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Bone marrow biopsy is the conventional staging and posttherapy evaluation method for assessing marrow involvement by lymphoma. Polymerase chain reactions (PCR) for antigen receptor rearrangements have the potential to increase the detection of minimal degrees of marrow involvement. The present study is a concurrent morphologic and PCR evaluation of 225 staging or posttherapy marrow biopsies from 127 patients with B-lineage non-Hodgkin's lymphoma. The biopsies were morphologically categorized into four groups: group 1 (positive for lymphoma), 60 biopsies (27%); group 2 (suspicious for lymphoma), 20 biopsies (9%); group 3 (lymphocytic lesions of indeterminate biology), 22 biopsies (10%); and group 4 (negative for lymphoma), 123 biopsies (54%). Molecular studies were performed on concurrently obtained aspirates and used consensus immunoglobulin-heavy-chain (IgH) and IgH/bcl-2 gene PCR primers. A molecular clone was detected in 53 of the 225 aspirates (24%): group 1, 34 aspirates (57%); group 2, five aspirates (25%); group 3, one aspirate (5%); and group 4, 13 aspirates (11%). A PCR-positive aspirate was present in 47% of follicular lymphomas, 58% of diffuse large cell lymphomas, and 72% of the other lymphomas in the group I specimens. Morphology or PCR was positive in 79 of the 225 cases (35%). The molecular detection of clonality in the aspirate DNA from cases with positive morphologic findings was lower than anticipated. The discordance between morphology and PCR results may be related to sample variation between the trephine biopsy and aspirate, a failure to aspirate sufficient lymphoma cells, or insufficient primer homology for amplification. DNA extracted from trephine sections may provide results more concordant with morphology, because PCR detected a clone in 10 of 11 DNA specimens extracted from trephine biopsies with positive morphologic findings and PCR negative aspirates.

Patients in accelerated phase or blast crisis of chronic myeloid leukemia (CML) frequently develop clonal cytogenetic abnormalities in addition to the Philadelphia chromosome. Using a DNA probe directed to the centromere of chromosome 8, we performed fluorescence in situ hybridization (FISH) on archival Wright-stained blood and bone marrow smears of seven patients with CML and with a known +8 clone by metaphase cytogenetics to determine the distribution of +8 in interphase cells. All slides had been stored at ambient temperature for 12-26 months. The bone marrow aspirate smears of 21 non-leukemic patients served as controls. Trisomy 8 was demonstrated in all myeloid cell lines including the neutrophils, basophils, eosinophils, monocytes, and erythroid precursors, but not in the lymphocytes. The extra chromosome 8 was present in mature segmented granulocytes as well as more immature precursors. The percentage of +8 cells was highest in specimens from patients with CML in myeloid blast crisis (mean 64%), followed by those in accelerated phase (mean 39%). Three specimens from patients in morphologic chronic phase showed the lowest percentage of +8 cells (mean 13%). One patient was studied twice and showed a substantial expansion of +8 cells with progression from accelerated phase to myeloid blast crisis. Compared to metaphase cytogenetics, the proportion of +8 cells detected by FISH was often lower. We conclude that the acquisition of trisomy 8 in CML occurs in a pluripotent myeloid stem cell apparently incapable of expressing mature lymphoid phenotype, and that morphologic progression of disease is generally associated with an expansion of the +8 component.

Sequential blood and bone marrow specimens from 53 patients receiving recombinant granulocyte (G-CSF) or granulocyte macrophage colony stimulating growth factor (GM-CSF) for neutropenia were evaluated. The blood findings were marked by a neutrophilia with a prominent left shift, increased azurophilic granulation, Döhle bodies, and an elevated leukocyte alkaline phosphatase; circulating myeloblasts were observed but did not exceed 2% of the leukocytes. Nuclear segmentation abnormalities consisting of hyposegmentation, hypersegmentation, and ring nuclei were noted but were not a prominent finding. A leukoerythroblastosis was present in 54% of patients. No consistent effect on cell lines other than neutrophils was found. A monocytosis was present in 12 patients, a transient lymphocytosis in 2 and an eosinophilia in 1. No effect was evident on basophils. The morphologic changes in the neutrophils in the bone marrow specimens were most pronounced in the early period of growth factor therapy with a relative neutrophil hyperplasia with a marked increase in promyelocytes and myelocytes. With increasing duration of therapy, the myeloid to erythroid ratio normalized and the percentage of promyelocytes decreased while myelocytes and band neutrophils increased. Thirteen patients had no response to growth factor. The nonresponding patients were clinically diverse; all bone marrow biopsy specimens in this group were virtually acellular. No differences were noted between G-CSF and GM-CSF.

