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A,k no\1i lco.l~emenIS •
InuothK110D 7
r an 1 Jl
The red cells and their precursors
,\'0 , ,"<11fo rms and ahnomwl \'arjaTlfJ

Pari 2 «r
., Granu lUl;)tes. monocyte» and
,ne!lilk ,t TytX-Y' CS
... N urnllll and nhnormal [n rm'
" Parl3 f'JI
...yrnphocy tcs , plasma cells a nd
their de rivatives and prccu r""rs
in t>1<ltlo.l a nd bone marro w
Nomla' and otmormat for....,
Part 4
:\h lol:c ll.:incous cell~ trom hone marro..
or Mood S OU:"IS. relicul()oenJot he lial
cc 11s. oaeoclasts and O!ItlNh!as,s.
foret,," cells and parasites
PanS 32<
Im prin ts a nd sections 0 1lymph nodd>
aed spleen
APf'C odi x: staining techniq ues .i T·
A hbrc\ iat ion s
Part 1

The red cells and their precursors

Norm al fo rms and abnormal variants

The nome nclat ure of red-cell prec ursors is co nfusing. Reti culocytes spe nd up to two days in the bo ne
The earliest recognizable member of the red-cell series. marrow before being released into the peripheral blood.
the procryrhro btast , has the cytoplasmic basophilia. the T here they make up nor mally less than I % of the red-
nuclco latcd and moderately lcptochrornatic nucleus cell populatio n and within a no ther o ne to two days lose
and the large cell size gene rally characteristic of the remn ant s of cytop lasmic basophilia which give them
primitive ce lls. It gives rise to a seq ue nce of nucleat ed their cha racte ristic staining properties. and become
cells. the erythroblasts , which progressively develop orthochromati c mature red ce lls.
increasing ly pac hychromatic nucl ei . lose their nucleoli Mature red cells survive some 120 da ys before de-
and their cyto plasmic basophili a and acq uire a rising struction. They ar e normally circula r and fairly uniform
haemoglobi n con te nt, Th is seq uence is subject 10 an in diam eter. but arc readil y distorted by exte rna l
arbi trary divisio n into stages. the co mmonest division pressure . as fro m neig hbo uring cells in a smear. Their
being into three : stru ctu re as bico ncave discs leads to wea ker eosinophil
staini ng at the centre than at the pe riphery. a fea ture
l. Th e baso philic o r early ery throblast . or no rmoblast which is least prominent at the tail of a blood smea r
A whe re the ce lls are most spread o ut and flatten ed . In
2. Th e polychro matic o r inte rmed iate e rythro blast . o r the body of the smea r it becom es more conspi cuou s and
normob last B this normal phenomenon must be appreciated and
3. Th e o rthoc hromatic or late ery thro blast. o r norm o- distinguished from hypochromia .
blast C.
Abnor ma l var iants: nucleated prec ursors
T he re are objectio ns to the use of many of these ter ms.
but the y are all so firmly entrenched in co mmon usage Th e chief cytological variants involving altera tion in
that they must he accepted . When autho rs use diffe rent morph ology rathe r than numbers or relative pro portions
or more elaborate staging and nomenclature they usually o f c ryth rob lasts are as follows:
de fine their terminology. but those who use any of the
syno nyms abov e expect them to he under stood without Macronormoblasts. Cells havin g the general nuclear
furt he r explanatio n. and cyto plasmic morpho logy of normoblasts but an
T he proeryth robla st is not itself the function al ste m increased average cell diamet er. Th ey occur especially
cell se rving as a self-maintai ning progenito r of the in sta tes of active ery throhlast ic hyperpl asia without
nor mo blast series. but is de rived from an earlier haem atinic defects. such as haemolytic anae mias , but
func tiona l myeloid stem cell of unide ntified ' mo rph- may be seen also in the early stages of d isorders that
ology. having pluri pote nt ial capacity for giving rise to subseque ntly become megalob lastic,
cells of eryt hro id. gra nulocytic . monocytic and
megakaryocyte -plate let lines. Mcgaloblasss. The esse ntial morphological cha nge in
Kine tic studies with radi o-isotopically labelled ce lls mcgnlobla sts as co mpared with normobl asts lies in the
suggest that four cell cycles culminating in mitoses more open chromatin pattern of the nucleus at all
occur duri ng developme nt from proerythroblast to late stages of developm ent. T he re is often a de gree of
no rmoblast. three at the procr yth robl ast and ea rly haemoglobini zation of the cytoplasm which appea rs
basophilic no rmoblast stages. and the last at the po ly- excessive for the sta te of nucle ar maturation . and later
chro matic intermediate nor moblast . stage. Nests of megaloblasts may appea r fully or thoc hromic. Mcgalo-
erythroblasts of diffe re nt stages of maturity co mmo nly blasts are lar ger than no rmo blasts of comparable
occur in appositio n around a ce ntrally situated reticulo- maturi ty_ Th ey may sho w mitoti c irregularities . with
endothelial cell . T ra nsfer of iro n may he effect ed in o nc multipolar mitoses.' sometimes asymmetrical. producing
or ot her d irectio n. and the ce ntra l macrophage is ofte n un equal daughter ce lls.'Cyto kinesis may not occu r and
rich in stai nable free iron . Late normoblasts do not giant cells with two or mor e nucle i. so metimes uneq ual
unde rgo a furt he r cell cycle but lose their nucl ei by in size . result . Chromosomes or fragments of chromatin
ext rusion and give rise to marrow re ticulocytes . may become separated from the spindle and constitut
accessory small nuclear masses : Th ese ' Howcll-Jolly or co nta in abnormal inclusio ns. such as the r
bodies' may rem ain in the red cells afte r the mai n bulk chro mat in materia l of the Howell -Jolly bodies.
of nuclear materia l has bee n extrude d. Rosette for- All these ab nor malities may be seen in vaf)i n ~
deg ree and frequ ency and severa l of the m may occur
mation. wit h several chrom atin masses linked by bridges.
togeth er in the same smea r.
may follow a halt of the mito tic process in metaph ase .
Megalo bla ts are present in the marrow in- state s of
B 1:, and folic acid deficie ncy. the com mo nest of which Disorders tnvotving chiefly the red- cell series. and thri r
are Add isonian pernicio us anae mia and cond itions of associated main cytological features
gastro-i ntcsti nal malabso rption d ue eithe r to disease or -
to ga_trie o r intestinal resectio ns. Th e folic acid
Megalo blastic anaemias. These disord ers are charac-
deficiency of pregnancy may lead to megalob lastic
terized by striking erythro blastic abnormalities arising
anae mia. Megalo blasts arc see n also in so me cases of
from deficiencies of e ither vitamin B l 2 or folic acid . The
refracto ry siderob lastic anaemia and in £!)'1bmclJliL
und erl ying bioch emical defect involves a slowing of
m~s . The y may be seen in acute leukaemi as.
DNA synthes is in (he S phase of the cell cycle . due
especially followin g treatme nt with antimet abolitcs .
principally to defective formation of thymidylate . which
is normally depend ent on bot h BJ2 a nd folate as eo-
Micronor moblasts. Sma ll normob lasts with a tcnd ency
facto rs in its synthesis. Nuclear division is thus retarded .
10 ragged cyto plasmic ou tline a nd irre gular sta ining a re
and the patt ern of nucle ar chro matin disposition and
found in slates of iro n deficien cy. Th e cha nges a re most
nuclear- cytopl asmic synchro niza tio n in develop ment is
evident in interme diate , and late normob lasts. which
affected . with the result s illustrat ed in 39-69. In fact,
also show defective haemog lohini zation .
the changes of megalohl asto sis. with increas e in ce ll
Side roblasts. Normobl asts containing free . non -haemo- size and opening of the nuclear chroma tin network . arc
globin, iron are best detected by the use of Prussian detect ahie in most prol iferating cells. such as those of
blue staining , but occasionally coarse accumulat ions of the gut mucosa. and includi ng granulocyte and platelet
free iron may be visible in Romanowsky preparations. precur sors in the bo ne marrow.
The findings in bo ne marrow aspirates and biopsies
include high ce llularity . the hyperplasia involving mainly
Bizarre cytological variants. G ross mitoti c and nuclear
the red -cell series. with mycloid-erythro id (M :E) ratio
abno rmalities. of the same kind as describ ed und er
comm onl y I :1 or even 1:2 - co mpared with the nor mal
megaloblas ts but much more ex tre me in degree . occ ur
in e rythraem ic myelosis. range of 5-20: 1. The re is a shift to the 1eft in red -eell
pre cu rso rs. with a n increased proport ion of large pro-
Reticule cytes e rythro blasts and ea rly basophil ic e rythrohl asts,
num e rous mito tic figures - often sho wing Howell-J olly
bodies - and the typ ical prem ature haemoglobinizat ion
Blood normally contai ns less than I % of ret iculccyt cs
best seen in interme di ate c rythrob lasts. G iant myclo-
and an increase in numbers indicates a heighten ed
cytes and mct am yelocyte s ca n be fo und. as can multi-
o utput of young red cells from the bon e marr ow. Th is
nuclea ted po lymorphs ( 7~) . and par allel changes
may occur durin g the co rrectio n by increase d marrow
involving asynchrony of nuclear- cytoplasmic maturation .
activity of any anaemic sta te . whet her spo ntaneo usly
with gra nular cyto plasm and relatively primitive nuclear
(as afte r an acute haem orrhage ) or following trea tment
structure. so metime s in mitosis. occur in promegak ar-
(as in pern iciou s anae mia aft er BJ2 or iro n deficiency
yocytes , while nuclear hypcrse gment at ion may be
anae mia afte r iron) . Reticul ocyto sis is especia lly
co nspicuo us in mature mega karyocy tes. Macrop hagcs
promine nt in haem olytic ana e mias , whe re great
usu ally show an increase d load of haem osiderin . with
e rythropoie tic activity att empts to co mpe nsate for the
the fast turnover patt ern of small particle s. resulting
shorte ned life spa n of periphe ral erythroc ytes .
from the con sider able co mpo nent of ineffective
In Ro manowsky prepara tion s reticulocyrcs may
erythro poiesis and co nseq uent intra med ullary break-
sometim es be detected as po lychro matic cells. with a
down of non- viable red-ee ll precurs ors.
blue or pu rple tinge. -or much less often may show a
The periphe ral blood find ings include a more or less
scatte ring of fine blue ' baso philic stipples'. Th ey arc
severe ana emi a with normoc hromic but ma rkedly
best recognized . ho wever . by the use of supravit al
macrocytic erythrocytes. the mean cell volume (MCV )
staini ng with brilliant cresyl blue . which reveals a
usually exceedi ng 115 fe mtolitres (ft) and reaching as
netwo rk of fine filaments and dots. Re ticulocytes a rc
high as 150ft. Th e mean ce ll haemoglob in (MCII ) is
ofte n a little lar ger in diam ete r than mature red cells.
raised abo ve 32 pico grams (pg) . but the mean cell
Matu re red cells haemoglobin concent ration (MC HC) is normal . not
over 36% . A nisocyto sis and poi kilocytos is appear ea rly
in the co urse of the anae mia and become increasingly
Red ce lls may diffe r from norm al in their appea rance in
seve re . large ovalocytcs bei ng particularly charac-
stained films by varia tio ns in size (a nisocytos is. micro-
teri stic. but other shapes . including tear-drop poiki lo-
cytosi s. macrocytosis). in shape (po ikilocyt osis. ellipto-
cyte s, may also be see n (711-73) . Th e red cells may
cytosis. sickle cell formatio n. cre scent formati o n.
occasion ally show basophilic stippling ( 126) and I lnwcll-
crenatio n) and in dept h of sta ining (hypoc hro mia .
Jolly nucle ar fragmen ts ( 146). but reticulocytes arc not
ani sochrnmi a . spheroc ytos is. target cell formatio n) .
usually increase d and may be depresse d. As the anaemi a
Th ey may also und ergo fragme ntatio n (schisto cytosis)
pro gresses. occasional late eryt nrob lasts with residual priate immunologica l studies. e nzymology. or haemo-
meg alobl ast ic features appea r in the circ ulation . globin electrop horesis. as the case may be . Neverthe-
Leuc openia aro und 2-t x 10"'/1 is usual in mega lo- less. red-cell morph ology can offe r some useful
blast ic an aemias. pe rha ps especia lly in perniciou s pointers .
anaemia . with neutrop e nia and a relative Iymp ho- Spherocy tes ( 135-137). apparen t in stained blood
cytosis . The neutrophils show a shift to the right with smears as small. deeply stained red cells. are always
increase d nuclear lobulation. most cells having fOUT present in HS and commo nly de tectab le in A IHA .
lobes a nd some hypcrse gmentc d cells having five or six. Elliptocytcs (138) formin g more than 5% of the red-
l Neutrophils may also manifest cellular gigantism - these cell populat ion are virtually confined to her editary
exce ptio nally large cells are known as macrop olycytes . e lliptocytosis. but a few marked ly oval or cigar-sh aped
Platelets may be present in normal number s. but red cells may be found wheneve r gross anisocytosis is
thrombocytope nia is more commo n and is sometimes presen t, as in seve re megalobla stic or iro n deficien cy
severe . while giant platelet s and occas iona l megak ar yo- anae mia and in thalassa emia. and a localized elllpro-
cyte fragme nts provi de furthe r evide nce of megalo- cytotic appe arance may be prod uced in some areas of a
blastic dyst hro mbopoi esis. smear as a spread ing artefact (139).
Echinocytes or 'burr cells' , erythrocytes with numerou s
Haemol ytic anaem ias. Excessive destruction of red cells
surface undul at ions or spicules ( 141), may be pro-
arises from two ver y broad gro ups of causes. intri nsic
duced by exposu re of nor mal 'discocytes' to an alka line
and ext rinsic. In the first group are defec ts of the cell
pH or to vario us cchinocytoge nic factors such as bile
constitution. ranging from heredit ary spherocy tosis acids, lysolecithins and fatty acids. Although the change
( HS). enzyme defects such as pyruvate kinase (PK) and is rever sible, it is associa ted with a tend ency to sphe ring
glucose -6-phos pha tc de hydroge nase (G6 PD) deficien -
a nd subseq ue nt haemolysis. In path ological states.
cies, and paroxys mal noctu rnal haemoglobinuria
echinocytes occu r especia lly in uraem ia. chronic liver
(PNH) . to haemoglobin opathi es such as the th al- disease , and acutely in severe bums and toxic infections.
assae mias and sickle cell disease. The secon d grou p
Acanth ocytes or 's pur cells". erythrocy tes with sha rp
includes acqui red auto- immune hae molytic anaemias spiny irreg ular projections ( 1.13). arc also associated
(A IHA) due to warm lytic antibod ies active at the red- with a haemolytic tende ncy. and occur in heredita ry
cell surface: cold hae magglut inin disease (C HAD) due acanthocytosis or congenital abeta ltpopro teinacm ia.
to high titre agglutinating antibod ies. usually with ant i-I and may develop in liver disease or after splenec tomy.
specificity: and hae molysis seconda ry to toxins. foreign Stomatocytes , cup-shaped erythrocytes which in
an tibodies as in mismatched transfusions, and circu- stained smears sho w an elo ngated slit of central pallo r
latory impedime nts such as occur in microangic pathy. instead of the norm al circular area ( 128 and 158).
thromh otic thrombocytopen ic purpura (TIP) . ren al are found conspicuously in heredita ry stomatocyrosis.
glomerular disease . dissemina ted intravascu lar coagu-
and not infrequently in haemolytic anaemias with altered
lation ( DIC) and artificial vascular prost heses . membra ne pe rmeabil ity. A few may usually be found in
All these conditions share features in common. arising normal blood smea rs. and thei r numbers may be
from the increased breakdown of red cells. with resulting increase d in hep atic cirr hosis and in many generalized
raised levels of seru m bilirubin and disappe ara nce of neoplastic sta tes .
haptoglobins, and attempt s at compensatory marrow
D repanocytes or sickle cells ( 155) are characteristic
erythro poietic hyperpl asia. with norm oblastic prolifer-
of haemoglobin S disease , being produ ced by the
ation. a redu ced M:E rat io. and an outpo uri ng of
crystallization of reduced HbS within the cell.
rcticulo cytes, sometimes accompa nied by late normc-
Codocytes or target cells . bell-sha ped eryt hrocytes
blasts. into the pe ripheral blood . The intense normo-
with a striking target appeara nce in stai ned smea rs
blastic hyperplasia. with oblite ration of fat spaces and
(150. 151 and 153). are especia lly promin ent in thal-
100% cellularity in trephin e sections . from a seve re
assaemia, but are found also in othe r haemoglob ino-
hae molytic anaemia due to PK deficiency . is shown in
pat hies , such as HbC and HbSC disease .
19 and 20. and a less marked but substantial erythro id
Leptocytes, or thin flat ery throcytes (150) . occur in
component in sections from a case of AIHA seco nda ry
the same conditions as target cells. and also in liver or
to non-Hodgkin's lymphom a (N HL) is shown in 21 and
gall bladd er disease with biliary obstruc tion. and after
splenecto my.
Tbe anae mia of hae molytic disease is usually normo-
Schistocytes , red cells with irreg ularly fragme nted
cbromic and neither macrocytic nor microcytic. although
sha pes due mostly to mechan ical da mage (134. 152. 163
~1~ and poikilocytosis are common. Neutrop hil and 164). a rc found especia lly in micro angiopath ic
~1osb may be seen. especially in acute haemolytic haem olytic anae mia and the related states o f DIC . TIP
reaction . but the count is ofte n normal. Apa rt from
and microva scular nep hropath y.
(he acqu ired hae molytic processes associated with
Heinz bodies (160) may be dem onstrable in the red
microan giopa thy, TIP and DIC. where there is seve re
cells in supravitally stained preparation s of blood from
thrombo cytope nia . platelet levels show no consiste nt
patient s with haemol ytic anae mias due to G6PD
trend . The chief morpho logical findings of differential
deficie ncy. unstable hacmoglobins, chemical dam age or
diagnostic value among this wide range of diseases are
thalassa emia. They arc someti mes remov ed by the
therefore to be found in the circu lating ery throcytes
spleen a nd therefor e are parti cularl y conspicuous after
themse lves. alth ough they are rare ly pathognomonic
splenec to my.
and need confirm ation or supplementation by appro-
· leucocyte alkaline phosph atase (LA P) sco re.
Haemoglobin H inclusio ns. which stain with supra-
vital cresyl blue a fte r prolo nged exposure ( 162), are A late transition to a myelo fi brotic. state occ urs in
found in the red cells of alpha-thalassaemia. around 15-20% of PRY cases . and when this change
ta kes place the marrow sections show . of course.
A part fro m these vario us pointers. the differential increasing reticulin and fibrosis (as in 30). and the
diagnosis bet ween haemolytic disorders is not greatly peripheral red cells manifest anisocy tosis and teardrop
assisted by morphological featu res present in the pe ri- poikilocytosis. Terminal tr ansformation to a pre-
pheral blood. and the only contributory differential leu kaemi c myelodysplastic state or to fra nk acute
findi ng in the bone marro w. where normo blastic or myelo id leukae mia (A ML) may also occur.
macrono rmoblastic hyperplasia is the co mmon ru le. is Seco ndary polycythaemia or erythrae mia resembles
the existence of strong periodic acid-Schiff ( PAS) PRY in having raised haemoglobin. haematocrit .
posiuvity in the erythroblasts of beta-thalassaemia erythrocyte count and red -cell mass. bu t differs in the
major and to a lesser exte nt in th ose of be ta- tha l- absence of leucocytosis and th rom bocytosis. and . when
assaemia minor. Ot her haemo lytic sta tes o nly ra rely d ue to chro nic cardiovascul ar or pulmonary disease , in
sho w any eryt hro blastic PAS pc sitivity. altho ugh this showing decrea sed arterial oxygen saturation. Morpho-
was a fea ture of foetal haemo lytic d isease . now fortun- logically. erythroid hypcrpla-..ia predominates in the
ately preventable and therefore uncommon where there bone marrow . withou t paralle l increase in o ther
are adeq uate medical services. lineages. and the overall cellularity of sections is
ge nerally less marked than in PR Y. as exemplified in
Aplastic and hypoplastic anaemias. Despite the titular 23.
e mphasis o n anae mia. these diseases arc usuall y
pancyto penias, with acco mpa nying neut ropen ia and Congenital dyserythrop oietic anaemias (CDA s). This
thrombocytopenia. all beco ming progressively mo re group of relatively uncommon disorders is of parti cular
severe as the disease adva nces . and associated with interest to the cytologist because the dyseryt hro poie nc
failure of myelopoiesis. The bone marrow is poorly abnormalities manifest in the erythroolasts are so striking
ce llular. with a predominance of fatty spaces and a and bizarre . There are thr ee main varieties of CDA .
reactive o r inflammatory inliltrat e ranging from a few Type I affects the later basophilic and intermediate
residual islands of Iymphocytes and plasma cells to erythroblasts predominan tly. with megaloblastoid
widespread d iffuse Iympho plasmacytosis. Marrow features and spo ngy chromatin patterns sometimes giving
aspirate s are generally acellular. and firm diagnosis an appearance of irre gularity in the nuclear membranes.
req uires trephine biopsy. Typical appearances at and with occasion al internuclear chromatin hridges.
diffe rent stages of disease arc shown in 24--27. Type 11 . the com mone st form . affects later ervthroblasts
The anae mia itse lf is usually no rmocytic and normo - especia lly. with conspicuous muitinuclea n ty and with
chromic with litt le anisocytosis o r poikilocytosis . and double nud ear membranes seen b)' electro n microscopy.
re ticulocyres arc scanty. In this type of CDA the erythrocytes are susceptible to
Pure red-cell aplasia . witho ut concomitant decrease haemolysis in an acid medium. hence the alte rnative
of granulocyt es and plate lets. and wi th a cellular marrow na me . HEMPA S - hereditary erythroblastic multi -
de void of red -cell precurso rs. occ urs o nly rarely. nuclearity with positive acidified serum test. Type III is
characterized by giant eryth roblasts. up to 70 micro ns
Primary and seconda ry po tycytnaemios. Polycythaemia in d iamet er. with either num ero u separa ted nuclei or a
rubra vera ( PRV) o r primary proliferative poly- single rnultiplo id lobul ated nucleu .
cytbae mia is characte rized by high haemoglobin . Exa mples of all these vari an ts of CDA and their
haematocrit and red-cell count . a raised red -cell mass. mai n cytological and cytochemical features are illu-
oonnal arterial oxygen saturation. rommonly significant strated in 78-88 .
plenomegaly. and usually elevat ed to tal leucocyte and
platelet counts. It is thus a pancytosis. and the high Erythruemic myelosis and erythroleukaemia. Alt hough
peripheral blood figures reflect a chron ic neopl astic an acute neoplastic state with vast preponderance of
myeloprolife ra tive state involving all cell series in the erythroblasts has lon g been recognized as erythrae mic
bone marrow (28 and 29). whe re fat spaces arc much myelo sis or Di Gu glielmo's disease. it is probable that
reduced in trephine sectio ns and trilineage hyperplasia this occ urs rarely if ever as a pu rely monolineage
ma) approach 100% ceJl ularity. Cytogenetic st udies in disorder. but that it is almost always. if not always. a
the stable ph ase of PR V re vea l non -random chro mo- bilineage o r trilineage disease from the sta rt, with
somal abnormalities in many patients. trisomy H. trisomy involve ment to a greater or less exte nt of the gra nu -
9. 5q- and. especially. 2Oq- being the most com mon . locytidmonocytic line and the megakar yocytic line .
thus co nfinning the clo nal neoplastic nature of the The name 'eryth roleukaemia' is the refore strictly more
disea se . Morpho logica lly. there arc few changes from co rrect in all cases. although erythrae rnic myelosis is
normal. with e rythro poiesis normoblastic and eryt hro- still co mmonly us-ed for cases where the erythroid
cytes no rmoc hro mic and normocytic. and with bot h co mpon ent is clearly dominant.
gra nulopoiesis and th rom bopoiesis regular and cyto- Cytoge netic abno rma lities are found in the maj ority
lo gically typical. apart from an occa sional increase in of cases . including (he co mmones t AM L alte ra tion.
basophils and a few gian t plat elets. at least during the trisomy 8 (8 + ), and defects of 5 and 7. but multipl e
main course of the disease . The one abnorm al cyto- nume rical and structural abe rra tions are usual. Th e
chemical fea ture almost invariably fo und is a raised cyto logy of the neoplastic erythroblasts in the bo ne
marrow and in the blood . where they may be numerous. cvt osi s and poikilocytosis ( 0 1 and 133 •
vane... fro m relauvelv normal to zrosslv bizarre (89-95) . indices, ~t C \' . ~ICH
and MCHC. aD O«_I<cla::1_ .....
C~ tochemica llv. the~ usually show conspicuous PAS The leucocyte co unt tends to be 10.... or DOl t

IX Iti\ ity (98- 102). and ofte n strong localized acid platelet count is often raised . U ntil ,rOIl U·. .......
pho-phatasc reactions ( 103 and I~ ) . started the rericulocvte count is 10.... and
pe ripheral polyc hromasia . Ervthropoese, iD
Refractory sideroblastic illJaemias (RSA 'i ). These dis- ma rrow is hype rp last ic. but with a bnonnal ~106~
o rde rs are characterized by a n overload of iro n in the e ryt hroblasts being small. poorly hac TTlOgIobiDizrd.
bo ne marrow ( 112) . and by hypercellular micronormo- ofte n with irregular and ragged outlines ( I aDd I
bla stic or occasiona lly rne galo basti c e rythropo iesis. The y may contai n PAS-po siti\·e mat e rial (l J
Coa rse sidero tic gra nules . demon strabl e by the Prussian marrow is not abl y de void of free iron whether in ~
blue stain. a re found a rra nge d in a rin g around th e phages o r e xtra-ce llula rly in part icles a nd flee s ( I l l
nucleus of man y c rythro btas rs. T he a ppea ra nce is mo st and there ar c virtually no sideroblasts or siderocy
st riking a nd involves the highest proportion o f These cyto logical features a re really diagnostic.
c ryth rob lasts in cases of primary acquired RSA . a nee- co nfirmat ion is give n by the findin g of lo w serum lTOO
pla...tic mye lodys plastic sta te which may tran sform to a nd rai sed total iro n-binding ca paci ty (TIBe) , .... ltb
• A ~ lL. Exa m ples o f the cyto logy a nd of ringed sidcro- decreased sa tura tio n and a low se ru m ferritin level.
blu ... ts are shown in 113-116. In hereditary RSA and in Other microcytic hypochromic a na e mia- generally have
acq uired cases seco nd a ry to age nts such as iso niazid, clear distinguishing features : the anaemia of chronic
cyclose rine . chloram phe nicol. a lco ho l a nd lead. th ere disorders. for e xa mp le. shows a n increase o f large-
a rc ue ne ra l!v fewe r sidc roblasts. a nd ontv interme dia te particle free iron in th e mar ro w. decreases in both serum
a nd ~I ate ervth roblas ts a rc affected. . iro n a nd TIB e . and norm al or ra ised ferritin . while
PAS posit ivity is found in a p ropo rtio n of the crythro- thalassaemia a nd HbC a nd H bS C diseases show con-
blas ts in so me cas es o f RSA . alt ho ug h the reaction is spicuo us target ce lls a nd increased marrow iron .
usua lly m uch we ak er than in c rythracrnic crvthroblasts
1118). Leucoervshrobtastic anaemia (myelophthisic anaemia.
myeloid me/aplasia). T his co mp lex form of a naemia -
A1W('mia ofblood loss und iron deficteucv. Acute blood with th e a ppea ra nce of bot h e ryth roblas ts a nd granulo-
lov, insuffici e nt to produce ca rd iovascular collapse cytc prec urso rs in the periphe ral blood . and with
re... ults in haemodilution and th e de velop me nt. o ver a moderat e ly seve re a nisocytosis a nd po ikilocytos is . the
pe riod of 2-1. hours or so. o f an anaemi a which is normo- latt er ofte n including dacr yocytcs - a rises when the
ch ro mic and normocyti c. hut usu all y associa te d with marrow is infiltra ted with met ast ati c tumour cells or
come increase in rcti culocytc s and a pa ralle l rise in othe r forei gn tissue . Megakaryocyt e fra gmen ts may he
le ucoc yte and platelet co unts as marrow act ivity is see n in the blood , and platele t morphology is frequ e ntly
-tim ulare d . a bnormal with distorted o r giant forms .
Ch ro nic blood loss leads to the developme nt of iro n Bone marrow aspira te s o r trephine biopsies re vea l the
dcficic ncv a naem ia. a nd is th e commonest cause by fa r nature of the infiltrate . Exampl es of ca usative invasion
of this d;s0rde r. cha rac te rize d by fallin g hae moglobin a rc illu strat ed and de scr ibed in Part -1.. but the resulting
.... 1Ih initia lly microcy tic a nd lat er hypoch ro mic red cells red-cell morphology ge nera lly resem bles that show n in
.... ith increasing ce ntral pall or a nd progressive aniso- 1.' 1.

- (

I 2


1-12 Romanowsky stains of bone marrow aspirates. 3

1. A sequence from procrythroblast through early.
intermediate and late normoblasts to non-n ucleated red
ce lls. The gradual progression in nuclear and cyto-
plasm ic maturation shown here indicates th e art ificial
nature of the arbitrary division into stages .

2. A proerythroblast and six intermediate-t o -late

no rm oh lasts . The procrythroblast has deeply basophilic
cytoplasm with a paler area to one side of the nucleus.
commonly seen at this cell stage. as in the proerythro-

blasts in I and 3 . and probably representing the Golgi
region . The nucleus has seve ra l poorly defined nucleoli .
recognizable as bluer areas in the centre . The normo-
blas ts have pachychrom atic nuclei and cytoplasmi c
hacmoglobinization. giving a polychromatic-to -
orthoc hromatic co lo ur in co mpariso n with the fully
hacmoglob inizcd and or thoc hroma tic co lour of the
ncig hhouring erythrocytes. T he field also conta ins two
lyrnphocyrcs and an eos inophil po lymorp h.

3 . A procrytbrobl ast and two ea rly normoblasts.

,I , s

~ A proeryt nro btasr in early prophase of mitosis. The

MKkar chroma tin i ~ Ilegmning to conde nse into distinct •
cbromo<;omes an d the integrit y o f the nuclear membrane
a divupllng. sho wing a reas of cytoplasm through t he
eeeee of the chromatin rna..s. Below a re a late no rmo-
bIMt a nd a Iympbocyte. a nd a bove is a cell of unce rtain
..mre, ~ ..ibly 11 poorly gra nular myeloc yte .

S . A proe ryt hro bta st . a [;IIC normoblas t and an early

.... nlObla..1 o r proeryth rnblast in mitosis (metaphase ).

•A group of normoblas ts with acco mpa nying granulo-

~ (or compa riso n. The ten normoblasts ra nge from
~ basophilic tolntc orthochrom atic stages . illustrat-
~ w reduction in size. progressive nuclear coo-
dt=-Uon a nd inc reasing cytoplasmic hacm oglohini-
PM__ tha t occur with mat urati on . The gra nulocytes
- heck a n eosmopt nt. two neut rophil stab cells, an early
."Dphil myelocyte a nd two mc ta mye locytes. The
• -aIUR' granu joc ytcs have' lighte r nuclei than the
d}rt ~l~. and pale , wea kly gran ular cytopla..m .

.. .. . h w 5ayJl

7. A not her example of proph ase o f mito sis in a pro- 9

e rvt hro blast. Th er e is evide nce of abnorrnulitv in th e
irregular loss of cytoplasmic basophilia and" in the
separa tio n of fragments of cytoplasm by a n exagger ated
process of buddi ng or exocytosis. The mature red cells
sho w rouleaux for ma tion. The cell below th e pro-
eryt hro blast is a no rmal neut rophil pol ymor ph. but the
one ab ove is a weakly granular mature neu troph il with a
single nuclear lobe - an examp le of pseud o Perger -Huct
phenomeno n - sugges ting tha t granulopo iesis is also
dysplastic. This ma rro w aspir ate is in fact fro rn a patient
with a refractory anae mia and dys myelopoiesis - ;'1
myelodysplas tic sta te (MDS) .

a nd 9. Two furt he r fields from th e sa me marrow

aspirate. both showing the dimo rp hic red -ce ll picture
comrnonlv found in MDS. with a mixtur e of eithe r
macrocytic or normocytic norm ochrom ic cells and
microcytic hypochrom ic ones. Ea ch field also co ntains a
proc rvt broblast o r ea rl)' basophilic normoblast with
con spicuous cvtoptasrnic budding - an exaggeration o f a
feature often sho wn less markedly by normal early red -
cell pr ecu rsors. In 8 the re is a neutrophil with fragment-
ing cytop lasm. and in 9 a pseudo Pelger- Huct
polymorph and an early myeloc yte with a hand-mirror
disto rt io n of tr ailin g cyto plasm.

10 11

I A group of normoblasts with two gra nulocytc 12

precu rso rs and a plasma ('C II. for comparison . The
~ a ce ll is at the upper left of the field and differs in
appeara m:c from the early and intermediate norrno-
by the more marked eccentricity of its nucleus and
1bc' greater amo unt of cytop lasm. Nevertheless. these
cxII types may o ften be difficult to distingui sh . since the
-=leaf chro matin patterns tend to he similarly coa rse ,
.cl no rmo blast nuclei arc often eccentric. as shown in
11 md I ! .
11 aDd 12. Nests o f normoblasts 'a round a central
oohagc. These er ythroblast island s ar e a common
in norma l ho ne marrow. serving the purpose o f
e cha nge betwee n the macrophage and the
..."oan"ing e rythrobJasts. There arc probably two
"Ol""l3g~ in the island sho wn in 11, their cyto plas m
v and with ind istinct outlines. but their nuclei
...-,_zable in the central a rea and at th e right -hand
of the ce ll clu mp by their light reddish-purple
..._..,. nd lcp toc hro matic density . as compar ed with
-black co lo ur and pachychromatic density o f
_rmobla t nuclei. Th e macrophages in both th ese
co ntain o ne o r two large iron particles.
"'-III! e- an o ra nge co lour in th ese Romanowsky prcp-
60. . ._ .. bu t I~, grossly particulate free iron is not
lbout special stai ning . as in 14 and 15.


13. Nor mo blasts aro und a macrophage - alkaline 15

phosphatase reaction . Th e stro ng po sitivity of the
macrophage spills ove r to give thr eads of posit ive
reaction over the surface of contiguous normoblasts.

14 and 15. Nests o f no rmobl asts around a centra l

macro phage - Prussian blue stain for free iron. The iron -
co ntaining cyto plas m of the macro phage e xte nds as a
long broad tail across the field in 15. Th e central
macrophagcs ofte n co ntain a few remn ant s of ingested
cellular fragments. and in the upper island of 14 these
are more striking tha n usual . with three o r four ghost
areas proba bly representi ng the sites o f inges ted
erythrocytes, and the encircled nucleu s of a lat e
normoblast. The lower island in the same field shows the
macrophage cyto plasm exte nd ing around and between
the neighbouri ng late no rmobl asts, hut not convincingly
ingesting them. If multiple red cells and norm o blasts
were in fact being engulfed. (he existence o f the path o-
logical state of malig na nt histiocytosis wou ld have to be
co nsidered .
16. Nor mal mature r ' ells. from the tail of a blood
mea r... trior var iatio ns in size and depth of sta ining are
:" ", ,-'f""!I-"'---"I!""_ IX
seen. toget he r with occasio nal pre ssur e distortion of
hape ,

I . ~ 9rmal mature red ce lls from the hod y of a blood

mear. The re is a grea te r te nde ncy her e for ce ll!'> to
o verlap o ne ano ther. and the weaker staining of thc
ce ntral a rca is more evide nt.

Mixture of normal adult a nd cord blood red ce lls

- Kle ihauer reaction. The HbF-containing co rd ce lls
remain untysed. while the Hb A-cont ainin g adult ce lls
. hae mo lysis. Acid and alkali resistance less mark ed
than chat of co rd cells but greater than that of
DOI111al red cells may be sho wn by the red cells in
beredital)' persistence of HbF and in some thalassaernias.
19 20

19 and 20. Trephine biopsy of bone marrow , sta ined I

by H& E . ffi)m a- patient with an auto -immune haemo- •
lytic an ae mia (A l l tA ) . showing i nten~~ryth rQb lm;t ic
hyperplasia, Th e low-power view ( 19) shows the suh-
• e
stantially complete re placeme nt o f fatt y spaces by pre-
dominan tly ery th ro poietic marrow, with o nly a few
• ·• • ••
• .'
•• •• •
clumps of gra nulocyte precursors having light er nuclear
sta ining and mor e cyto plasm than the eryt h roblasts . and
three o r fou r mcg aka ryocy tcs . In the high er -po we r field
(20). there is an ove rw.. helming preponder an ce of

•• .'.• • ••

eryt hro blasts. with all stages of maturity rep resent ed .

from proeryt hroblnsts to late normohlasts. There is no
• • •
uggestion of megalob lastic cha nge . Nuclei freq ue nt ly • ••
appear ecce ntric. so me times sufficic ntly so as to mimic • • ••
plasm a ce lls. hut it is doubtful whether there are act ually • - I. ••
•• •••
•• • • • ••••• ••
fII' •
any plasma cells present. A sma ll number of neu trophil
polymorp hs, with twisted and seg me nte d nucle i. ca n be
•• ••
made o ut .

21. Trephine biopsy of bone marrow . sta ined by

H&E. from ano ther patient with AIHA. in this case

•..' •

• ••••
.: • • ••
• ... •
secondary to a lymphoma wit h sple no mega ly. The •
• •
overall cellularity here is less than in the previou s
sections. with about 40% of the marrow occ upied by fat. • •
but erythropoiesis again predomina tes . includ ing
er yth ro blasts of all stages and . in this field . conside ra ble •
num be rs of mature red cells . There is no evidence of
infiltratin g lymph om a cells in th is speci me n.

• •••

22. A higher-power view of part of the field sho wn in 21
'A herevirtually all of the ce lls can be c1carl y identified as
o f the erythroid series. Th e largc proeryth ro blasts with
leptochro matic nuclei and conspicuo us nucleo li arc •
pa rticularly well shown .

23. H& E-staincd section of marrow trep hine biopsy • •

from a patient with polycyt haemia (or more properly ,
eryt hrae mia) seco ndary to chro nic lung disease. The
IT O""" sho ws increased cellu larity . with reduction in fat
and a prcdominance of eryt hropoiesis. and with
OlbC'r cell series present in red uced amount . Contrary to
u ual finding in polycythaemia rubra vera (PRV) . ,
daere is no increase in mega ka ryocytes . Th e re is co n-
of sinuses and conside rable haem o rrhage.

1-1 In co mplete contras t to the previou s hyperplastic

, •
this treph ine biop sy of iliac cres t ma rrow fro m
a _ ng: wom an with a dru g-induced severe aplastic
aaacmia shows loss of virtuall y all haemopoi eti c tissue .
ooJ ~· a few rcsid ual lymphocytcs distri buted among • •
e ensive fat SP;;ll'CS~ and little to suggest any reactive , ~ '.
mato ry increase in perivascular Iymph ocytes • •
plasma cells - thus grade 0 histology. T his non -
reoct"·'" ma rrow picture may indicate a reduced likeli- •
of response 10 anti-lymphocyte globu lin or o the r
____ ppr ive therapy. ,,' .

