromosome
56
How to diagnose/detect Dyskeratosis Congenita?
Flow cytometry FISH test for detection of short telomeres Pancytopenia and macrocytic RBCs
57
Treatment/prognosis of someone with Dyskeratosis Congenita?
Median survival = 42 yrs Androgen therapy treats, but does not halt progression of BM failure
58
What is Shwachman-Bodian-Diamond syndrome (SBDS)?
Multisystem disorder characterized by pancreatic insufficiency, cytopenias, skeletal abnormalities, and a predisposition to hematologic malignancies
59
Clinical findings of SBDS?
- Peripheral blood cytopenia - Decreased pancreatic enzyme secretion - Immune dysfunction - Short stature
60
Genetics/pathophysiology of SBDS
Biallelic mutations in the SBDS gene Deficiencies in CD34+ cells Increased apoptosis in HSCs Short telomeres in granulocytes
61
Laboratory findings in SBDS
Neutropenia Anemia/thrombocytopenia Hypocellular bone marrow Increased fecal fat
62
Treatment for SBDS
- G-CSF for neutropenia - Transfusion support for anemia/thrombocytopenia - Enzyme replacement for pancreatic insufficiency - Stem cell transplant if AML/MDS develops
63
What is PRCA and how does it differ from the other types of BM failure disorders discussed?
Rare disorder of erythropoiesis characterized by severe decrease in erythroid precursors ONLY in an otherwise normal bone marrow **Difference is that this disorder has normal WBC/PLT counts
64
What are the two types of PCRA and describe them
Acquired PRCA: aka transient erythroblastopenia of childhood, many patients have a history of viral infection Congenital PCRA: Diamond-Blackfan Anemia - mutations in the RPS19 gene with craniofacial dysmorphisms, short stature, neck and thumb malformations
65
What are CDAs?
Congenital dyserythropoietic anemias characterized by refractory anemia, reticulocytopenia, hypocellular bone marrow with markedly ineffective erythropoiesis and distinctive dysplastic changes in BM erythroblasts
66
Briefly describe CDA I
Macrocytic RBCs Megaloblastoid erythroblasts with internuclear chromatin bridges or nuclear stranding; spongy heterochromatin with a swiss cheese appearance
67
Briefly describe CDA II
The most common subtype Normocytic RBCs Normoblastic erythroblasts with some binucleated forms
68
Briefly describe CDA III
Least common subtype Macrocytic RBCs Megaloblastic erythroblsats with up to 12 nuclei
69
Describe myelophthisic anemia
Due to infiltration of abnormal cells into the BM and subsequent destruction and replacement of normal hematopoietic cells - Leukoerythroblastic
70
What is the primary cause of anemia in chronic kidney disease?
Inadequate renal production of EPO
71
Define cytogenetics
The study of chromosomes, their structure, and their inheritance
72
What is the purpose of cytogenetic testing?
To analyze chromosome disorders
73
Why might cytogenetic testing be ordered on a patient?
Intellectual disability Infertility Ambiguous genitalia Short stature Fetal loss Risk of genetic or chromosomal disease Cancer
74
What is metaphase and why are metaphase chromosomes important in cytogenetic testing?
Metaphase is the stage in mitosis in which chromosomes align on the equatorial plate. This is important because they are highly condensed and have a high mitotic rate
75
Define haploid. What is the haploid number in humans?
Haploid represents gametes and have half the diploid number (23 chromosomes in these cells) it is represented as "n".
76
Define diploid. What is the diploid number in humans?
Diploid is the number in dividing somatic cells and is 46 in humans. It is represented as "2n".
77
Nucleosome
DNA looped around a core of histones
78
Solenoid
Nucleosomes are coiled into twisted forms
79
Metacentric centromeres
Centromere located in the middle of the chromosome
80
Submetacentric centromeres
Off centered centromeres
81
Acrocentric centromeres
Located at one end of the chromosome
82
Mitogens
Stimulate division of specific cell types
83
p arm vs q arm
p arm = short arm of chromosome q arm = long arm of chromosome
84
What is Q banding?
Differentiates chromosomes into bands of differing widths and relative brightnesses Utilizes a dye called quinacrine mustard which binds to A-T rich areas
85
What is G banding?
The most common method used for staining chromosomes Utilizes Giemsa stain, stains A-T rich areas
86
What is C banding?
Stains the centromere and the surrounding condensed heterochromatin; Giemsa stain used
87
Karyotype
Summary of the chromosome analysis, resulted into a karyogram (picture of all the chromosomes aligned from 1-22)
88
Describe FISH. What information can FISH results provide?
A molecular technique used to detect and locate a specific DNA sequence on a chromosome - Can provide information on structural/numeric abnormalities of chromosomes, Ability to diagnose
89
How would the karyotype nomenclature look like for a patient with a Trisomy of chromosome 8 in a male?
47,XY,+8
90
What would the karyotype nomenclature for a normal male and female look like?
Male: 46,XY Female: 46,XX
91
Translocation
Designated "t", gene has moved from one area to another
92
Deletion
Designated "del", gene has been deleted from a chromosome, loss of the segment
93
Aneuploidy
ANY abnormal number of chromosomes that is NOT a multiple of the haploid number (23)
94
Trisomy
Presence of an extra chromosome
95
Monosomy
Absence of a single chromosome
96
Polyploidy
Chromosome number higher than 46, but is ALWAYS an exact multiple of the haploid chromosome number (23) Ex. Triploidy and Tetraploidy
97
Triploidy
Karyotype with 69 chromosomes (3n)
98
Tetraploidy
Karyotype with 92 chromosomes (4n)
99
Hypodiploid
Cell has fewer than 45 chromosomes
100
Hyperdiploid
Cell has more than 46 chromosomes
101
High hyperdiploidy
Cell has more than 50 chromosomes
102
Inversions
One or two breaks in a single chromosome, no loss or gain of material
103
Insertion
Movement of a segment of a chromosome from one location to another
104
Duplication
Partial trisomy for part of a chromosome
105
What would Down syndrome nomenclature look like for a male?
46,XY,21+
106
What is the tissue most frequently used to study the cytogenetics of a hematologic malignancy?
Bone marrow
107
What abnormal chromosome is associated with CML and how is it treated? How is the treatment monitored?
Philadelphia chromosome Treated with imatinib mesylate Pt response is monitored by cytogenetic analysis and FISH
108
What is the amplification of HER2 gene on chromosome 17 associated with?
Aggressive form of invasive breast cancer
109
What is a good prognosis for childhood ALL?
>50 chromosomes (high hyperdiploidy)

Hematology (10 decks)

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