In the present study we used multiparameter flow cytometry and cell sorting to evaluate fetal bone marrow, a rich source of cells early in lymphoid development. We found CD7 to be expressed on a subset of CD19+ cells, including some that had matured to cytoplasmic mu+ (pre-B) and surface mu+ (B) cells. In addition, a less mature CD7+19+ population was characterized as mu- and CD34+/-. The CD7+19+ population was clearly distinct from the mature T cells. The CD7+19+ cells were negative for nuclear TdT in contrast to CD7-19+ cells, which frequently contained TdT. CD10, which is coexpressed on the cell surface of more than 90% of CD19+ lymphocytes, was detected in a minority of CD7+19+ lymphocytes. The CD7+19+34+ cell population may be B-lineage committed, or may represent uncommitted lymphoid precursors. The biologic role of the expression of CD7 on immature and mature cells, including those of the B lineage, may indicate (1) the presence of CD7+19+ lymphoid precursor cells and/or (2) an alternate pathway of B-cell development, in which cells coexpress CD7 with other B-lineage markers.

Morphologic and clinical features of 30 patients with peripheral T-cell lymphoma (PTCL) were studied with particular attention to bone marrow and blood manifestations. Twenty-four (80%) patients had marrow involvement with lymphoma in trephine biopsies at initial diagnosis; two other patients subsequently developed marrow involvement. The bone marrow lesions were diffuse in 58% of the cases and focal, nonparatrabecular in 42%. A morphologic spectrum of lymphoma cells was seen with cases classified into small cell, mixed cell, and large cell/immunoblastic lymphoma. The bone marrow lesions were characterized by a heteromorphous population of lymphocytes, prominent vascularity with endothelial cell proliferation, reticulin fibrosis, and a polycellular infiltrate composed of plasma cells, eosinophils, and histiocytes. The histopathologic features in bone marrow biopsies were not pathognomonic for PTCL; the differential diagnosis may include non-Hodgkin's lymphomas of B-cell type, polymorphous reactive lymphoid lesions, including those from patients with acquired immune deficiency syndrome (AIDS), angioimmunoblastic lymphadenopathy, Hodgkin's disease, and systemic mastocytosis. The patients ranged in age from 13 to 81 years (median, 61 years) and generally presented with constitutional symptoms, lymphadenopathy, and hepatosplenomegaly. Abnormalities in one or more hematologic parameters were common and, in general, related to the degree of bone marrow involvement. Hypocalcemia was found in 40% of the patients studied and hypercalcemia in 4%. The median survival for PTCL patients was 11 months. Patients with small cell lymphoma, large cell/immunoblastic lymphoma, and marked eosinophilia had the shortest median survivals.

We have evaluated the usefulness of bilateral rather than unilateral posterior iliac spine trephine biopsies in searching for lymphoma and other neoplastic diseases in the bone marrow. Two hundred and eighty-two patients with these diseases were studied. Tumor was found on only one side in 22% of patients with non-Hodgkin's malignant lymphoma, in 43% of patients with Hodgkin's disease, and in 36% of patients with other neoplastic processes. Thus, the second biopsy yields an additional 11% to 22% of positive biopsies. We conclude that bilateral trephine bone marrow biopsies should be routinely performed when searching for tumor in the bone marrow.

Morphological and clinical features of 39 patients with nodular lymphoma were studied with particular reference to bone marrow and blood involvement. Twenty-one patients (54%) were found to have bone marrow involvement at the time of initial diagnosis. Thirteen (33%) also had peripheral blood involvement. A specific cell type, the small nodular lymphoma cell, was found in the bone marrow smears of 19 and the 21 patients with bone marrow involvement and in the peripheral blood smears of all patients with blood involvement. When large cells predominated in the lymph node or bone marrow sections, the bone marrow smears and the imprints of the lymph node and trephine biopsy demonstrated these large cells to have morphological qualities of lymphocytes rather than histiocytes.

McKenna, Robert W., and Brunning, Richard D. Reed-Sternberg-like cells in nodular lymphoma involving the bone marrow. Am JClin Pathol 63: 779-785, 1975. Two patients with cells indistinguishable from Reed-Sternberg cells in bone marrow lesions of nodular poorly differentiated lymphocytic lymphoma are described. Both patients had lymph node biopsies showing nodular lymphoma. Bone marrow and blood involvement with the lymphoma was demonstrated at the time of initial diagnosis. Reed-Sternberg-like cells were not demonstrated in either case until later in the course of the disease, after the patients had been treated with numerous chemotherapeutic agents. Other similarities of bone marrow involvement with nodular lymphoma to Hodgkin's disease of the bone marrow are noted. The origin of the Reed-Sternberg-like cells in nodular lymphoma is not clear, but they could result from morphologicalteration of lymphoma cells by chemotherapy. The finding of Reed-Sternberg cells in bone marrow lesions should be interpreted with caution unless diagnostic biopsy material from other sites is available for study. (Key words: Bone marrow lymphoma' nodular lymphoma; Reed-Sternberg cells).