• •

• •

25. An iliac crest tr ephine biopsy from a you ng woman 27

with pe riphe ral blood pancytopenia whose marrow
shows moderately se vere hypoplastic changes. Fatty
spaces co nstitute over 90% o f th e mar row and. apa rt
from mature erythrocytes. residual haemi c ce lls ar e •
scanty. wit h merely a scattering of Iymphocytcs and
plasma ce lls. and no gran ulocytes in this field. Ncve rthe-
le ·S. there are severa l norrn o hlasts present and this
offe rs so me prospect of recover y. wheth er spo nta neo us
or in response to trea tme nt. Bone marrow aspirate at
this tage yielded on ly blood .
26. A furt he r biopsy from the same pa tient during the
recovery pha se. following treatmen t with nnti-lympho-
eyre globuli n (A LG ). Active haem opoi esis now
occupies 7~% o f th e tot al marrow . wit h nume ro us
island of normob lastic hyperplasia and of early

gra nulocvte precursors.
27. T rephine biopsy from a you ng adult with severe •
a plastic anaemia. sho wing almost co mplete loss of
haemopo ietic acti vity. Th e few residu al nucleated ce lls
are chiefly lymphocyt cs . Th is ma rro w picture . gra de 0 •
histo logy. when associa ted with very sev ere pe riphe ra l
pancytopenia . ma y· indicate less cha nce of response to
ALG than o ne with a more co nsiderab le increase in
inflamm ato ry infiltr ation by Iymphocytes an d p lasma
cells - whe the r modest (gr ade I ). mar ked hut irregularly
distributed (grade 2). o r marked and diffusely distributed
{grade 3) .

2S and 29. Respecti vel y thi ck (6-micro n) and thin (2-

micro n) sec tions o f iliac crest tr ephi ne biopsy from a
patient with PRY in a stable erythrocyto tic phase. Both • .. "• • • .. -

.. ,. *

show overall increased cellularity with trilincagc involve-

me nt - erythroi d . gra nulocytic and megakar yocytic. In
• • • • I
2S the black nuclei of the thicklv sectioned nor moblasts • •
allo w their relat ive proport ions to be assessed easily. •
and the megakaryocytosis can be readily appreciated.
while in 29 the finer details of cvtoloav in the thinner
section permit more accurate identification of individual

•"'L Section of marr ow trephi ne biopsy fro m a patient

• .
with long-sta nding PR Y . now moving into a phase of
mvelo fibrosis. as occurs in abo ut 15- 20% of case s. The
, ••
sectio n shows persiste nce of trilin eage hyperpl asia , hut
(here is now a strong com po nen t o f fibro blustic prolifer-
• ••
atio n , and th e picture is beco ming ind istinguisha h le
fro m that of idio pa thic myelofibrosis ( I~1F) or .. • ••
agnoge nic myelo id met apl asia ( A M M). At this stage the
raised haemoglob in and red-ce ll co unt ten d to fall
towa rd s normal. while splenomegaly increases. and
tea rd rop po ikilocytes appear in the blood . A ttem pts to
asp irate marrow arc likely to yield a d ry tap .
• •-.
• •
. .. '.

31 32


32. Ear ly and intermediate rnacronormobl asts . showing

cytoplasmic maturation with accumulation of haemo-
globi n in some cells 10 a degree more advanced th an
would no rmall y accompany their stat e of nuclear
matu ration.

33. Macron orrnobl asts. from early to late stages . Th er e

is a lymphocyte o n the right.

3-$. A gro up of four basophilic norrnoblasts derived

from a single cell as a result of two recent successive
mitot ic divisions. with the cytoplasm of each pair still
linked by fine th rea ds of ce ll membrane. and with a
further cross-loo ping of the threa ds. To the left arc two
inte rmediate-l a-late normobJ asts with dense nucle ar
chro matin and polychro matic. partially haemoglobin -
izcd cytoplasm . and at the bottom right is a late
norm ob last shedding its nucleu s.


35. Late telo phase of mito tic division in a macronormo- 37

blast. with daughter cells eac h containi ng two uneq ual
nuclear masses. A mature neutrophil and a myeloc yte
are also present.

-:»: Periodi c acid-Schiff (P.AS) reac tion on a no rma l

bo ne marrow as~rale. shcmiilg an erythrob lastic island
;Iiound a macroPhage. Th e macrophage nucleu s. with
an o ~ n chromatin network . is in the midline a third of
the way from the bottom . and its cytoplasm . with a
scatte ring of PAS-positive gran ules especially towards
the ma rgins. spreads o ut between the ce lls cluste ring
around. Among these are 14 cryt hroblasts. all PAS-
negati ve. as are four others in the top-ri ght corn er.
Across the lower part of the field arc several gran u-
jocyt e-s. with a gro up of immat ure cells on the lef t. and a
stab ce ll and a matur e segmented neut rophil o n the
right. These show the typ ical increasi ng PAS positlvity
l ib increa sing cell maturity. A single plasma cell just
\ e the pro mye locyte shows moderately intense PAS

_ . Macro no rmo blastic hype rplasia in foeta l haemo-

~tic disease. sta ined by the PAS reaction . Normal
~I) throblasts are PAS-ne gativc. but positive material is
f~nd in foetal haemolytic disease. tha lassaemia. iro n
deficiency anaemia. refr actory sidc rob lastic anae mia
and erythrae mic myelosis or eryt hro leukaemia. Here .
late ervr hrob lasts sho w moderately heavy positive
3H 39

• •


.lX. Haemorrhage and hyperplastic areas of ery thro- , .&n

poie tic ac tivity. tog ether with an increase in rncg akuryo-
cytcs. in it trephine biopsy of bon e marrow from an
elderly patient with idiopathic (auto- immune )
thrombocytope nic purpura (fT P) . Two of the mega-
karvocyrcs arc immat ure . wit h single ""Iohed nuc~
i"i romhwn in thisdisorder. I here IS no (hcl all ma rrOw
hype rpl;:i'Si'aiif t hi~ rx:um c n . and a normal proportion o f
fat spaces rema ins.

39 and .w. Respectively low- and high-power fields

from a marrow biopsy sec tio n taken from a patient with
Brc deficiency seco ndary to int rinsic facto r deficie ncy -
pernicio us anae mia. T he first field (39) gives a good

impre....ion of the moderate degree of hyperpl asia . with
no great diminution in rat spaces in this case . but with a
predominance of e ryth ro po iesis. In the second (.&0) . the
shift to the Icft in c rythro hlasts is appa re nt . with
nume rou ... nucleoi atcd proery throh lasts. and a sugges-
tio n of rncgalobla..tic cha nge can he appreciated . Never-
th eles.... the histological de tai l is much inferior to the
cytological detail evident in smear preparations fro m
aspirated marrow . as sho wn in the illustr at io ns that
follow .


L, ra , vie w o f a marrow sme a r from a patien t

~.... it h pe rn icious anaemia. E rythro blasts grea tly pre-
do minate . and c rylh m po i" sis is ..megalob laWc. Early
tag es In th e seq ue nce from procrythrohlast onwards arc

pa n icularly co m m o n .

-&2. Proerythro blasts (nuclco la te d ) and ea rly a nd

inte rmed iate mcgalobl asts. While the nuclear pattern of
proeryt ro lasts In perniciou s anaemia and ot he r
megaloblastic a nae rnias is no t d istinct ive lv differe nt
!ro;n that o f no rma l proerythrobl asts . th ere is a ten -
delle); for cyto plasm to be more ab unda nt and nucleoli
larg er and more co nspicuo us . Th e field con tain s a late
mega loblast o f large size and havin g an irr egular
pycnotic nucle us. Th er e is also a se pa ra ted fragment of
polychro matic megalo blast cyto plasm.

-15 -16

·0 . An ea rly megalo blast with nuclcol ur traces and deep -17

cytoplasmic basophilia . and an inte rme d iate megalo-
blast o f gigan tic size.

-1.4. A mat ure neutrophil with a proer yth rohlast , an

ea rly-to-intermedi ate megalo blast and a late megalo-
blast. This last cell has not quite reached the stage of
complete nuclear pycnosis. hut contains a Howell -JoJly
body .

4S and -U.. T wo fields fro m a per iphe ral blo od h uffy coat
smear from a pat ient with chronic mye loid leukaemia
(C t L) treated with the antimetabolite hyd roxyurea .
In -15 two basophil's and two neut roph il stab ce lls
accompany two lar ge intermedia te mc galo blasts . a nd in-
..u, arc sho wn a sta b ce ll. two neutrophil polymorphs. a
met am yeloc yte and two late mcg!Uohl asts. widely
sep arated but with inco mple te nuclea r' reconstitu tio n
after a p rece ding mitosis. . /

~ Early . int ermedi ate and late rncgalobl usts. th e last

containing two Howell -Jollv bodies . At the nuclear
margin ~re fo ur addi lion~ 1 chroma tin fragmen ts.
appa ren tly still attached to th e nuclear membrane but of
the sa me character as Howell -Jolly bodies.


57. This series of fields showing mcgulo blasts with

alTO cvtotogicat obno nna ttues ( '0"U'5 from marrow or
pnip heral MoOtI sam ples from patients with pernicious
-.ocmia. and illustrates thut gross abnormalities may be
in rem ediable B I ! 1/(jid ellcy ami are not confi ned
"J throleukuemias .

A giga ntic early megaloblast with four nuclei.

bly res ulting from two co nsecutive incomplete
• ""''''''. with nuclea r divis ion unacco mp an ied by cyto- •
- division.

An intermed iate and a late megalobl ast . the former

..,,...__ nuclear distortion of minor de gree .

intermed iate megaloblast with two nucl ei .

megaloblasts. Onc is gigantic. with two con -
irregular nucle ar masses and a free Howc ll-Jo lly

~ in ular nuclea r mass a pproachi ng extrusion in



• I

53 and 54. Late megalo blast!'. showin g typical nuclear
rosette for mation . probably arising from an incomplete
mitos is with hold- up at metaphase .

55. Metaphase of mitosis in an early megaloblast. The

chro moso mes are notably long and thin and unusu ally
wide ly scatte red .

56. Telophase in late mcgalo blasts. T he mitotic process

has bee n defect ive and several chromat in fragments
(pe rhaps whole chromatids) have been lost fro m the
spindle and appear separate from the ma in bodies of the
reconsti tu ted nuclei . This illustrates the genesis of
Howe fl-Joll y bod ies. -

57. An abno rmal tr ipolar mitosis. approaching

telophase . in a baso philic megaloblast. T wo more early 57
megaloblasts. o ne already con taining a Howell-Jolly
body . usually see n mostly in lat er mcgaloblasts. and a
late erythroblast with pycnoti c nucle us ma ke up the
field .

n intermediate megaloblast and a Iymphocytc (fo r 62

"",'o n) in the blood ,

intermediate megalo blast with nuclear distor-

The eccentric pos ition of the nucleus and the
">CnollCDlr basophilia of the cyto plasm give a resem -
to a plasma cell.

6 t , Late megaloblasts in the peri phera l blood .

'S almost co mple te extru sion of the pycnoti c
........._ With loss of the nucleu s a polychromatic
"'XlI""'~_'le o r young erythrocyte will remain.

proe ryrhro btast and a late megaloblast. sur-

___oN . erythrocytes showing macrocytosis and
ytosis and poikilocytos is. A few sma ll
_""'"JoII ~ bodi es are visible in several of the mature

.. ...".,.
~"" •.-'"L

~ ~
• ~:"$"
, 1"-

6.'. A range o f cryr hrob lasts with minimal mc galo -
blastic cha nge . T he confus ing terms ' intermed iate' and
' tra nsitio nal" rncgalobl asts arc so metimes applied to
such c rythroblasts, whet her ea rly or late in the rnuturu-
tiu n sequ en ce . A late megaloblast with densel y pycnou c
pai red nuclei shows hasop hilic stippling of th e ortho-
chro matic cyto plasm . At the top o f the field is a
ne utro phil metamyelocyte .

(H an d h5. Further gro ups of crythroblasts with minor

rnegalobla...tic changes. The nuclear pattern is mo re
open tha n that of co mparable normoblast s. hUI less so
than in tlo rid mcgal oblasts. The cell at the bottom of (H
is a lymphocyte . and the loss of nucleus from a lute
normoblast <JI the top leaves a stippled red cell . There is
another lymphocvtc at the bottom of the field in 65. with
several neighbou ring plate lets .

,\ se ries of fields illustr atin g recogn izable but 6H

galo blastic cha nges in cryth roblusts from the
8i11TOW of a pa tient in an ear ly stage of perni ciou s
_~_ It i-, interesting to not e tha t ther e is alre ady
red nuclea r-cyto plasmic asynchron y of de-
_. ~_..... ~ wit h conspicuous premature haemoglobin iz-
.-x:om panying mod erate nuclear chro matin co n-
iIe. . . . . . . alt ho ugh the nuclear pattern do es not sho w
. open and fully megalohlastic chro matin net-
ic abno rmalities arc also alr ead y occ urring.
.......tri·ng Howell-Jolly bodies in two lat e megalo-
69 70

69. Further minor megaloblastic changes in e rythro- 71

blasts. The large cell in the ce ntre is a ' giant mctam c lo-
c~h a ract e ris t ica ll y found in perni cious anae mia.

70. Polych rom asia in a Lcishman-stained prepa ration

from the per iphe ral bloo d of a pat ient with a megalo-
blastic anae mia responding to specific treatment. Such
polychromatic eryt hrocy tes tend . as her e . to be larger
than more mature o rt hoc hro mat ic cells . and with crcsyl
blue supravital staining are shown to be rcticulocytes.

71. A simila r specimen to 70. stai ned with cresyl blue

supravitally. ote that the haemoglo bin co ntent of the

rcticulocvtes appears high - an element of hypochrom ia

accompanied the megaloblastic changes in this case.
'Dimorphic' pa tterns with macroc ytosis and hypo -
chromia and de ficiencies of both vitamin Bc! (or folic
acid) and iron occur especially in association with
intest inal malabsorption.


~ .

71. Peri pheral bloo d in pernicious ana emia . There arc 74

late mcgalob tasts with nuclear rose tte form ation
Md basophil stip pling (a not he r man ifestation of rei -
yte material). The red cells show macroc ytosis.
.-rosis and poikilocytosis.

- 3. imila r changes in red cells from ano the r ar ea in th e

Yme specimen as appea red in 72. Thi s field includes
JI late meg alo blast and a mult i-lo bed neu trophil
~i1llOrph .

Another field showing macrocytosis. and minor

~ tosis and poi kilocytos is. with a striking multi-
oe utro phil po lymor ph.
75 76

75. A hon e marrow aspirat e sta ined by Sudan black 77

(SB). showing vacuolation in iroc rythrobla sts following
toxic react ion to chlora mp lel11CO . le proe rythrohlast s
are SR negative . while the sudano philic grunulocytcs
sho w no vacuo lation. A simila r vacuo lated <l ppeara n"ce
in early red-ce ll precursors may result from exce ss
alco ho l e xpos u re ,

6 and 77. Examples uf giant p.fOe rythroblasts in the

bon e' ma rro w o f a patient with HS du n ng (he Cd ll) stag es
o f recovery fro m a n a plastic c'iiSi.,. These cells may be so
large a, 10 be mist ake n for mo nonuclear promcgak urvo -
cvte . hut th er e is no doubt th at they arc actually giant
proervtbroblasts. which eme rge . perhaps under the
mnuence of the pa rvovirus. after the temporary cessation
of cl) thropoiesis cha racte rizing aplastic crises of HS and
thought usually to be due to th at gro up uf o rga nisms.
a nd 79. Co ngc nita l d yserythr op oict ic a naem ia
(C OA l. type I. Late r oa ~o p h i l ic and po lychromatic
e rythro blasu chief! affect ed : mt;galoolastoid cha nges;
bi n~d ce lls with intern uclear chromatm bndges ;
~ngy ch romatin with irregular nuclear o utline ,

. CO A, typ£ 11. Late cfvthroolasts chi' . . ed :

ma O'" bi nucleate" cells. double nuclear membra ne is
isible only o n electro n microscopy. In type 11 COA
(he red itary eryth roblastic multin uclcarity with positive
...cidified se rum test - II E!\tP A S) the red ce lls ar c
ptib le to ad d haem olysis.

81. CD A, type II. A furthe r example showing two
erythrob lasts with doubl e nuclei and on e with four
uneq ual nuclei.

82 and 83. C J:) A. typc Ill. Gian t crytbroblasts...-wil b

multiple nuclei or a sillgle large lobulated nucleus
~H . Cytochemical reactions oferythroblusts in ClJA . K7
Tile patte rns iliustruted app ear com mon 10 all types .

84 . PAS reacti on shows weak diffu se . and some finely

gra nular. positivity . much less tha n usual in er ythrae mic
eryt hroblusts.

• . Prussia n blu e stain. Excess free iron in eryt hro-

bla sts. hut no ringed sideroblasts see n.

86. Klciha ue r reaction . C DA ervt hrohl asts and som e

erythrocytes show acid-resista nt ft bF.

. Acid phosp ha tase : nor mal posinvit v in ;'1 1l1;'ICro-

phage an d an eosi no phil myeloc yte . C DA ery throblasts
are esse ntially negativ e. in co ntras t to crythrucmic
I) throh lasts .

Double este rase: normal chlo roace tare est erase

(C E ) positivity in a neut rophil sta b cell : negative
reaction in CDA cryt hrob lasts, unlike th e po sitive
tyra te este rase ( BE) in crythrac mic cr yth ro btasts .
'/0 r 89 . Bizarre nucl ear ab norma litie s in c rvt hr o b tas ts fro m
t he hone marrow of a pat ient wit h c ryt hracmi c mye losis.
Most cells p resen t are erythro h las ts (apart fro m thr ee
pla sma ce lls) a nd se ve ra l sho w m ultiple nucle ar ma sses
of irr e gul ar size a nd sha pe . as well as sma lle r Hc we ll-
Joll y bodi es . At th e to p-rig ht co rne r is a gro up of thre e
ce lls with light -stai ning nucle i. posxihlc nucl eo li. a nd
weak ly ba sophil ic cyto plas m. ,,\..hich ma y he mvclo-
blasts. rep rese nting a rel a tivel y inconspicu o us gra nulo-
eyre pre cursor co mpo ne nt o f Ihis pr edo mina nt ly
c ryt hrac m ic e ryth ro leukae m ia.

90 . Mul tinuc le a ted giant cryt hroblas ts or pr oerythro-

blasts in c ryt hrac rnic my elosis . Th e lntcr e ryth ro bla sts to
th e right. wi th o rt hoc hro mat ic cy to plas m . sho w seve ra l
e xce ptio na lly lar ge nucle ar frag men ts or Ho wcll-Jull y
bodi es se para te d fro m t he ma in 1ll1(.' !cU S.


91- 94. Hi ghly ab no rmal e rythro hlas ts fro m c ryt h-
rac micrnvclosis.
Cc llula"r gigantism. mu ltiple a nd irr egu la r nucl ear
ma..-.c:s and ab norma l mitotic figures occ ur in c rythro -
bla cts at d ifferent stuucs of nuclear ma tur at ion a nd
~ to plasrnic haem oglobin izat io n .
Ab norma lities as st riking and bizarre as these are
virt ua llv restricted 10 c rvth racrnic mvc losis and e rvt hro -
Icul acmias. hut they ' are probab ly not cssc~( ia lly
diffe re nt in kind fro m the simi lar but much less frequent
nd promine nt nuclea r ab norma lities illust rat ed earlier
a, occ u rring in the co mmon megalo blastic anae rnias , or
the freq ue nt hut more reg ular rnulu nuc lca rity of C DA .

- .'
95 96

95. A gro up of procrythroblasts with so me later 97

crythroblasts of var ious stages of maturity surr ound ing
the m . fro m a pati ent with crythracmic myelosis . Mitotic
ab no rmalities were not gross or frequent in this case. hut
e rvthro blas ts vastly predominat ed .

96. Another example of bone marrow cytology in

cryth rac rnic myelosis. Althou gh the ce lls arc mostly
proeryt hroblasts. they show a suggestion of megalo-
blastic cha nge . Ery thro hlasts a rc always negative to S8
and for pero xidase . Thi s smear sho ws a perox idase sta in.
with strong pociuvity in two ncut rophils but a co mplete
absence of reactio n in the red -cell precurs ors.

97. B stai n on a fur the r marrow aspirate from

eryth raemic myelo sis. The e rythro blasts are negati ve .
\\ hilc three gra nulocytc precu rsors show characte ristic
posttivitv .


and 99. Two examp les of PAS positivity in eryt hro- .---- .. ilK)
IS • from erythraernic myelosis. Coa rse granul ar
positiviry is conspicuous in earl y erythroblasts. with •
diffuse positivity. sometimes very intense . in later
eryt hroblasts. Both these fields contain gran ulocytcs ,
four mctarnyclocytes at the top and a possible myelo-
blast ne xt to the diffusely PAS-positive late eryt hroh last
. . and three myelobla sts or early prom yelccyres and
a tab cell in 99. The se cells show the expect ed pattern of
PAS positivity for their respective stages of maturity.
and thei r presence again demonstrates the existence of
multilineage involve ment in eryth raemic myelosis.

_ PAS positivity in two grossly abnormal giant

eryt roblasts from erythracmic myelosis.

101 102


101 and 102. Further examp les o f PAS posmvny in 1115

cryth rae mic e rythrohlasts, o ne in mitosis. Ea rly
gran ulocytc precurs ors in th ese two fie lds sho w negative
reactions. Of . as in the promyelocyte in 102. on ly a weak
diffu se tinge o f positivh y.

HU. Acid phosp hatase In crytbrne rnic myelosis .

Although normal er yt hro blasts also show para nuclear
acid phos phatase positlvity . the reacti on tend s to he
mo re ma rked in certain prol iferat ive sta te s. no tabl y
erythroleu kae mias and megalohlast ic a nac mias . Th e
enzyme in erythroblasts. unlike that in 01(')'1,1 other haemic
cells hut like the acid p hos phatase en zyme in hairy ce lls.
is tart rate resistant .

It.... . A nother case of ervthracmic mvclo sis showing

eve n coarse r acid phosphatase positivity in e rythro -

105. Do uble esterase in ery thrac rnic myelosis. The

early crvthrohlas ts show a mixture of bot h RE and CE
po...itivity , chiefly the forme r. Normal red-ce ll pre-
cursors arc usually negativ e for hot h tiE and CE .
although thc v may exhibit a weak reac tion for acetate
este rase . Th ~ re · is·a neut rophil polymorp h at the lower
left. showing norm al on g positivity for CE .

106 ~1 07. Erythroblasts fro m th e bo ne marro w in IIIK
~de~i~ ncy anae mia. Erythro poiesis is normoblastic.
1 the no rmo hlasts tend to he sma ll. with ragge d
lliI1t.~ arid defective hacmoglon mlzation . The
Ill. joio-crvt broid ratio appea rs no tab ly low in the se
fiellh. with few gra nuloc ytcs prese nt . bu t although this is
ot en th e case in iro n deficiency a nae mia. ery thro id
b~pe rp l as i a is not always cons p icuo us .

I PA S positivity in the small and ragged latc •

eryt bro blasts of iron deficie ncy anae mia . This is a
Ir ue nt hut not inva riab le findin g in iron deficien cy.
Ea rlie r red -cell precursors in thi s field show littl e or no
pcsiu vitv. while th e two metamyclocytcs and onc stab
cdl prese nt sho w the expected stro ng reactions.

109 III


• :

.' I

... ..
; "..
.- . ..
.. .
:.~. r.
~ .

109. Lc ishman stai n of a marro w fleck co nta ining 112

scattered brow nish-black gran ules , prob ably mostly
within rc ticulo-cn dothc lial ( RE) ce lls.

110. Co nsecutive free iron stain on the same field

show ing that the granules reac t for iron
,. '\

111. A cellula r fleck fro m a bo ne ma rrow smea r in iron

deficie ncy anaemia . stai ned for free iron by the Prussi an
blue m thod . Free iron is abse nt.

112. A similar preparation fro m a patient with a

sideroblastic anaemia and increased iron stores.
(. 'o rmal subj ects have stainable free iron in amounts
mid way bet we e n these two extremes.)
IU 11

• ,

. ...

.....""' sta in. bo ne marrow from a pati ent 115

obIas-tic anaemia. Th ere is a suggestion of
nucle.ilLc~a1]~ S and irregular cyto plasmic
the ery throhlasts.

for free iron o n the same marrow speci men.

Iy positive ringed sideroblasts - cr ythro-
tree iro n gra nules arra nged as a co ntinuo us.
.nuo us. ring aro und the nucleu s. Thi s iron
ntrated in mitoc hond ria .

Prussian blue stain for free iron. showing

es of ringed sideroblasts. /


- •

117 11 . Free iron in erythroblasls (siderohlasts) with a
on-ringed distribution. Th is exa mple is of the 'normal'
pattern of free iron dist ribution in ery throblasts , hut the
positive cells (sideroblasts) arc mo re nu merous than

I ·--~nsecutivc reaction s for PA S po sitivity a nd free

~ ~Olthc marrow fro m ..I pa tient with refractory
sideroblastic anae mia. T her e arc ringed slder o blasrs
present a nd a lso gra nular PA S positivity in ea rly
cryt hro hlasts.
Simil ar pict u res may be see n in erythraemic myelosis.
e xcept that the iron tends to be less abu ndant a nd ra rely
in ringed for m. and the PAS posuivity is often stronger.
especially in later cryt brob lusts.


I 11



: •

12 1

" .
122 123

., I

122. Hey) stain of a peripher al blood buffy coa t pre- ..........-..

~ • 124
pa ra tion fro m a pati ent with a n ~IDS . havin g a stro ng
compo nent of sidero blastosis hut also an excess of blast
ce lls. and mark ed evide nce of dysmcgak ar yocyto -
poiesis. Th e field sho ws granulocytcs at all stages of
maturi ty. including seve ral basophils and an eos inophil
as well as nc utrophils, a nd a numbe r o fJate nor mobl asts:
. 9-
• '.
gro ups of abno rmal giant platelet s are particularly
co nspicuo us.

123. H& E stain of a trephine biopsy bone marrow

section fro m the same pa tient as fea tured in 122. The
specimen is inte nsely ce llular. with primitive cells.
including binuclea ted and multinucleated megakaryo-
blasts> widely distributed throu ghout the field . and with
numerous macrophages heavily lade n with hae mo-
siderin . Eryth roblasts and cells of the granutocyte series
can also be easily recognized . Th is marrow picture
suggests imminent trilinea ge leuk ac rnic tran sform ati on .

12-'. Prussian blue stain o n the same biopsy speci men

• •;
.. J ~"
as 123. Th ere is free iron as haemosiderin in the
'.. ,~.
, ·1'
nume rous macro phagcs, as seen in the previous H& E
sta in. but in addition , the ervt broblasts ca n now be see n
to contain the hcavv rings 'o f mitochondrial free iron
" -..
• •
-- .'
cha racte ristic of ringed sideroblasts. • ' I~
.. ,
.. ~
- l ' •

I~ 1~6

I _'-I!S . \ 'ariOllS app m f(lfl CeS of reuc ulocvses. 127

Polvc hro masta. In this Ro manowsky-stained

mea r fro m a patien t with a mega loblastic
_oauia respo nding with a brisk ret iculocytosis to B 1:!.
nz red ce lls freshlv released from the bone
-~- ap pear a little larger than mature red cells and
~ a purple tinge to their no n-nucleated cytoplasm .
colour resu lts fro m a deficit in haemoglobin. still
vnth ecized. and a residuum of the earlier
cY',. .~..b·l3s.t cyto plasmic basophilia due to RNA.

Basophilic stippling. T he same residu al ribo-

em may form discrete aggregated deposi ts to
baso philic stippling. This appea rance is
~_......,t in lea d poison ing and in thalassaem ias. but is
as a mino r component of the ret iculocyte
..."" in ot her anaernias. as in this case of li S. with
.-<"", Iai Somali de nse sphcrocytcs contrasting wit h the

cliculln material afte r sup ravital brilliant cresyl

;; Leishma n counte rsta in . Th is met hod
~ = preci pitates the residual R NA mater ial 10
partially clum ped network of blue- staini ng
Diff rent stages of reticulocyte maturation
recognized accor ding to the q uantity and
- - - - - of the preci pita ted mate rial. the earlier
bein g genera lly restricted to the marrow.
I2S 128Aticulocytcs sta ine d supra vita lly. hut uncounte r-
sta ined . So me ery throcy tes manif est a precipitat ed
re ticulin ne two rk . while seve ra l othe rs in this field show
a po lychromasia with the crcsy l blue dye . accompan ying
minimal de pos it at th e cell pe ripher y. Am ong the re d
cells illustrated here a rc seve ra l with a ce ntral slit of
pallor inste ad of the usual circular area stomatocyfcs -
\"'/Wfl ich ma he see n occas IOna lly In man y sta tes of
cryt rop OIetlc yperp asia.

129. Gms ' loe tosis - appco <lching 80% - in a

pati ent with haemol 1lC- ~!I1<).!-:~!_- ..~_ -=:wea n ' COl al
pyruvat e-kin ase e icien cy. IS rsor e r Involves
a defiCie ncy o f the penu ltimat e enzyme III the Embden

J Mc ycrhof pathway of carbo hydrate met ab olism . which

ca ta lyses th e tran sfer o f ph osphate from phosphocn ol
pyru vat e to ade nine di phosphate . with the formation o f
pyru vat e and ad enine tr iphos pha te . PK deficien cy is
inh erit ed as a n a utosoma l recessive defect with severe
V1ack of e nzyme in ho mozygot es (us ua lly. in fact. co m-
po und he te ro zygotes with a het e roge neou s pair of allelic
defects) a nd interme diate level s in het erozygot es. In
seve re de ficiency the red ce lls have <I grea tly reduced life
I spa n a nd . despi te inten se e rythropoietic hyper plasia in
the ho ne mar ro w with th e con sequ ent high reti cul ocyte
co unt illustra ted her e . the haem oglobin is co mmo nly
arou nd RO gll.

129 ~



L Ani socytosis. Th e red ce lls show var iat io ns in size.

Ifis rnear Illustrates minim al changes . Grosser aniso-
. is usually acco mpanied by o the r defects, such as
alocyt osis.

ut. Poi kilocytosis. The red cells show variations in

_ This smea r also illustr ates mini'mal changes ,
)' of ' tf.j;lrd n,p' ch 'It"J!'t (~r dacryocyto sis: G rosse r
"-lex') tosis usua lly occ urs togci her with o ther
. Mild teardrop poikilocytos is of this sorf'rnoy
_<wio,v the first ind ica tio n of e merging mye lolibrosis or
infiltration--with fo reign cells as III metastatic

~n~::'hromia and micro cyto sis - a gene ral low·

vi ew. A few cells stai n normall y and are of normal
....... (arc normoch romic and no rmocytic) but most have
s ce nt ral pallor (hypoc hro mia) and small
';';'_de r (microcytosis). This is the picture of severe
deficie n" .. anae mia . The red-cell indice s, Mev:
aod MCH C. would all be much below nor ma l.
133 133. H YQQ~hromi a anisocyl o sis ~and _poik iloc yt osis ;
from a pa tient with iron deficienc y an aemi a . All th e red
cells show mark ed hypochromic central pallor . A few
also display an c lliptoc ytic or t ear~ f.Qp-di storti on of a
fre q ue nc y and ki ntf oftcn se e n III simple iron deficien cy
anaemia. and no t indicat ing th e existe nce o f anothe r
pathological disord er .

134. Mark ed hypochromia . anisocytosis and poikilo-

cytosis. Wh er e . as here . i~re glllar fra gments of red cell s
or ver y grossly d istorted cells ar e see n. the term 'sctli:ito-
cvto sis' may he a plied . TIle relatively mod erate degre e
of hypochromia an t le extent of hizarr~)ik\!QcytoS! S
mak e thi s unlikely to he an e xa mple of iron deficiency
and rath er sugges t a hacmoglohin opathy (despite th e
ah sen ce of targ et cells). or possibl y onc of the micro -
an giopathi c d iso rders.


• •

.-•• •

- ..
IJS a nd 136. Respective ly low - and high-power views ol~
sDherocytcs. Th ese are red cells wiffi more sphe rica l

IX tha ll no rma l. reco gnizabl e in stai ne d smears by

lbcir apparent small diam eter a nd dense stainin g. More
half the ce lls in these fields are acceptable as
soemat: o nly the small . vcry dee ply stain ed cells can he
regarded with fai r ce rta inty as spherocytes. •
IJ . Anisocvtosis due to a mixture of 01 'chro matic
cclicuTocytcs and sma ller s£ lCroCytcs from a G ISC o f li S.
SUpra\'lta l staining With n lh;'lnt c rcsyl~ conhrms
I the po lychro matic red cells co nta in residual RNA
JWCCipitab le as a network . with a n overall reticulocy te
coao t around 60"'/0.

138 139

U8 . Elliptocy tos is. An inhe rited ano ma ly of th e red 140

cells which Involves. in th is case . some 50% of th e red -
cell po pulation. T he affected ce lls appc~val O f cigar-

139. PscudO-CllipHlChlosis . A co mmon artef act o f

siile'3n ng . rcc ogmi..a b c as suc h by two ch ief po ints :
(a) th e psc udo-elliproc ytcs ar e fo und in ce rta in areas of
the smea r o nly. usually nea r th e tail. and
~ h) their Ion axes are eoerall . acallet or nearl y so,
""hcr~~urnC-cllip locyt cs show ran om scattcn n of •
dis "ilio n (a s in 138).

v l -W. (rescent cells - d isrupted erythrocytes drawn o ut

into a crcsccnnc form . Thi s is a fairly co mmo n a rtefact of
smearing. especially in anae mic blood. ---

• •
1 ~2

I ~ I. ' Cre nation', Cre nated erythrocytes show an 14.1

eregutar undulation of th ~~.1LJncmbf.ill1c in fhed
smears. Th e;;ppc.lfancc may be indu ced by exposing
redcells to hype rto nic s<i line or otherwise causing loss of
id fro m '"t he ccliS-:-- in J.'i~'o, this defect usually
acco mpa llles other defects of size. shape and stru ct ure .
n the fea ture is mark ed . as here . the te rm ' burr cell"
or ecni nocyte may he applied .

1 ~2 .
Ery throcytes showing a tend ency to cre nat ion and
~ eVidence o t ph ySIcal da mage o r distortIOn--
-ing the ce ll mem br ane. o ne red cell in the up per
pan of the field showing a co nstrictive defect so that it
rubles a co ttag e loaf in sectio n and a lower cell
ari ng to have lost a bite from the pe riphe ry.
Prooablv bo th these defects result from mechanical
ma (ro m fibrin thr eads.

So-ca lled 'spll[ cdls' or 'If''lO thoq·tcs. showing

rese mblance to cren ated cells. hut with sharper
ions. ey occur. 0 tcnmassociation as here
fragm ented schisrocytes . particularly in uraemia
mkroangio pathy. bu t may also be see n afte r
-:::om~' and in abe tali po prote inaemia and
• rpti ve states.

1+1 145

14.4 . Mode rate rou leaux formation; some hypo- 146

chro mia:-RQ!llcaux arc ag~a tlOns or piles of erythro -
C)'les a rra nged like rolls or sac ks 01 ca ms . I he re is a
tende ncy for red ce lls to adopt this arra ngeme nt within
the circu lation an d to manifest it in the thicker part s o f
blood sme ars. but the presen ce o f ro ulea ux in areas
where red ce lls are well dist ribut ed suggests some
ad ditional pre disposi ng factor. A mon g the most
impo rta nt of these a TC co nditions associated with a high
.,./ erythrocyte sed imentatio n rate such as chronic in-
ftamma t;lry or malig na nt d isease. as in the p resen t slide
from a pa tient with Hod gkin's disease . and sta tes of
hvpe rgammag lobulinacmia and hyperfibrinogcn ac mia.
The com mo nes t cause of marked ro uleaux form ation is
multiple myelo ma. mac roglobulinae mia or other •
monoclonaJ ga mmopathy. •
145. .MQ!~m ;uke <L roul~ n ; this and the
~re(,Cn ce of a plasma ce ll suggests the possible diagnosis
of myelom a .

l.ui . Macrocytic er ythroc ytes from pe rn icious anaem ia.

with Ho well-Jolly bod ies in two o f th~CfCiS'3slig ht
~ e-
n of o ~.~ anIsoc~osis
valocno"-J(. and r-~ . but most
disto rt io ns of shape appea r to be tne cs ult of co m-
pression by neigh bo uring. cells rather than true poi kilo-
cytosis . The red ce lls are well haemoglobinized .


1..$1. Romanowsky stain showing a HowclI-JolI body 1 ~9

and a blue-staining side rotic granule o r Pappcnhcim er
y in the same red cell. fro m th e peripher al blood of a
patie nt with megaloblastic anaemia. The red cells arc
macrocytic. wit h an occasi o nal stomatoc yte .
_ A rema rkable giant binucleated lat e erythroblast
"m poly chro masia and coa rse baso phil stippling o f th e
irregularly stained cyto plasm. in the blood o f a patient
ith A ~ f L and mega loblastic e rythropoiesis ind uced by
a co mbinatio n of purine and pyrimidine antime ta bo lite
cbe motherapy. Co nspicuo us basophjlic stippling du e
-"" 322rc e:ates of RNA is a i.lfticular feature of er thro-
~ e pyrimidinc-5-nucleoti ase e ctcncy. wether con-
e- mta l o r acq ulTcd. as In lead or o the r heavy met al
ing: its occur rence following the use of a pyrimi-
diDe ana logue may indicate interference with the action
t enzy me and conseq uent failure to complete the
do wn of cyto plasmic RNA .

, PAS reac tio n o n a slide of bo ne marr ow aspirate
a patien t with glycogen sto rage disease . which
as a conseq uence of congenita l deficiency of
......glucosidase . Var ious granulocytes show substa n-
~ eo rmal patte rns of glycogen distrib ution . while a
DOIlIlOblast in the ce ntre of the fi eld cont ains a single
of glycogen. resem bling the localized PAS-
....._ ..... vacuoles see n in lymphocytes in this disorder.

150 151

ISO. Ta rget ce lls or codocytcs. with accompanying 152

an isocytos is and poikilocytosis. and hypo chromia - from
~l case o f he. it-thalassaemia minor . Th e field also sho ws
thin flat cel ls or leptocytcs. Sever al elliptocytcs a rc

151. Anot he r field from th e sa me spec ime n. wher e

ta rget cells greatly predominat e . The striking appea r-
ance o f these red ce lls. with wel l-haernoglobinized
cent re and periphery. and a pale ring betwee n. re flects
\,../ thei r be ll-like o r'Mexican hat d istortion . TliCfrcq uc ncy
see~ figure is almost restricted to haem oglo bin-
opathics. especially beta-tha lassaemia . hut the appear-
ance affects a smaller proportion of ce lls in live r d is-
ease. in obs tructive jau ndice. in her ed itar y lecithin-
cholesterol acyl- tr ansferase ( LeAT) deficien cy, and
after splenectomy .

152. Po i .itocytcsis, with conspicuo us sharp-angled

' helmet' cc us. lro m a case of thrombotic m rom bocvt o-
~ mc purpura . Th is type o f deformity , probably du e to
mcchamcal damage fro m fo rced passage through a fibrin
meshwork , is co mmonly found in any of the micro-
nngiopat hic haemolytic anae mias and in other conditions
associated with the intravascul ar deposition of fibrin .
such as d isseminated intravascul ar co agulation ( D ie). ~>

o .\!-> .,..
,d' , .

15J/~ ce lls, macrocytcs, spherocytcs, schistocyt cs

, 155
--- - luiJing helmet ce lls - a nd sma ll cell fra gment s. from
o f seve re bet a-th ala ssaemia .

L..... Leishman-staincd fres h fixed blood smea r. from

pa tie nt with sickle ce ll disease. Elongated or sickled
are rare .. but anisocytos is an d poik ilocytos is. and
.~t ~I; are mo re co m mo n . 1
cells. drepanocy tcs, fo rmed by exposing
~ rocytcs fro m a pa hcnt with sickle ce ll di se ase (0 the
ing actio n of sod ium met abisulphite under a sealed
rslip. As the reduced HbS crysta llizes with in the
. they all co me to assume the disto rted elo ngated
sha pe .

C" J,. !' M
JuJ/1/ t/10
JjT n" t~~

156 158



156 and 157. Cahot riggs. respectively r~d and in 159

fi~urc- o f-e ig h t
form , In stippled red cells. The y are
pro"b3D y an RNA--of protein precipitation artefac t of
little diagnostic significance but sho uld not be co nfuse d
with malaria parasites.

158. Lcishman-staincd erythrocytes from a patient with

haemolytic anae mia and incre ased iron sto res . Th er e is
faint polychromasia present and also Howell-JoJly
bodies. Gra nules of free iron are occasio nally
de tectable. Several sto matocytes are prese nt with
elo ngated areas of central pallor.

159. Prus ian blue stain for free iron on the same
blood speci me n as in 158. Siderocytes (eryt hrocy tes with
free iron) are seen to be numerou s.


, •

0n.z bo dies in ery throcy tes from haem olytic 162

........:ei::l assocIa ted wJlh deficle nc of alucosc-e-
... .. ~ ' rogenasc . ese Ot ICS, show n her e in
la methyl viole t sta in. a re pr ecipi tat es of
_ ed_hacm<: gIQ ~_m r~sulti n g fro m the lack 0 reduc-
me . Heinz bo dies a ppear to e rmli f ixed to
me mbra ne . Th e y occur in small nu mb er s
.. but arc remo ved by the splee n. and thus some
de ected in most pat ients ~ft e r splenectomy.

nte rstai ned pr e pa rati on of re d ce lls from

......-t5.iG3 soae mla expIT"ed to cresylbluc s t arrr-for ten •
- tettcu locyrcs have ta ke n up th e stai n .

'Ja r p repa ra tio n fro m the sa me blood sa mp le

r's exposure la sta in. Th e mult iple do tted •
- "go lf-ball' pattern in ma ny ce lls is that of
in H inclus ions. A high proport io n of the red
H dis ease co ntai n te tr a rner s o f th e be ta chain
- ~ o xidize a nd p rec ipitate as th ese inclusion
quite small numb e rs of ce lls with HbH can be
. supra vita l staining a nd allo w th e dia gnosis of
...............sae mia var iants with minima l H bH forma-
, ,

163 IM

163 and 164. Targe t ce lls. sp ur ce lls o r acant hocyte s
with mult iple sharp pro ject ion s. schistocytcs of irregular
frag mented shape and 'sput nik' cells. aca nthocytes with
two or three elongated spurs. Such changes are see n in
micro angiopathy especially and may he conspicuo us in
sple necto mized pati ent s. Th ese preparat ions are in fact
fro m a patient with congenita l PK deficiency and severe
haemolytic a nae mia. who had nee" sple nectomized 20
years previously, and had recen tly developed obstruc-
tive jaund ice as a result o f the accum ulat io n of pigm ent
sto nes in the gall bladd er .

165. Freque nt co nspicuous te ar drop_poikilQc'y'!cs -

dacO'CKytC5 in mycl fibro sis. Suc h ce lls m ay he fo und
in most conditions of m~o w infiltration causing the
de\'elopment of a le ucoc rytFiiUblas IC anacmla_. anOTh
smalle r numbers in megalob lastic anacmias .

Part 2

Granulocytes, monocytes and megakaryocytes

'ormal and abnorm al forms

blasts or eve n from pro cr ythrobt a,c, in so me leukacmi c

and cry thrac mic states. Cyto che mical and immunocyto -
che mical reaction s will usuullv resolv e such di fficulties.
C ha rac te ristic cytoche mical ' p<l ttcrns helpful in this
regar d are the refore includ ed amo ng th e illustration s
where appro priate .
Mcgak uryoc yres usually present no difficult y in
recogniti on . but their 'mega karyoblast' precursors arc
much sma ller. and th ey loo have similarities with othe r
imm ature precurso rs o f th e myelo id se ries. Early but
recognizable stages in the mcgak ar yoblast-m egak ar yo-
eyre line may be seen in idiop athi c thrombocytopenic
purpura and may occasio nally he distinguished in acute
myeloid leuka emi a (AMLY; however , the ea rliest cells
committed to this line . which are pre sumed by analogy
to resemble the mye lob last and mo nob last, canno t he
certainly different iated eve n by cytochemi cal means -
altho ugh they may sho w peripheral periodi c acid-Schiff
(PAS ) positiv ity at a n ea rly stage and also aceta te
es te rase rather than but yrate este rase positivity. while
ultrastru cturally platelet pe roxidase may be present and
th er e may be immunocytoch em ica l reac tivity with
a ntibod ies to platelet glycop rorcms.
The illustra tio ns have bee n chose n to allow the ra nge
o f appea ra nces sho wn by different ce ll type s to be
appreciated and to allow frequen t co mpar iso ns bet ween
cells o f di ffere nt lines o r of differ ent stages of maturity.
The parti cular impo rt ance of cytoc he mical reaction s
amo ng th e ce lls dealt with in this section is emphasized ,
espe ciall y in th e d iffer enti at ion of th e varieti es of AML.

Disorders im'oh'in~ chid l)' the aranelocyte. mcnecyt e

and megakaryoc yte lineages and thei r associated main
C)' t o l (J~ i (. al features

A cwe leukuemius of myeloid origin. Leuka emias are

clonal neoplastic proliferations arising from stem ce lls.

Fo r the A"ILs. the origi na ting cell m3Y be the ge ne ral into clinical use, different factors rnav we ll be found to
mye lo id precursor. the CF - G E ~ I ~ 1. capable of giving have more appropriate use in mo nolincage and multi -
rise 10 colonies ill vitro containing grunulocytcs . ".10no- lineage cases , res pectively.
C)tc_ macrophugcs . erythrob last- and mcgakaryocy tes : The second broad de fect of the FAH class ification is
o r perhaps the mo re narrowly co m mi tted granuloeyte ~_u!1.9ue. rel~nc~ o.n Rqm anowsk~' ~)10!ogy as a n ind~x 7"
monocyte macrophage pre cur sor , the C FU-G ~ I : or the of ce ll d lftCrentlatJOn kSudanophlha , often shown by
corre pend ing e ryt hroblas t or mega ka ryocy te pre- mat uring rnyclo blasts before azurophil granula tion
CUN.l~, HF U-E a nd C FU- Meg , res pective ly. Pur e becomes e vide nt in Rom an owsk y sta ins . is pr o babl y the )
ervt hrob lastic or mcgak aryo blast!c -lcukacmias' mus t be hest sing le prognost ic factor in AML. a part fro m age .
\eT) rare , if they occur at <I ll, since a predomi na nce of Surface antigcnic markers hav e not proved of gre at
these ce lls see ms al ways to be acco mp anied by at least discri mi natory value in A I\IL. a lt ho ugh po sitivitv to the
so me ncoplas t!c co m pone nt of gra nulocyrcs a nd/or major G M marke rs (CR..t.~ and/or C D33) hel ps to
mo nocvtcs . d isti nguish poorly dif fer enti at ed AML from Al. T'(ucut e
The causes of A M L a rc sti ll not de termin ed , a ltho ugh lym phoblastic leukaemi a ). a nd reactions with anti-
activa tio n o r ot he r functiona l change of proto - bod ies to glycophorin A or to platelet glycoproteins m,ly
o nco gcncs. which norm a lly pla y a controll ing role in furt her aid the recognition of c rvt hrob lastic or rnc aa-
myelopoiesis , ma y be importa nt in this re gard , and ma y ku ryo blast ic co mpo n"'e nts. · "-
res ult from the ch ro moso mal rcarra ngc rnents tha t arc Cy toge netic cha nges ma y we ll ha ve pa t hog e net ic
"readi ly demonstrab le in about SO 'Yo of A ML cases, and significance a nd arc of some pr ognostic va lue , t( :21).
probably occur at a less easi ly recognized level in t he t( 15:17) , im'( 16 ), und trisomy X as a n isol ated defect. all
rem ammg cases . havi ng rel a tivel y good prognos is , ttv : 11), monosorny 7,
It is not sur p rising, give n th e co mplex ity of hon e del e tion s of 7 o r 5, a nd most m ultiple ab norma lities,
marrow cytology. that ma ny cyto logical varia nts of ha vin g .1poor one, a nd ot her str uct ura l ah nor ma lities
A ML occ ur . T he)' have bee n cla ssified traditionally for having inte rmed iate prognostic significance. How eve r .
the last 6U yea rs or more according to the nature of the diffe rences o f this kind tend to d iminis h as treatme nts
pre domina ting ce ll in the ho ne mar row , a nd this becom e mo re effec tive . In a nv case . since so me SO% of
a pp roa ch fo rmed t he basis of the FAH subdivisio ns AML cas es do nut e xhibit an o bvio us chro mos oma l
proposed by a group of Fren ch , American and British abno rmality. cytogenet ic da ta do nu t a t pr esent provide
( FA R) haem a tol ogists in 1976, subse q ue ntly widely a satisfactory bas is for a gene ra l cla ssifica tion .
ado pted. For A M L the divisio ns ar c : ~1 I . jnyeloblastic The a uthors hav e deve loped a simple cla ssificat io n of
(>90'X) myc fob tasts}: r\'12, mye lo blastic wit h AML whi ch tak es th ese vari ou s co nsiderat ions int o
gr an ul.ocy.!iE.-matura tio n (> 10°(0 pnj myclocytcs or Inter account . Mon olin cagccascsu rc gro uped .tS T ).:r.£J and
granulocytcs] : ~t3 . p-.IQ!TIyeloc}tic (either coarsely mult ilineuge a~ Ty~_U . Each type is furthe r sP.!!t into A
gra nular or rnicrogranular promyclocyrcs prcdominat- and B uccordinu to whet her > or < 50% oft he lcukucrnic
ing): ~.I-t , myelornonocy tic (>20% gran ulocytcs , or G M cc lls a re ;uda no philic. T ype lA thus incl udes .all
pr ecursors a nd > 20'Yo mo nocytcs o r precurso rs) ; :\15, t(X;21) . inv (16) a nd 1(15 ;17) cascs . a nd may be o f an y
monocyt ic (M5a predomina nt ly monoblastic. M5b wit h FAB gro up fro m ~1l _ 1o--,\ I5 . Type IIJ. with little
diffe re ntia tio n): ~1 6 , erythro leukaemi a (>50% erythro- diffe rent iation , includes most t(\' ;1 I) , and again crosses
blasts}: a nd ~1 7 , mega kuryo blastic (>SO% mega kuryo- the FA ll groups widel y from Ml to MS, excluding ~ 13 .
blasts}. A M L with mini ma l differentiation hut po sitive T ype 11 cas es include most wit h poo r progn osis cyto-
antige nic markers ma y be gro uped as MO. ge net ics, as we ll as FAB groups !\.16 a nd M7 a nd <I
Th is classification is based on a rb itrary borde rlines proportion of all the remaining groups except M3.
bet ween the gro ups, a nd alt hou gh broadly -in co nformity Type I A~1 Ls , including cases wit h the assoc ia te d
with thc ge ne ra l usage of pred omin a ting cel l classifica - chromosoma l defects listed above . a re illustrated in
(io ns in the e a rly IlJ70s it has two import ant defect s . One pa rallel with ot he r disor der s a ffec ting gran ulocy rcs
conce rn !'! its fa ilure to discr iminate bet wee n mon o - a nd/or monocytes early in thi s sectio n. T ype 11 A MLs ,
lineage (co unting th e pro geny of the CF U-G~ I as of one with multiple line age invol ve ment. a rc grouped at the
lineage ) and m ulti lincage cases (with granukx... yte / end of the section . wit h t he myclodysplasttc sta te!'! wh ich
mo noc yte (G ~ 1l involve men t hut a lso erythroid an d/o r a rc mostl y also clona l neo plastic diso rd e rs with multiple
mc ga ka rvoc vn c ). Thi s ma y he of so me im po rtance in linea ge exp ression .
pr ogno sis . y, ith m ulrilineagc ca se- po ssibly surviving less The c ha racte ristic feat ures o f all these var iants of
well overall , although with adva ncing cfficacv of treat - A ML arc de scribed in the respective captions to the
ment this diffe renl:e may well dimLini sh . Of greater re leva nt cyto log ical and cy tochem ical illustrations, as
sig nifican ce , how ever . ma y be the different pat ho- arc t hc fea t ures found in bo ne marrow as pira tes a nd
ge neti c mec han ism , ac tive in pr oducing. resp ectively. tr ephi ne biopsies d urin g emerging remi ssion or de velop -
monoline ae c or multilincaee disease , with e it he r a ing relapse .
d ifferent 1~\·e1 o f stem cell 'affected or a d ifferen ce in
ste rn ce ll e xpression dict at e d by biologica l co ntr o lling
mech ani sms. A s bioloeical ac tiva to rs such , IS colo nv- Chro nic mvctoid leukucmiu (CM I.) , This d isease is
stimulati ng factor!'! (G~ I -CSF etc.) co me mo re widel\'.
- a not he r clo na l neoplasttc state , probably a rising in t he
mined plu ripote ntial haemopoietic ste m cell. but and/or the presence of A uer n S - hence presumed to
lh differentiatio n exp ression initi ally co nfined to th e be close r to transformation to A~1L ( RAE Bt) - and.
doid ce ll lines . Som e X5 ft!c. of cases mani fest th e Ph fina lly. chronic rnyelomonocytic leuk aem ia (C ~ I ~ 1L ) .
cmosome. a sho rt ch ro moso me 22 resu lting fro m a Th is nom en clature is tha t propo sed hy th e FA R group
reci procal tra nslocation betw een parts o f its I~Jn g arm for con d itions descr ibed over man y yea rs under var ious
- ' the long arm of chromosom e 9.1(9 ;22) (q 34;ql I) . nam es. which pro bably mak e up a bro ad spec tru m uf
lh the transfe r o f th e c-ahl on cogenc from 9q to a site indolent or smouldering c1on al1cukaernic states, alread y
~ q .nown as th e breakpoint cluster region (b.£r ). associated with non -random cytoge netic abnormali ties.
Tbe combi ned chime ric gene at thi s site produces an Th e way in which th ese d iso rder s evo lve is errat ic:
.iboormal protei n kinase . characte ristic for C ~ 1 L Most transformation to a floridl y lcukae mic p ictur e o f multi-
the rem aining 15% of -cases with the cyto log ical lineage (Type 11 ) AM L m;;I Y occ ur in a ny of them ,
ure of C ~ I L - with a high leu cocyte co unt and perhaps more commonly in RA EB and RA EB t. but
nee o f granutocvtc p rec ursors in the blood , many patients with MDS die from chronic anaemi a.
~ ulocy t i c hyperplasia of th e bo ne marrow . freq ue nt infectio n or haemorrhage without any suc h over-
philia and basophilia. and a low leu cocyte whelm ingly blast ic meta morphosis .
ine phospha tase (LA P) sco re in the neu tro phils c- T he histo logy. cytology and cytoche mistry o f RAEB
evide nce that a morph ologicall y inapparen t trans- and CMML <Ire illustrated exte nsively in 560-565 and
tio n has occ ur red. with production of the bcr-ab l 569-594. T he distin ction betw een RA EB and RA EBt is
cbimeric gene . 10 the ext ent that th e same abnormal esse ntially·a qu antliah vC Otit' , with up to l Ot?., hlasts I
pro tein kinas e ge ne product as in Ph +vc Cfvl l, can be the marrow III the lormer an Irom 2(}:j 0 10 thc.lauer
de tec ted and c-ab l probes locat e this on cogcn c at the her : alt ho ug h the presen ce of re adil y detectab le A uer rod s
le o n chro moso me 21. allows less b lastic cases to be c asse as B t.
C ML is well co ntrolled by single agent che mo the ra py. -./ E\'Idence of mu ltilincagc IIwol veme nt in e r\'t hrobla"sts
ally busulphan o r hyd roxyurea . for var iable pe riods includ es-nuclear fluddm"g o r ro...ct te formation . multiple
from a few mon ths to many years. unt il a change in th e nuCl eI. sldero6htstoslS. megalotilastos ls. and PAS
pa tern o f disease happen s. with mal ignan t progression pos . ega .arvocytcs atypical mononuclear
hypop las ia . myelofi brosi s. or an ac ute lcuk acm ic or multi-nuclea r forms and ei the r giant or micro-
pecture , usually th at o f Al\1L but occasionally ALL in megakar yocyte.... Defective gra nu la rity in myelocytes
. -pe. In tra nsfo rma tio ns to an AML·like sta te there is and acquired Pclger-Hu ct nuclear anomaly in
lten an eryt h rae mic and/o r a megak .eyocyric co m- mc ntc d cells provide evide nce of dysplasia in the
pone nt. with a multiline age T ype 11 cyto logy - althou gh , gra nuloc ytc se ries. while mon ocytcs may shO\..· biza rre
som etimes. a more purel y monolm eage GM form [Type nuclear morph olo gy espe ciall y in C MML.
It develo ps. A t thi s stag e furth er chro moso me ub nor -
IDalilies arc freque ntly found . not abl y one or mor e ex tra Reactive chunges ill granu tocytes and monocytes.
.22 trans locatio ns, struct ural ano ma lies o f 17q. and Leu cocytosis with incre ase in the WBC above the
trisomies o f S or 19. normal up pe r limit o f I I x 10"'/1 occurs chiettv in
Th e hae matolo aical findi ngs in bo th chro nic and infe ctive and mftammato ry states with jI reacii\'e
transfo rmed phases of C ~ ll . a~l" illustrated in 320-37.$. inc rease In neu trophils accompanied by a ' shift to the
be rc cha racteristic features of histology, cytology and left ":""'wtth a IJ ised pro po rt ion Of stab cells and po ly·
. tochc mistrv arc fur ther descr ibed in the ca ptions. morphs with fcw nuclear lobes . Occasiona lly. mor e
immature pre cursor s. mctamyclocytes - o r even a n odd
JIII enile C \I L. Thi s is a form o f subac ute ncopl astic myelocyte - may be found in the peripheral bloo d. Th e
~oIi fe ra t i o n with Ic.uurcs inte rmedi ate be twee n th e neutrophils may sho w coa rse darkly _stain ing 'to xic'
It type of Ph +ve C~lL (which itself occurs in granules. and ther e may he bluish Dohlcbodics visible
dliIdIiKx)(J. hut o nly rarely) a nd a myelom on oc ytic acut e ift ~Romanowsky p!.cpa ra ti(H1S -in- th cir cyto plas m,
ae mia . This d isease is not associated with tl 9:22). r~pre~entin g ureasof. hj-peractive aggregated ro ugh or
about 50% of cases sho w chro mosomal ub no rmali- smoo th end oplasmic.reticulum .
much the co mmo nes t being mOllosom y 7. Th e Le ucopemas with gra nulocyte co unts < 1.5 x IU"/l arc
is illustrated in 375-383. where ad dit ional seen in states o f pri mary or secondary marrow
PtI\C material is included in the captions. hypoplasia or aplasia . with generally defective myclo-
poicsis and assoc iated ana e mia and thro mbocvtopcrna :
vsplassic states (.\ 1DS ) ami other preleukaemic ho wever. selective neut ro pe nia may occur in o ver -
rs. A mong the conditions gro uped toge the r whelmingly seve re infec tions. whether bac terial. viral.
me title o f ~1 D S arc refr acto ry a nae mia ( RA) and rickett sial o r pro tozoal, an d may proceed to ag ra nulo-
-dn.:to~ a nae mia with side ro hlas ts (RA S), bo th o f cytos is. with circula ting neut rophil s < O.S x 10"/1 . A
......1 . D,,~ e bee n discussed and illustrated alr ead y in Part similar selective neutropenia may result from se nsitivity
prese nt sectio n includes the remaining MDS to certa in dru gs. includi ng sulpho namides , ant i-thy roid
. re fracto rv anaemia with e xcess o f blast.. agents and some anti -con vulsan ts.
.-..E8 . the- ~m~ with a hi-g:hc"'r- prorXlTli on of bElsts Cytoplas mic inclusio ns o f degeneratin g nuclear
material resulting from the action of an anti-nuclear T he Ched lak-H jgashi-Steinh rlnck syndro me is a ra re
facto r (ANF) form a special feature of systemic lupus inherited d isease . usually fatal in early life . with severe
c rvt hc rnatosi-, (SL E) . and are of cyto logical inte rest as cytopc nias and a lyrnphorna-Iike clinical picture. associ-
we ll as pro vidi ng a rapid diagnostic test. although their atcd with rem ark abl y lar ge cyto plas mic gra nules in
pract ical impo rtance has been largel y replaced hy va rious tissue ce lls - incl ud ing man y lcu coc ytcs o f blood
immunological testing for ANF. Examples arc illus- a nd bo ne marrow . especially gra nulocy tcs (398). T hese
trated in .'S-a and 385. coa rse gran ules arc probably lysoso mal in nature .
The reverse of the infective ' left shift" in neutrophils is Pseu do-C hed iak inclusions may develop as an acq uired
seen in megaloblastic anaemia». where deficiency of B l.:! phen o menon in so me acute lcukaemias. notably cases of
o r folat e leads to nuclear changes involving a ' right shif t' A ML with the 8;2 1 tra nslocation (211 and 213 ).
with an increase in the ave rage number of nuclear lobes
in neutrophil polymorph, and the presence of some cells Platelet disorders , \Vhile qualitative defects of platelets
with six or more nuclear lobes. macropolycytes or arc best det ected by platelet funct ion tes ts and arc not
hvpcrscgmcntcd ne utrophi ls. reliably recogn ized by changes in pla telet morphology.
Eosinophilia . with blood levels over O.5 x 10"/1. may quanti tative cha nges thrombocytopcnias and
he seen a, a familial ano maly. but occurs as a reactive thrombocvtosis or th rombocvt haernia - arc associated
phenome non - especia lly in skin disorders. allergic with char~cteristic cyto logica l findings . not on ly in ter ms
states, and pu rasitic infestat ion - and has add itio na lly of numbers of circulating platelets hut a lso with regard
Peen fou nd wit h associated mya lgia in pa tie nts la king to the cytology of mcgakarvocyrcs and the process of
dietary supple me nts of Ltrypro ph nn. Buso ph ilia. with thrombopoiesis as observed in marrow smears and
counts ovcr u.zx 10<)/1 . may also be seen in so me allergic sections.
or inflammatory states, altho ugh it is relat ively T hro mbocytopenia. with reduction in circ ulat ing
uncom mo n. p latelets be low 150x 10"/1. arises in most instances fro m
Mo nocytosis. above the nor mal upper level of o ne or two broad causes: defective formation of plate lets
I x 10"/ 1. may occur in more chro nic infective states or in (as in prim ary or secondary aplastic or hypopl astic
those d ue to non -pyogenic bacteria . viral or rickettsia l sta tes . inclu din g th e effects of myelotoxic che mo the rapy
infections and so me p rotozo al or oth er pa rasitic infes ta- and so me less co mmo n d rug sensitivities) . and increased
tion s. A reacti ve mon ocytosis may a lso he seen in so me de struction o f plat elets in the periphera l circulat ion and
auto- immune disorde rs and co llage n diseases, and in splee n (a rising ge ne ra lly from auto-i mmune sc nsitizu-
so me cases o f disseminated malignancy. tion of platel ets. render ing them liable to phag ocy tos is
by macrop hagcs ). Th e fo rm er type of thru mbocy to pcnia
Congr nitul anom alies and acquired parallels. Alth ou gh is associated with a reduction or abse nce of mcgakaryo-
ma ny an o ma lies o f leu coc ytc s have bee n described . cytcs in the hon e marr ow - an amcgakaryocy tic
most a rc ve ry uncommo n; on ly the four most important thrombocytop eni a - wher eas, in the latt er . mcgak ar yo -
arc described and illustr ated her e . cytcs arc gene ra lly plentifu l and ofte n incre ase d in
The l)l'IJ,:l·r·llut't nuclear ano ma ly occu rs as a ra re nu mb er s, alth ou gh they may a ppear cyto logica lly
benign familial inh erited diso rder P S7) . hut it is see n unu sual in hav ing immature nuclea r feat ures and
very co mmon ly as an acqui red o r ' pse udo' fo rm in man y defective gra nularity. with often promi nent glycoge n
cases of myelo dys plasia an d bo th ac ute (e .g . 215) and inclusion bod ies and few peripheral p latele ts (467- *73) .
ch ro nic (3AA) myeloid leuk aem ia . Thrombocytos is. with counts over 500 x 1tI<J/ I occurs
Th e Ma~' - l h1:.g l i n ano maly. like the Pe tge r-Hu ct us a co mpo ne nt fea ture of many states invol ving marrow
anomaly. is a ge nera lly be nign co ndition inherited as an hyperplasia . fro m iron-deficiency and haem olytic
autoso mal domi nant . It is associated with the for ma tio n anaemias to acute infections. It mav also be a feat ure of
of large oval or crcsccnuc basophilic inclusions (394 and disse mina ted malignancy . This tyre of platelet increase
395) in th e cytoplasm of gra nulccyrcs and occasionally is a secondary or reactive phenomenon of no great
also o f monocytcs. These represe nt a special type of clinica l significance.
inclusio n material rather than an aggregation of no rmal A mo re severe and ~rsistent increase in plat elets,
cytoplasmi c structures. and arc thus essentially different often to over 1000x 10 11. occurs in csse ntiul thrombo-
horn Doh le bodies. Giant platelets may also be found in cythernia or megakaryocytic myelosis. a chronic nco-
this ano ma ly. and there is sometimes thrombocytopenia plastic myeloproliferative disorder whic h appears to he
and leucopenia . largely co nfined to the megakaryocyte-plate let line .
The Aldrr-Rrilh' a no ma lv. which mav occur in associ- Th ro rnbocythcmia of similar degree m;'IY also he seen in
anon with various mucopolysaccharidcscs. involves the mullilineage proliferations. especially polycythemia
development of coarse azurophific granules in the cyto- ve ra. but also occasionally in C ML. In all these co n-
plasm of gr anulocyrcs (389) . The material of the ditions ther e is a conspicuous increase in megak aryo-
gra nules is derived from the mucopolysaccharide and cytes in the hone marrow. often with imma ture or
resem bles basophil granules somewhat. in reacting ot herwise atypical cyto logy (477--U«2). and clumps of
met ach rom atically with toluidine blue. aggregated pla telets are freq ue ntly found in the pc ripb-

C'f'JII blood smears . where megakaryocyte nuclei and rubru vera (PRV) or CML (339-348). More mature
-=lear fragments may also sometimes be present. megakaryocyte proliferation . arising in a fashion
Icga .arvoblastic proliferation in the bone rnarrov as either a primary or a secondary condition. ap~a rs
. be promine nt in some trilineage acute leukaemia- often to stimulate the development of myelofibroti c or
may occasionally predominate. This occurs in some osteomyelosclerotic changes. prohahly. thr,!ugh t~e
. apparently arising de nm 'o (48R--l95) . hut also production of growth factors and other biological a~tI\"·
rg as a form of blastic transfo rmation or malignant atcrs of fihroblast proliferation and collagen formation .
eeceression in the ter minal phases of polycythemia

• •
. #, I
•• • • •


166. Tre phine biop sy scsJion of norm al bo ne marrow 16H

from a c h iJ~). showing somcc:9ll% ovcrntt cellu >
la rity a nd good rep resen tatio n of m o ~.or '.!!~I1l <lnQ)\·
cells. includin g mcgaki!ryocytcs. (lfythro 0.1tsts. and
g r!!n u l oc ~ tes at var ious stag~~Q f maturity. Th e gra nulo-
t yres inclU'aechicfly n cu ~rop hils . with a few cosi no phils.
and the ratio o f gra n ulocytes_~Uh(Qb lasts - the so-
calle d mvcloid-c rvthro id or M:E ra tio - is abo ut 3: 1.
. .--t. { 3-
167 and 168. Trephine hiop~y section. viewed at low
and higher mag nification, respective ly. from the bon e
marrow of an adult wit h a rcfractorv anae mia and a
cellula r ma rrow contai ning a higher proportion of
gr anulocyt e precurso rs - ~t : ~ ra tio 6: 1: and wit h a shi ft
10 the left. i.e . rclarivclv mor e nucleola tcd imma ture
cells. myelo blasts and p romyclocytcs. and fewe r 'later
non-n ucleolated granuloc ytcs. The di<l gno sis suggested
,p)' this marrcw.picnnc. ~c......uLJ h e myclodvsplastic
!'lli.lJS::i., refr actorv anac mia wi th e xcess of hlasts
( RA EB ), furt her illustra ted late r. T his figure is includ ed
ti t'l C to show th e exte nt la which the gra nulocyte
ma tu rati on sta ges ca n he reco gnized in histo log ica l
sections, and for co mpa riso n with th e much greate r
cytological detail foun d in smea rs . as dep icted in the
succeed ing figures . •

169. A r1!1~ h ) ~ l as t w i t h _1 W O-C( mspi c:.uo us....!!.~ c1co l i . a 171
\acuo lcy nd a few uzuro philic gran ules. a larger-pro-
myelocyte . a myelocyte and a sta b cell o f th e neutro ph il
series. toge the r with a lat e no rmoblast. Bot h th e cells at
the pro mye locyte and early myelocyte stages show
fad ing nucleo li and azurophil gra nules. th e smaller and
mo re ma ture myelocyt e also having less sharply de fined
and less stro ngly coloured neutrophil spec ific gra nules.
li .e tho se in the acco mpa nying stab cell.

1 O. A seque nce of granu locyrcs. with a myelob last.

pro myelocyte . myelocyte (with neut rophil gra nules).
and a late neutrophil meta myelocyte or early stab cell.
The myeloblast. o n the left o f the gro up . has a clearly
defi ned nucleolu s within a dar k ring of nucleolu s-
a.....sociated chromatin: th e prom yelo cyte . in th e centre .
ha three less distinct nucleo li visible in th e upper part of
the nucleus and numerou s coa rse azu rophil gra nules:
hilc the two maturing ncutro ph ils show a de nse r
eucl ear ch romatin patt ern and have man y speci fic
~n u l c s. Th e red cells arc abno rmal. with anisoc ytosis
and irregular hypoc hro mia.

1/ 1. A pro myelocyte. two myclocyrcs. a rnetamyelo-

. e and a st ab ce ll. o f the neu trophi l se ries . Th e red cells
in sho w anisocytosis and marked hypo chro mia .

172 173

172. A myelocyte and four metamyelocytcs of in Teas-
ing maturit y (with increa sin gly ind ented nucl ei) . Th e
myelocyte is the sma llest cell in thi s gro up and has the
most basophilic cytop lasm . th ou gh without any det ect-
able azu ro phil granu les. and its nucl eu s has sev era l sma ll
but fad ing nucleoli . Spe cific granules are inconspicuous
in th is ce ll but numerous in all the metamyelocytes.
The re is aga in hypoch romia of the red cells and a
stomatocyte with a nei ghbouring dacryocyrc towards the
upper left.

173. A myelobla st and an earl y neutrophil myelocyte .

The cyto plas mic basophilia , due to residual RNA . and
the three o r fou r pale b lue nucleoli of th e myeloblast are
well sho wn her e an d in 174 and 175.

174. A myeloblast with a monocyte for co mpariso n.

The monocyte sho ws a coarse r nucl ear chromatin
pattern. a n absence o f nucleo li, and a gre yish rather tha n
a basophilic cytoplasm .

I ~

1 S. A myeloblast with a neutrophil stab cell . To the 177

right o f the myeloblast-and impinging on its cyto plasm is
.Ji rat her large platelet. Three small er platelets ar c
prese nt at the top of th e field.

li6. Below is a promyelocyte with num erou s azuro phil

~an u l e sin its mod er ately basophilic cyto p las m and
a mooth leptochrornatic nucleus witho ut clea rly
inguishable nucl eoli. while above is a neut roph il
~ e n t e d po lymo rp h. There a re three platelet s present
.ad the re d cells sho w o nly slightl y exagger ated ce ntra l
Ior. sca rcely amo unting to hypochrom ia .

. Two rnyelob lasts. the sma ller showing diminut ion

cyt o plasmic baso philia and the first appea ra nce o f
azurophilic gra nulatio n. a promyelocyte with coa rse
ulari ty and co nside ra bly larg er size th an the
loblasts (a frequent finding) . and a monocyte . for

17 179

178. A seq uence of neutrophil grunulocytcs with a IHO

myelobl ast . pro myelocyte (with vac uo le ) . myelocyte .
met am yelocyte and two stab cells. Th e myelobl as t and
the promyelocyte eac h contain three or four nucleo li.
so me with co nspicuo us nucle olus associated chromatin.
while the late r ce lls h ;'IVC lost th cir nucl eoli a nd sho w
increasingly pachychrom a tic nu clei.

179. Perox id ase reaction on norm al ho ne marrow

cells; a seq ue nce o f gra nulocytc precursors shows stro ng
positiv ny: c rythroblusts <Ire negat ive .

180. SB stain o n normal ma rrow , illustrat ing the in-

creasingly heavy posit ivity in the developing gra nule-
cytcs . Eryth roblasts ar e negative. as is a lyrnphocyte at
the hoUO I11 right. A vacuolated monocyte . bo tto m left. ... a few positi ve gra nules .


' - I. SB stain o n norm al buffy coat smear. T he coarse IK3

uvirv in neu trophil po lymorphs con trasts with the
er reac tio ns in mo nocvtcs - o ne negativ e . o ne with
fine era nulcs and thr ee with ~a tt cred granules.
disc rete than in the neut rophils. Th er e is an
no phil with hollow positi ve granu les. a negative
hil and a negative Iymphocyte . I3I."Side the basophil .
the top left of the fie ld . is a clump of negati ve platelets.

~ B sta in on norma l peripheral blood , illustr ati ng

ntras t betwee n the den se and coarse posit ivity in
re era nutocvtcs and the d iscrete scatte red granul e
m ~)f monocytcs. Lyrnphocyt es arc nega tive.

, B stain o n norm al buffy coat showing the presence

myelo blast. as can usually he found in no rma l cir-
g blood if carefully so ught . Two negative base-
. 0-. 0 normally reac ting neu trophil po lymo rphv. a
_le and a Iymphocytc co mplete the field.

I~ 185

IH4. Peroxidase stain on no rma l pe riph er al blood . 186

T wo ne utrophil polymo rphs arc stro ngly posit ive: a
basophil is negati ve and on c of two rnonocytcs sho ws
loca lized cytoplasmic positivity co ntrasting with the
discre te scatte red granules o f the SB rea ction in
mo nocytcs.

ISS. Peri odi c acid-Schiff (PAS ) reaction on a normal

Pone marrow smear. to illustrat e the gra dual increase in
positivi ty found in the gra nulocytc se ries with increa sing
cell mat urity. Erythrohlasts arc nega tive. Th e d isrupted
cell with cen trally situa ted nucleus and co arse gra nules
of material co nta ining free iron . sp reading out between
neighbouring cells. is a ret iculo-en do theli al ( RE ) ce ll.

186. PA S reaction o n no rma l huffy coa t . sho wing two

positive neutrophlts. a coa rsely reactin g basophil . two
negative Iymphocytcs, two monocyte, with fain t diffuse
reaction . and an eosi no phil with ne gativ e gra nules
against a PA S·pos itive bac kgro und.

; .
..' -,

.., ...
".'~ . ~,
,. , .
I . Acid pho sphatase in grunulocytcs in normal IH9
aarr m" ; myelobl ast . promyelocyte , st ab and two
~ e n t c d neutrophils. All these gra nulocytcs sho w a
- ueri ng of fine granules . probably represent ing the
prima ry lysoso mal azuro phil granules which first appea r
• the late mye loblast to ea rly promyelocyte stage and
in in the cyto plasm of later gra nulccyres . altho ugh
led in co nce ntratio n by division at the myelocyte
. A cid phosphatase positivitv in the norm al cell
is the rclore generally most conspic uo us an
) cloc vtes.

Dual esterase. o n normal marrow ce lls - seve n

op hil granulocytcs. includin g two myclocyrcs. o nc
itosis, all showing chlo roac etat e este rase (eE)
tivitl. two negative eosino phil rnyelocyt cs. a
_ _ x-..le o f mixed butyrate es te rase ( BE) a nd CE
-eactIon. and a negative late normoblast and Iymph o-

Dual este rase on normal peripheral blood ,

CE- positivc polymo rph and BE· positive
_ _0) .1<.
)'iO 191


t9(~19-l , A ser ies of stains on bone mar ro w smears 193

fro m a case of acu te mve lob lastic leu kaem ia. show ing j , ..
re lative ly litt le c~;i dc ncc- 0 1 differentia tion an d non e o~f I \
erythroblas tic or rnegak ar yobl astic involve me nt . a nd
thus classifiab le as T ype III ~ Th ere a re neit her
gra nules nor Au cr ro ds visib le In th e Hc vl stai n ( 190)
and < 10% of blast cells are 58 positive (i91). There is
wea k d iffuse PAS positivi tv in most blast cells in 192.
and o nly a late r neu trophil and onc of the grou p
of rnyelo blasts sho w CE positi vitv in 193. In
19-1 . ho we ver. there is clear positivi ry to the myeloid
MA b C DD in this al ka line ph ospha tase-a nti-
alkaline phos pha tas e (A PA A P) immunocytoche mica l
About 20% of cases of acute rnveloid leukae mia
(A \ tL) fall into th is category . and [bcv have a rela-
tively poorer pro gnosis tha~ mo re clearly differenti ated 19 ~
ea scv. with 58 pcsi nvit v in > 5U% of the blast cells or
with Aucr rod.. or other inclusions readily found .
Wh e n few sign of myelo id differentiation a re present.
apart from positive antige n marke rs . the FA R clasvili-
ca tio n \111 may be appl ied.
193 196

195-198 . An oth er examp le o f a hon e mar ro w smear 19H

from a case of Type III AM L. aga in witho ut multi -
lineage involvement and with only poor ly differentiated
blast cells present . where the cytology in the
Roma no wsky stai n ( 195) sho ws so me inde ntati on of
nuclea r me m branes .•md t he identifica tion of the blas ts
as mve loblasts rat her tha n monohlast s (l\11 rat her tha n
~tS) 'is uncert ain. Th e prese nce of localized rath er than
scat tered SB posirivity. eve n in onl y < 10% of ce lls in
196 . suggests th e form er. Th e weak d iffuse PA S
rea ctio n with an occasiona l posi tive gra nule (197) is
equivocal on this issue . as is the positive surface
membrane APAA P reaction to C Ol3 s ~own in 198.
Reac tions to bo th d ua l cst c rnscs and the mon ocvt c
~ I Ah C D 1-1. were negative . T he cas e is ther efor e almost
ce rtainly myelo blastic (7\11) - but in term s o f the Type
IB classification th e possible d ifference is un imp ort an t.
the prese nce of < 50% S lr-positi ve bla st ce lls ca rry ing a
poor pro gnosis. whateve r the precise ba lance be twee n
the gra nulocytc an d mon ocyte precur sor co mpo ne nts
of an es se ntially mo nolin cugc AM L
199 200


199. A gro up of myelob lasts from an AM L. sho wing 202

Auc r rod s and az uropt-ilic inclus ions . T here is also a
myelocyte and two lyrnph ocyrcs in this field .