The clinical, radiologic, ultrastructural, and histopathologic findings in 14 patients with systemic mastocytosis were evaluated. Seven patients had evidence of urticaria pigmentosa (UP) and seven patients presented with no recognizable cutaneous lesions. There were no major clinical differences between patients with or without UP except for splenomegaly, which was present in one/seven patients with UP and five/seven patients without UP and the median age, 44 in patients with UP, and 75 in patients without UP. Bone marrow involvement was present in 13/13 specimens studied. Involvement was both focal and diffuse. The focal involvement occurred frequently in a perivascular and paratrabecular location. The diffuse involvement resembled myelofibrosis. Involved lymph nodes exhibited prominent sinusoidal and paracortical infiltration by mast cells. Splenic involvement was characterized by fibrosis occurring both focally and diffusely. The focal splenic involvement was perivascular and involved both the red and white pulp in a nonpreferential manner. Liver specimens showed prominent portal fibrosis. The morphology of the mast cells in the different lesions varied considerably; some were typical, others were spindle-shaped, and some resembled histocytes. The mast cells reacted positively with toluidine blue and chloroacetate esterase. Six patients had radiologic changes: three were osteoblastic, two osteolytic, and one osteoblastic and osteolytic. Two patients developed a poorly differentiated lymphoreticular tumor and one a myeloproliferative disorder after the diagnosis of mastocytosis.

An indirect immunofluorescent technic was used to identify cells with terminal deoxynucleotidyl transferase (TdT) activity in bone marrow smears from 169 patients without a clinically or morphologically apparent hematologic malignancy: 73 normal individuals, 27 bone marrow transplant recipients, 25 with neuroblastoma or retinoblastoma, 19 with acute lymphoblastic leukemia (ALL) in remission, and 25 with miscellaneous benign conditions. In selected cases, additional bone marrow smears were investigated for TdT-positive cells, using one of two immunoperoxidase methods, the peroxidase-antiperoxidase (PAP) technic or the avidin-biotin-peroxidase complex (ABC) technic. Superior preparations were obtained using the ABC technic. Fifty-eight of the 169 smears contained 2% or more TdT-positive cells, range 2%-20%. The morphologic characteristics of the TdT-positive cells in phase-contrast illumination and in Wright's-Giemsa counterstained immunoperoxidase preparations indicated that many of these cells may be hematogones. TdT-positive cells in the bone marrow of a patient with ALL in remission following chemotherapy or bone marrow transplantation do not necessarily denote relapse.

The incidence, pattern, extent, and morphology of bone marrow involvement in 176 cases of non-Hodgkin's lymphoma (NHL) were studied in relationship to the Lukes--Collins classification. Ninety percent of the cases were B-cell lymphomas; 10% were T-cell lymphomas. In 53% of cases there was bone marrow involvement by lymphoma at diagnosis. Marrow involvement was most frequently found in the small lymphocyte (B), small cleaved follicular center cell (FCC), and convoluted lymphocyte lymphomas. Frequently, the extent of bone marrow biopsy replacement by lymphoma was less than 30%; the pattern of infiltration was predominantly focal (70%). Cytologic agreement between lymph node and bone marrow specimens was always present in small lymphocyte (B), small noncleaved FCC, convoluted lymphocyte, and lymphoepithelioid cell lymphomas. Cytologic diversity between lymph node and marrow was noted in 20% of small cleaved FCC, 40% (2/5) of large cleaved FCC, and 38% (3/8) of large noncleaved FCC lymphomas. In 79% of all involved cases, both bone marrow biopsy sections and aspirate smears were diagnostic of NHL; only biopsy sections were positive in 18%, and only smears were positive in 3%. The Lukes--Collins classification predicts a high incidence of bone marrow involvement for small lymphocyte (B), small cleaved FCC, and convoluted lymphocyte lymphomas.

Blood findings at diagnosis, in 140 adults with lymphoma, were correlated with bone marrow involvement and survival. An abnormal haemoglobin, leucocyte count or platelet count was found in 57% of patients. Lymphocytopenia occurred in 46%. All patients with thrombocytopenia or neutropenia, 69% with leucopenia and 63% with anaemia had marrow involvement with lymphoma. Marrow involvement in histiocytic and stem cell lymphoma was always associated with anaemia. Marrow involvement in poorly differentiated lymphocytic lymphoma (PDL) was associated with anaemia, thrombocytopenia, leucopenia, lymphocytopenia or lymphoma cells in the blood in 93% of patients. Bone marrow involvement was found in only 13% of patients with normal haematological parameters. In the absence of marrow involvement blood abnormalities at diagnosis did not generally correlate with survival. However, among patients with diffuse PDL who had marrow involvement, anaemia, thrombocytopenia and leucopenia adversely affected survival. Lymphocytopenia did not correlate with survival.