ZOO. Perox idase reaction in A ML. show ing pos itivity •

virtua lly co nfined to Au cr rod s whic h are prese nt in all
th e blast cells in thi s field . A sing le lymph ocyte is
negative .

201. Mvet ob lasts and pol ymorph s fro m a similar case

o f AM L. Several mye lob lasts show pero xida se posi-
nvity. and inclu sio ns ap pear pos itively stained. Th e
poly morp hs in th is case display stro ngly positive
reaction as in norma l polymorphs - although some-
times in AML the mature po lymo rphs show wea k o r
even negat ive reactio ns.
202. 5B reaction in AML . showing severa l stro ngly
po sitive A ucr rod s and loca lized reac tion.

203. SB reaction in myelob lasts of A ML. Stro ng

positivity is mostly localized to cytoplasm with a positive
Auer rod in one myelobl ast.


PAS reaction in a simila r acut e leukaemi a . Th e 2117

po lymo rph is normall y po sitive . whi le the
liv e cells give a reaction ra nging from negat ive to
a· diffuse positive tinge ove r most of the cyto-
. So me times fine gra nules a re also prese nt . but o n
gro und o f diffuse tingeing unlik e th e clear bac k-
seen in Iympho blasts .

PAS reac tio n in marrow cells from ano the r case

A ~ 1 L.T he field sho ws a ce ntra l group of four
_ .doollasts a nd a met am yelocyte . all with diffuse to
gra nula r po sirivity . and a nega tive la te norrno-
a t the uppe r right. One of the mye loblasts
;:::~ a wea kly positive Au cr rod o verlying the

Acid phos phatase reaction in a similar case .

Id)' coa rse gra nula r po sitivity is present.

Dua l ester ase reaction in the same case. The

IS sho w a weak . lincly gra nular . sca tte red CE
. ~'. A single ne utrophil po lymorph sho ws stro ng
I lQCtion .

2f1K 2119

20K-215. Humun n wsky stains of how! mllrrow and
blood SUI i' ll rS f rom cases of A M L wilh tilt' X;21 l rans -
locution - 1(8;21) (q22;q22).
In thi... A MI. variant the b last cells ar e gen era lly la rge
hut ... how vunab ilit v in size and in the amount of
cvtoplu ...m. which is basop hilic , oft e n con tai n... lo ng a nd
...lender A ucr rod s, and may also co ntain vacuole ... and
ulcbular indu... ion s. T he nucleu s may he eccent ric. with
commonly an inde nta tion o n the side next to the mai n
mass 01' cvtopla... m . v. here t he re may he a pale -... raining
area representi ng th e Gnlgi body and where inclu... ions
o ften tend to he localized. Th ere arc so met ime ...
disto ru o n-, of the nucleus and sepa ra ted nuclear
trua mc m , mac he foun d . N ucle o li are ac ne ra llv laru e
and. pale. and- tw 0 or three are co mmo nly de tectable ,
u... u .J1I~ ",idd~ spaced. Th e- pro mye locy te ... o fte n po.........·......
many coa r-e azurophil (p rima ry ) gra nules and may large pveudo-Chcdiak inclusions as well as slende r
Auer rod .... u...uallv ...inulc . Later staces o f maturati on .
fn~m myelocyte... ~mv.;rds . show defect ive pro d uction
(lCs~cifiC' gr -notc ~ o plas-m--- t h a l -a p pc a r ... -
pJ!lkish:)dlo", aitht=myeTocyfe sfagC ...omcti mc... with
a residual pcnpherartlmofl1eejJoa...opfii~ he re arc
par allel defects in nuclear maturation. with occasio na l
ring nuclei and. at the end of the maturation ...cquc ncc .
some neu tro phil... with pscudo- Pclgc r-Huct nucle i in
the ir agra nula r cytoplasm . Occasional abnor ma l
cosinophib may he see n. with atypical greeoic h-grcv or
blue-staining gra nules (St'e also 220).

216 2 17

216-225. Cytochemical reactions in cases of1(8;21). 2211

Peroxidase and Sudan black reactions (2 16-2 19) always
sho w stro ng localized cytoplasmic positivity in the great
majo rity of blast s. Generally . this is concentrated at the
nuclear indentatio n hut often it involves most of the
cytoplasm and. in the case of Sudan black espec ially.
tends to obsc ure the frequent positively reactin g Auer
rods . which a re therefore best see n in diam ino-
be nzid ine (DA B)-pc roxidase prepar ations. but may
occasio nally be found in maturing eosi nophils. too (see
217). The inclusions sccn in Romanowsk y stai ns a re
also usually peroxidase positive and sudanophilic.
Occasio nal nega tively rea ctin g neutroph il po lymo rphs
may be seen .
PAS st ains show the usual weak diffus e o r finely
granula r positivity of lcuk aemi c myeloblasts, but may
also sho w coarse gran ules o r block s of positive reaction 221
(223). an o therwise q uite unu sual fea ture for AML with
granul ocyt e lineage predo minance . Auer rod s may
sometimes stain positively (222) . Th e atypical granules
seen in eos inophils in Rom anow sky stain s (220) may
show PAS posit ivity (221), unlike normal eosinophil
granules. which are PAS · negative against a background
of cytoplasmic positiviry .
Dual esterase staining with eit he r do uble (224) or
single (225) capture agents shows CE positivity in most
leuk aemic cells with posit ive Auer rods co mmo nly
visible . someti mes with a negative co re, and similar
reacti ons in other inclusions. CE positivity of Auer rods
is not often see n in cases of A ML ot her tha n the 8;21
and 15:17 translocat ion s



226 227

226-256 . Cytology and cytochem istry of AM I. cases 228

with the / 5: / 7 translocation, t! /5: 17l (lJ22;q21) - (K w e
promvelocvtic leuka emia (A PL ).

226. A n A PL with ea rly gra nula rity in th e urcho -

pluvrruc lone next to the nucleu s in most cells. Th e cells •
arc Icukac mic pr omycloc ytcs. hut do not show mult ip le
Auc r rods. althou gh th er e is it sugges tio n o f the
coarsely lo bular nuclea r changes of th e typ e ofte n seen
in APL. Striking vac uo lation was a feature o f thi s case .

227. 58 reaction in the same ea-c . TIle den se cytoplasmic

poviti vity resembles that seen in no rm al late r gran u-
k:~te"S from myelocyte to po lymo rph. In this prepar at ion
the I ndcncy towa rds nuclear ind e ntat ion to produc e
twinned o r unevenly pai re d lobes . a strikin g fea tur e of
APL. can be discerned in seve ral cells. 229

228 . The PAS reaction o n these ce lls sho ws diffu se

po..itivitv with some increased gra nula rity in the a rchc-
plasmic zones . Thiv i-, the PAS pictu re of AML wit h
pr o m vcloc ytic prepondera nce .

229 . D ual c.....tcra-e reaction in the same cells, with strong

CE posi tivi tv . including a Cli-po-itivc Aucr rod .

1.. A PL with coa rse azurop hil (prima ry) gra nu les 232
_e1 ~' filling the cyto plasm of all the le ukaem ic pro·
jocytcs. Nucleo li arc co nspicuo us and va riab le in
bcr hut the ove rlapping o r dumb-bell type of
ar shape often see n in A Pt is no t shown he re , a nd
Iller rods arc not visible in this l.cis hma n-staincd

.=J I. Ano ther preparation from the same case . stained

\t GG . Co nspicuo us multiple Au er rod s are now
in seve ra l cells. The differen ce in staining
ion of A uc r rod s in APL to Leishman and ~ IGG
. thoug h no t always shown . is frequently striking .

Anothe r case o f APL with granular promyclo..

. seve ral ha ving multiple Auer rod s and so me
__ typical nuclea r lobulati on .

233. Myc lobla sts a nd prornyelocytcs from the 235

peripheral blood of anoth er case of APL. all showing the
virt ua lly diagno stic nuclea r patt ern altho ugh only the
ce ntra l ce ll is he avily gra nular.

2..\4 . Another case of APL. showing few o r no cyto -

plasm ic gra nules a nd no Auer rods with e ither Lcishm an
or MGG sta ins. hut with the char acter istic and diag-
nostic nuclea r shape with dumb-bell appea rance o r
ove rla pping of twinned nuclear lo bes. Thi s var iant of
A PL is sometimes d istinguished as a sepa rate
'agra nular' o r ' microgranula r' for m. although usually -
as her e and in 235 - a n occas ional norma lly granu lar
promyelocyte may be seen .

235. Anothe r example of microgranul ar APL. with

minimal granula rity. hut aga in with seve ral cells showing
the nuclear struct ure typical of APL. Th at these ce lls arc
not ntially different from those of the more co mmon
coarsely granular var iant is indicated by the ir havin g the
sa me chromosomal defe ct . the 15:17 tr anslocat ion . and
also by thei r capacity to de velo p coa rse azuroph il
granul ation afte r short pe riods of culture ill vitro (.'it·f·

I )

136. T he sa me ma rrow as see n in 234. here af ter 20

hours in culture: coarse azuroph i l gran ules have now
appeare d in the cytoplasm of all the promye locytes .

237. A ma rro w fro m AP L:SS sta in showing heavy

ove rall positivity. with positive ly sta ined Aue r rods .

238. Anothe r case o f A PL :SS sta in of ma rrow cells

sho ws similar ove ra ll positivit y. but here the Aue r rods .
seen in the ce ll at th e extreme right of th e field. appear
boIlo w with a sudanop hilic outer coat but a negative
core .

!J9. A similar S H prepa rat ion from another case of

~Pl . again showing stro ng positivity and with
bo th
-solid and hollow Auer rods visib le in cells to the right
~ left of the field . respect ively. T here is also
pt ing promye locyte show n. with sca ttered suda no-
- gra nules among which several positively reacting
r rods can he made o ut. Multiple Auer rods .
limes a rranged in leashes o r fasce s. arc diagnostic-
rJ cha racte ristic of APL. and can often be best
ed in SB sta ins. especial ly in thinner parts of the
~ . ~ he re they are less likely to be obscure d
by heavy
granula r posi tivity. He re they may show up as
e rods (if they have hollow SS-nega tive cores) , or
d amo ng the scatte red gra nules of disrupting


240. PA S reaction in APL. showing mod er ately stro ng. 243

diffuse and finely gra nular po sitivity. Occasional nucl ei
sho w the A PL type of twinning or distortio n.

24 1. An other field fro m the sa me pr ep ar at io n sho wing

unus ua lly stro ngly PAS-positive Au er rods. including
se veral in the cyto plas mic rim and othe rs ove rlying the
nucle us in the cell at th e right of the field .

242. Anot he r exa mple o f stro ng PA S pos itivity in an

Aue r rod overlying th e nucleus in a lcukae mic pro-
myelocyte in A PL.

2-lJ. Acid phosp ha tase reactio n in APL: th e leuk acm ic

pro mvc jocytcs sho w only a very weak gran ular reac tio n.
con tra ling with th e stro nge r reacti on in a neig hbouring
plasma cell. As normal promye locyt e azurophil granules
arc u ua lly q uite rich in acid phosp hatase . this weak
reaction may indicate a lysosomal functional defic ie ncy
in APL.

• 0

, .•..0; '

_...a..I Dua l este rase reaction in APL: th er e is a negative 2 ~7
. throhlast pr esent hut all live promyclocytc s e xhihit
g gra nula r Cfi po sitivity a nd two of them contain
In ple Aue r rod s which ar e her e int en sel y CE-
tivc. T he strong reactio n for CE, with or without
_ativc or Bfi-posuivc ce ntra l cores, is not usuall y see n
Auer rods except in the 15: 17 a nd 8:2 1 tru nstocati on s.

_ ~ Dual esterase reaction in AP L: a negati ve ea rly

hro b last a nd two Cli-positivc promye locyte s con -
g mu ltiple A ucr rods sho wing Cfi-posuive outl ines
ne gative cor es.

D ual este rase react ion in APL: the leukaemic

sho w C E positivity with nume rous strongly CE-
u ve A ucr rods: the de nse circula r or ring -like Cfi-
ve structur es, some with a hollow Cfi- nega rivc
ue, see n es pec ia lly in o nc of th e prom yelocyrcs.
bly represen t early stages in th e form ati on of Au e r
A seq ue nce betw een these hollo w rings and the
co mmo n holl ow rod s (as shown in 2~5 ) ca n he
o ur.

.- A dual es te rase react io n in a nother case o f APL:

lo w rings and short Auer rod s in seve ra l o f th e
. elocvtes here d isplay a CE-pos itive envelope with
-pos n ivc co re .

248. Section of bone marrow trephin e biop sy ( H& E 2511

sta in) from a pati ent with APL. showing high overall
ce llularity with almost complete replace ment of norm al
marrow cells by nuclcolat cd prim itive ce lls in which it is
just poss ible to discern the granularity of their cyto-
plusm. and among which some show signs of the double
lohu latio n nuclear pat ter n. T here are a few residual
e rythro blasts.

U9 . Anot her sect ion from the same biops y sta ined with
Gie msa. hut not providin g better gra nule definiti on o r
clea re r cell differentia tion . although the lcptochrom utic
nucle i with pro minent nucleoli arc well visua lized and
the prese nce of occas io nal nuclear twinni ng can be
... •

detected .

2: . A thin plastic-embedded H&E-stained section of 25J

another trephine biopsy from a patient with APL. in
which this high-po wer view reveals the cytop lasmic
azurophil gra nules of the pro myelocytes more clearl y.

251. A still-higher-power view of the same section.

where several leashes of Auer rods ca n be see n in the
poorly defined cytoplasm of the leu kaemic cells. While
this sequence of histological sections does include
diagnostic material and illustr ates the power of modern
histologica l techniq ues. especia lly with the use of plastic
embeddin g, there ca n be no compa rison with the much
supe rior cytology of smea r prepa rations .


151-256 . A [urthcr APL variant. 255

1S1. APL variant- the cells show numerous mod eratel y

rse granules hut no Auer rod s were visible in eithe r
Leish rnan (here ) o r MGG stains.

':3 . Heavy granular SB positivity typical of prom yclo-

but again no Au er rods.

tro ng diffuse tinge of PAS positivity - the

eristic A PL patt ern .

-, 'egative reac tion o r fine scattered gra nules o nly of

phos phatase positivity.

Dual este rase - a rem arkable mixtur e of strong

<c.oCbD"'_ to bo th CE and BE . perhaps sha red someti mes
same granule (ef. 2-17 ). A mixtur e of CE and BE
-C} is quite commonly found in APL. eit her in
- , ; : : ce lls making up a du al populatio n with
01: • e1}' CE and BE posi tivity. o r with both kinds of
.",...... prese nt in the same cells. Ab out a third of cases
feature . hut it is accompa nied. as in this ease .
'ise typ ical pro myelocytic cytoc hemistry and
IIIaJ .er immunology and does not ind icat e the
...~.,. of a mo nocytic compo nent.


257 258

257. Exce ptio nally lar ge pro mycloc ytcs. myclo cytcs 259
and rnctu myelocytes may he enco untere d in the marrow
of pernicio us anae mia ( PA) and someti mes of other
megaloblastic (and rar ely nor mob lastic) anacmias. Her e
arc e xamples of gia nt pro myelocyte and myelocyte from
258. A neutrophil sta b cell and a segmented cell from
nq rmal periphera l blood .

259. Th ree segmented neutrophil po lymorphs, onc

showing a drumstick appendage . Two small sessile
appe nda ges. not co untable as drum sticks. arc visible in
the uppe r ce ll. Well-separated small nuclear append-
age . attached to the main nucleu s by a short narrow
strand. arc found in fem ale neutrophils o nly and rep -
resent the same inactive late- replica ting X-chromosome
material as is visible in the Barr bod ies of buccal muco sal
or other epithelial cells . They are not to be confused with
the smaller prot ru sio ns. which have a broad attachment
rath er than a nar row stalk. and which occur quite often
in the ne utrop hils of either sex.

16 1

160. Th ree segmented neu trophil polymorphs a nd 262

a myelocyte . The myelo cyte still retains a degree of
. to plasmic basophi lia as co mpared with the late r
eeutrophils. and the nucleus - although showin g the
irreg ularly dense chro matin patt ern associated with
mat uration - is less pachychro mati c tha n in the case of
the polymo rphs.

161. A dru mstick appe ndage attached to the nucleus of

a tab cell. A lthough the connecting strand is a litt le
. ker than in the typical appe ndag e . the size is abo ut
~ t and the body is accept able as a fema le dr umstick
appenda ge.

~. A segmented neutr op hil pol ymorp h. with dru m-

appe ndage and a monocyte . T he lighter grey
ilaining of the mono cyte cyto plasm and the mor e op en
chro matin patte rn of the nucleus contrast clea rly with
me sta ining colour and inte nsity of the neutrophil.
ite the granularity of this monocyte cytoplasm. Th e
ulev are also different , bei ng generally finer and
a mo re reddish and less purple colour in the
~..e as co mpared with the neut rop hil polymorp h.


263. Three segment ed neut roph il polymorphs in the 266

centre o f th e field. with an eos ino phil pol ymorph and
a mo nocy te . T wo more neu trophils appear at the edges
of the field.

UM. Nuclea r twinning in neu tro phil po lymorphs: there

appears to be so methi ng approaching a mirror image
disposition of nuclear lobes . This specimen was from an
AML following chemot herapy.

265. A multi-lobed polymorph from the peripheral

blood in a megaloblastic anaemia. These macropoly-
cytes may be found in megaloblastic states d ue to
defic iencies of eit her cya nocoba lamin or folic acid.
Th ere is anisocytosis and macrocytosis of the accomp-
anying red ce lls visib le in thi s field .
266. Coa rse gra nularity in stab cells from an infective
state wit h leucocy tosis and left shift. Th is appearance is
so metimes ca lled toxic gra nularity.

267. An other neu troph il showing very coa rse toxic

gran ulation. in this case a bilobed po lymorph. aga in
fro m a severe infection with a ma rked left shift . i.e . a
relat iv·e increase in th e numbers of stab ce lls an d
neu trophil po lymorp hs with onl y two lobes as compared
with thr ee- and fou r-lobed cells.
normally gra nular and a non-gra nular neutrophil 270""'rph. toge the r with a Iymphocytc . Ab senc e of
~_lI3rit )" in po lymorphs is most co mmon in leukacmi c
but may occasio nally he sce n in mo st a naemic or
.nlaJpenic states.

-\ poorly gra nula r mult i-lobed po lymorph fro m th e

8laJTOW in a case of pe rnicious anae mia . A second
~~:cd~ cell with four nuclear lobes, a hasophil
.... and various earlier gra nulocytes ma ke up the
........oder of the field .\In>ma
smear fro m the buffy coat of a blood sample
pat ient who developed se vere deficien cy o f
.. and folic ac id while o n parenteral nutrition in
."''''·C the rapy uni t. The field shows an ea rly
~ galoblast and a mult i-lobed pol ymo rph or
• le. Two red cells co ntain Howell-Jo lly

271. LClU..ocytc a lkaline pho sphatase ( LA P) reaction . 27J
w eak and stro nger povitivity in neu troph ils. with a
nega tive lymphocyte . Positive reaction s in hae mic cells
arc virtually confined to neutrophil stabs and segme nted
cells. although macropbagcs may also show positivity.

272. Grades of posinvity in polymorphs. rang ing from

1 (+ ) to -t ( + + + + ). Summation of ratings on 100
neutrop hils gives a sco re with possible range fro m 0 to
400. T he norm al range is betwee n 15 and 100.

273. Increased LAP sco re. with man y strongly po sitive

ce lls from an inllammatory leucocytosis. Similarly high
scores may be found in po lycytha emi a vera . myelo-
fibrosis. hairy cell leukaemi a (Hf. L} and Hodgkin's
disease (11 0) . G


_ -_ Cytology ami cysochemiu rv of bon e m llrrow

om a patient witlt tm hereditary leucocyte defect

ell: yme deficiencies and the Peiger-Huet

Romanowsky sta in illustra ting var iou s sta ges o f

~,_"".l e mat ura tion and a single late no rmoblast at
om o f t he field . A ZUTOp hil gran ule s a rc visible in
vclocvrc just above the normoblast. and specific
!'""..._ ..... a re prese nt in th e three ma ture eos lno phils. but
trophils show litt le or no gra nu larity. A ll the 277
a n uloc yte s , nc utro phil s a nd cosinoph ils a like .
gme nted coa rsely pac hychro matic nuclei with
o r cu rved ba nd o r dumb be ll-like structure .
of the ra re homozygous form of the Pelger -Huct
Thi s is a be nign familial disorder . inherited as
...._ omal do minant. In th e comm on er hcter o-

ncutrophils have mostly bilob cd nuclei .
ed form of this ano maly . which occurs q uite
roliferative slates and generally resembles
. _o tic form has already been illustr at ed in
th the S::!t tr anslocation vari an t of AML

B and DA B-pero xidase . respectively .

IIOI1Jl3l1y positive eosinophils hut negative
Tbe deficie ncy of myclopc roxida sc (MPO) . 278
m the familial form which . like the Pclgcr -
_ _.... . is inhe rited as an autoso ma l do mina nt.
commonly as an acqu ired fea ture in
eve stat es. especially in AML. CM L.
aDd mvelod vsplastic sta tes .

P react io n is nor mally positive in the

taini nz reve als a red uctio n in ex-

the ncutrophils for CE. although
n t.

279 280

281 2M2

279 and 280. Respectively low- and high-power views 2H

o f a bo ne marrow trephi ne biops y from a patient with an
infective leucoc ytos is. T he first sho ws the den se ove ra ll
cell ula rity of the spec imen and the seco nd allows the
co nstit uent ce lls to be recognized as predo minant ly later
gra nulocytcs, mostly at th e metam yeloc yte to po ly-
morph stages . A few late norrn o blasts with dense black
round nuclei and minimal cytoplasm can be distinguished.
but the M:E rati o is o ver 20:1. well above the norm al
ra nge of 2: 1 to 8: 1.

281 and 282. Similar low- and high-po wer views of

ano ther tre phine biopsy fro m a pat ient with a reactive
leucocy tosis in HD agai n showing de nse cel lularity , but
with a mor e mixed cytological pictur e . including
erythroblasts and cosinophils as well as the predominating
neut rop hil gra nulocyte s. which here include a higher
proportion of ea rlier stages. bo th myelocyte, and some
nucle olated promyelocytes . Th e M:E ratio is again high .
around 10: J.

283. Another tre phine biopsy section fro m a pat ient

with HO and a reac tive eos ino philia . Thi s high-power

view shows a generally pleo morphic cyto logy, with
various e rythroblast and gra nulocyte stages and a mono-
nuclear mega karyocy te . together with numerous
eosi no phile. mostly at the myelocyte stage. alt houg h a
few have more mature bilobed nuclei . Th e cosi ncphils
tend 10 be gro upe d along the line of a cap illary blood
vesse l in the lower left part of the field . whe re the
vascula r end ot helial cells are also conspicuous.

I _


Eosi no phil myelocytcs and met am yelocyte in bon e 287

....... _The re is also a neutro phil myelocyte , various
-.:I segmented ncutrophils, and a late normoblast.

: :ic no rmal eos inophil po lymorph. showing the
'spectacle' arrangement of the nuclear
. which are usua lly two in nu mber. The sur-
red ce lls show slight hypochromia and there is
relet o verlying one of them .

pted eosino phil. In this and the next two

me rela tively lar ge size of eosino phil as
_ _Ird -ith neutro phil specific granu les ca n be

Eosi no phil po lymor phs with agran ular

• cyto plasm. This appearance is not
. but beco mes most freque nt a nd co n-
• Ie1J .acmias. The lower cell has a typica lly
but the upper has an annular or ring
tu re on ly occasionally see n in norm al
ca..."",ohi l o r neutrophils although more
form. of A ML. not ably case. with 8;21
-, -l-
289 2'10

289 . Fami lia l eosino philia : ge ne ra l " icy.' of ho ne 291

mar ro w; a ll st ages o f ma turation in the eos ino phil se ries •
arc present.

290 . Th e sa me case: high -powe r view to show

'a mp ho phil" a ppe a rances (hot h ba so phil a nd eos ino phil-
stai ning gra n ules) in eo sinop hil p ro myelocyt e and
mycl ocytcs . T he ' basophil" gra nu les probabl y rep rese nt
pri mary eos inophil gra nules. Th is a mphophi l ar rea r-

a nce of granules in cosinophils. see n he re in an her ed ita ry
eos ino philia. is a striking a mi co nspic uo us fea ture o f
ce rtai n va ria nts o f Ar..1L. es pecial ly cas es with chro me-
so ma l a b nor mal ities af fec ting the lon g a rm o f 16 . a nd
als o to a lesser e xte nt those wit h S:2 1 tra nsloca tion .

291 . Pe riph eral blood in th e sa me case as in 289 a nd 290 .

Nu me ro us mature e os inop hil pol ymorphs ar c presen t.

I •

_ 1-304 . Cvtologv and cytochemistry of bone marrow

from cases of A AI L with abnormalities - deletions ,
eruons or translocutions - involving the long arm of
, mosome 10 - del(l6) ('1221, il/l'(l6)(1'13;q22) , or
[0111'13;'122 ).

_ :-_ -1 . Ge ne ra l low -power views of hone marrow

I fro m three cases orA ~ l L with chro moso me 16
_Such cases show a highly ce llula r mixed pop ula-
uh a predominan ce of blast ce lls. usually. hut not
__. includ ing some with nu cle a r twistin g or i lld c n ( a ~
2\!.C'sti n g mOl1ocvtic linea ge a nd o thers with
kxvtic ~)f Iute r g~an ulocvt lc features. T he cases
led he- re all shll\\':"" these mixed features . but abo ut
cases have 111 0re purely gra nulocytic pre cur sors .
sio na l cas t's arc esse ntia lly mo nocytic . A mo ng
cells a re scatt e re d var iable numbe rs of
. a t all stages of ma turatio n . wit h freque nt
i ie-, o f gra nule sta ining a nd d ispos itio n . In 292
rous eos inophile mostly have a blue tinge .
1'93 a nd 29.J the colo u r of mos t granu les is more
I so me ce lls sho w an adm ixtur e of da rke r.
ilic, gra nules . illustr a te d in more deta il in

295 296


.. . \ ... ......: '-.... ..
. . s : t- ..

295-298. Higher-power views of the marrow ce lls in 299

A~1L with 16q abno rma lities. T here are abnormal
eosi no phils in each field. Th ey arc least prominent in
295. which has five cosinophi ls. three with normal
granules. o ne disrupting. and the fifth with so me amp ho-
philia. 111e lowest cell shows lack of seg me nta tion of
its o the rwise mature nucleu s. a pseud o-Pelgcr-Hu et
phenomeno n frequently see n in these cases . The two
eos ino phils in 296 arc grossly ab no rmal. with a scatter-
ing of coarse deep red or basophilic granules and a blue- •
black colour replacin g the norm al eosin sta in of the
pre do minant granules . Similar features arc sho wn in
variable degrees in 297 and 298. the granule colour
repl acing eos in rang ing from hlue to greenish-gre y and
the baso philic granu les varyin g widel y in numbers.
These fields also demonstr at e the variable size of blast
cells and the common presence o f both granulocyte and 300
mono cyte precursors .

299 and J ( H) , Low- and high-power views of SB sta ining

in a case of inv( 16). In 299 the presenc e of strong
localized or heavy overall posit ivity of the granulocytic
type in six blast cells con trast s with the mo nocytic type of
discrete scatte red granules of positivity in four. In this
field. and also in 300. the eosinophil granules show a
mixture of the norm al reaction - positive she ll with
negative centre - and solid sudanophilia. the latter •
probably in the coarse r and more basophilic ah normal

- I

_ I and .l02. PAS react ion s in marrow cells from AML

inv( In). sho wing negat ive o r weak finely granular
-.:I diff use pos itivity in blast cel ls. but stro ng and
ariable positivity in the atypical cos inop hils. Some
ules show the usual negat ive reaction against a
uve cyto plasmic bac kgro und. while o. hcrs rea ct
a solid positivity. A d isru pting ear ly eos inophil in
t has pos itive granules of this type , so me bein g
rered wide ly acro ss th e whole field .

1. Dual es terase reaction in a similar case. showing

- e e ryt hro blasts. one apparently co nta ining
~'_""'''' i l granules within a vacuole. severa l rnyelo-
o r pro mye locytcs with weak -to -strong CE posi-
_. o nc mo noblast with stro ng BE re actio n. and two
ring degene rating and partially disrupted
ils at the centre left of th e gro up. o ne with weak
uivity in so me o f th e coarse r gra nules . a feat ure
..-.all ~ seen in cos lnoptuts.

Daal terase reaction co mbined with Chlorazo l

(a dye reacting spec ifically with eosinophil
-0_ ......) to show th e va riable pa ttern o f CE posit ivity
~ules . seve ral co sinop hils showing onl y th e
Plo.\. ..... in but ot he rs. notably the ce ll at the to p left.
for CE. Blast ce lls of granu locytic and
sho w respective ly CE and BE positivity,


J05. Basophil precursors. together with neutrophil 307

prec urso rs . in the blood o f a pa tient with chroni c
mye loid leuk aemia (C i\tl . ).

•'06 . A basophil polymorph . to gether with two neutro-

phil s , an eos inop hil and a lyr nphocytc .

.'07. Another basophil polymorph . These cells do not

show the clear separation of nuclear lobes seen in
mat ure polymorph ... of o the r kinds . but o verlapping
lobes mav he distingui shed . Here. thc coarse granules
do not e nt ire ly obsc ure the nud e-m struct ure . whic h ca n
be seen to have th ree inco mpletely separated lob es.

•\t n~ . A disrupted degeneratin g bu...ophil. with 10...... of

nuclea r structure and ... caucrina of er anulcs. The indi-
vid ual basophil granules, scattere d in thi s way and
u...uallv seen at the tai l o f the smear , va rv con siderahlv in
size and shape. often being large r tha n nor mal ncuiro-
phit or eosino phil granul es and sometimes having a rod
...hapc .


313. Bone marrow sme ars fr om all unusual case of

leukaemia with basophilia .

A Romanowsky prepa rat io n showing a collectio n

eecleo tated pr imitive cells with a ge ne rally low
ar-cyto plavmic ratio . the ample cyto plasm co n-
~ nume rous vacuo lcs and fine basop hil granules.
re is a neutro phil sta b ce ll, a lyrnphocyte and a nak ed "
.. 312

-'~""' Iast nucle us also pre sen t in th is field.

A ...imilar field to that in 309 but sta ined with

"ne bl ue. which rea cts with the basop hil granules
a bluis h-purple coloration . One blast cell he re is
c. as <I re a ne utro phil stab cel l. a lymphocyt e at
er left co rner. and a late no rmo blast.

,.\ "tide fro m th e sa me case as in .'10 . stained with

T prim itive cells show the usual positi ve reactio n
o f neu tro phil pr ecursor s. while seve n others give
romatic reac tion with the dye . resu lting in a
a in . a pict ure not infreq uentl y see n in~ both
MId pat ho logical baso phils. 313

ber slide from this marrow stained with the

. The re is o ne negat ive blast cc ll and a
reacting ne utrophil metam yelocyte : th e
~-_. etaht vacuo lated blast ce lls show inte nse and
~ula r povitivit y. characte ristic o f basop hils.

stain fro m this seq ue nce is a d ual es te rase

g CE pos itivity is present in a single
-eecursor with a poss ible Cti- pc sit ivc Auer
the lowe r borde r o f the nucl eu s. but the "
ne ighbouring vacuo lat ed pr imitiv e cclis
eithe r C E o r BE activity. as ar c nor mal

JI ~ JI5

314. PAS reaction in mature polymorphs of neutrophil. J ib

eos ino phil and basophil se ries . T he ce ntral neut rophi l
has dense stro nggra nula r pos itivity. packin g the cyto-
plasm to leave no visible back grou nd . Th e eosino phil
shows granules with unstained. negative appearance
agai nst bac kgro und positivity,
The baso phil gra nules are discretely scattered . very
heavily positive , against it negative o r weak ly stai ned
bac kground . Salivary amylase removes most positivit y.
but not that of the baso phil granules. which presum abl y
do no t cont ain glycoge n. T he unstained gra nules in the
eosi no phil are ce rta inly the specific gra nules scc n in
Rom anows ky sta ins. but the I)AS-posit ive granules in
the basophil ar e not ide ntical with th, pccific gra nules
in that ce ll.

315. 5B reaction in neut rophil. eosinophil and

basophil po lymo rphs. Neut rophil granules are positive .
eos inophil gra nules show positivity with a ho llow cent re .
and basophil gra nules are negat ive (as her e) or oc-
casio nally show positi ve or met achromatic sta ining.

316. Peroxi dase react ion in a similar trio . with appea r-

ances ge nerally similar to those in the SB reaction .


317. Al kaline phosphat ase reactio n in a similar cell 319

~p:'on ly the neut roph il shows positivity . Th e eo slno-
immediately below the neutrophil has a typical
d nucleus. while th..1t of the lower basophi l has
-=omplete ly separated lo bes. Neith er sho ws any
ine phosphatase activity.

.3 cid phosphatase reaction in neutro phil. eos ine -

and baso phil polymo rp hs and a monocyt e.
neutrophil and mon ocyte show no rmally po sitive
r rea ctio ns: the eosinophil and basophil sho w
litt le pos itivity with o nly a ra re positively reacting

Dual esterase in a group of basophil. eosi nophil.

eeatrophits a nd a mon ocyte. Th e baso phil and
il cells arc esse ntially negativ e . while the
.....,pllils show typical CE pos itivity and the monoc yte
BE positivity.

32 1

320. A low-pow er view of pe riphera l blood fro m a

pati ent with CML. Gran ulocytes o f all stages of matura-
tion ca n be seen, mostly neut rophil s hut with occasio nal
basophils. Alt ho ugh myclcbl asts a nd pr omyeloc yrcs arc /J
distinguishable . they arc relati vely few and much o ut-
num be red hy later grunulocyrcs from myelocy te
o nwards. A periphe ral blood smea r with as many
lcucocytcs of differe nt stages of mat urity as shown he re
is found o nly in CML. wher e the wue at present ation is
co mmonly above 50 and may exceed 500 x 10"/1.
~UJ . A higher-power view of anot he r prep aration sho w-
ing va riou s granulocyte precur sors . includ ing severa l ."
baso phils. In additio n to the grunutocyres. two nor mo- ~
blasts arc present. Th ere is a single myelobl ast in the
field but lat er gm nulocyrcs grea tly predom inate .
. .a.
322. A chro moso me spread fro m a male patient with
at 12
C ~ I L. The Philade lphia (Ph) chromoso me. seen

o'cloc k. results from a translocation hetvece n the: lon g ~
arms of chromoso mes 22 and 9 (usually) visible in
unba nded preparatio ns as a loss of materia l fro m the
long arms of on e of the small acrocen tric chro moso mes
(no . 22). T he translocati on is a reciproc al one. involving
the exchange of mater ial between the two chro moso mes
- t(9 :22) (q34:q l l) - and is found in virt ually all haemic
marrow cells. including those of arunulocvtic. e rythro id
and megakaryocytic se'-ries . thu s confirm ing that t ~ I L is
a multilineage neoplas m.

-po wer view of a hone marrow smear from a 325

"rh C ~ I L. sho wing a ce llular pr eparation with a
t :E ratio and preponde ra nce o f neut rophil grunu-
i th all stag es o f developmen t rep resen ted .
scat te red cryth roh lasts and a proc ryrhroblast
bottom of the Iiekl can be seen . and an
il myelocyte a nd po lymorph . whi le the two
,...ith dee ply stained nuclei and coarse gran ules
hab le in t he na rrow rim of cytoplasm .
10 either side of a sma ll cent rally place d
_.-.... myeloc yte. arc baso phil poly morphs.

rnea r from a pa tient with C M L. showing

~ mo rph
granules. A basophil is on the left
phil is to the upper rig ht of the central
: the re ma ining cells arc all neutrophils
gra nula rity. from a n a lmost agranular
tbe partly sectioned cell at the bottom . to
. _ranularity in the polymorph at the top and
h o r the eosi no phil. Variations of this kind
_ _mo o in CM L.

Iv there rnav be an almost total abse nce

ID later ne utro phils in C~tL. as in this
sample ......he re the central promycto-
_""';>0111 granules but the remaining late r cells.
metam veloc vtcs and two matu re
c de void of specific gra nules . The dense
"",...._1JIl but minimal segmentation or th e
suggests that a pscu do-Pelgcr -Huet

J 16 1ioI'!7'~ · 327

326. A section of a trep hine biopsy from the hone 32K

marrow of a patient with CML. Th e spec imen shows
intense cellularity with ob literation of fat spaces. and
eve n at this low power it is appa rent that all cell seri es are
well represented. with a scatte ring of mcgakar yocytcs .
num erous gran ulocytc precursor stage s with lightly
staining nuclei and ample cytoplasm. and later granule-
cytcs a nd erythrob lasts having pac hychro matic nuclei.
the for me r more irregular in o utline .

327. A further example of bone marrow trephine

histology fro m ano ther pati ent with CML. In this case
the re arc num erous residual fat spaces and less de nse
ove rall cc llula rity. and later granulocyecs predomin ate.
but there is also ano ther feature sometime s see n in
ma rrow biopsies from CML. namely the marked pro-
liferation of megak aryocytes . In this fic ld at least a
dozen ca n be seen . with various degrees of nuclea r
segmenta tio n and complexity. but most often with single
o r bilobcd nuclei. Such cells. and eve n smalle r ones
some times called micro mcgakaryocyrcs. are charac-
Icristica lly fou nd in trephine sections fro m ahout X(llYo of
cases of CML. although not necessa rily associated with
increased thrombopoiesis.

328. A sect ion of a needle biopsy of liver from a patient h CML. showing an area of leukae mic infiltration
around a po rta l tract . with a dense accumulation of
granulocytcs compressing the su rro unding liver ce lls.


'. '
:: . '~ ' ''.

• ,
I A se ries of views at low, intermed iate and -'-' I
rs o f sectio ns made from a biopsy o f skin and
_ ' . . . .""'''' tissue tak en from a pati ent with C ML.
a k ukaemic infiltration. The first two figur es
a section stained with H& E and th e third is
"~~~~::,-stJ i ned section. Th e first field shows the
- . with the infiltrate ext ensively involving
.....rt.!iolg_ de rmis. producing vascular erosion and
- . . orrhagc . In the second field the nature of

:::~.~ceIlS can be d istinguished mor e clea rly,
ntly nuclcolatcd myeloblasts and fewer
ytes spreading bet ween th e subcutaneous
_ _oeti,..e tissue . Th e third field shows th e edge
e as it reaches the epide rmis. where the
ma tu re granulocyte precursors inter-
co llagen fibrils and macrophagcs lad en
.... .. .L eithe r free iron or possibly ca rbon particles.
__ .... «11 is visible towards th e lower left co rne r.
no w skin deposits arc no t unco mmo n in
_ times nume ro us and wide spread so a,s
-,......, a lru aemic skin rash . es pecially. as in the
~ at the time o f gene ral metamorphosis o f
fro m the chro nic to a more acute
appearance may therefo re have a poor
. nee. More bulk y a nd restri cted
"",,,,,,,... may also occu r. less co mmon ly. at any
. and are sometimes referred to as

• •• •

JJ2 333

332. LAP reaction in CML. Th e polymo rph s are 33-1

virtually devoid of enzyme . This is a striking and almost
uniform characte ristic of ne utr ophils in C ~1L.

333. Unde r effectiv e trea tme nt . whe n the blood pictur e

returns qu antit atively to nor mal. the LAP score rem ains
low (and precursors still have the Ph chro mosome) . bu t
an improve me nt towards the lower no rmal range often
occu rs.
Th is preparati on shows the pre sence of faint positivity
in so me pol ymorphs fro m .1 buffy coat in well-co ntrolled
C ~ I L. although nearly all of the neutrophils remain
quite negat ive.

334. When blastic crisis emerges. the LAP sco re usuallv

rises sharply. This figure shows + to ++ reactions in
polymorphs in a pe ripheral blood film from a pa tient at
this stage of the disease. Surroundin g the gro up of
po lymor phs arc pre dom inant ly blast ce lls.


·T'Tu.Jlase re action in C~t L. Except ionally strong 3.17

the rule in polymorp hs in this disease .
pe roxidase-negative cells can be found in
and mav occasionallv be numerous. Th e
....""ou\< polymo rphs may' includ e so me baso-
rs of them are certa inly neutrophils.

. n in CM L. The pol ymorphs may react

tro ng posi tivity. as here . but th e reaction
ea "er than nor mal and neg ative poly -
fou nd . includi ng so me baso phils (cf.
a proportio n of the neutro phils. which
allel absence of peroxida se reac tivity.

mav show a metachro matic redd ish

field from CM L progressi ng to ward s
hich also shows typical positivity in
ce utro phits with S8 .

C\ IL showing S8 positivity in ncut ro-

hile four baso phils show varying
~.""""' . partly met achrom atic. O ne o f the


339-34H. CM L p rogressio n to myelofib rosis/mega-

karyocytic myelopr oliferative state.

339. Section of bon e marr ow trephi ne biopsy from a

patie nt with CML who showed progression to a phase of
hacmor rhagic hypopl asia afte r a peri od of prolong ed
co ntro l of the chro nic disea se by pu lse chemo therapy
with busulphan. Th e marrow is poorl y cellular. with a
backgro und of necrotic and haemorrh agic suppo rting
tissue co nta ining a scatterin g of iron -laden macrop hagcs
and bot h lymphocytcs and plasma ce lls. but few rcco g-
nizab le myelo id cells. A picture such as this may arise in
CM L as a co nseq uence of mycloto xicit y fro m undul y
aggress ive chemot he rapy. but may also he a spon -
taneous phase in disea se progression . genera lly pre ced -
ing a myelofi bro tic transfor mation.

3-W . A re ticulin-stained thi n section from the same

marr ow biopsy as in 339 . showing that ther e is already a
clear increa se in reticulin fibrils. and that the disease is
undergoing a meta mo rphosis to a mye lofibrotic phase .
This. in turn . is co mmo nly supe rseded after a variable
peri od of weeks o r months by a more tloridly ce llular
acute leuk aernic type of bloo d a nd bone ma rrow picture .
no t infreque ntly sho wing at lea st a tr ansient mega-
karyo blastic o r megakar yocytic co mpo nent .

..l41 . Sectio n of bone marrow tre phine biopsy from a

pati en t who showed the type of tr ansfo rmation de -
scribed in 3-W. with the replacemen t of successive
chr on ic leukaem ic and myelofibro tic ph ases by a highly
cellul ar acute tr ansform ation . the primitive ce lls having
megaka ryo blastic featu res. sho wn furthe r in the next
three fields (3-12--3+1).

11 8

-~ Thi n plastic-e mbedde d sec tions fro m th e

ma rro w trep hine bio psy as in 341 . stai ned
~--"CI~ with H&E. Giemsa and the PAS reaction.
~ an area has bee n selected for photomicro-
mowa sectioned hlood vessel . with ncopl ast ic
it hin and surro undi ng it. Wh ile th ese are
.......... all me mbe rs o f the same ncoplastic clo nal
......111<111. the ir loca lization affects their cytological

:~:~.; \\ith the intramedullary blasts. despite the
. of their cytop lasm. having more unifonnly
- --.... fea tures o f Iept och rom at ic nuclear staining,
ible nucleoli. especia lly in the G iemsa
".,- - - • • hereas the intravascular cells have a
r nuclea r pattern and also show the
• topIasmic o utlines cha rac te ristic of mcga -
aod early mcgaka ryoc ytcs when see n in
......ontions. Alt ho ugh th e PAS reac tion whe n
CMl plastic sectio ns usually gives much less
.[\ in haemic cells than is found in PA S
"(d oJ.Ul). some peri phe ra l cytop lasmic
disce rned in th e primitive cells in 344 .
....,_.... in the intravascular than in th e intr a-
tio ns. The differences in cyto logy
ites may be partly a consequence of
_ ......... from contiguo us cells in the marrow
the vascula r lume n. but may also
ease in maturity associated with
vessel wall.

345-348 . Cyto logical and cytoche mical details of m ega-
karvoblastic and m egakaryocytic transformation in CM L
as seen in smear preparations of bone marrow aspirates.

345. Rom anow sky stain shows two hlast cells. to left
and right. several megak aryocyte nuclei and masses of
variably sized platelets.
,. ..
346. PAS reaction sho ws the coa rse pos itivity in
plat elet and megakar yocyte precur sors.

347. Acid phosphatase is strongly posit ive in mega-

karyocyte precursors .

348. Dual estera se shows strong CE reaction in poly-

morphs hut o nly weak BE reaction in a megakaryocyte
and so me platele ts. and in a blast cell. A stronger
reaction might be expec te d in cells of the megakaryocyte
series if alpha naphthyl aceta te rather than but yrate is
used as the subst rate for the esterase reaction.

1. C \ f L progression to myeloblast-typ e crisis.
of plastic-embedded bone marrow trephine
sectio ns (3-19- 35 7) and cYIOI01-:Y and cy lO-
ry of smears fro m bone marrow aspinnrs 351
1 ).

-powe r view of a thin sectio n of ma rro w

from a pa tient und ergoin g myeloblastic tr ans-
of C ~ t L. with islan ds o f pr imiti ve cells
through the marrow . amo ng residu al are as o f
-phase cytology. I n this fie ld th e lower right area

the myelo blastic component while the upp er
\loS resid ual chronic-phase mixed cytology.

:s.IOO o f CM L co mmo nly develops with a pat ch y
- _ " " o f blast-ce ll island s. and a more reliabl e
the process may he obt ained from trephine
lhom fro m aspira tes.

r-po we r view o f th e upper left part of ~9 . •

chronic-p hase cyto logy with num erous
polvmorphs. metam yeloc ytes and myelo -
blast cells. occasiona l cryrhrob lasts . and
a ryocytes, includ ing typical micromega-
• .,

contr ast is this view. at th e sa me increased

-::;::~_ of the lower left area of ~~9 . wher e th e
• e- cells are rnycto blasrs with fine lcpto-
ar chroma tin contai ning co nspicuo us
only o ne or . less oft en . two visible in •
~ sectio ned cells). Th e few scatte red •
raining nuclei are either erythroh lasts

I ~l
...~ --- --.." ...- - - -... .\53
351 ,

Ano ther exa mple of myelob lastic transfo rmatio n
~'5 2 .
develo ping in CML. In this thin sectio n of plastic-
embedd ed trephine biopsy mater ial fro m the iliac crest
bone marrow . the edge of a blastic nod ule is on the right .
betw een bon y trabeculae above and be low. with
resid ual chro nic phase cells havin g gene rally da rker
nuclei o n the left.

353. A higher -powe r view of the same section as in 352.

showing a ton gue of myelobl astic cyto logy penetra ting
be tween chronic phase ce lls to the uppe r right and lower
left. Th e finely Icpt och romatic nuclear structur e and
nucleo li of the myelobl asts arc well shown. contras ting
with the da rker a nd mo re polymo rphic nuclea r patt ern
of the late r granulocytes of the chro nic phase.

3,5.4 . A similar thin sectio n fro m anot her patient with

eme rging myelobl astic transformation. her e illustrating
the dest ructive trabecular erosion sometimes produ ced
b)' the myelob lastic proli fer at ion . which in this section
ca n be see n to be co nce ntrated around the dam aged
trabecu lae . Th ere arc resid ual lat er granulocytes and
erythro blasts fro m the chro nic phase of the disease in the
upper left and lower right co rne rs of the field .
Increase d bo ny destr uctio n. associated with the onset
of bo ne pain and the developm ent of radi ological
changes. is o ne of the more commo n for ms of present a-
tion of blastic met amorph osis in C ~l L.


• I . #' •

• ,,
• of

..... • • 0'
. :.. . • •

.. , , t• 0


0 • o.
• ,
.. . • ,

-S-J57. T hree furt he r thin sectio ns from the same 357
ine bio psy as in 354. Th e first (355) shows at higher
"ficatio n an area similar to that reproduced at low
in 3.5-4 . with a clea rly visib le co ntrast bet wee n the
_ _dve nucleo latcd and lep toch rom atic myclobJasts
... the irregularly eroded trabecular margin and the
e of more mature cells space d furt her away . The
reil wit h large darkly stai ned nucleus. direc tly
........ a sem i-circular bo ny erosion at the middle of
I ma rgin of the field. is probably a poly ploid
_:udlast . The second field. in 356. from a Ponceau S·
pre paratio n. reveals an absence of collagenous
aDd fibro b lasts fro m an area of myeloblastic
....n1>e<" lar proliferation very similar to that shown
preceding two figures . T he third similar field (357)
3 prepa ratio n sta ined for argyro phil retic ulin
~ n . the re is a notable absence of such fibrils in
_ urhood of the tr abecula e , wher e the myelo-
proliferatio n is co ncentra te d.



358 , A smea r pre parat ion fro m a bon e ma rrow aspi rate
take n fro m a pa tien t in the blastic phase o f CM L. A
Ro ma nows ky sta in shows a grou p o f blas t lTUS with little
evide nce of differ enti ati on .

359. Th e Sll stain sho ws th at all th e blast ce lls co ntain

localized st ro ng cytop lasmic positivity of gra nu locy tic -,
type .

360 . Th e blast ce lls arc largely PA S-negative or wea kly •

react ing with di ffuse posit ivity and fine gra nules . A
mo nocy te/m acrophage shows some coarse PA S-positive
gra n ules - a po lymorp h is norm ally pos itive,

361. Th e acid pho sphatase react io n shows a few coa rse

granules of positivit y in most blast cells a nd a tr ail of
stro ngly po sitive granules from a parti ally d isrupting 362
ma cro phag e .

362. The dua l es terase reaction displ ays mod eratel y

stro ng CE po sitivity in most of the blast ce lls.



, ..

• 4 f

• •


• •

• •
\...370. C \! L progression to a lymphobla st-type crisis.
C·A L L untigrnic findin gs. Histology of trephine •
(363- 365 ) ami cytology and cytochemistry of
_ ....Don , m ears (J 66-J70) .

th in sec tio n showing a sca tte red infiltration of

lis amo ng resid ual later ura nulo cvtcs of the
phase o( CM L. Alth ou gh this view includes
spaces. the overall ce llulari ty of the specime n is
...."'~~. de nse . with closel y packe d cells a nd litt le to
.I prece d ing stage o f myelofibrosis.

hi_he r-po we r view 'If the same preparation .

:=- the inte rmingling o f scatte red nuclco latcd
cells with late r . .ura nuloc vrcs - rnvelocvt cs.
. te-, and poly·fllorp hs. · Onl y a' few' late
5 ca n be recognized . Th e p ro port io n o f blast
50°0. exceeds th at to he found during the
o f C~ H .. and ind icates the emergence of
o rmatio n. •
r e xamp le of blas tic tran sformat ion o f
in a thin section of plastic-em bedded
~ specime n of ho ne marrow. In this case
n depicts an almost comple te repl acement
....,..,.,.pha...-.e cyto logy hy a unifor m sheet of blast
)e nucleo li and ver y op en nucl ear chro-
--..... The re is a mitotic figure at the lower
probable late neut rophils. and a plasm a
ot the blast cells ca nnot he determined
o&og:ical preparat io ns. but para llel
_De....·_" f) s-ho ws the m to he Iymp hoblasts .

366. Roma nowsky stai n shows agran ular blast cells 369
with high nuclear-cytopl asmic ratio . in this smear of
bone marrow aspirate from blastic crisis of CML.

367. Th e blast cells are negative to 58. Th ere is a single

suda no philic myelocyte in the ce ntre of the field next to a
mito tic figure .

368. The PAS sta in shows occa sional block o r coa rse
gra nula r positivity of lymphoblasti c type .

369. Acid phosphatase stai ning sho ws scattered posi tive

reaction . not espec ially concentrated at o ne pole of the

370. Dual esterase sta mmg shows a strongly CE -

positi ve granulocyte out o nly weak scatte red BE posi- 370
u vity in the blast cells.

J 1

Ji-l Basophil predo m inance in malignant progres- 373


ano wsky stai n sho ws a mixture of gra nulo-

aDd their p rec urso rs i tcluding two blast ce lls,
.......""e>. stab cells and fnur basophils .
Slain in the same case , showing a myc to-
ne utro phil myelocytes with no rma lly strong
_ _ "'P","lia and four bascphils from promyelocyte to
with mos tly reddish met achromatic staining
hil gra nules.

react io n in the same case , sho wing coa rse

_ pos itivity in four basop hils at vario us stages
" ~ fro m promyelocyte o nwa rd s. Ne utro phil
_ _ sho w nor mal diffuse tinge. 37~

reaction in anothe r exa mple of basophil

........_ _ece duri ng malignant prog ression ofCML. In
~""- re are two early neut roph il precu rso rs at the
;I neutro phil metamye locyte at the bottom ,

remai ning cell s are of th e basophil se ries and

_ degrees of coarse gra nular PAS positivity
cell series. ' ,




~\75-JHJ . Preparations f rom cases of juvenile CM L. 379

375 . A Leishrna n sta in o f blood smea r showing pro-

mine nt mon ocytic co mpo ne nt. seve ral monocyte - being
vacuola ted .

376. Leishman sta in of bon e marrow smear fro m th e

same patient . showing resem blance to C ML. with various
grunulocytc pre curso rs predo minant .

377 a nd 378. Ro manowsky (Heyl) stai ns of bo ne

ma rrow aspira te smea rs fro m ano ther case of j uve nile
C ~t L. showing respectively low- and higher -power
views of the cvroloav. which falls betw een tha t of an
acute ffiyc hlffil; nocvtfc leukaemia (A MML ) and a C I\IL.
This COItditinn is S()~cti ml."S called 'A~I ~I L of childhood'
and is proba bly best trea ted as an ac ute leu kaem ia .
Unlike CML pro per . which doe s occur rarely in child-
hood . so-called j uvenile C ML does not show th e 9 :22
tra nslocatio n. alt ho ugh the LAP sco re is usua llv low.
There is typically a high level of H bF and low Hb A 2 • and
the infantile rati o (3:1) of glycine to ala nine at position
136 o n the gamma cha ins of Hb F is ret ained .

J 79 . S8 stain o n 5100d smea r: coarse posi tivity in

neutro phile an d d iscrete sca tte red gra nules in several
mo noc yto id cells.
. I

...·, •


PA S stain on blood smear: a blast cell with 382

_",,~·t ic r AS-positivity pattern, two vacuolated
_""~'t es . a nd two neutrophil polymorphs with normal
P rea ct io ns.

I. Acid phos pha tase : three polymorpbs and three

_ _xytes in peripheral blood show moderately strong
Iar positivity,

Dual este rase: two polymorphs show CE positivit y

- t 'x mo nocytes and precursors show moderate BE
. -ity.

Anothe r exa mple of the du al esterase react ion on a

~ of bone marrow cells from (he same case of
_nik C ML as shown in 377 and 378 . The mix ture of
--~.1ic a nd gra nulocytic precursors with respect - 383
BE and CE positivity is well shown . Several later
.......>phil also show CE positivity.


38-4. An ' LE' cell . The characteristic inclusion body of

ingested nuclea r materi al prod uced in leucocyres -
especially polymorphs - as a result of the action of a
factor prese nt in the sc ru m of patients with dissem inat ed
lup us erythe matosus. Th e factor is an antibody to 3116
nucle oprotein. chiefly histone . which acts in the
presence of complement as an opso nizing age nt.
rende ring the sensitized nuclei susceptible to phago-
cytosis by neutrophil polymorphs and to a lesser exte nt
by eos inop hils and mon ocytes. T he smoo th and swollen
appearance of the ingested nuclear material. resulting
from the imm une process . is characteristically different
from the smalle r and often denser nuclear remnants
engu lfed by polymorphs o r monocytcs following the
death of senesce nt cells. as see n. for exa mple . in the
' tart' cell illust rated in 386. Alth ou gh the demon str at ion
of LE cells remai ns a useful and rapid diagnostic
procedure . it has now largel y been replaced by o ther
immunological tests for anti-nuclea r facto rs. and mor e
specific tests for the antibodies to dou ble-str and ed D NA
that especially disting uish syste mic lupu s ery thematos us
(SLE) from othe r collagenoses . Neverthe less. the LE
ce ll remains a st riking cytological phenomenon .

385. An oth er exa mple of an LE cell with a lar ge but

partially d ivided inclusion .

386. A ' tart' cell . as commonly found in preparations

made in the sea rch for LE cells . T he inclusio n is usuallv.
as he re. in a mon ocyte . and co nsists of a ce ll nucleus,
mos t often of a Iymphocyte . The inclusion stains more
deeply th an does the LE body . These tar t ce lls ar e of no
kno wn pathological significance and must be d istin-
guished from LE cells.


e- r-Huet phe no meno n. In the hom ozygou s 389

pol yrno rp hs sho w a single ro unded dense
the zra nulocvtes arc affected in the her ed i-
of this disorder. but the change ma y a ffect
in myeloid leuk aemi a . giving a 'p se udo-
ranee .

-HUCl phe no me no n. Het ero zygous for m

pol yrno rphs showing a ' ba nd' o r bilo bed
structur e. Th is a ppea ra nce ma y occ ur as a
rma lity. but may be mimicked in the
~~ .p,."'_
eer' poly morphs so me times see n in acute
..,. .., mye loid leuk aerni as and in myelofibrosis.
a_pie illustrated here is from a patient with
of the ce lls shows twinning of bilobed
_~I'd~,r nuclei.

red d ish-vio let gra nules in leucocytcs in

___ ~', a fa milial diso rde r o f leucocyte gra nu-
arance in the neutro phi ls resem bles the
,...,_.... commo nlv see n in leucocvtosis of
in 390-392) , but the acco ';' pa nying )
phOC~l CS. some times with in vac uo les . f tJ--
. sho winga 'co mma' shape . arc stro ngly
r's a no maly.

3 391

392 393

390-392. Examples of the blue-staini ng areas in the

cyto plasm of neutrophil polyniorphs sometimes see n in
infections. especially pneumonia . -Th ey arc known as
Dohle bodies. The polymorphs also show some coa rse
toxic gran ularity . Th e D ohte bodi es of infec tion
rep resent area s of aggregat ed ro ugh endo plasmic
ret iculum, as see n in the electron microscop e. and are
essen tially different from the inclusion bod ies, some-
times incorrectly given the same name , which occur in
the May-Hegglin ano maly . .

393. Further examples of Dohlc bodies in neut rophil

polymo rphs. In this Instance the specific gra nules are
wea k rath er than coarse , and the Do bte inclusio ns more
readily visible . Do hle bod ies may be found in
poly mo rphs in any fo rm of leukaem ia , but appea r to
arise as a co nseq uence of associated infection rat her 395
th an be ing intrinsic to the neopl astic process.

3 9~ and 395. Examples of the May-H egglin ano maly. an

inherited disorde r with basophilic inclusions. 2-5
microns in diameter. in gra n ulocyies . Th e inclusio ns arc
larger than Dohle bodies and not relat ed to infectio n.
Ult rastructurally. they con ta in particulate material
includ ing rod- like structures unlike any nor mal cyto-
plas mic co mpo nent.

... m . Furthe r unusual inclusions . some 3-5

- 398

~.~ eter, weakly basophilic and apparently
-bound, in granulocyte precursors and in
from a child with a transient pancytopenia
. syndrome. The material seems likely to
..._ _,i) protein.

granulation. with both red and pale blue

.. a neutrophil polymorph . Similar giant
- _ ...... kucocytes of all kinds may be seen in the rare
<.1:Irdiak· Higashi·Steinbrinck anom aly. These
-::.;::::~a~re thought to be deriv ed by the fusion of
.. a l azurophil granules at the promyelo-
c:arl)" myelocyte stages. There are similar
_ ...._ be found in many oth er tissues in this
ed polymorphs appear hyperactive in
but ineffective in killing and destroying 399
ria or other material.

,::::~::: inclusion par ticles. probably carbon .

bkxxI monocyte . Such material may be
- _..... a pe riod of temporary sequestration
rory tract.

~O l


400 . Bone marrow as pirate fro m a patie nt with seve re

ag ran u lo~ tosis a nd pe ripheral neu tro phil co unt
< O. Sx 10 11. T her e is not a single neutro phil polymorph
to be see n. and few neutroph ils beyo nd the p rom yelo-
cyte and ea rly mye locyte stag es. alt ho ugh crythro-
blasts. eosl nop hils. Iymp hocytes and an occas ional
mo nocyte ca n be recognized .

0$0 I and 0$02. Lo w- and highe r-po wer views o f bo ne

ma rrow tr ephine bio psy sectio n fro m a patient with
leu kopc nia due to dr ugs. Th e re is adequate ove rall
ce llulari ty with plenti ful rncgak aryocytes and numerous
mono nuclea r cells. shown in 402 to inclu de norm o blasts.
lymphocy tes and plasma cells. but a virtu ally co mp lete
absence of po ly morphs and recognizable earl ier
granulocytes .

..ao3 and 0$0-1 . Two views at incr easingly higher powers of

thin sections from a bone marrow sa mple take n at post
rnortem from a you ng woman who died fro m an
o verwhelming streptococcal septicae mia. unresponsive
to antibiotics. Her peri phe ral neutrophi l co unt had
fallen precipitously to < O.2 x 109/1 . The bone marrow
sho ws complete abse nce of gra nulocytes at any stage of
maturity. the relatively high ce llula rity bei ng made up o f
mononuclear cells including erythroblasts but also
nu merous plasma cells.

1: .
Various mOlOcytes f rom norm al periph eral ~07

ocvte with some reddish granules in the grey

. togethe r with a lymphocyte , a stab cell. and
.......ophil segmented polymorphs. The extent of
- "_ _11 or more gross convolution of the monocyte
ite variable . A ve rv few rnonocvtes with
....,,,,,,,,,,>liccytoplasm and nud ear chromatin pattern
i witho ut inde ntation. perh aps 20% have
inde ntation. as in the uppe r cell in 406. but
_ _lC).l es in the periph eral blood show more
-..dear bending or twisting. as in the remaining
in .w~ 07 . Cytoplasmic gran ularity is also
little or none to relatively coarse . weakl y
~ul es as in the central cell of 406 and the

,. •
""JO(~.- t es .
one with vacuoles. and a lyrnpho-
..c1_" are probably all phagocytic. one ' till
~ _ in :- ted platele t and the other two having
d( este d their contents.
_ _lC).lCS and. a stab cell. The m onocyte-
cytoplasmic granularity and typical


408 and 409. Co nsecutive Rom anow sky and d uplicate 411
Prussian btue sta ins on the same field , fro m a buffy coat
smea r made from the peripheral blood of a pat ient with
chronic myelomon ocytic leuk aem ia (C MML). la show
more bizarr e forms of nucl ear convo lutio n than are
usua lly see n in normal monocytes. The furth er tr ans-
for mation of mon ocytes to macrophages normally
occu rs in tissues. but may occasionally. as her e , take
place in the blood. Th e transforming mon ocyte co ntai ns
phagocytosed nuclear fragments and also a heavy load of
free iron . as demon str ated in 409.

410. Promo nocytes from a case of AML with pre-

do minance of the mon ocytic series . Th e cells. tho ugh
nucleolared. show nuclear indentations and a cyto-
plasmic colour tending towards the mon ocyt ic grey
rat her than the baso philia of less differ en tiated ce lls.
Pure ' mc noblastic' o r "monocytic' leukaem ias are
very unco mmo n; there is nearly always some gra nulo-
eytic element present. so that the name ' mye lomono-
cytic' migh t strictly be used , but, as in this case. ce lls of
the monocyte se ries may great ly predom inate . and it is
con venient to retain the term ' acute mon ocyti c
leukaemia' (A Mo nL) for such cases. When recognizable
gra nulocyt es make up less than 20% of the marrow cells
the FA B classificatio n wou ld be M5.
.$11. S8 staining in the same case as in 410. The
promonocytes show discre te scattered gra nules of pos i-
tivity, here chiefly co nfined to the cyto plasm, but not
densely clumped as in gra nulocyte precursors.
l~ . AMonL. with monocyte precursors of variable
-.rpbology and state of maturity. This field also iIIus-
a scattering of plasma cells. An incre ase in plasma
generally focal or patchy in distribution , is

ca_.ooly observed in acute leukaemias of any kind and
seen when o the r malignant processes invade the

B reaction in the same case . A single stro ngly

:=~~ i1ic polymorph contrasts sha rply with the

. 1 C precu rsors. with their reactions ranging from
.,..iYe to moderately strong positivity of the discrete
., granule type.

Three pri mitive cells from an acute leukaemia with

...-..aI morphological signs of differentiation in
ky preparation. The SB reaction, shown
the typica l distribution of positive granules
dI..,,,,,,rn-,,ic of the monocytic series . The primitive
are the refore monoblasts.

~1 6

-lI S. AM onL: peroxidase reaction . Monocytes and ~1 7

the ir p rec ursors arc genera lly negat ive for peroxidase.
hut may show a faint localized cytoplas mic reaction . •
Auer rods. as shown in th e upper left corner . arc
strongly peroxidase -pos itive . T hei r prese nce co nfirms
the myelomonocyti c nature of th e disease . since Au er
rod s probab ly do not occur in th e monocyte line hut ar e
confined 10 granutocytc pre cursor s. bein g derived
chiefly from primary azu rop hil granules. •

-116. An other exa mple of peroxidase stai ning in an

A Mo nL. Th e mon ocytes ap pear ra the r mo re di fferen-
tiated th an in the previous exa mple . and have a negative
reaction .

-Il7. 5B reaction in the same case: the monocyte , .. ..

mos tly show discret e sca tte red gra nules . A myelobl ast
with two posi tive Au er rod s is also see n.

• .



' .

-lIK. A gro up of mo nocyte pre cur sors from an A~lo llL. 421

.l)9. The same licit! . co nsec utively stained with the PAS
react ion. Mon ocyte precur sor s show co nsiderable •
variability in thei r positivity to PAS . fro m co mp letely
negative reaction s to coarsely gran ular. heavy pos itive
ones. Her e the ce lls show a mixt ure of d iffuse cyto-
plasmic stai ning and fine granules.

00 o f mon ocytcs and prec ursors from an

. (0illustrate the range of variatio n e ncounte red
rC'aCti'"i ty in this cell ~se rics .

(1) stro ng PAS pos ltivitv with coarse blocks in

.. fro m a furthe r case of mvclornon ocvtic
with predomina nce of well: di ffcr cntia'tcd



.: , . , ',

.. ' ..

422. A cid phospha tase reaction in acute mon ocytic 424

leukae mia : most cells sho w stro ng and coarsely gra nular

423. Du al esterase reac tio n in acute mo nocytic

leu kaemia: mon ocyte precur so rs sho w stro ng but yrat e '"
esterase (BE) po sitivity in this case , while a gra nulocy te
shows strong chloroacctate esterase (CE) positivity .

424. Dual este rase reaction in a case of acute myc lo- •

monocytic leuk aem ia. In this insta nce the monocyte
precursors sho w o nly weak reac tions with scanty
scatte red gra nular BE positivity. Two myclo blasts sho w
chie fly CE positivity, but so me granules of BE reaction
a re also detectable.

•• ' 4j.

425--427. Rom anowsky. PAS and dual esterase 427

reactio ns on the cells of an AMML. with predominantly
monocytic morphology and typ ically mono cytic mixed
diffuse and granular PAS react ion . but with weak CE
rather than BE positivity in the rnonoc ytes. Thi s is a ver y
unco mmo n picture out illustrates the potential varia-
bility of mon ocytic este rase conte nt.

~2 9

• • •




'. .. • • •
• • •

•• •
• • .. .• .,

..• •• • ., •
." •• ... . • •• •
• •
·U H- B O. Var iou s histological fields fro m thin sections
of bone marro w tre phine biopsi es fro m cases of acute
mo nocytic le uk ne mlas. In 428 and 429 . respectively low-
an d higher -power views of th e same sect ion ( H&E
stai n ). co nside rab le resid ual fat spaces re main . and
islands o f erythropoietic tissue can be d istingui shed : but
the cel lular a reas arc predo mina ntly occu pied by lar ge .
poo rly di ffer ent iated blast cells wit h nucle i sufficie ntly
widely spaced 10 ind icate a mp le cytoplasm . and wit h
several nucleo li o fte n visible under the high er po wer . A
suggestion of nuclear twisting ca n be d iscerned in ·*29.
This is a more rcadil v recog nized feat ure of ·B O. a
thin ne r section sta ined 'with Gie msa fro m anot her case.
whe re there is denser ce llula rity wit h a sca ttering of
cryt hroblasts having da rk nuclei a nd eosi no philic cyto-
plas m - but . aga in. a preponder an ce of nuclco lat cd
pr imitive ce lls wit h nuclear twist ing of the mo nocyto id
type . T hes e sectio ns prov ide valuable supple mentary
info rmatio n o n o vera ll ce llula rity and relat ive pro -
po rtions of differen t ce ll types. but for cytologi cal deta il
and co mpre hensive cytoc he mistry it is nece ssar y to
stud y smea r prepar at ion s in parallel.


431-B3 . Sections of a trephine biopsy from a case of

A ~ IL with mon ocytic fea tures . In aspiration smea rs th e
cyto logy showed a well-di ffer entiated mon ocytic
patte rn; this is reflected in the predo minant cell ap-
peara nce in these sections. wher e the H&E stain in 431 ,
a nd ·H 2. a t respectively low a nd higher magnificati o n .
shows moderately dense nuclear chro matin. occasio nal
nuclea r inde ntat ion . nu cle oli. a nd a ge nerally low
nuclea r-cytoplasmic ratio . Residu al nest s of e rythro -
blastic ac tivity a rc apparent in -131, a nd sca tte red
no rmo blasts with small dark nuclei are present in ·H2 .
but the striking a nd unexpect ed fea ture in these
sectio ns. not previously note d in the marrow smears. is
the conspicuous increase in macro phages. many heavily

laden with haemoside rin and some conraininz other
phagocytosed ce llular mate rial. T he sectio n appearing
in 0$33 is of an acetate esterase stain o n plastic-em bedded
mate rial. with reddi sh positivity in a proporti on of the
leukac rnic monocyt es .
The nor mal seq uence of monocyte developm ent
proce eds from the common granulocyte-rnonocyte
pr _en itor to a co mmitted mon obl ast. then pro mono-
~ e and mat ure mo nocyte . with a final potentia l tran s-
[ion to tissue macrophage (or o the r rela ted cell
as osteoclast or Lan gerhans cell) occu rring afte r the
_ _1<'_ te has migrated from the pe riphe ral blood into
(sues. Ncop lastic disord ers chiefly involving
hagcs arc dealt with in Part 4. but the present
\\~ the emergence of some differentiat ion to that
III an o the rwise typical mon ocytic AML.

1 ~3


434-413. Examples of cytology and cytochemistry of

A M L cast's with abnormalities involving / Jq23.
Leuka emias with tr ansl ocation s o r deleti ons involvin g
chromosome llq23 occur in young patient s especially-
often childre n - and are mos tly of monoblastic o r
monocytic cytology. MyeJomonocytic cases arc less
commo n, while o nly a very few have been reported with
grunulocytic predominance .

-'34. A blood smear from a child of nine months with

AML and t(9; 11). In this low-power view all the
' nucleated ce lls are of the mon ocyte seri es . ran ging fro m
sma ll undifferentiated blasts with minimal cyto plasm (a
gro up of three arc at the lower right) , to well-differenti-
ated prom onocytes with multi-lobulated nuclei and
ample cyto plasm.

·435. A higher-po wer view of the same smear . showing a 438

good seq uence of maturati on stages from small mono-
blast to late prom onocyte. again with marked lobula-
tion .

·U 6. Ro manowsk y-stained bon e marr ow ce lls from

another case of AML with t(I1 ; 19) and predominantly
monoblastic or prom onocytic cytology.

437 and 438. S8 stains on bone marrow smears from

two patients with AML a nd . respectively. t(II ;17) and
t(9 ;11). The leukacmic ce lls arc Sls-nega tivc . There is a
single Sls-positive myelocy te in 438. Weak or negative
stai ning for S8 and peroxidase is usuall y found in the se
detects of I Iq2J.





• -
37 439. PAS reaction o n the same speci men as in 434.
T he re rsa negati ve o r weak reaction in the least mature
blast cells. increasing to moderately coa rse gra nular
positivity against a diffusely positive hackgro und in the
more mature pro mon ocytes.

and 441. PA S reac tions fro m two furt he r cases of

AML with 1(9;11). showing a similar pattern of incj eas- "
ing positivity wit h increasing ma turity. but in ge neral
co nfo rmity with the pa tterns of PA S react ion us ually
encountered in leuk ae mic monocytes. In 4-10 there is a
ty pica lly mon ocytic pattern of positivity in t he promono-
cytc s and a negative eryth roblast . and in 441 six almos t
nega tive monoblasts and one very coarsely positive
pro monocyte.

138 442 and 443. Dual esterase reaction s in I( 11; J7) and
1(9; 11). respect ively . The low-po wer view in 442 sho ws
the variable positivity for BE in the leukaem ic cells. with
gene rally negative blasts and mor e marked posi tivity in
the most mature-looki ng promonocytes. The higher-
po wer view in 443 illustrates the same pattern . with four
nega tive monoblasts and a BE -pos itive promo nocyte .

444. A n AML with mixed gran ulocyte and monocyte

precurso rs; when ad mixture is marked . as in this case
(suggested by the Romanowsky stain and confirmed by
the Sudan black) . the term ' rnyelomonocytic' is con-
veniently applied. The conspicuous Auer rods in two
blast cells and the localized accumulation of azurop hil
granules to the left of the nucleus in another iden tify
myeloblasts and a promyelocyte . However. the remain-
ing cells might be of either granulocytic or monocytic
lineage . and cytochemistry is required to asce rtain

~5 . SB reaction from the same case; the localized

cytoplasmic positivity in the early granulocyte precursors
contrasts with the discrete scattered granule pattern of
the monocyte precursors.

~6 . Dua l esterase reaction in a similar case. with

typica l BE react ion in the mono cyte precursors and CE
reaction in gran ulocytic precurso rs. An erythrob last
with distorted nucleus is esterase-negative.
~7 . An A ML with mixed e rythro id. granulocytic and
mo nocytic prec urso rs - an crythro -myelo-mcnocytic
jeu .ae mia. Such mixed leukac mias are qu ite com mon.
an o bservatio n which supports the concept of a myeloid
e m ce ll with multiple potentialities. Such a stem cell is
pre umab ly the donogenic leuk ae mic cell with multi-
lineage expression in cases like this o ne . whe re the
gran ulocytc and mo nocyte involvement is acco mpa nied
b~ erythroid and/or megakar yocytic ncopl astic cells -
de mo nstrable . by cytoge net ic or biochemical rech -
Diques. as heing of the same clona l orig in. All multi-
age cases are mo re sensibly grouped toget her as
Type H AML (HA with > SO% SB positive blasts and
liB with less) rather than scatte red among a wide range
of FA B groups, M I. M2, M4, MSa or b. M6 or M7,
acco rding to precise differenti al counts. e.

The SB reaction helps to differentiate the negative
rvth ro blasts from the myelob lasts I with dense
..x:alized posit ivity and the monoblasts with scattered

.' ...
A zeneral view of a bone marrow smea r from the
case as shown in the previo us figures. sta ined by
PAS reaction. T he diffuse and finely gra nular
- -ity of granulocyte precurso rs. increasing in in-
: with increasing maturity. is shown ; the stro ng
. reaction in some ery throblasts is very character-
of erythraernic involvem ent in a mixed leukac mic


"'50. AML. with mixed proli fe ration of erythroid and ~52

granulocytc precur sors - an 'e rythro rnyeloid' lcu -

kae rma. Most cases of eryt hrac mic myelosis have from
the ea rliest stages so me component of gran ulocytic or
mo nocytic ce ll-line involvement . which . tho ugh it may
be minim al <I t first . ofte n comes to dom inate the picture
eve ntually.

...51. A higher-power view of primitive cells from the

same case; they are not altogethe r easy to classify o n the
Rom anow sky preparat ion s and cytoc hemical assista nce
is requ ired . Th e blast cell with conspicuo us pe ripheral
cyto plasmic budding just below the centre of (he field is
pro bably a megakaryocyte pre cursor" thus suggesting
additio nal lineage involvement in this case . )

"'52. Th e SB reaction on a smea r from the same case of

erythro leukae mia as sho wn in the last two figures .
Eryt hroid precur so rs are negative . while gra nulocyte
prec urso rs show typical coa rse locali zed pos itivity.
• ••

..tSJ. PAS reaction in the same case. Stron g positivity 455

.. red-ce ll precursors at differ ent stages of maturity is
ecespicuous. while myclohlasts and prom yeJocytes
show their custo mary negative reactions or faint diffuse
. _e of the cytop lasm. At upper mid-left is another
buddi ng cell with PA S-positive fragme nts. again suggcs-
IiBg megakaryocyte line involvement.

s . Acid phosp hatase reaction in mixed eryt hro-

.teloid leukaemia. Coa rse positivity. especia lly para-
-=lear. in all cells presen t.