Leukemic cells from 13 patients with therapy-related acute nonlymphocytic leukemia (ANLL) were studied by electron microscopy. All of the patients had radiotherapy, and/or alkylating agent chemotherapy for other neoplastic disease 25 to 182 months prior to the diagnosis of ANLL. All cases manifested ultrastructural evidence of a panmyelopathy. All marrow cell lines exhibited nuclear--cytoplasmic asynchrony and abnormalities of cell size. Developing granulocytes exhibited decreased primary and/or secondary granule formation and abnormal granules characterized by irregular shape, large size and internal membranous lamellae. Monocytes showed perinuclear bundles of microfilaments. In some cases, the predominant leukemic blasts showed evidence of early basophil granule development which was not appreciated in light microscopy. Abnormalities in erythroid cells included abundant intracristal mitochondrial iron, large vacuoles, infoldings of redundant membrane and membrane-bound nuclear blebs and intranuclear clefts. Megakaryocytes manifested decreased numbers of granules and demarcation membranes. Excessively large platelets with decreased or abnormal granules were identified; giant compound granules with irregular contour and variable electron density were present. Several of the changes in the developing hematopoietic cells were similar to those described in preleukemia and in certain nonneoplastic disorders. The consistent panmyelosis in therapy-related ANLL together with several uniform clinical features defines a specific clinicopathologic entity.

Bone marrow trephine biopsies were performed on 107 previously untreated patients with Hodgkin's disease (HD). Fifteen patients (14%) exhibited bone marrow involvement. These consisted of two of three patients (67%) with lymphocyte depletion, six of 27 patients (22%) with mixed cellularity, five of 64 patients (8%) with nodular sclerosis, and two who were unclassified. Twelve patients manifested a diffuse pattern of involvement; three, a focal pattern. In eight patients more than 70% of the marrow biopsy was replaced by Hodgkin's tissue, in one patient 50% of the marrow biopsy was replaced, and in six patients less than 30% of the marrow biopsy was replaced. Typical Reed-Sternberg (RS) cells were found in the trephine biopsies in 13 of the 15 patients and mononuclear RS variants in two. Bone marrow involvement was the only evidence of stage IV disease in 10 of the 15 patients. In addition to the 15 patients with initial involvement with HD, 11 patients without marrow involvement exhibited granulomas (six) and benign lymphocytic aggregates (five) in their trephine sections. Hematological parameters were studied in all pretreatment patients. Only in the nodular sclerosis group were these parameters useful in differentiating patients with and without Hodgkin's involvement of the marrow. Seventeen additional patients who had been previously treated at the time HD was demonstrated in their bone marrow were also studied. Large areas of necrosis were frequently seen in previously treated patients and one patient demonstrated cryptococcosis in the bone marrow.

The light- and electron-microscopic features and histochemical characterization of three consecutive cases of malignant histiocytosis (MH) are reported. Each case demonstrated involvement of lymph nodes and bone marrow. In the lymph node, the characteristic destructive sinusoidal pattern of involvement by cytologically malignant cells was present. Phagocytosis by malignant cells was rare and most readily appreciated in the imprint preparations. The major problem in differential diagnosis related to defining the histiocytic nature of the malignant cells. This question was resolved by the demonstration of diffuse cytoplasmic staining with the nonspecific esterase and acid phosphatase reactions as well as the ultrastructural demonstration of histiocytes. Although benign, reactive histiocytes were positive, malignant histiocytes did not stain for lysozyme by an immunoperoxidase technique. In contrast to the uniform appearance of these cases, many reports of MH in the past have consisted of heterogeneous cases with variable histologic appearances from a proliferation of predominantly mature histiocytes with marked phagocytosis to cytologically malignant cells with little apparent functional activity. This variation in histologic appearance is due in part to inclusion of cases of reactive histiocytic proliferations, including the recently described virus-associated hemophagocytic syndrome.

Pretreatment lymph nodes, bone marrow, and blood were examined in 176 cases of non-Hodgkin's lymphoma. By the criteria of the Lukes and Collins functional--morphological classification, 158 (90%) were B-cell lymphomas and 17 (10%) were T-cell lymphomas. Bone marrow involvement was present in 53% of cases: 51% of B-cell types and 65% of T-cell types. Marrow involvement was most frequent in small lymphocyte (B) (89%), convoluted lymphocyte (60%), and small cleaved follicular center cell (FCC) lymphomas (55%). The pattern of bone marrow involvement was most frequently focal paratrabecular in B-cell lymphomas and diffuse in T-cell lymphomas. Blood involvement was present in 50% of cases with bone marrow lymphoma and generally reflected extensive bone marrow disease. There was a higher incidence of both bone marrow and blood involvement in pediatric patients than in adults.