'5. Dua l esterase react ion in the same case. An ea rly

_ ulocyte precursor shows CE positivity and the
erythrobtasts have tine granular positivity of mixed BE
_ CE ,ype.


~S 7



.$56 . A normall y granular mature mega ka ryocyte . with
minimal plat elet formation at the periphery.

457. A megakaryocyte with disrupting cyto plasm which

has been actively for ming plat elet s.

458 . A poo rly gra nula r meg akaryoc yte with minim al
platelet formation .

459. A pair of megakaryocytes. very actively releasing

plate lets . and almost devoid of cytoplasm.

460. Stages in the for matio n of megakar yocytes. Th e

large ce ll with thr ee nuclei and fragmenting cyto plasm
might he ca lled a 'promega ka ryocyte ". and the ac-
co mpanying prim itive cell. like an unusually large
myeloblast. may be a ' megakaryo blast' .
mcgakaryocytcs with stro ng gra nularity of ~ 63

e- aryocyte fragment in the peripher al blood

crisis in CML). Th is may represent a
precur sor . of the megakaryo blast or
-.c:"'...."!'~.·l e stage . since the re is com monly a
(he mega ka ryocyte line involved in blastic
and the nucle ar pattern of this cell look s
the prese nce of a few platelets on the right
ea er mat urity.

platelet of snake-like form. beside various

_:aII""'rs in the bo ne marrow of a pati ent with

46 S

464. Phagocytosis of platel ets by neutrophil poly-

morphs in an auto-immune disorder with circulating • •
Immuno blasts. two of which are see n in this field.

465. PAS reacti on in a normal megakaryocyte. Diffuse

cytoplasmic positiv ity, weak in intensity . is accom panied
by occas ional stro ngly po sitive glycogen inclusion bodies .

-166. \Vhen plat elet formation is acti ve or imminent. a

peri phe ral rim of denser positivity may also be o bserved .
In this low-power view of normal marr ow, the mega-
karyoc yte is surro unded by o ther marrow cells which
show the increas ing positivit y with grea ter matu rity in
the granulocyte series. Erythroid precursors are

• •

IS ~

-167. Num erou s megakar yocytes without peripheral -169

platelets from the mar row of a pati ent with chro nic
idiopathic th rombocytopen ic purpura (ITP).

-168 . An immature megak aryocyte from another pat ient

wi th auto-immune ITP . showing two large nuclear lobes
and minimal cyto plasmic gran ulari ty o r platelet accumu-
lation at the cytoplasmic rim.

-169. PAS react ion; megakaryocytcs fro m another

pa tient with chronic ITP show the inte nse accumulation
of glycoge n inclusion bod ies sometimes sce n in this
diso rde r.

470. A mega karyocyte fro m the same pati ent as in 469

but after spenectomy (with good respons e), to show the
disappearance of glycogen inclusion bodies in the PAS
sta in.


~ I , ~ Z
, • t

.. • •
, ••
• e

, .~.e

• • ,• e , &
.. •

" . • .:.; . 0

• •• •
, ...". • • 0

, • ••
, e. •

•• ,

t. • ".; •

, e ,. • .• •


471. Fo ur mcgakaryocytcs from a ho ne marrow smea r
-. " ,.
~ 73

,·- -.:..;.,...••.-- .. ..,.: -·f, -. ...

in another case of IT P. stained by the PAS rea ction to
demonstrate considerable cytoplasmic gra nular glyco- I 4. .... • ,
ge n but few inclusio n bodies. The megak ar yocytcs show . ». - • •' , ..',.....
.• • -
•6 -
a vcry striking accumulation of PAS-positive neutrophil ~ ~

_,-=... . .
....•. -'
gra nulocytcs within th eir cytoplasm . mor e probably
, . ~ • .; ~

.,". _, 4.',.
resultin g from a passive incor poration or emperipo lcsis
-: . ,.e
than an active phagoc ytic process (ef. ~ 77-479 ) .

472 a nd -173. H&E and G icmsa stains. respe ctively. of

. . ~~
• !J," - . . ..
sec tions of ho ne marrow trephin e biopsies ta ke n fro m
two patients with auto-immune ITP. In ea ch case the re ~ ~ .... I. ~y .~r.~
... ~ ·ite~~".
has bee n sufficient blood loss from haem orrhage to

, ' . •,~..
·It fI' .
-. ";""I
, c •• ' .
· 41· .. .
. ..r _. .• -_

- . .......'.,.
.... --...
sti mulate erythro id hyperplasia - but without prod ucing •• • .: . /# ",.e.... ~ , . . .
any marked increase in ove rall mar row cellularity. since I'. .... ,.. ," ·A e_a.

fat spaces are plenti ful. Megakar yocytosis is clea rly
evident with generally somewhat prim itive . defectively ' ",
~~ .
.• :e!. ,.. .., e/.tf ' _.
lobu lated nuclei and poo rly gra nular cyto plasm in most
rnegakaryocytes . Th e absence of per iphe ral plate lets in :" ".
'. ...
. _" ,..1
megakaryocytcs in ITP reflects their ra pid release into
the circulation and destru ction there. rath er than am:
r·:.....,t."..",. ,.1, .

.-., .. .
defect in productio n. for the o utput of functionally ~ .. ~ . ,
active platelets in IT P is usually several times nor ma l. \ -.-. "' .. '."> ..
,"" . ,~-", , .
.,~ ,. , ..
_.7... . "


474. Acid phosphatase react ion. showing coa rse gra n- -, ~ 76

ular scatte red positivity in a megakar yocyte ; two

myelocy tes show a few gra nules. as does a lat e norm o-
blast , and a lymph ocytc is negat ive.

475. Dual este rase reaction showing wea k granular

BE pos itivity in a megak ar yocyte : three gra nulocytes
show CE pos itivity, a monocyte is BE-positive . and two
Iymphocytcs are negativ e .

476. a-Naphthyl ace tate esterase (AE) reaction in a

mega karyocy te - the positivit y is much stro nger and
de nser than with butyra te as substrare. a cha racte ristic
fea ture of mcgakar yocytes.


477 and 478. Gross phagocytosis of an erythrobl ast
clump by one megakaryocyte and phagocytosis of other
cellular debri s and red cells by othe r megakaryocytes in
a myelop rolifer at ive disorder with megakaryocytic
hyperplasia .

479. PAS stai n in the same case . showing coa rse PAS
pos itivity in two megak aryoc ytes, eac h of which co ntai ns
ingested leucocytes.

480--482 . Thin sect ions of bon e marrow trephine / ~K 2

biopsies from thr ee differ en t examples of megak aryo-
cytic hyperplasia . In 4HO the background co ndition is •
hairy cell leukaemia (HCL) with a secondary infection
prod ucing o nly minimal neutrophil leucocytosis (re flect-
ing the severe neut ropenia co mmo n in HCL). but an
at te mpt at megak ar yocyte prolifera tio n which resulted
in so me platele t increase . Th er e are no mo re than a few
recognizable HCs present . but there are two lar ge mega-
karyocyres - the lower with seve ral se para ted nuclei and •
the uppe r in po lyploid mitosis with three o r perhaps fou r
sepa rate spindles.
G ross hype rplasia involving bo th gra nulocytic and
mega karyocytic lines is visible in 481. with disa p-
pea rance of fat spaces a nd an almost co mplete absence • • o·
of erythro blasts. Th e small cells with deeply sta ined and •
often lobulate d nuclei are neu trophil polymorphs: the
• #
large pale-staining cells are all megakar yocytes at
va ri o us stages of matur ity, most with poorly lobulated
nucle i, the few with densely stained nuclear mat erial

bei ng in variou s stages of mitosis . T his is another
exa mple of CML with rncgakary ocytosis, many of these
cetls being classifiable as micromegak aryocytcs.
The third example. 482. is from a patient with a
chronic myelopro liferat ive disea se (C MPD) associated
"'lh a high platelet count (> lOO()x 109/1) and numerous
mature . sometimes almost gigantic, megakar yocytes
multiple nuclear lobes and ample cytoplasm present
iD the bo ne marro w. This disor der is vario usly called
essential thrornbocythemia' or ' megaka ryocytic
..,d lSi's· of mature ce ll type .

- -

• • -.. •

• - •

• •

~3 . A th in section of bon e marrow trephin e biop sy

fro m a patient with C ML. now movin g into a blastic
tra nsfo rma tion. The re is a very mixed and pleo morphic
cytological picture. with ery throblas ts , gra nulocy tes at
various stages of maturation . and a subs tant ial
component of primitive-looki ng cells with leptoc hro-
malic a nd sometimes nuclcol at ed nuclei . sho wn by
cytoche mistry and immunology of their counte rpa rts in
marr ow smears (cf . 487) to be immature ce lls of the
megaka ryocyte line.

-184. j ume rous mega karyocyt e fragments and probable

megak aryocyte precursors in the pe riph eral blood of a
patient with an Al\.IL with megak ar yocytic preponder-
ance - the te rms acut e megakaryocytic myelo sis o r
megakaryoblast ic leukaemia may be applied . Large and
fully developed megak ar yocyte s are not pre sent. but
these arc multiple mega ka ryoc yte fragme nts or
ab no rma l sma ll cells of tha t se ries. wher e the usual
po lyplo idy has not occurred .

485 . A furth er field fro m acute megak ar yocytic

myelosis. The nucleolated primitive ce lls ha ve a similar-
ity to rnyelo blasts. but may be ' Ieukaemic' megakaryo-

486. S8 reaction in the same case . A megakaryocyte
wi th thre e phagocytosed lymphocytes or erythroblasts is
negative. as is the neighbour ing megakaryoblast.

. PAS reaction in acute megakaryocytic myelosis.

TIle tro ng and coarse irregular positivity in the 'Ieu-
·3 mic' megakaryocytic cells resemb les that in platelets.
The diffuse tinge in certain precursors does not allow a
dear distinction from myeloblasts to be made .




48~95 . Examples ofthe cytology and cytochemistry of

multilineage (Ty pe /I) A M L with chromosome abnor-
malities involving inversion or insertion 3;3.

T hese chromoso me changes arc associate d with an

creas e in megakaryoblasts and later megaka ryocyte
stages in the marrow. together usuall y with both
eryt hroblastic and granulocytidmon ocytic involvement.

488. High-power view of bo ne mar row smea r from a

case of inv(3;3) . showin g predominance of megakaryo-
blasts and prcmegakaryocytes . with cytoplasmic dis-
ruption in so me ce lls and. at the upper part of the field .
forma tion of seve ral giant platelets. Th e blast at the top
left of the lower ce ll clump con tains an Au er rod . and is
probably a myeloblast . as is the blast with minimal
cyto plasm near the upp er left corn er of the field .

-189. Another exa mple of AML with inv(3:3). showing

the very characteristic cyto logy of megakaryobl asts.
with freq uently irre gular cytoplasmic o utlines and a
tendency to form bud s which often cont ain vacuoles.

490. Alt ho ugh these ce lls arc negative 10 myeloper-

o xidase sta ining. they do possess platelet peroxidase
(PPO ). hest demon strated by electron mieroscopy. This
enzyme activity is confine d to the endoplasmic retic ulum
and perinuclear space . as illustrated here.
~91 2


491. 58 stain o n the same specimen as in 488. ~9~

showi ng granulocyte- type positivity in several myelo-
blasts and negative reaction s in two megakaryobl asts.
excep t for a stro ngly positive Au er rod in the upper
megaka ryob last and seve ral possi ble but mo re weakl y
sudano philic Auer rods in the lower one. probably
resu lting from phagocytosis.

492. PAS reaction on the same bone marrow as in 488

and 491, sho wing mixture of granulocytic and mega-
karyocy tic pa tte rns of positivity.

493. PAS reaction on the same bone marrow as in

489. whe re all the blast cells in the field arc megakaryo-
blas ts with coa rse granular positivity , especially in the
pe riphe ral cvaginations.
494. A furt her exa mple of PAS stai ning in a case of
ins(3;3), with a gro up of megakaryohl asts to the left ,
toget her with a pair of probable mono blasts to the right.
Between the two grou ps is a late neut rophi l with
mat ure ly conde nsed nuclea r chro ma tin but an unseg-
mented nucleu s, possibly a normal stab cell but perhaps
exe mplifying the pseudo-Pelger phen omenon ofte n
encou ntered in these cases .

495. A PA S reaction o n clumped ce lls from a nothe r

case of ins(3:3), to show both multinuclearity and gross
phagocytic activity of some megak aryocytes in this form
of A ML. Th ere are also several gro ups of PAS-positive
ery thro blasts pres ent in this field.

/0 /
-196-502 . Examples uf the cytology and cytochemis try of
AM L with trisom y 8.

T riso my 8 is the co m mo nes t chro moso ma l abnorma lity

found in AML. and of te n co-exists with o ther cyto-
ge netic abe rratio ns. pe rhaps chiefly as a seconda ry
phe no me no n in cases whi ch a rc usu ally of muhiline age
(Ty pe 11) e xp ress io n a nd which hav e a ge ne ra lly poor
prog nos is. W he n tr iso my 8 occ urs a lone . as it does in
ab out a th ird of all cases with this ab normality. t he
cyto log ica l picture is predomin antl y gra nulocytic with
ma rked evide nce o f dysplastic maturation . Rom an owsky
stai ns of bo ne marrow sme a rs fro m th re e d iffe re nt cases
o f trisomy 8 appea r in -I96--l9S .

-196 . T ypicall y va riab le matu rat ion . with e noug h

gra nular ity in the more primiti ve cells to indi cat e the ir
gra nulocytic rath er tha n monocytoid linea ge. hut with

ag ra nular lat er nc ut roph ils show ing acquired Pclg cr-
Huct nucle i.

..197 . M veloblasts , one with an unstai ned A ucr rod

ove rtvine the nucleus. defective neut ro phil myelocyte
ara nularitv . and various eoslnophils. some wit h green-
ish granul es .

..I9g . A more primit ive blast ic picture. with de e p nu clear

lob ulatio n in on e cell a nd lar ge pinkish inclu sions or
vac uolcs overlvinu the nucle us and in th e cyto plasm of
a no the r. A pt)(; rl )~g.ra n u l a r neutrophil poly mo rph is also
p rese nt.

I h'


B sta in on ho ne marrow smea r from th e case S02

trated in ~ 98 . thre e primitive blasts showing local-
izIed cytoplasmic pos ni vu v o f myeloblastic pattern -
ina a dense Au cr rod in the lower blast and eit her
Auer rods or o the r inclu sion s in th e upper ce ll of
group. Th e fourth blast cell has an o vera ll granul ar
iadanophilia together with stro ng localized positivity .
. xc gra nulocytic tha n mo nocytic in pattern. A norm-
. react ing eo sinophil is in the lower right corner o f the

B stain o n the bo ne mar row of ano the r pat ien t

A ~ IL and triso my 8. illustratin g the fre que nt
g in th is co ndition of unexpectedly poor sudano-
_ The central de nsely positive cell. probably a
ophil pol ymo rp h. shows a strong norm al reaction .
promye locyte at the left . with an Au er rod . and
lbe eosino phil a nd neu trophil myelocytes, arc very
_ posi tive with a gre enish-brown rath er th an black

PA reaction in th is form of A ML gene rally has

I findings. the blast cells having negative or
reac tio ns. as her e .

dual este rase rea ctio n sho wn here illustra tes

.ngs. with mos t blast cells negative but C E
appearing in lat er gra nulocyres from pro-
on wards. T he re is BE positivit y in two plasma
m severa l e rythro blas ts,

503-5 20. Examples of the cyto logy and cytochemistry of
AM L associated with an interstitial deletion of 'he 10nK

arm of chromosome 9 between bands ql 3 to q22. 9q-
(q/3 ;q22)(Type /lA ). 505

Although most cases of9q- have predominantly myclo-

blastic cytology . they show evidence of erythroid and
megakaryocytic dysplasia .

503 and 5().l. Typical low-power fields (Heyl slain). with

blasts of variable size. dysplastic erythrobl asts and. in
503. an occasional plasm a cell and eosinophil.

505-510. High-power details of the bone marr ow cell

cyto logy from seve ral different cases of9q-A ML. In 505
there are two mycloblasrs with vacuol ar inclusions and a
poo rly granula r stab cell. In 506 a myelo blast sho wing
nuclea r co nvolution resembling that commonly seen in
A PL is acco mpanied by two very coa rsely granular
co sino phils; 507 shows ten myeloblasts, two with Auer 506
rods. and a pro myelocyte , 508 an eosinop hil pro myelo-
cyte with mixed granules. and four myclob lasts, 509 six
blasts, one with a bilobed nucleus. anot her with a
twisted mon ocytoid nucleus, one with primary granules,
and o ne with a vacuole, and 510, four variably sized
blasts with vacuolcs or small azurophilic inclusions .

511-513 . DAB peroxidase reactions. with posit ive

Auer rods , ot her coa rse inclusions and granular posi-
tivity in most blast cells.

51~ . SS positivitv of chunky inclusions. usually with

nega tive cores. in vacuo lated myelobl asts.




51 ~



5 15-5 18. Furth er illustr ation of the striking pa ttern s of 519

SB posltivity in 9q- A ML. with very coarse granules or
inclusions usually sho wing a positive peripher y..and a
hollow negative centr e . Con spicuou s vacuolcs in some
blast cells mani fest weak suda nophilia - especially at the
circumfe rence. as in 516 - while Au er rod s may ap pea r
as nee dle- o r spindle-shaped structures . or as shor t thick
rods with either solid or hollow ce ntres (517 and 5 18). In
518 there arc also two c rvthroblasts. o ne binu cleutcd
with a Howcll-Jollv body. and with a suggestion of
residual megalo blastic nuclear features .

519. PAS reactio n on blast cells fro m 9q- AM L. The

positivitv is typically weak . as here. with no mor e than a
faint diffuse tinge or fine gran ular reaction . Nucleo li are
revealed ver y clea rly in this prep aratio n. and their
dispo sition. when pai red. at oppos ite poles of the
nucleu s is well see n. T wo late crythrob lasts are present
in this field. ho th with evidence of d ysplasia . one having
it separated nuclear fragmen t o r Howet l-Jolly body and
the o ther a trifolia te nucleus. Neit her shows convinci ng
PAS positivity.

520. Dual esterase reaction in ano the r case of 9q-

A~1L. showing the presence of strong CE pos invitv in
ea ch of thr ee blast cells. with even it possible positive
Auer rod in the upper most.


521-523 . Examples of A ML associated with mOllosomy

7. 7q- and 5q-( Type 11,1).

These chromoso me abnor ma lities are co mmon in

mvclo dysplastic states ( ~ I DS) and occur in bo th prima ry
( de " Ol'O) a nd seco ndary AML. Monosom y 7 and 7q-
are o fte n fo und toget he r with other ch romoso mal
defects . Cases usuall y show dysp lasia of both erythro id
and megak aryocytic lines as well as eithe r myclo blasts o r
monoblasts. or bot h. 5q- is rela tively uncom mon as a
sole abno rmality in AM L but has usually been associated
with a rath er similar picture so far as er yth ro id and
mc aakarvocvuc invo lvem ent is concerned . but with
mos tly myelobl astic and later gra nulocytic cells ra the r
tha n those of the mo nocyte line.

521. A lo w-power view of a hone marrow smea r [Hcyl

ta in) fro m ;'1 patient with Af\.lL and mon osom y 7.
sho wing blast cells with so me granulocytic matu rati on . a
gro up of ab nor mal mcgakar yocytcs includin g mono-
nuclear. binuclea r and tr inuclear form s. a nd ten e rvthro-
blasts. seve ral o f which shoev nuclear deformities o r
me galoblastic cha nge. There is a central plasma ce ll.

522. An exam ple of th e bone marro w cyto logy in A f\. IL

rh 5q- . showing a predominan tly myelobl astic a nd
peom ve locyuc pictu re with ;'1 nor ma lly granular seg-
men ted neut ro phil and two eryth roblas ts. o nc bi-

513. A smea r fro m a case o f AML with mult iple

osomul defects. includ ing mo nosomy 7 and
y 8. The re are myeloblasts with nuclear ring
no n and a sugges tio n of both def ective gra nularity
P lger-H uct nucle i in later neut rophils.

5U 526


524-532 . Examples ofthe cytology and cytochemistry of 527

A M L with 6;9 /ranslocation. t(6;9) (p2J;qJ./) .

This chro mosomal defect is usua lly. though not quite

always . associa ted with a stro ng basophilic component.
including mature basophil s and numero us baso phil
precursors from prom yelocytcs o nwards. and freq uently
with abnor mally coarse o r poorl y staining granules o r
aty pical nuclear forms. Cases have bee n classified
mostly in FA B gro up M2. le55 commonly in M l. M4. or
as MDS. but as there are often minor components of
bo th erythroid and megakaryocytic involvemen t with
d ysplasia and microm egakaryocytes. most cases prob-
ably fit Type HA.

524-527. Various fields from the bo ne marrow of a

patient with t(6;9) A ML. stained by Romanowsky dyes
to illust rate these abnormalities. In 524 the re are two
late basophils with recognizable nuclear structure but
poo rly stained gra nules . while two of the blast ce lls show
a suggestio n of baso philic granulation . Four myelo-
blasts . a neut rophil stab cell and a coa rsely granular
basop hil myelocyte can be see n in 525. while 526 has
three blast cells with little differentiation. a binuclea tcd
er ythro blast and . at the top . a poor ly granular basophi l
pol ymo rph. There are no basophils present in 527. but
there a re four erythrobtasts, one with some megalo-
blastic change. and a binucleated micromegakaryocyte.


~'l; ... .'


::Z8-532. Further fields from cytochemicnlly stained 532

slides of the same bone marrow aspirate as in 524-527.

518 and 529. Fields stained with toluidine blue, which

fC'3C1S spe cifically with the mucopolysaccharide of
ph il granules. Po sitively reacti ng cells can be picked
t with case and gene rally prove to be mo re numerous
man had been thought fro m the Rom anowsky stains .
Here. the coarse granularity of more mature basophils
aDd the finer gra nules in basophil myclocytcs are clea rly
. jble.

and 531. S8 stains. 5,\() showing ;'1 nega tively

reacti ng segmented basophi l. a negat ive myelobl ast and
a sormally positive eosinophil myelocyte. 531 a meta-
dIroma rica lly stai ning basophil. normally reac ting
K8Uo phil-prccurso rs - o ne with a pos itive A uer rod - •
nega tive crythroblasts.
-, PAS stain on the same mate rial, showing two
obla sts with cyto plasm ic positivity. two myelo-
with single nucleo li and a negat ive or weak diffuse
Ion. and a norma lly reacti ng met amyelocyte , There
110 basophils in this field ,

533, A sectio n of bone marrow trephine biop sy from a

patie nt with a multilin cage AML and co mplex
chro moso me abno rmalities. seco ndary to a preceding
MDS. T he predo mina nt cells are blasts. pro bab ly
myelo blasts , but there are islands of crythrob lastic
pro lifera tion and several dys plastic mcgakaryocytes.
Ove rall ce llularity is high .

5~ and 535. Low- and higher-power views. respect -

ively. of a trephine biopsy sect ion fro m anot he r patient
with multilin eage AM L. showing again a mar ginal
predominance of nuclco tatc d blast cells. many with
twiste d mo nocytoi d nuclei . amo ng a substa ntial co m-
po nent of eryt h roblasts of d iffere nt stages of maturity. A
few mcgak ar yocytcs. some appare ntly mo nonuclear.
can be distinguished . T here is an occasional late neutro -
phil with dense but seg mented o r twisted nucleus.
Sections of this kind help to estab lish the overall
cellularity and broad differential proport ions of ce ll lines
in cases of AM L. but smea r prepa ra tions arc required
for more accurate recognition of dysplas tic changes and
det ailed differentiation of pri mitive cell types.

I 'll
5~'6-S47 . Earlv cytological signs of emerging myeloid 53ll
haemopoietic ;lctivity during remission development in
aClde leuk aemia. The fea tures illustrated are usually
fo und in ma rrows which otherwise remain hypoplastic
fo llo wing cytotoxic therapy,

5~\6 . A plas ma ce ll. an RE cell (macrophage) and the

granular. pla tele t-for ming cyto plasm of a mcgak nryo-
cyte .

537 and 5.'H . Young mega karyocytes. showing new

pla te let format ion at sites wher e the primitive cyto-
pia mic basophilia is first lost.


- •

539. A more mature megakaryocyte . bu t still with 5-1 1

patc hes of residua l baso phi lia.

540, R E cells may appear relatively numerous at this

phase - the marrow fleck here is composed almost
entire ly of them . Elsewhere the marrow sho wed gross
hypo plasia . yet remis sion e nsued within a few days.

541. A higher -pow er view of the cells in this fleck - the

nuclear patte rn is characteristic of R E ce lls.


• -,

542. A group of typical rem ission -associated cells:
plasma ce lls, RE cells. megakaryocyte-plate lets . a single
blast cell. granulocytc precursors and a giant megalo-
blast following an timetabolite chemot herapy.

543. A myelo blast . two coa rsely gran ular prom yelo-
cvtes (as typically found in ea rly remissio n) and a
meta myelocyte.

5-1-1 . A similar seq uence of gran ulocyte precursor s

toge ther with stab and segment ed neu trop hils of nor mal
appea rance.

545-547 . Examp les of giant o r mult ilobed neutrophil 547
mcta myclocyt cs or pol ymor ph » in ho ne mnTTOW aspi r-
at cs taken du ring ea rly stages of re mission e me rge nce in
ac ute leukae mia. An ac tivated Iymph ocyte or imrn uno-
eyre approaching pla sma -cell morphology is also shown
in 547 , Patho logical though the mu ltilohed neut rophils
a ppe a r, they do see m freque ntly to precede remission
de ve lopme nt .


S-4K-550 . Three fur ther illustr a tion s o f ph ases of 550

eme rging re missio n in ho ne marrow as pira tes from
pat ien ts with AML afte r successful indu ction th e rap y. In
the first (5-lK). a n islan d of e rythrob lasts with cy to plas m
rang ing from baso philic to po lychr om ati c surro unds a
macrop hage. as active erythropoiesis e merges . In the
sec o nd (549 ), a single neut roph il m ye locyt e is presen t in
a field co ntain ing pr edom ina ntly e rythroblast s, fro m
pro-e rythroblast to late norm oblast. Th er e is evide nt
po lychromasia amo ng the red ce lls. no do ubt re flected
by a retic ulocytosis in the pe rip he ral blood. T he thi rd
field (550) shows a ra nge o f ne ut rophil grunu locytcs.
illus tra ting maturat io n stages fro m nucle ol a ted mvelo-
blast at t h~ bottom . through promyelocyte and myelocyte .
to met amvctocvte and stab cell. Fo ur ervthrob lasts. a
pos....ible h;ISOphil. and a co mpressed lymphocyt e nucleus
ar e a lso present .
5:'1 ,
.. •


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551-553. A ve ry low -po we r field a nd two high e r-power
views of hon e marro w tr e phin e bio psy sect io ns from a
pat ien t wi th AML a fte r remi ssion induction th e rap y. In
551 the ma rrow id ve ry po o rly cell ula r wit h mult iple fa t
spaces . scatte red haem orrh age a nd m acrophages lad e n
with haernoside rin . and a residual nodu le of what ar c
seen, in 552 (a high e r magnification of pa rt of the sa me
Held), to he lymph o id ce lls. Th is picture is one co m-
monly fo und immed iatel y after agg ressive co mbi natio n
ch emot he rapy and re pr esen ts the hypo plastic phase
preceding e mergence of remiss ion . T he th ird Iield in this
gro up is fro m another biopsy ta ken a week later fro m the
same patient . T here is no w a mixed pict ure p resent , with
islands of crythroblast ic activi ty e vident a mong the fat

spaces. especially in the uppe r part of the field. hut also
recu rr e nt myelornonocytic blast cell proliferation
e lsewhe re . Pa ra lle l aspiration smears confirmed thi s
lcukaemic recurrence and furt her induction chcmo-
therapy was indicated . •

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55~ and 555, Low- and higher -power views. res pect- 556
iv·:ly. o'f a bo ne mar row trephine biopsy sectio n ta ken
from a pat ie nt with seco ndary AML. afte r repeated
courses of re mission induction therapy were followed by
a pro lo nged period of marrow hypoplasia and pe riphe ral
pancytope nia, A t this stage the marrow under low
power (55-4) shows a reticular stroma with recoven ng
<;,Ci.l tlered ce llularity and fresh cell proli ferati on .
e!'oopccially along cap illaries . Th e higher magnifici.ltion of

555 revea ls that the cytology is pleom orphic. with
plasma cells along the cap illaries and cells of vi.lrio us
lineages sci.lttered through the stro ma . a mong them.

primitive immi.lture cells. possibly represent ing leu -
kac mic recurre nce . hut possibly nor mal e merge nt
prec urso rs.

556. A fur ther biopsy ta ken a week lat er from the same
patient as in 554 and 555 resolves the qu estion of re lapse
or early remi ssion , Thi s thin sectio n shows a few resid ua l
plasma ce lls but also goo d mat ur ation in the gra nuloeyte
~ri c s. with all stages fro m pro myelocyte o nwards
recognizable. toge ther with scatte red eryt hrob lastic
pro liferation. Clearly. remission is now eme rging.


• •
• •
• •


557. A thin section o f ho ne marrow tr ep hine bio psy
fro m a patient with A ML afte r inducti on o f a temporary
remissio n . now showing evide nce o f re lapse . This high -
po wer field conta ins <lOOU! 50% lightly sta ining large
blas t ce lls. with conspicuo us nucl eoli a nd va ria ble
myclomon ocytic nuclear sha pes a nd nuclear-
cyto plasmic ratio . Th er e arc res id ua l no rmal er yth ro-
blas ts a nd late r gra nulocy tcs . b ut full rela pse is now
inevita ble unle ss fresh inten sive treatmen t is sta rted .

S5K. Anot her simila r field a t lowe r powe r. showing he re

so me XO'Yo Icuk acm ic blast ce lls . with fewer resid ual
norma l hae mop oieti c cells.

559 . A no the r thi n sectio n fro m a bo ne marrow tre phine

biopsy taken fro m a pat ient wit h A l\IL . afte r repeated
co ur ses o f remi ssio n induction and con solidation
che mot he ra py. now followed by late relapse . Th e
speci me n shows mark ed po st-ther ap y fibros is. with
fibroblasts a nd plasma cells pro min ent at th e uppn righ t
part o f the field . but with reduced num bers o f res idual
normal marrow ce lls a nd with recurrent blast cells
sca tter ed a mo ng th e m . not abl y in the low er hal f of th e
fiel d .


560-565. Examples of defecti ve granulogencsis - with a 562

"use- eosinophilic staining of the cytoplasm of mye lo-
ami few specific granutcs. This appearance is most
n observed in preleukaemic stales, including defective
~th ropoies is wnb excess of mvetobtasts. neutrophilic
elogranulur dysplasia , smouldering leukaemia and all
of mvetodvsptastic syndrome (,\/ DS) .

A typical appea rance of myelocytic cytoplasm in

conditio n as seen by Ro man owsky staining.

L A myelo blast, two probable premit oti c pr crn yclo -

with scattered azur ophil granules and promin ent
..:Ieoli . five rnyelocyt es with diffuse eosi nophilic
ing. and two later granulocy tes with a mo re nor -
~ gran ular cytoplasm.

Further gra nulocytes from the sa me case . showing

diffuse a nd finely granular eosinophilic staining in
ce lls.

563. S8 stain on the same marrow sample. showing

strong sudanophilia , de spite the lack of clear specific
granules in the Rom anowsky preparations.

564. A high-power view of the S8 sta in in this co n-

dit ion . The sudanophilic granules are of the same size as
those seen in myelocyte s with normal specific granules.

565. Dual este rase stain showing norm al Cfi -positive

gra nules in three of these unusu al myelocytes, despite
(heir poo r granularity with the Rom anow sky stai ns.


566- 568. A n exam ple of transient myeloproliferative 568

disorder (T MD) of Down 's syndrome, trisomy 21.

Patie nts with Down 's syndro me are at much increased

risk of acu te leuk aemi a , including a form of A ML with a
megakaryo blastic compo nent. They are subject to a
tra nsient non-clon al blastic pro liferatio n, with a strong
megakaryoblastic compo nent, which is man ifest in the
peripheral blood and persists for a few week s before
spo ntaneously disappearing witho ut trea tment . For-
runa tely. this transien t disorder (TMD) can usually be
eas ily distinguished fro m acu te megakar yobl astic
leukaemia (AMegL) by its earl ier age incidence , < 1
month as compared with > 3 months, the presenc e of a
higher proportion of blasts in the blood than in the
marrow and the relatively nor mal levels of haemoglobin
and platelets. T hese three field s are fro m the bo ne
marro w aspirate in a neon ate with TM D and blast cells
in the periphe ral hlood. The first (566) has a typica lly
'ariable blast cell population, with generally Iow nuclear-
cyto plasmic ratio , vacuolation, nuclear twisting or
lobu lation with multiple nucleoli, a giant prom yelocyte
rith coa rse azuro phil gra nulation , a plasma cell and a
aeutrophil segmented cell with nuclear twinning . T he
secon d field (567) sho ws ano ther area to illustrate
especi ally the varied gran ulocyte developmen t , with
'eral eosinophils as well as lat er neut rophils; while the
- d (568) shows the cdge of a dense clump of cells of
. xc unifo rm mo rphology consiste nt with megakaryo-
, with occasional intermingled macroph ages.

569 5 0
. ... "
," •

• ,•

" .


~ *~.
., ,.,

" ."
.. . ' .
:;:69-571. Thin sections of bon e marr ow treph ine 571
bio psy fro m a pa tient with a n MDS involvi ng com-
po nents o f ref rac tory sidc roblustic anaemia a nd
excessive blastic pr oliferat ion toge ther with a n increase •
in mcgak a ryocytcs . In 569 th e low-powe r view sho ws
genera lly high ce llula rity with a very pleo morphic •
picture. including numerous scatte red macro phagcs
laden with haem osiderin a nd seve ral multin ucleated
rnegakaryocytes. T he higher -pow er view in 570 is of a
neig hbo uring area with more residu al fat spaces . whe re •
the megakaryocytic cytology is well shown . a nd where
there a rc several areas of haemo rrh age of the kind from
which the haemosidcr in in the macroph agcs in 569 was
do ub tless de rived . T he rem aining ce lls in this field
include grn nulocyrcs chie fly fro m myeloc yte o nwa rds
and ervt hroblasts with densclv sta ined nuclei. In the
reti cultn-staincd prepa ration ' at still high er power
illustrated in 571 . the abse nce o f a ny increase in re ticuli n
a nd the pre se nce o f lade n macroph ages. a nd also o f
nuc lco la tcd blast cells with lightl y sta ined nucl ei . a rc
clea rly evide nt.

572. Prussian blue stain for free iron on cells in a hone 57.t
marro w smear made from the same patient whose
trephine sections arc shown in 569-571. Th e cluste r of
ervthrc biasts in this field shows a high conte nt of free
iro n with occasional ringed distributi on .

573. In this Rom anow sky stain. a buff y coat prepa ra-
tion from pe ripheral blood - agai n. from the same
patient - shows a myelobl ast , a prom yelocyte . later
neutrophils, two lat e erythrohlasts on eith er side of a
megakaryocyte nuclear fragment . a nd a mass of giant

This who le sequence of slides (569-573). tak en at the

' time from o ne patient. illustr ates the complex
. totogy of the multilineage myclod ysplasias a nd the
com mon ove rlap bet wee n the recognized subd ivisions.

57'" An other bo ne mar row sample fro m a pat ient with

iDS. this time classified as refr actorv anae mia with
cess blast' (RAE B). Th ere is a shift in the left in the
eranulocyte series . hut. as this field reveals. there is
picuo us granular dysplasia. with defective ncutro-
granulatio n fro m myelocyte to polymorph . and
8Bdear defects ranging from pseud o-P elger-Hu et lack
segmentatio n (in the three upper neut rophils ) to
persegmentatio n in the lower polymorph .

5 5 576

-•.- .'........
. "


57:-577. Sections of trephine biopsies from furthe r 577
pa tients with MDS . In 575 and 576. an exampl e is shown
of the mor e hypocellu lar variant of MDS . in this case
associa ted with mark ed dysmega karyocytosis (micro-
forms and multinu cleat ed ce lls be ing especially con-
spicuo us in 575) ; the presence of erythrob lastic island s
and the abse nce of collagenous fibrosis are mani fest in
the Van G ieson stai n of 576. Th e section appearing in
577 is fro m anot he r pat ient with the RAEB form of
MDS , associa ted also with the chro moso me anomaly
5q-. This defec t occurs most common ly in elde rly
females . as in this case . and is usually found in associa-
tion with ref racto ry a naemia. dysgranulo poiesis with left
shirt. and a cha racte ristic megakaryocyte picture with
mononuclear or bilobed ce lls. Typical dysplastic mega-
karyoc yres showing this feature are seen in the upper
part of the field. A mo ng the scattered islands of e rythro-
blastic hyperplasia and later granulocytes occupying
much of the lower part of the field are several small
groups of blast cells. well away from the endosteal
surfaces of bony trabeculae whe re early myeloid pre -
cursors are norma lly concent rated . Th is 'abno rmal
local ization of immature precursors' (All ?) may
pe rhaps predicate immi nen t leukaemic transfo rmat ion.

578-580. Two low-powe r views and a higher-power 5110
field. respectiv ely . from a thin sec tio n o f bon e mar row
tre phine biopsy from a pat ient with MD S. showing
RAEB with trilin eage dysp lasia . In 578 there is a
generally pleo mo rphic picture with mon onuclear mega-
.aryocytcs and ot hers with multip le perip heral nuclei.
an evident increase in early granulocytes - though with
poorly gra nular cytoplasm - a few later neutrophi ls and
inophils. and a sca ttered c ryth roblastic component
' th deeply stai ned co mpact nuclei. A broadly similar
field is shown in 579 . but w ith several abnormal rnega-
ryocytcs having lar ge sing le o r do uble nuclei. In both
fields occas iona l cells with elo ngated nuclei
~ est the prese nce of fibroblasts . The high-po we r view
of 5SO clearly illustrat es the nucleo lat cd myelo blasts
ich predo mina te . toge the r with eryt hroblastic islands
• top a nd bottom of th e field showing some rncga lo-
tic feat ures. and var ious ce lls of th e megakar yocyte
. includ ing a hi nucleat ed cell at mid -centre left and a
-Kro megakaryocyte at the right edge . a thi rd up from
bo tto m.


5KI-583. Two furt her examples of typica l bo ne marrow 5
trephine b iopsy appea ran ces in va ria nts o f MDS with
incre ase in blasts (RA Ell) . Both show hyperplastic
ccllularity with few rat spaces a nti marked pleo-
morphism . the first case - with la\\'- and highe r-power
field s shown in 581 and 582 - havin g all myelo id cell
series well represent ed. but with an evide nt increase in
immatu re cells. especially of the gra nulocyte se ries.
bo th neutrophil and eosinophil. as revealed in more
det ail in 582. The thicker section from anothe r case
shown in 583 is agai n highly cellu lar. with all cell series
pre se nt . hut with a co nspicuou s shift to the left in the
grun ulocy res. with se ve ra l clumps of nuclcol a te d myc lo-
blasts. Both these cases illustrate A LII' , possibly sug-
gestive of early progression to florid trilin cagc A~t L.


584--587. A success io n of fields from bo ne mar ro w 586

aspira tes take n fro m pa tie nt s with RA E B to dem o n-
stra te so me o f the co mmo n cyto logica l a nd cytoc he mica l
fea tures o f dysp lasia in th e myelopo ie tic se ries seen in
~tDS . In 584 c ryt hrob lasts show irregula r. twisted o r
fragme nting nuclei. the re is an immature bin uclca tcd
megakar yocyte with ingested red ce lls. a nd seve ra l
ne utro phil rnyelocytcs show th e yellow cyto plasm ic
co lour a nd defective gra nulation ofte n seen in myelo-
dysp lasia (cf . 561 ). Figure 585 sho ws a not he r slide from
the sa me asp irate . sta ined wit h SB. whe re a du al
po pula tio n o f gra nulocyres is ap parent . wit h six strongly
po sitive rnyelocyres or prcmyclocyrcs and three totally
negative cells . a myeloblast. a pro myelocyte or early
myeloc yte . a nd a neu trophil stab cell . Figures 586 and
SS7 a re from slides of a nothe r bone marrow aspira te
take n from a second patient with RA EB and stained 587
r pccnvc ly for peroxidase and with S8 . In 586 a
promyeloc yte is strongly peroxidase-pos itive , while
th ree poorly gra nu lar segmented neutrophils arc qui te
ecga nvc. In 587 one ne utroph il polymorph is normally
sudano philic , while two others show on ly weak sca ttered
~ nula r positivity.


588-591. Buffy coat prep arations from the peripheral 59 1

blood of a pat ient with CMML . ano the r variant ofte n
class ified amo ng Ihe myelod ysplastic sta tes . T he blood
picture in this disorder shows a substa ntial mo nocytosis .
com monly 5-lO x 10'1/1. and the monocytes may have
ma rked ly convo luted or hypcrscgmenled nuclei. as
illust rated here. Th ere may also be occas ional immal ure
, .
gra nulocytes in the bloo d . and . as at the lo p of the field ,
in 588. dysplastic megak ar yocytes o r naked nuclei. and •
irregular o r giant platelet s. In 589 and 590 the per-
ox ida se co nte nt and SB reactions arc revealed as
generally normal for bo th gra nulocytcs and mon ocytcs
in this case. altho ugh erratic sta ining is so metimes
found . and mon ocyte, may give negative o r weak
reactions. As shown in the dua l esterase reactio n
depicted in 591. the monocytcs arc usually stro ngly
positive for BE. while neu trophil s react norm ally for
CE. T he re arc two negatively reactin g basophil s in this
field .



592 and 593. T he lo w- and higher-po wer views. respect- 5~

ively. shown here arc from a bone marrow trephi ne
biopsy taken from a patient with CMML and a similar
pe riphe ra l blood picture to that illustrated in 5~59 1 .
Mo nocy tos is is usuall y evide nt in th e marrow . but is less
co nspicuous than in the blood. and is acco mpa nied by
ot her fea tures o f MDS . including vari abl e signs o f
tri lineage dyspla sia . Th e sec tion illust rated here has
bee n stai ned fo r the mon ocyte e nzyme mur amidase
(lysoz yme). which allows th e mon ocyte co mponent ( 0
be distinguishe d more clearly tha n is po ssible in simple
H& E o r Giemsa stai ns . In 592 seve ra l mult inucl eat ed
megakaryoc ytes ca n be see n. and in 593 the re is a
pleo mo rp hic picture with num erous gran ulocytes at
diffe re nt stages of maturation.

594. T his section o f a trephine biopsy is from a patient

with a long-stand ing C MML. now transforming to a
more florid acute leukaem ia . with increasing numbers of
blas t cells in the blood . The histology shows an almost
uniform replacement of marrow tissue with immature
CC'lIs havi ng promonocyti c features. including relatively
. nuclea r-cyto plasmic ratio with poorly defin ed cyto-
plas mic o utlines and occasio nal nucle ar twist ing or
I8de ntatio n. Th er e ar c two mitotic figure s visible .
Part 3
Lymphocytes, plasma cells and their
derivatives and precursors in blood and bone
ormal and abnormal fo rms
Lym phocytes are form ed chiefly in the lymph glands , undergo furth er cyto logical transformation to give rise
~c n. Peycrs patches and other nodal sites . among to plasma cells.
which must be included nodules of lymphocytic nature Morphological variations in both Iymphocytes and
in the bone marrow. Precursors. 1)1npfiO blastrand plasma ce lts cover a much wider ran ge th an amo ng
peolyrn phocyt cs. arc difficult to recognize in norm al, gra nulocytes . In infections . particularly th ose du e to
marrow aspirates. however . and are illustrated from viru ses . Iymphocytes show activated o r immunoblastic
pathological conditions, principallY.;ll'Ute lymphoblastic featu res intermedia te between mature and pr imitiv e
an dyprolymphocytic leuk aemia . where the y beco me cells. with increa se in cytoplasmic basophilia. and
commo n in th e marrow and so met imes a lso in the some time s the appeara nce o f visible nucleol i. Even in
peri pheral blood . normal blood th er e may be co nsidera ble variation s in
Whi le the ea rliest stages of lymph oid ce ll dev elop - the size o f Iymphocytes and the amount o f cytoplasm .
ment from the probable co mmo n stem cell shared with Cytoplasmic vacu ole s and inclusions are not infrequent.
the mye lo id series arc still uncertain . it seems likely Fine or coar se gra nules and eve n blocks of glycoge n
tha t a funct ion al ste m ce ll for the lymph ocytic cell may occ ur in Iymphocytes and lymphoblasts, and o fte n
series exists which gives rise to two main so rts of appear espe ciall y co nspicuo us in leu kaemi as or other
lymp hocyte: T cells and B ce lls. Th e form er have a lymphoprolifer ativ e states.
special role in ce ll-me diated immune responses and Plasma cells sho w even mor e abundant cytological
ma y have helper (TjL 'subset) or suppresso r (Ty subset) variants. mostl y connected . there is litt le doubt . with
functio ns in relat ion to Hcell activity. B ce lls are thei r production of immunoglobulins and the
larg e ly responsible for hum oral immune respon ses. accumula tion o f part o r the whol e of th ese protein
These cells. and sma lle r gro ups of Iymphocytes which molecules in vari ou s morphological guises in the cyto-
seem to fall into diffe rent . less clear . ca tegories are plasm . Here aga in. the cytological vari ant s are most
distinguishable by imm unological means. but also have conspicuous in mu ltiple myelom a . th e plasma-cell
certain morphological and cytochemical differ ences equivalent o f leukaemia . but an y o f the m may be see n
which are illustra ted in this sec tio n. and which are occas ionally in plasma ce lls from othe r conditions and
some times also manifest in neoplastic st ates . even in normal marrows. and non e appears to be
Imm unologically. T cells from th e earli est stages o f spe cifical ly confined to myeloma .
ma tu rity show a capacity to fo rm rosettes with she ep
red cells, and reac t with the MAbs C D2, C D3 and
C D? Th e helper subset reacts also with CD4 a nd th e
uppressor subset with C D8 . From an ea rly stage. B· A CUle l\'w phoblastic leuk aemias fA L Lr ). These. are
cell co mmitted precursors show immunoglobulin ge ne monoclonal neoplastic d iseases arising from Iympho·
rea rra ngements, express io n of HLA-D r and ant igen s blastic precursors of Iymphocytes . ALL makes up about
reacting with CD 19 and CD9. At a transient early 85% o f all acute leukacmic cases occurring below the
phase o f development they react also with C D 10. and age o f 16, a nd has been class ified morphologica lly by
late r tra nsiently express cyto plasmic immunog lob ulin the FAB group into three subtypes according principally
(cIg) before producing surface membran e immune- 10 th e size of the leukaemic cells : Ll cases have ho mo-
zlo bulin (sm lg). T hese features are all o f importance in geneous small blasts with litt le cytoplasm . L2 cases
de termining the stage of ma turation at which neoplas tic hete rogeneous larger blasts with var iable amo unts of
cha nge e me rges. and ar e especially valu abl e in c1assi- cyto plasm . and L3 case s homogeneous large blasts with
tying lympho id leuk aemias. vacuolated basophilic cytoplasm . Although this classifi-
Unde r stimulatio n by phytoh aem agglutinin norm al T catio n doe s not correlate well with immu nolo gical or
. mphocytes may undergo. in vitro. a process of cytogenetic characteristics . except to an extent for th e
dedi fferentiation o r transfonnation to prod uce primitive uncom mo n L3 gro up, which includes most cases with
cells . with basophilic cytoplasm and leptochromatic the Bccell mark er of smIg production . and th e 8 ;14
leo lated nuclei . able to divide. A similar trans- tr an slocation. it has some prognostic significanc e . L2
rma tio n of B cells may occur following antigenic cases .do ing less well th an Ll cases. This ma y pe rhaps
." ' . 30d the primiti f'e cells resulti0l! may redectthe phaseofpro/ikrativeactivityratherthan an)'

19 1
CD3 and CD7 , and usually with CD4. Th ese cases are
ntial diffe re nce in cell type o r o rigin, since cases
prese nting as II ofte n show a change to U in relapse . classifiabl e as T -Cl L and are to be disting uished from
The disaimi nating morpho logical fea tures are never- T-proly mphocytic leuk aemia and also fro m CD +
illustrated in subsequ ent figures and furth er granula r T -ce ll lymp hocytosis. wheth er in an ea rly no n-
descri bed in the ir caption s. malignant sta ge . o r frankl y neoplas tic . Th ey co mmonl y
I unologically, A LL ca n be subd ivided into man y show skin infiltrati on and a mo re aggressive clinical
diffe rent types. but ther e arc five main gro ups: T-ALL co urse th an B-CL L.
derived from 'f-cell precursors (TdT+ , CD3+ , CD7+);
' null" ALL and C· ALL fro m ea rly B-<:ell precurs ors Prolymp hocytic leukaem ia (PL L) . This subacu te and
(TdT+ , CD 19+ and respecli vely CD I()- and CD I() + ); clinicall y intracta ble varia nt may eme rge by a form of
pre- B ALL from B precurs ors at a somewhat later malignan t progres sion in Cl. L. or may arise de novo .
sta ge (TdT + /-, cl gM + ); and B-ALL fro m a still usually in association with gross spleno megaly and
late r stage of Bccell develop menl (TdT-, srnlg -i- ). C- ofte n also he pat ome galy. The periphe ral cell count is
ALL makes up abo ut 70% of childho od cases, T-ALL usually very high , with prolymp bocyr ic feat ures of
abo ut 15% , null ALL about 12% , and B-ALL < 2%, In nucleolat ed but moderately pachych rom atic nuclear
ad ults. where only abo ut 15% of acute leukaem ias are chro matin and variable amount s of gran ular cyto plasm.
lympho blastic , C-A LL is relatively infreque nt , co m- Mosl cases of PLL sho w a Bcce ll phenot ype , with
prising perhaps 40% of all cases. o ther early B and pre - stro nger expressio n of sml g than in B-CLl, and with
B cases making up the differen ce . A small proport ion CD l9 positlvit y. but up to 20% of cases have a T-cell
of cases «2%) with dubiou s or mixed reactions rem ain phenotype , most often CD4+ .
d ifficult to classify immun ologi cally . Ap art from the
part ial association of B-AlL immuno logy with L3 Hairy cell leukaem ia (HC L) or leuk uem ic reticulo -
mor phology. there are few distin guishing cyto logical endosheliosis (LR E). Thi s cytolo gically fascinatin g
feat ures in parallel with the rem ainin g sub type s, except leukaem ia of B-eell lineage occurs in middl e years or
for the pres ence of localized par anuclea r dot positi vity lat er . four times as commo nly in men as in women. and
to acid phosphat ase and less markedly to o ther acid is associated with ge neral malaise , spleno megaly.
hyd rolases in T-ALL. occasio na l abdo minal lymph adenop ath y, mod er ate
Cytoge netically , seve ral non -random chro moso mal anae mia , th rom boc ytopeni a and neu tropeni a , and
abno rma lities have been identified in ALL. The se con spicuou s monocytop eni a . A few e ryth roblasts are
includ e t(9:22 ). occurring in nearly 20% of adult ALL usuall y to he found in the periphe ral blood . Th e bo ne
case s, h ut in only abo ut 5% of child hood cases; t(8;14) marrow is d iffuse ly infiltrate d with hairy ce lls (HCs)
in most cases of B-ALL ; t(I ;19), t( v; 12) and 6q- in a a nd also shows d iffuse fibrosis. so that atte mpts at
small proport ion of earl y B-cell cases; t(4; 1I ) in aspiration usually result in a dr y tap. T rephine biopsies
uncomm on cases with a tenden cy to develop mixed sho w a very characte ristic picture . as illustrat ed in
lymphob lastic and mon ob lastic fea tures ; and t(11;14) in 767-772 . The HCs ca n be recog nized and studied in
T-A lL. More import ant than these individual structural blood smea rs or in buffy coa t prepar at ions (7~766);
ano malies in terms of overall prognosis for the ALL the y have a striking and diagnostic cyto logica l appear -
ance in Rom anowsk y stains and have tartrat e-resistant
gro up as a whole arc chromo some num bers. hyper -
diploidy with 50--60c hromos omes be ing associated with acid phosph at ase (T RA P) positivit y and typica l PA S
a relatively good response to treatme nt , dipl oidy and cytoc hemistry . Th e lA P score is not abl y high .
near haploid y with an inte rmed iate one , and minor lmmun ologically, He . , like B-CLL cells, have receptors
hypodi ploid y o r pse udodi plo idy with most structura l for C3h (CD l1+) hUI , unl ike CLL ce lls, not for C3d
ab no rma lities a worse o ne . (C D21- ). They express activatio n ma rke rs such as IU
recepto rs (CD25 +) and have certa in relatively specific
Chronic lympho cytic leukaemia (C LL) . Thi s disease is mark ers such as CD22 antigen , strongly pres ent o n
rare before middle years and has an increasing incidence HCs but o nly weak ly present o n a minori ty of normal
with rising age . There is a periphe ral lymphocytosis B ce lls. Biochem ically, the ce lls produce mon oclon al
usually over lSx 10' /1, with variable lymph adenopathy , Ig, and DNA analysis indicate s the pre sen ce of clon al
sple no megaly, hepatom egaly a nd defe cts of marrow rearr an gements of both light and hea vy chain genes .
function manifest by anae mia and thromboc ytopenia. All these fea tures sugges t that HCs are activated
The extent of thes e clinical features forms the basis of B ce lls. at a stage before maturat ion to plasma cells.
various stagi ng systems, now in internat io nal use . Some HeL is of furth er unique int erest in bein g the onl y
10% of pat ients with ClL also show a more o r less haem atological malignancy to show almost inva ria bly a
seve re auto-im mune haem olyt ic anaemi a with sphero- dr amatic therape utic response to the biological age nt
cytos is and a positive antiglo bulin test. Hypoga mma- alpha-in terferon .
globulinaemia is co mmo n, especia lly in mor e advance d
stages of disease, and a monocl onal par aprot ein may be Sezary syndrom e (SS) . Thi s chronic T-eell neoplasm
produce d . proba bly always in case s with a Iymph o- represe nts the leukaemi c ph ase of mycosis fungoid es .
plasmac yto id co mpo nent to the cytology of both peri- combin ing the skin infiltr ation . nodular and exfoli ative
pher al blood and lymph nod es. CLL is usually a Bccell dermatitis and epide rmal Pautrier 's microabscesses,
disease with CDl9 positivity and at least wea k expression with the presence of typical Sezary cells in the circulating
of smlg, but a small proport ion «5%) of cases with blood . Th e cha racteris tics of Sezary cells includ e , most
CLL morphology and sma ll ag ranular lymph ocyte s importantl y. a deeply convoluted o r cerebrifo rm
with non -convo luted nuclei show par anuclear focal acid nucleus . not always clearly manifest . altho ugh it may be
phospha tase posi tivity. and react with the pa n-T MA bs suspecte d . in smea rs viewed under the light micro-

sco pe . but striking in electro n microsco pic preparati on s diagnostic. as illustrated in 798-830. although indivi
(cf. 77&-788). Th ere is genera lly a high nuclear-cyto- cytological features such as mult inuclearity. fragme u .
plas mic rati o . surface mem br ane reactivity with the ing cells, flaming cells. the saurocytes. Mott cells. grape
pa n-T MAb CD3 and usua lly with the helper cell cells. cells with intranuclear or cyto plasmic inclusion
marker CD4. although rarely with the suppressor cell and so forth are not in themselves indicative of neo-
marke r COS instead. T he cells are usually PAS·positive plastic change . since any of them may be found in
but rarely show localized acid phosp hatase reaction . It reactive plasmacytosis. An incr ease in plasma cells
seems likely that Sezary cells are the same as the con- abov e 20% in the bo ne marrow . or a smaller increase
volu ted T cells of mycosis fungoides. alt ho ugh the latt er with demon str ab le light chain restricti on . provides
sho w some immunological differences. notably CD? accept ab le evidence of myelo ma . confirmed when
and C 0 2S positivit y. suggesting that a possible activa- taken in conjunction with Xcray evidence of oste olytic
tion effect may follow infiltration into the dermis. lesions and the dem on strat ion of a circulatin g mono-
clonal paraprotein .
Large granular lymp hocytosis (L C L) and granular Clinically. the bony destru ction ofte n leads to hyper-
lymphocytic leukaemia (CLL) . This chro nic diso rder calcae mia. and myelo matou s infiltratio n of the kidn ey
with over lu x lU'J/l large gra nular Iymph ocytes in the freq uentl y produces renal failure and urae mia. Blood
peripheral blood, associated with splenomegaly but findings include a raised ES R and variable anaemia.
little other organ invo lvement. may have a ben ign but plasma cells are not often seen. except occasion ally
co urse when found as a respo nse to variou s chro nic in buffy coat preparations, and leucocytes and platelets
infective or auto-immune co nditions. but may also are generally present in no rma l nu mbers. altho ugh
occur in an appa rently pri mary neoplastic form when it ther e may be a mild leucoer yth roblastic picture with
is best regarded as a form ofT·CLL. T he large granular infrequent e rythroblasts and myelocytes de tect able .
Iymphocytes, with typically lymphocytic nuclei but with Levels of seru m beta 2 microglo bulin become in-
a mode rate ly low nuclear-cytop lasmic ratio and fine creasingly elevated with advancing disease and probably
scattered azurophilic granules in the cytopla sm. as pro vide thc best single prognostic index . although the
illustrated in 643. express the pan-T cell marke r CD? degree of ana emia and of ren al failure are also of
and are usuall y COR+ve. They may have cytotoxic progno stic importance .
functions, includin g natural killer (N K) cell activity. w aldenstro m's macroglobulinaemia is a form of
The y do not usua lly show focal paranuclear acid Iymphoplasmacytoid immunocytoma with bone marrow
phosphatase positivit y. but scattered granul ar react ion involvement and prod uction of a circulating monoclonal
(644 ). IgM paraprotein . As in myeloma, the re is usually a
high ESR and mod erat e-to -severe ana emia. but
A dult T-cell leuka emia/lymphoma lA TL ). This neo - leucocytes and platelets are genera lly normal. Th e
plastic disease has cyto logical feat ures somewhat bo ne marrow shows infiltration with Iympho plasma-
resemb ling. thou gh mo re exaggera ted than . those of cytoid cells and com monly an increase in macrophage
SS. with circulating T ce lls having con spicuously co n- iron and in tissue mast cells. manifest in both aspirat es
voluted nuclei . scattered acid phosp hat ase positivity. (834-842 and 844) and histological sections (843 and
and an imm unophenotype includ ing CD3 and C0 4 845-851). where the large intranuclear inclusions known
positlvity. but unlike SS. the disease is du e to infection as Dut che r bod ies and characteristic of this dise ase may
with a retroviru s. human Teccll Iymphotrophic virus 1 also be conspicuo us. Clinically. the course is ge ner ally
( HT LV l) , and is largely restricted to ce rtai n areas in more indolent than that of myeloma . and there is mor e
Japan and to Caribbeans of African descent. Clinically. resemb lance to a low-grade no n-Hodgkin's lymphoma.
the co ndition is associated with lymphadeno path y. with lymphade nopathy and some degree of hepa to-
hepatosple no megaly and co mmo nly hype rcalcaemia , splenomegaly mor e often fou nd .
and generally pu rsues an acute aggressive co urse .
alt ho ugh chronic fo rms exist. Lym phoma. Th is malignant disease arising in lymph
node s and involving ce lls of more or less matur e de gree
Mvetoma and waldenstrom:s macroglob ulinaemia . in the lympho cytic line . commo nly extends at some
T hese disorde rs involve a neoplastic gro wth of the stage to involve the bo ne marr ow and to liberate
plasma ce lls or Iymphoplasmacytoid cells at the end of abno rmal lymph ocytes in the pe riphe ral blood . If the
the Bvccl l maturation chain . with the form ati on and cell type is mature the disease is cytologically ind istin-
secretio n of a mo noclon al immunoglobulin or its guishable from chronic lympho cytic leukaem ia (C LL),
co mpo nent parts. In myelom a the plasma cells in an y and, if very primitive. as it may be in children especially.
individ ual case are usually of a single clone (rarely it is equally indistinguishable from acute T- or B-cell
biclonal). pro liferating in and displacing the hon e lymphoblastic leukaemia. In some cases. however.
marrow and producing a specific Ig. biochemically and abnormal 'lymphoma cells'. unlike either mature Iympho-
immunologically uniqu e. This is usuall y IgG or IgA . cytes o r the Iymphoblasts of acute le ukaemia bu t with
rarely IgM and even mor e rarely IgD or IgE ; but in characte ristics inte rmediate between the two . mav be
abo ut a third of cases . sometimes called Bence-Jo ncs see n. T hese cells arc usuall y of the B-cell line bu t 'J1l3.~
myeloma. o nly the light chain. kap pa or lambda. is be of T-ce ll lineage and include neoplastic vari ants ot
produced . There is associated bo ne destruction . d ue to the centrocytcs . ccntrobl asts and immunoblasts preseee
increased osteocla stic act ivity. secondary to production in lymph nodes and illustrat ed mor e fully in Pan S.
by the neop lastic cells of an oste oclast activatin g facto r The cytology and cytochemistry of all these
(O AF). Th e histological picture in treph ine biopsies is and abnor ma l variants as seen in blood and man
characte ristic and the cytology in aspirates usually illustrated in the following pages.

59~39 . A cute lymphoblastic leukaemia (A L L).

including examples of the range of m orph ology classi-
fiable under the FAH system as LI (small blast cells with
high nuclear-cytoplasmic ratio , regular nuclear outlines
ap art f rom poss ible Rieder cell f orm ation , and poorly
visible nucleoli} (596 and 598-#)9). as U (cells generally
larger, with relatively more cytoplasm, more indentations
in nuclear outline and more easily visible nu cleoli) (597
and 6 /()...(, 12J, o r as L3 (large cells with regular flue/ear
outlines and homogeneous nuclear chromatin with
readily visible nucleoli , and with ample basophilic
cytoplasm sometim es containing vacuol es) (625-629).
Immunoptienotypes co rrelate poorly with morphology.
apart f rom an association betw een L3 and B-A LL and
cytochem ical paranuclear localization of acid phos-
phatase positivity in blasts of T-A L L.
595. A lymphob last with a mature Iymphocyte aod a
'stab cell, from the peripheral blood of a patient with

596. Lyrnphoblasts from the com mon type of non-T

000 -8 acute lymphoblastic leuk aemia (e-A LL).
snowing the high nuclear-cytoplasmic ratio and occa-
sional nuclear cleavage - Rieder cell form ation . There
are a few mature Iymphocyte s and some interm ed iate
' prolymphocytes' present. Despite the nuclear cleavage
this cytological picture is pro bably best classified as Ll .

5fJ7. Another example of C-ALL. There are two granulo-

eytic cells present - a metamyelocyt e and an eosinophil
myelocyte - and also some cells with denser nuclei
maturing along the lym phocytic line. This field illustrates
the difficulty of achieving the certain allocation of acute
leukae mia to a specific type based ,pn the appea rances
in Romano wsky stains alo ne. Cytoche mical staining in
this case gave the typical findings shown in the following
figures and estab lished the diagnosis unequiv ocally.
Alth ough the cell size is much the same as in 596. the
lower nuclear-cyto plasmic ratio and more conspicuous
nucleoli confo rm with the criteria for L2.

l 194
~ --

; 98. 5 B stain in C- A LL. There is a myelo cyte with MMI

no rmal positivity pre sent (for contrast) . hut the lympho-
blasts and occ asionally mor e mature cells of the lyrnph o-
cyte line arc uniforml y negativ e . As well as the high
nuclear--cyto plasmic rati o . occasion al vacuol ation ca n be
599 . Peroxidase rea ction in C-A LL. Lymphoblasts are
uniformly ne gative . A polymorph pre sent is normall y
positive. !•
. PAS sta in in acu te lymphobl astic leukae mia
IC-A LL). T he Iymphobl asts mostl y sho w num erou s fine
and coa rse gra nules of positivity. Note th at th e cryth ro-
ts present arc ne gat ive - unlik e th ose formi ng an
erythraernic compo nent in mixed myeloid leu kaem ias. A
. gle myelocyte shows norm al diffuse but wea k PA S


601 602


601. Another example of PAS staining in ALL. In this
case so me ce lls co ntain blo cks in additio n to coa rse
granules .

602. A group of Iymphob lasts from C-AL L. The cyto-

plasm shows frequent irregularities of staining and
occasional vacuoles. particularly in cytoplasmic buds.

603 . The same field as abo ve . co nsccutivelv stained

with the PAS reaction. Most of the lymphoblasts contain
coarse granules of PAS· positive material. often eo-
inciding with vacuo les or areas of lighter staining within
'h e cytop lasm and. especia lly. in cytop lasmic pro-
tru bcrances - as shown in 602. J ;(



6O-l. PAS reaction in a furt her case of C-A LL with 606

minima l positivity. Even such almo st entirely nega tive
b mphoblasts commonly show so me granul ar positivity
in a very occasional cell. Wea k reactions are per haps
commoner in T-cell cases, but this is not a verv useful
discriminatory feature since much variation exists.

5. Acid phosphatase reaction in the same case ,

wing little positivity. typically for C-A LL. There is a
eormally positive polymorph presen t.

Dual esterase reaction with weak scattered butyrate

te rase (BE) positivity in lymph ob lasts of C-ALL.
Tbls patte rn is usual in non-B non-T cases.


607. Immunocytochemical alkaline phosphatase-anti-

alkaline phosphatase (A PAAP) reaction for the presence
of terminal deoxynucleotide transferase (TdT) in the
nuclei of lymphoblasts from the bone marrow in a case
of C-ALL. Nuclear TdT is demonstrable in the primi-
tive cells of more than 90% of cases of ALL, including
C-A LL. null ALL. most pre -B ALL. and T-ALL. but
is absent from B-ALL. TdT positivity in acute Icukacmic
cells is not confined to ALL. however. being detectable
also in the blast ce lls of around 20% of acut e myeloid
leu kaemia (A ML) cases, most of them with no other
fea tu re to suggest mixed phenotypic expression .

608 and 609. Further examples of immunocytoc hemical

A PAA P rea ction s o n lympboblasts of C-A LL to
demonstra te surface antigens of discrimin ative value in
diffe re ntia l diagn osis. A posit ive reacti on is sho wn in
608 to the mon oclon al antibody (MA b) CD 10. and a
negative reaction in 609 to the myeloid MA b C D I3 .
Immunocytochemical reaction s for cell-surface
antigens are not illustr ated extensiv ely in relat ion to all
the varieties of leu kaemia becau se the appea ra nces do
not reve al impo rta nt differences in d istribution patte rns
of positivity . cells be ing simply positiv e o r nega tive .
what ever MA b is used. Th e interpretat ion of positi vity
patterns wit h different MAbs therefore depends esse n-
tially o n the cap tions. with C-A LL. for exa mple.
showing typically cells tbat arc TdT+. CDIO +. CD 19+
and CD3-. CDI3-.

610 11

610. Roman owsky stain o n bon e marrow cells from 612

an adult case of null ALL (TdT+, CD I9+, CD W-,
CDJ--, CD IJ--), sho wing, mor e clearly than in the
ea rlie r 597. th e patt ern of larger cell size. lower nuclear-
cytoplasmic ratio , mor e eas ily visible nucleo li and
occa sio nal inde ntation of nuclear outline that is classi- •
fiable under the FAB syste m as the L2 variant.
This variant is seen in adults more often than in
child ren. at least at th e time of diagnos is. and carries a
poo rer prog nosis than the more common Ll variant.
There is no co rrelation, however. betw een immun o-
logical phe notype and LI or L2 murphology, and cases
IDi tially classed as Ll may sho w an L2 picture at

6 11. SB stain o n the sa me mar row sample. showing a

itive myelocyte but negative reactions in the remain-
blast cells .

.1 Ano ther example of an AL L bone marrow aspirate

illustr ate the freq uent difficulty in applying the FA B
....ssification. The cells are generally large with
-SCrale nuclea r--eytoplasmic ratio , regular nw:lear
.""'le<;. some conspicuous nucleoli. and moderately
ilic cyto plasm with scatte red vacuoles. This
4'p<;arance conforms best to L3, but immun ophen o-
_ revealed a patt ern of null ALL as in the previous
and reclassif ication as 12 was thought appropriate.
6 13



613-4j17. Cytology and cytochemistry of aspirated hone

marrow from a case of pre-B ALL (TdT+ . CD IY+ .
C D W+. c1gM +) . Th e Rom anowsky stain in 613 shows
co nside rable variati on in ce ll size and irr egularit y of
cyto plasmic o utlines. with a scatte ring o f per ipher al
cytoplasmic fragment s. and variabl e nuclear-
cyto plas mic ra tio. Sever al cells show two or thr ee sma ll
nucleoli . Th e cytopl asm is gene rally basophilic. with a
suggestio n of vacuole form atio n. and in this area the
appea ra nces woul d be co nsiste nt with L2 o r L3.
T he Su -stained field (6 14) and the re ma ining cyto-
che mical stains (6 15-617) from the same prepar atio n.
howeve r. show much mo re u nifor m cyto logy with
smoo th nuclear chromatin. regular nuclear membranes.
poorly visible nucleoli. and no more th an a minimal rim
o f cytop lasm. ge nerally more co nsiste nt with an L1
classificatio n. Sudanoph ilic granulocyte precursors arc
present in 61~ . and a neut roph il metamyelocyte and
poly mo rp h with typical PA S po sjtivity in 615 . although
the blast cells in caetfl'Uf these s have the charac-
teristic rea ctions of lympho blasts.tnegan ve to S8 and
with coa rsely gran ular positivi ty to PAS. The acid
phosph at ase reaction in 616 shows scattered pos itivity
in a neut rophil stab ce ll and a polymorp h, but the blast
cells are essentially negative. The dual este rase stain in
617 Is also negative in the lymphoblas alt ho ugh a
chloroacc tate esterase (CE)-positivc neu trophil
myelocyte and a BE-positive mo nocyte are also prese nt
in this field.
6 18

618. Aci d pho sph atase reaction in a T-cc ll A LL. 620

ho wing the stro ng locali zed paranuclear po sitivity in
mos t Iympho blasts ch ara cteri stic o f thi s ALL vari an t.
uch posi tivity is much less co mmo nly found in C- A LL
an d null-cell ALL , and is absent in only a small
mino rity of cases ofT-A LL.
, •
' 19. Dua l esterase reactio n. sho wing localized BE
itivity in Iymphob lasts of T-ce ll A LL.

Scattered BE po sitivity in Iymph obl asts. with a

It'Dlk ncy 10 loca lization o n o nc side of the nucl eu s (less
. ing than in 619). T his pattern suggests aT-ce ll
ge , but the cells are in fact fro m a C-A LL case .

~O l
621 622

62 1~24 . T-ALL plus mark ed eosinophilia. (Curiously, 6'

eosinophilia if at least as common in ALL as in AML.)

621. Seven Iymphobl asts with seven eos ino phil or

eos inophil pr ecur sor s and a lat e no rmobl ast ; from the
~~ of a patient with T -ALL.

622. A lymph o blast , a lympbocyte aod nine path o-

logical eosi no phils; from the peripheral blood of the
same case of T-A LL with gross eos inophilia. Th e
eosinophil granules arc defective in num ber and smaller
in size than no rma l.

623. Acid phosphatase reaction o n the same marr ow

aspirate , showing scatte red gra nules of coarse positivity
in three eosinop hils and strong localized paran uclear
pos itivity in the T Iymphoblasls.

624. Du al este rase reaction o n the same aspir ate .

showing a single Cli-positive neutrophil metamyelocyte
but negatively rea cting eosino phil and blast ~e ll s .



615-629. Bon e marrow and blood smear preparation s 628

fro m an ad ult patient with B-ALL. Th e Heyl sta in in
615 shows a clump of marrow cells with mod er ate size,
visible nucleoli , so mewhat irregular nucle ar outlines .
high nuclea r--eytoplasmic rati o , and basop hilic but
inimal cytoplasm. difficult 10 classify o n the FA H
# (em. There were num erous smea r ce lls presen t. T he
B stain (626) showed the unu sual patte rn of coarsely
~an u l a r . glob ular suda no philia found in <2% of ALL

The B lymphoblasts in the peripheral blood from this

tie nt show a more typical L3 cytology than the
ITO W blasts. with a greate r amoun t of basophilic
qcoo(ated cytoplasm. as seen in 627. while the immuno-
. oche mical APAA P reactions sho w positivity to
(D19 in 628 and nega tivity to C DW in 629. The ce lls
TdT-and smIg+ . 629


63~2. Cytochemical react ions. respective ly rnyelo-

peroxid ase (630) , SIl (63 1), a nd du al este rase (632).
on a bone marrow asp irate from a pat ient variously
diagnosed on morphological and cytochemical grounds
by different haematologists as either AML or ALL.
The Romanowsky appeara nces were as shown by the
Heyl counterstain in 630. where peroxidase positivtty is
confined to a single neutrophil stab cell and the negative
blast cells show no features strongly suggestive of either
myeloid or lymphoid lines. The SB stain reveals discrete
sca ttered granula r positivity of monocytic character in
some 30% of the blast cells. with two of seven blasts
positive in 631. and the esterase reaction shows strong
CE positivity in otherwi se recognizable but infrequ ent
neutrophil granulocytes. like the myelocyte in 632. but
quite strong BE positivity in most of the blast cells.
resembling more the reaction of mono blasts than that
usually seen in Iymphoblasts. Th e PAS reaction . not
shown here . was negative .
Immunocytochemistry revealed a mixed phen otype.
with variable but overlapping surface expression of
antige ns reacting with CO W. C0 19. COB and CD1S.
indicating the probable existence of an acute leukaem ia
of mixed lineage. Cytogenetic studies were not available.
but this type of hybrid leukaemia has been found
part icularly in associatio n with a 4;11 translocation or
other abnormali ty involving a brea kpoint at I Jq23.

633 6.!

,~ ,. ,
, I


.. 4

,. •
•••••• • • • •

•• • • •.:,- •• • •
.-.. ....

•• • •• •
•• 0.
" • ,."
, ••
'. • ..- ..... ..
• .....
. •••• • e. • • e - •

• •·t •

633--635. A sequence of bone marrow tre phi ne biopsies 636
fro m a pati ent with C-A LL. und er going remission
ind uctio n. In 633. ta ken at the sta rt of therapy . the
specime n shows an overwhelming prep ond er ance of
primitive cells with large and leptochr o matic nuclei
often co ntaini ng visible nucleol i. There are only a few
cells of the ery thro id or later granulocyte series present.
wit h more pach ych ro matic nucl ei. A fte r two weeks of
01010xic combination chemot herapy. marrow aspirates
gave o nly a poorly ce llula r speci me n with too few cells
for differential assess ment , but the tr ep hine biopsy
sho wn in 634 revealed a severely hypopl astic picture
still containing a substa ntial pr opor tion of blast ce lls.
vith the co ntinuation of treatmen t . a furthe r trephin e
biopsy two weeks later reveal ed the emergence of a
remi ssio n picture with active pro lifera tion of normal
mopoietic cells of all myelo id lines, alt hough with
ervthroblasts predomina ting , as shown in 635.
Th ese fields illustra te again the impo rtant additional
-.formatio n to be o btained from mar ro w sect ions in
e le ukaemias, especially with regard to ove rall •
rity and the differe ntial compos ition of hypo-
. marrow du ring phases of att empte d re mission
. n.

C-....LL plus normoblastic hyperplasia . The field

some 20 blasts. 16 normobl asts and a reticulo-
........i!adlial ( RE) cell. Thi s type of mixed cytology is
paases of e merging remi ssio n o r relapse in



• •• ••

. - ••
637-639. Sections of bone marr ow tre phine biopsy
fro m the iliac cres t of an ad ult pa tient with sm Ig+ B-

ALL. moving from a period of chemo therapy-induced
remission to relapse. T he H&E-stained paraffin sectio n
show n in 637 illustrates the very mixed cell pop ulation
at this stage . with a megakaryocyte at the left and
numerous scatte red e rythroblasts and later gra nule-
cytes, but with blast cells having large leptochromatic
and freque nt ly nucleolated nuclei making up some
50% of the whole. The PAS stai n in 638 reveals
positively reacting neu trophi l polymorphs and earlier
granulocyte precu rsors . but the blast cells appear
negative. A furt her H& E stain , this time of a plasti c-
embedded thin section. again shows the mixed cytology.
with cells of different lineage readily distinguishable .
The B lymphoblasts. with their pale nuclear chromatin
and conspicuous nucleoli . co nstitute about 50% of the
pop ulation.


{HO. Three mature Iymphocytes , together with a baso- 642

phil, an eo sinophil . and two segmented neutrophil
pcl yr norphs.

{Ht. A hinucl eatcd Iymphocyte . Such ce lls ma y rarely

be see n in norm al blood and are not. as at on e time •
tho ught. suggest ive of an irr adiation effect.

~2 . A Iymph ocytc with more cytoplasm th an th ose

sho wn above , and with az uro phil gra nules . possibl y a
suppresso r T cell (Ty) . A neutrophil pol ymorph is also
prese nt.

&B . Vari at ion s in lyrnphocyte cyto logy in a norm al
buffy coat smear . On e of the five Iymphocytes has litt le
cyto plasm and is prob ably either a B or a T I-l cell; o ne
has some marginal hair-li ke processes . not infrequentl y
seen in nor mal lymphocytes and not to be confused •
with the appeara nce of ha iry cells (see 748-750 ); and
the remaini ng thr ee Iymphocytes have relatively large
amo unts of cytopl asm with a few scatte red granules.
and are probabl y T y cells. A persiste nt increase in ce lls
of this cyto logical cha racte r. with positivity to the pan-
T MAb CD? and the suppresso r subset MAh CD S. is
found in large gra nula r lymphoc ytosis and granular
lymp hocytic leuk aem ia.

644. Acid phosphat ase rea ction in buffy coat ce lls.

Two of the thr ee lymph ocytes showloc al ized coa rse dot
positivit y cha racte ristic of the TIJ. ce ll subset; the thir d •
is larger with more cytoplasm. and with a little scattered
pos itivity o nly. and is probabl y a T y cell.

(MS. Acid phosph atase rea ction in pe riphe ral blood

lyrnpho cytes: the proport ion of cells with the localize d
pos itlvity see n here in three Iymphocytc s closely
pa rallels the Tit cell proport ion by surface mark er
techniq ues . Thi s He ld also shows gra nular acid phos-
phatase positivit y in two neutrophils. a basophil and an


646. Dual esterase reaction. Localized T-ccll positivity

in o ne lymphocyte . probably a TJoL cell. and weak
granular BE positivit y in a seco nd. Thi s may be a null
cell or pe rhaps a cell of the 1'y subset. Th ere are four
CE-positive po lymor phs and a BE-reacting monocyte .

6-17. T wo oormally rea ctin g (CE-positivc) polymorphs.

a BE-positive mo nocyte and four Iymphocytcs - two
showing the localized dot-like Tu-subset type positivity.
o ne a sma ll. negative . probab le B cell. the o the r a
large r lymphocyte with ample negative cyto plasm.
probably of the T y subset.

MS. A mono cyt e and a polymorph, toget her with two

lymphocytes of the T J.L subset .

649-660. Reactive 'immunoblusts' and 'virocytes' arising
in various infective states. These activated lymphocy tes
are generally PAS, acid and alkalin e ph osphatase und
esterase negative.

649. A blood smea r from a pati ent with infectious

mon onucl eosis. Ap art from a ce ntral mon ocyte (with
phagocy tic vacuoles) and a seg mented neu trophi l. the
nucleat ed cells are all lyrnphocytes. Th e mito tic figure
(in te lophase) sho ws the increased cyto plasmic baso-
philia ofte n encounte red in the abnor mal Iymphocytes
of this disease . Mitoses in mo no nuclear cells are very
unco mmon in nor mal periphe ral blood. but are seen
much mo re ofte n in activated Iymphocytes.

650 and 651. Fur ther examples . from two different

patients. of the ab no rmal morphology of Iymphocytes
in infectious mono nucleosis. Th e nuclear chro matin in
the most abno rma l cells is still too coa rse and the
cytoplas m too abunda nt for real confusion to exist
be twee n these cells and Iymphohlasts.


652. A n immunoblast in the marrow of a pat ient with 654

ALL ie remission. but with a viral infection. Such cells
ust no t be confused with leuk aem ic blast cells.

653. A disrupted RE ce ll and a binucleated irnrnuno-

t fro m the same case.

Three stabs . two Iymphocytes and five immune-

. from an infective episode during remission
c.ergence in A ML. One of the immunoblasts shows
_ "flaming"of the cytoplasm (cf. 807-809)"

655. Two neutrophil s. two lymp hocytc s. a mo nocyte
and four immun oblasts (activa ted Iymphocytes) - from
the buffy coat of a leuk aemic pat ient in remissio n but
with a mycop lasma infect ion. T hese cells must be
distingu ished fro m ea rly mo nocytes o r leukaemic blast
ce lls.

656. PAS reaction . showing two stab cells. o ne

lyrnphocyte and eight immun o blasts. from the same
buffy coa t as in 655. T he immun oblasts are almost
ent irely PAS-nega tive .

657. Peroxidase reaction on a buffy coat from a

pat ient with hairy cell leukae mia (Hel) (onc hair y cell
at top right), showing 24% of immune reactive plasma
cells resulting fro m acute bacterial infection. The
ncutrophils show normal peroxidase positivity. while
the remaining cells are negati ve.


6: A vacuolated imrnunoblast and two stab cells with

io xic granules. mo re co nspicuous in one of them . fro m
blood of a child with a pseud o mon as infection. •
A binuclea ted immunoblast . showing a tendency
nuclear distortion and peripher al cytoplasm ic baso-
- ia. fro m a pat ient with a viral infection .

A mo no nuclear immunoblast with twisted nucleu s

Md fine azurophil stippling of cytoplasm. but with
philia at the periphe ry. from thc same case .

661-663. Sections ofbone marrow trephine biopsy from ",1_ ,- ... 66..'
a patient with diffu se marro w involvement with angio- (1 '7
im munoblustic lymphadenopathy (A IL) . . ,
A IL is generally regarded as a reactive process. although
with a high risk of transformation to a floridly neoplastic
non-Hodgkin :S lympho ma (NH L) . Mar row involve-
ment may be either focal or diff use . The low- and
higher-power views sho wn in 661 and 662 reveal the
cha racte ristic morphological picture , with a swirling
patte rn of branching endothel ium-lined blood vessels,
an interspers ed proli feratio n of activated lymp hocytes -
plasmacytoid immunobl asts and plasma cells. and a n
interstitial deposit of weakly staining amorphous eosino-
philic materi al. Th ere is often a compo ne nt of haem o-
lytic anaemia pr esen t in the se cases, and the marrow
may show areas of nor moblastic hyperplasia . as in 662.
wher e there is an island of normoblastic proliferation at .- ~
~ ,-

--. -.
;;- ,
the upper right corner. In the low-power view of a ,
reticulin stain in 663. the characteristic increase in , ",0
..... -...
reticulin fibres and their distribution in a swirling patt ern
around the pseudo-vessels is well sho wn.
-./,,.... .
1./-;--. ,
'. I

The periphe ral blood in AIL ofte n contains lyrnpho-

plasmacytoid immunoblasts and occasio nal mature t' ' -,
plasma cells. and there is commo nly a polyclonal '" I !
dysproteinaemia. , I


- '-- ,

~ I.. ..

66+-675. Protymphocytic leukaemia (PL L) . 666

6tH . PLL, Romanowsky stain: the cells show more

basophilic cyto plasm and more pro nounced nucleo li
tha n is the case with lymphocytcs. but have moderately
pachychromatic nuclei. unlike blast cells.

"-5 , PLL. Romanowsky stain. a T-ccll case : the large

size and moderately pachychromatic nuclear pattern .
'm occasional variab le nucleoli. contrast sharply with
two normal lymphocytes present .
PLL. Leishman stain on another case; this was of
8-«11 origin. The nuclear cleavage and invaginations
times seen in PLL cells are well shown in this case.


667. S8 on PLL: a nor ma lly reactin g eosinop hil with

prol ymphocytes of var iab le cyto logy b ut un iformly
negative rea ctions.

668. PLL. PAS reaction: the prolymphocytes are esse nti-

ally PAS-negat ive in this 'J-ccll case .

669. PAS reaction o n a R-cell PLL case . Th e pro-

Iymphocytes are again essentially negative hut one , more
immature . blast cell (top right ) shows a rim of granular
PAS positivity.


2 16
670 "I

\72 673

.' -,

670. P [ ~L: acid phosphatase reactio n. In this T-cell case
all the pro lymphocytes show strong localized reaction .

671. PLL: dual esterase on the same T-cell case as

illustrated in 665. 668 and 670. The reaction is almost

6 2. PLL: acid phosphatase reaction . Another T-cell

cas.e showi ng variable positivity. abo ut half the cells •
ving one or two coarse granules. as often seen in
re TI' cells. "

' -3 . Dual esterase reaction in the same case as 672;

t half the pro lymphocy tcs showed moderately
_ localized BE positivity.

Acid phosphatase reaction in a H-ccll PLL The 675

"S a normally positive polymorph and seven
,:::::~;.tes. with occasional granules of coarse
.. scattered mostly over the nucleus rather than
_ _Ird in me paranuclear zone.

terase o n the same case as in 674. Two

~ .......... polymo rphs and a BE-positive norm al T~
with the virtually negative B prol ympho-


677 676. A general view of a peripheral blood smear from

chronic lymphocytic leukaemia (Cl.L). The intact cells
arc nearly all lymphocytes. showing some variation in
morphology probabl y in parallel with maturit y. The
smea red disrupt ed cells are typically numerou s in this
disease . The spread nuclear remn ants arc sometimes
know n as 'G umprecht's shado ws' ,

677. Another example of the blood picture in C t. L.

The range ' of morphological variation is not great . but a
few precursors .: pro lymphocytes or lymphohlasts - can
be seen . and the smea red cells are again conspicuous.

2 1S

678. A high-power view of the perip heral blood io 680

Cl.L. Again an occasional precursor is visible.

679. PAS reaction io e LL. The Iyrnphocytes show a

pattern of positivity like that of normal lymphocytes.
but a higher proportion of cells shows positivity than in
a normal specimen.

Anotherexample of PAS reaction in Cl.L .



6H1. Acid phosphatase in C l.L. Most cells show

scatte red positivity without mar ked pa ranuclear con-

682. Dual esterase in e LL. Th e lymphocytes show

mostly 'negative reactions; a few have scatte red weak
BE pos itivity. Normal CE reaction in a polymorph and
BE positivity in a mo nocyte a rc shown.

683. Dual esterase in another case of e l l . showing an

occasional crcscc ntic positive reaction . similar to that
usually sccn in HCL.

68~ -

". (

, f r> ,
) /:)
-, --

tJ8.l . A, buffy coat preparation from the peri pheral 6S6

blood of a patient with B-CLL . stained for alkaline
phosphatase . showing the rare finding of positivity for
this enzyme in the neoplastic Iymphocytes. Four neut ro-
phil pol ymo rphs show fro m 0--2+ positivit y. and most
of the CLl cells show scattered positive granules.
Altho ugh this findin g is quit e uncommon in e l l. the
lympho id cells of NHL. especially the centrocytes and
ce ntroblasrs of follicular lymphomas. show it rat her •
more often.

.: ; . An immunocytochemical alkaline phos phatase -

u-alkaline phosphatase (A PA A P) prep ar ati on of B-
U l pe ripheral blood buffy coa t. showing a stro ng
IDemb rane reactio n for IgM .

A similar APAAP react ion o n peripher al blood

fro m a T-CLL. sho wing membrane positiv ity to
- T-<xII ~IAb C D3.

687 ~ . .:~.....
.. "'\ -r: -,
: . ' . '.
........ ",
" .' ,
.~. ':
.. .
;~ ~ :.~

. -"0- .. ~
.( ; -~":.

·1 '
:.,..;~ ~
- .',..
• .'

." , -,.'. :
• •
687-692. Trephine biopsy sections from various cases
of e L L to illustrate the common morphological patterns
of infiltration.

687. A very low-power view of a marrow with about

50% overall cellularit y and with a single focus of eLL
toward s the bottom left. The remain ing marrow cells
represent esse ntially normal haemopoietic tissue . This
type of focal involvement is commonly seen in the more
indolent stages of eLL.

688. Another very low-power view of a thin section of

marrow trephine biopsy from another pat ient with a
so mewhat denser nodular infiltr ation , partly distributed
randomly and partly of paratrabecular disposition. The
residual normal marrow tissue, with its looser structure
and recognizable scattered megakaryocytes , cont rasts
with the dense focus of eLL cells in the upper part of
the field and the similar paratrabecular focus at the
lower right corner.

689. A third exampl e of eLL infiltration in the bone

marrow , here with a more general diffuse distribution ,
as usually see n in more adva nced or rapidly prog ressive
disease. Residual normal marrow in this specimen was
virtually confined to the immediate paratrabecular
areas . as illustrated in this field.

690 r---,• o •.
• ·. I

•• ••
.' ..
. •.
......-,1..,. .• .


. .

•• l ··
'. ..
• -. • .- o

e • • ".
• ..J •
. • •

• 0

•. •'
... .. ..-
• ••
. . ...

.:.,. , ~
• • • • •o

• .:•
4 •


·...'..-. ..- ••• •.

•• •• o
o .
•• •
· .,

,, {.
••' .. o ••
..• ••
• ~ .
•• · . •..
0_ '

• •_ e,
• • .'

o • •
o •
690. A high-power view of bo ne marrow in late e L L 692
showing the diffu se nature of the infiltrate and its uni-
formity in bot h interstitia l and parat rabe cular areas,
and also the overwhelming predom inance of Iympho-
cytes and the pau city of resid ual no rma l haemopoietic
tissue . T his type of picture is usu ally found at advanced
sta ges of disease , commonly in association with marked
anaemia and thrombocytopenia.

691 and 692. Intermediate and high-power views, res-

pectively. of a bone mar row trephine biopsy section
fro m a patient with B-CLL and an accompan ying
auto- immune haemolytic anaemia. Ther e is some
_ ne ralized diffuse lymph oc ytic infiltrati on , but also a
local collectio n of lymph ocytes at the lower left of the
Id in 691, aga inst a cellular background of gross
ervthroblastlc hyperplasia. The higher magnification of
2 reveals more cytological detail, and shows the

:~~rp~h iC character of the interstitial cells, with
..res. various granulocyte stages, and a pre-
of erythroblasts, including numerous nudeo-
peoe ryt hro blasts. There is a suggestion of megalo-
change among the early erythroblasts.

693 69-1


693-697. Smears of a buffy coa t prepar at ion . made

fro m the periphe ral hloo d of a pat ieo t with B-CLL in
co urse of malignant progressio n to an immunoblastic
leukae mia/lympho ma . T his type of tr ansform ation -
Richt er's syndrome - develops as a terminal mani-
festation in abo ut 5% of patients with Cl. L. and is
usuall y characterized by recurrent lymphadenop athy . 6
fever . weight loss . and resistance to previou sly effective
chemot herapy. Immunoblasts arc usually pres ent in the
peripheral blood and heavil y infiltrate the marr ow
(see 69S-7(0) .
"There are three residual lyrnphocytes and a neu trophil
po lymo rph in 693. bu t the predom inant cell po pu lat ion
is made up of immunohla sts with basophilic cyto plasm
and so mewha t plasmacyto id nuclei .
A part from the immun o hJasts in the blood . there
may be other unu sual reactive eleme nts. like the rare
tissue mast cell appea ring in 694. whe re the re are also
seve ral neutroph ils. o ne of them polyseg memed. and a
basophil. as well as a Iymphocyte and seve ral immuno-
blas ts of vari ed size.
The S8 stain in 695 shows the pred om inat ing
imm unoblasts to be negative . the positive cells in this
field including two neutroph il stab ce lls. a baso phil to
the right , and two probah le monocytes toward s the top
left .
Th e PAS reacti on in 696 reve als three no rmally
posi tive neutrophil polymorp hs. a monocyte with " .. :
peripheral gra nular positivit y, th ree negative lymp ho-
cytes . and nine immuno blasts with either negative
react ions o r no mor e than a faint tinge of pos itivity.
The acid phosphatase stai n in 697 shows no rmal
positivity in polymorp hs, a stro nge r reaction in a mon o-
cyte . a few positive gran ules in most of the immuno-
blasts . and paranuclear do ts of posi tivity in two
T lymphocytes next to the monocyte .

• , 0

•,., ,
• '.J •., , •
· '.. o" •
• •
v-, .·,. . "
• • ••• •

,..(. ,
• .. •

...i- . ..........-.,-#-
• ~.I ....e' •
..., ,.

'. " .11 '.
..- . -.
, •,
' ' •
";1, . . ... .. . "
,et" .. ••••
-.- ,¥••


....0,.ro '';

,, •
...•,. ... : • • • 0

•• ••• • • '. ~I ,, ,
o '" ..
, o

• •• '
... •
• • .0
• •
• o•

1l!I~:IOO .Sections of bon e marrow tre ph ine biop sy 700

"I'luO>e ns ta ke n fro m pati ents with e L L und er goin g
"". .k>trmatio n to Richt er 's syndro me .
field in 698 is of a jun ction al area with resid ual
pbocytcs at the lower right half and large cells
r nuclei and more ample cyto plasm occupying

lbe upper left half.
... a low-po wer view of another transforming
_ ....... sample reveals 3 less nodula r and more diffuse
of infiltratio n with large immunoblastic cells .
. also evide nce in this field of acco mpa nying
.."....oIa!"'·ic react ion.
a highe r-power view of the same section as in
s details of the cytology, including a

;::~_ of the large cells with vesicular nucl ei and
co nspicuo us nucleoli amo ng a mixed po pu-
c idual small Cl.L lymphocytcs. occasional
_lIP:" and erythroblasts, capillary endot helial
scantv fibrob lasts. Several of the large ce lls
ed nuclei and bear a gene ral resemblance
"_C!'1O and it is not surprising that Richter' s
at one time thought to represent a
tic tra nsforma tio n of Cl.l.. but both
aDd cytochemistry of these cells in smears
:EqII<n1 de mo nstra tion that they exp ress mono-
un m uno globulin co nfirm that they are
_ _obIasts.
701 a:

701. Four lymph om a cells fro m the hlood of a patien t

with lo ngstanding N HL recently spreading to involve
bo ne marrow and bloo d. The ce lls resem ble neither
matur e lymphocytes nor leukaemic Iymphoblasts, but
have intermediate characteristics . O ne ce ll shows a
tendency to nuclear cleav ing. These ce lls are of 'centro-
eyrie' or 'follicular centre cell' (FeC) type .

702. Anot her exam ple of lymp homa cells in the blood :
this represents a leukaemic phase of a secondary
ce ntroblastic lympho ma. There are multiple small
nucle oli visible in the irregular nuclei and cytop lasmic
basophilia is moderate.

703. A third example of lymphoma cells in the blood -

in this case the cell s have deep cytoplasmic basophilia
and multiple nucleoli. and are of immunoblastic

.. .'

7()..a . A lympho ma ce ll from the specime n illus trated in 706

101, stained with the PAS reaction , to show coa rse
gra nules and two sma ll hlock s of positivity. A
po lymo rph reacts normally. Ce nt rocy tes of this kind
mo re o fte n show PAS positivity when circulating in the
jeukac mic phase tha n do simila r ce lls in lymph node
imp rints .

-; : . Stro ng PAS reaction. with rings of moderately

coa rse gra nules around the nuclei in circulating
.mpho ma cells , from the case illustrated in 702 . Fine
MKt mod e rately coarse granular positivity is present.

. Al most negative PAS reaction in the circulati ng

1IeOp1a..\ tic immunobJasts from the case illustrated in

707 and 70H . Rom anowsky stains on two fur ther

e xa mples of ce lls fro m the pe ripher al blood of a patient
in a lcuk aemic ph ase o f irnmuno blastic lymphom a . Th e
lar ge ce ll size . deep cyto plasmic basophilia , irregula r .
somewhat plasmacytoid. but generally primitive, nuclear
chro matin patte rn . the presen ce of large centrally
placed nucleoli in so me ce lls. and the variabi lity of
nuclear shape from uniforml y round to deeply indent ed .
all cha racte ristic featu res of ma lignant immu nob lasts .
a rc well sho wn .

709. Scattered BE posi tivity in three neoplastic irnmuno..

blasts. a normally BE-positive mon ocyte . a T lymph o-
cyte with localized ' do t' BE positlvity. a nd a CE-
positive neutrophil .
710 711


710. A sec tion of bo ne marrow tre phine biopsy fro m 712

a pa tient with a lar ge-cell di ffuse immunobl astic
lymp ho ma. showi ng extensive dif fuse infiltratio n o f the
marrow pa re nchyma with mos tly large immu noblastic
cells. often having co nsp icuous cent rally placed single
nucleo li. The remaining cells with darker nuclea r
ch ro matin and less visible cytoplasm arc residu al
hae mopo ietic e leme nts of erythroid and granulocytic
111. A nother higher -power view of a tr eph ine biopsy
o f ho ne marrow from a pat ient with a lar ge-cell
lymphoma . thi s time aga in showi ng diffuse infilt ra tion
but with cc nlro blasts rath er th an irnmun obl ust s. These
ce lls ge ne rally show more twisted and indented nuclear
ou tlines. and their nucleoli arc sma ller and more ofte n
multiple and near the nuclear membra ne ; these cyto-
logica l cha rac teristics arc those of ce ntroblasts or large-
cseaved follicular centre ce lls.

"'12. A high-po wer view of a section of marrow trephine

y with centro blastic lymphomatous infiltration.
lar ge. if so mewha t va riable. cell size and th e
~ Ia; nuclea r o ut lines. which give rise to the alter-
o e na me of ' large-cleaved cell". arc well shown .


7]3-715. Sections of bone marrow trephine biopsies

from another patient with a diffuse follicular ce ntre cell
or centrocytic lymphoma. showing response to treat-
ment with an anti-lymphoid MAb. The respective low-
and higher-power views of the pre-treatment bio psy in
713 and 714 illustrate the extensive nature of the
marrow infiltration and the cytology of che cells as
predominantly non-cleaved centrocytes . In 715. the
fresh biopsy taken afte r a sho rt course of MA b therapy
sho ws an entirely change d picture , with retu rn to the
no rma l highly pleomorphic cell mixture of norm al
haem opoietic tissue , including erythroblast s, granulo-
cytes of all stages, and mcgakaryocytes, the only
apparent abnormality being a rea ctive increase in
Trephine biopsies are essential in the assessment of
respo nse to therapy when marrow infiltration exists,
since they allow the degree of residual tumou r-cell
persistence to be measured with much greater accuracy
than is possible in aspiration biopsies.
• • ,
•• • •
•• • • # •

• .t-.
~ •


716 117

7 16-7 18 . Blood smears at stages during the pr ogression 718

of a lymphoblastic lymphoma , convoluted (T-cell) typ e,
10 a picture virtually indistinguishable [rom ALL.

716. A lymphocyte and two lymphoma cells at a stage

when involvement of the bloo d first occurred . with
small numbers- of cells.

717. The lymphomatous lymphohlasts now predominate

and the total leucocyte co unt has risen above normal.
In this field. as in the precedin g one , the twisted and
co nvoluted nuclear o utlines of the T lymphoblasts are

718. A fully leuka emic picture. The T lymphohlasts at

this stage tend to lose their previousl y conspicuous
nuclear convolution. and come to resemble the lympho-
blasts of primary, de no vo, T-A LL.

7 19 ....- ------------- 7



719. A sec tion of bone marrow tr eph ine biopsy from a

pati ent with co nvoluted T-celI lymphom a . prior to
leukaemic progression. Th ere is a scatt ered diffuse
infiltra te with lar ge ce lls. ofte n showing mark edl y
twisted and co nvoluted nuclea r outlines , but with
perhaps 30% of the whole cell populati on in this field
composed of residu al no rmal haemopo iet ic tissue .

720. T he cells from the peripheral blood . du ring and

after the emergence of the leu kaemic phase of con-
voluted T -cell lymph oma . sho w coarse PAS positivity
of the lymp hoblastic patte rn.

721. Acid phosphatase reac tion sho ws strong localized

pcsitivity in most cells.

722. Dual esterase reaction in the same cells shows

negativity to BE but a few scatte red CE gra nules o nly.
in the T lymphoblasts .

723-725 . Circulating lymphoma cells from a case of 725

[ollicular lymphoma (mixed small and large Fee tumour ,
centro blastictcentrocy tic typ e],

723. Romanowsky sta in: a monocyte . two neu tro phils

and seve n lymphoid cells of vari able cytology. includ ing
a nucleolatcd ccntroblast.

724. PAS reacti on : variable positivit y in ce ntroblasts

and ccm rocy tes.

725. Alk alin e phosph atase reacti on showing positivity

in lympho ma cells - a most unu sual finding in the
pe riphe ral blood . Th e seven neutrophils prese nt show
positivity ranging from + to + + +.

726 i

726-733 . Cytological ana cytochemical pr eparations

from the peripheral blood buffy coat of a patient with
circulating centroblostic lym phoma cells.

726 and 727. Romanowsky stains of ccntroblasts in the

buffy coa t , accompa nied in 727 by two Iymphocytes and
two neutrophil polymorphs. The distinctive cytological
feat ures o f centroblasts as see n in smea r preparations
are well shown ; large size , indented or cleaved nuclear
outlines. moder ately dense nuclear chromatin, o nc to
several, generally small, nucleoli, tending to be disposed
at the nuclear membrane. grey rather than deeply
basop hilic cytoplasm. and a nuclear-eytoplasmi c ratio
ranging from high to medium.

728. S8 stain of these cells shows them to be negative .

The two heavily sudanophilic cells in this field are
neutrophil polymorphs, and the two with discrete
scattered granules o f positi vity and co nspicuo us vacu-
o lation are monocytes. The negative cell to the right 01
the upper monocyte is prob ably a Iymphocyte , but all
the remaining cells are centrobl asts.



729. Acid phosphatase reaction on the same preparation 732

revealsthat most cent ro blasts have no more tha n a few
scatte red granules of positivity, without any paranuclear
o r other parti cular localization . T he trio of cells at the
top of this field are . fro m left to right , a moderately
stro ngly positive monocyte. a T Iymph ocytc with a
collection of paranucl ear gra nules. and a neu trophil
polymorph with the usual scattering of positive granules.
The rem aining cells are all centroblasts.
730 and 731. PAS sta ins for glycogeo on these cells
show their reactions to be generally less stro ng than
those see n in the ea rlier example of centroblastic PAS
reaction (70S), here ranging from fine to moder ately
coarse granular positivity. There is a nor mally reacting
polymo rp h and a negative Iymph ocyte in 730.
732 and 733. T wo fields fro m a du al ester ase sta in on
the same huffy coa t. Th e first (732) shows three CE-
positive neutro phil pol ymorphs and a T Iymph ocyte
with a do t of localized paranuclear react ion. but the
remaining centroblasts are esse ntially negative with no
more tha n a faint non -specific dustin g of mixed reactio n
prod uct. In 733 the re are six negativel y reactin g centra-
blasts. six positive neutrophil s, a negati ve late normo-
blast. and , above it , a metamyelocyte with localized CE
posi tivity to one side of the nucleus.


734-736. Sections of bone marrow trephine biopsies,

from patients Wilh nodular [ollicular centre cell or
cenuocytic-centrobtostic lymph oma and marrow inii itra-

734 and 735. Low- and higher-power views, respectively.

of a lymphom atous nodu le in the bo ne marrow
pare nchyma . Th e nodu le occ upies most of the field in
7~ . The mixed cytology. with the larger centroblasts
and smaller and more pachychro matic cem rocytes. is
visible in 734. but can be sce n much mor e clearl y at the
highe r magnification of 735, wher e the mo re lepto-
chro matic. vesicular. and ofte n cleaved nuclei of the
centroblasts, with their conspicuous perip herally dis-
posed nucleoli. differ clearly from the denser and
smalle r nuclei of the centrocytes. Occas ional no rmal
marr ow elements are recognizabl e.

736 . A high-power view of a bone marrow treph ine

biop sy section fro m another patien t with a more
mark edly centrocytic follicular lymp homa. A minority
of ce ntroblasts can be see n, bu t with a clear pre-
dominance of ccntrocytcs , with thc prese nce , in somc
areas, of more mature cells with plasmacy toid features.
including ecce ntric nuclei with cloc k-face chromatin
marki ngs.
This case illustrates the close relationship be tween
ce nt rocytic-ce ntroblastic lympho mas and Iympho-
plasmacyto id lymphom as. alt ho ugh the former arc
mor e ofte n nod ular and the latter di ffuse .
737 ... ...


· ' ...
I . .
• •
•• •
• ••

• '.

,. -. ••
. \.

• •• • •

737-739. Sections of bone marrow trephine biopsies 739

from patients with lymphocytic and Iymphocytic-
centrocy ttc lymphohltlSana marrow mjJlrratlOn.

737 and 73S. Respectively low- and highe r-power views

of a mixed nodul ar 3,Jld lymp hocytic infiltrate . a
bo rde r 01 less dcllsCiy mhltrated marrow rissue
rem aini ng in the uppe r third of the field in 7 ~7 . which .
is o the rwise lar gely occup ied hy a nodular foc us of
lymp ho ma . In thts field. and mor e clea rly in 738. the I

namre of !b e infilt rating lymphom a cells is apparentas

ma ture sma ll lymphoc ytcs. morphologically mdlstlO·

~is hab le from those found infiltrat ing the marrow In

739. Th is pa rat rabecu lar nodule of lympho mato us

deposit sho ws ra ther mor e pleom orphic cytology, with
two o r three cosi nop bils. a few elongated vascula r
e ndo thelia! ce lls, and an occasional late no rmoblast,
but chiefly a lymp homa "ce ll po pulatio n of mixed
lymphoc ytcs (with sma ll dense nuclei), cen trocy tes
(with mo re open nuclear chro matin and freq uent
inde ntatio n or cleavage of their nuclear outlines), and
lympho plasmacyto id cells (with ecce ntric nuclei having
cloc k-face blocks of chro matin) .
Th is case again illustrates the close interrelatio nship
bet wee n the vario us 'lo w-grade' NHLs.

~I l

740. A circul atin g lymph om a cell from a case of

lymphoblastic lymph om a , B-cell type , with only
occasional lymphoma cells in the peripheral blood. The
field also co ntains two Iymphocytes and a segmented

741. Marrow infiltra tion in the same case : the

lympho ma cells show a more lymphoblastic appearance,
with higher nuclear-cyto plasmic ratio . tha n those in the
peri pheral blood .

742 and 743. Low- and higher-power views fro m a

sect ion of bo ne marrow tre phine biopsy . taken fro m a
patie nt with a B-Iymph oblastic lymphom a of Burk itt
cell type . bo th showing almost complete replacem ent of
the normal marrow elements by the lymphomatous infil-
trate. The lymph oblasts are lar ge and pale-stainin g.
with very lept ochrom atic nuclei mostly conta ining
several co nsp icuo us small nucleoli. In bo th fields the re
are to be seen macrophages containin g pha gocytosed
ce llular materi al , similar to tho se giving the classical
'starry sky' appearance in histological sections of
Burkitt 's lympho ma proper.


744-747. The first two figures are of Ro mano wsky 746

stains and the latt er two of SB and PAS preparations.
respec tively, from the bon e mar row of a child with
Bur kitt's lymph om a. An appea rance comp arable with
lympho matous or acute leu kaemic invasion , is. seen .
This type of exte nsive mar row repl acemen t by tumour
is unus ua l in Burkitt's lymphom a.
T he mo rphology of the cells is unlik e that of typical
leukaemic lymphoblasts; the nuclear chro mat in is
coarser and more stranded , and most cells are PAS-
nega tive. T he vacuola tion, charac te ristic of the tum our
cells in this disease , is well shown, but similar vacuoles
may so met imes be see n in acute leuk aem ias andthis
feature is no t pathognomonic.



7 ~ 8-76 1. Preparations from typical H e L - leukuernic

reticulo -endo theliosis (L R E). ln all these smears mono-
cytes are conspicuous by their absence.

7..S . HCL. Leishm an stain of peripheral blood . Two

neu trophils. a normal lyrnphocyte and four hairy cells
(HC s). showing the typical eccentric nucle us with
mode rate ly coarse chromatin . the pa le slate-blue cyto-
plasm. and the fine surface pro jections o r hai rs. A rod-
shaped nega tively staining inclusion in o ne of the HCs
may represent a ribosom e-lamella (R-L) complex.

7~ 9 . HCL. Leishrnan stain of peripheral blood from

ano the r case . A group of six HCs togethe r with one
lymp hocyte a nd two segmen ted ncut roph ils. T he
nuclear staining of the HCs sho ws the sponge-like or
checke rboa rd pa ttern often see n .

750. HeL. Leishma n sta in of ano the r example. with an

He showing the conspicuo us cyto plasmic vacuo lation
which is often a fea ture of these ce lls. together with a
nor mal lvmp hocytc. a neutrophil polymor ph and an
irnmun ocyte o r plasm a ce ll. fro m a pat ient with HCL
and a virus infection .

751 754

751. HCL. Lcishman stain of a bone marrow smea r. 755

showing a cluster of HCs with the azurophilic inclusions
so metimes present and seen. es pecially. after sho rt-
te rm culture .

752. Co nsec utive PAS stain o n the same field as in 751 .

The tinge and fine granu lar pos itivity are typical of
HC, .

753 and 754. HC, in peripheral blood before and after

a pe riod of 48 hou rs in culture . sho wing increase in
cyto plasmic granularity and the occurrence of mitos is.

755. A further exa mple of HC, afte r 48 hours in

culture. showing phagocytosis of red cells and bacteria.

756. HCL. SB reaction, showing normal positivity in

two neutr ophils, a negative Iymphocyte and two nega-
tive HCs.

757. H CL. PA S reactio n, showing typ ical diffuse and

granular positivity in HCs. A normally reacting neut ro-
phil and a negative Iymph ocyte co mplete the field. •
75H . HCL. Acid phosp hatase reactio n. Five poly-
morphs, four probable TI-' Iymphocytes and two HCs,
all showing typical positivity. That in the HCs is tartrate-

759 ;

759. A further example of acid phosphatase staining in , 761

HCL , showing a neutrophil, two TI' cells and five HCs,
several containing rod -like structures with positive
staining, possibly representin g R-L complexes. Such
inclusions are seen more commonly after acid phos-
phatase staining than in Rom anowsky preparations.

760. Dual esterase reaction in HCL. Two CE- positive

nc ut ro phils. a TJ.L ce ll with localized BE po sitivity.
and an He with gra nular positivit y tending to sho w a
cresccntic localization at eithe r side of the nucleu s.

76 1. Alk aline phosphatase reaction in neutroph ils in

HCL. Th e score is almos t invari abl y high as in this
case whe re most neutrophils sho w + + + to + + + +
pos itivity.

--- - - - -- -

762-776 . An example of atyp ical HCL (HC L variant),

with high leucocytosis, presence of monocytes. normal
LA P score and chronic course.

762. Rom anowsky stain. showing more central nuclei .

mo re co nspicuo us nucleoli. and coarse r cyto plasmic
projections than usual in HCs.

763. SB sta in. sho wing thr ee negative HCs. two posi-
tive neutrophil s and two monocytes with var iable
scatte red positiv e granu les.

764. PAS sta in showing the usual HC pattern - quit e

unlike that of. for exa mple. e l l o r PL L.

765. Acid phosphatase sho wing a mo re ma rkedly po lar

d istribu tion than in typica l HCL.

766. Dual este rase in atypical HCL. Two CE-posi tive

ncutrc phils. o ne heavily vacuolated and with only a few
positive gra nules . two BE-positive vacuolated mon o-
cytes and three nucleolated HCs. one showing polar
BE positivity .
767 •

-.....••....._.......- ..
# ~

• •
- , -,
s. ."

t •
' .,.
..- .'.•
• iI •
• a ""

767-772 . Various sections of hone marrow trephin e 769

biopsies from patients with Hef. ami marrow infiltration.
Marrow involvem ent in HC L may he irregular and
patchy, but where it occurs the lie distribut ion is diffu se
rather than foc al. •
, •
767. A low-power view of a bo ne marrow sec tio n
heavily infiltrated with B eL. Th e overall ccllular ity is
• •
around 70'Yo with substantial redu ction in the proport ion •
of fat spaces; the cell populati on ca n be seen to have
two main compon ent s. HCs with relatively light-staining
nuclei and ampl e cytoplasm . and erythroblasts with
smalle r size and den sely stained nuclei. Onc o r two
megakaryocytcs can be discerne d , but there is a notable
abse nce of granulocytcs. in keeping with the mark ed
pe riphe ral leucope nia almost invariably found in I-I C L.

; A Giem sa-st ain ed section fro m the sam e biopsy as

in 767. demonstrating more striking ly the wide spacing
of HC nuclei and the co nde nsat ion o f peripheral cyto-

mic mate rial. including hairy proce sses. at th e cell
te rfaces, prod ucing the so-ca lled ' ha lo' effect.

- 9. PAS reaction on a thin sectio n from the sa me

pr pa ra tion as in 767 and 768. sho wing cyto plas mic
itivity in the HCs. with a re cognizably mixed diffuse
gra nular patte rn closely rese mbling that sec n in •
.-ear prepa rations (cf. 757) . There is a positive mast
towards the to p centre .


770 and 771. T hick and thin sectio ns. respective ly,
from par affin- a nd plastic-em bedded bone ma rro w
tre phin e biopsy prep ar at ion s taken from a pati en t with
Be l d uring th e course o f remi ssion-induction treat-
ment with alpha-in terferon . In bot h sect ions, cha rac-
te ristic HCs are now in a minority, thoug h readily
recog nizable; no rma l haemopoietic mar row elements
predomina te, with erythroblasts most numerous bu t
with megakar yocytes and eve n occas ional gran ulocytcs
present. In 770 a tissue mast cell is see n at the lower
right and a plasma ce ll at the upper left ncar a mitotic
figure . In th is pai r of slides the thin section offers little
additional info rma tio n .

772. A further example of a thin section from a

marrow biopsy in HCL . this time from a patient with a
co nco mita nt toxoplasma infection. giving rise to a
marked immunoblastic reaction with numerous trans-
formed lyrnphocytes in the pe riphe ral blood. and both
lymph oplasrnacytoid and plasma cells in the bone
marrow . In the field shown here these reactive immune
cells predominate. with smaller nu mbe rs 'of scatte red
HCs recognizable by thei r paler nuclei and larger size.

, ,

•• 774

• •
• ~
• •

• , •
• •
77~7 75 . Sections ofbon e marrow trephine biopsy fro m 775
patients with p eriph eral Tscell lymp ho m a and marrow
infiltration . Th is type of lymphoma is m orphologically
variable, composed of T cells ranging f rom sm all m ature
/ymphocy tes to large im munoblasts, and classifiable as
of either low or high-grade severity. They show a high
incidence of bone marrow involveme nt, mostly diffuse
but occasionally with a randomly scattered foca l distri-
bution. The histological structure of infiltrates mimics
that of the parent lymphoma , with an inflammatory
element and prominent vascularity, difficult to distin-
guish f rom pleomo rphic Hodgkin 's disease or various
reactive stales such as A I L , connective tissue diseases.
or im m une deficiency syndrom es. including A IDS.

n 3. A very low-power view of a large focal infiltrate .

• 'ith relative ly norm al mar row above the upper trabe-
cular process. To the right. the margin of the focus is
DOt sharp but me rges into a zone of diffuse infiltration.

, 4. A high-power field fro m a seco nd case of poly-

IDOrp hic peripheral T-cell lymp ho ma , showing diffuse
. tration with large lymphoma ce lls. so metimes
. ucleated and superficially rese mbli ng Reed-
ern berg ce lls. polymorphs with de nse twisted nuclei.
aod elonga ted vascula r endothe lial cells. ep ithelioid
. -te s and occas ional fibrob lasts.

A PAS stai n o n the same biopsy material as in 774

out the PAS-pos itive vascular endo thelial ce lls
scattered epithelioid histiocytes.
776 •

776-7 88. Circulating abnormal neap/astir T cells from

cases of Sezary 's syndrome (SS) . This disorder is a
variant of mycosis f ungoides (M F) with leukaemic
involvement of blood and bone marrow , as well as the
sk in infiltration and tile subcutaneous fo ci of rumour
cells and reactive elements kno wn as Pautrier's micro-
abscesses, fo und in AI F. The T cells of ss are usually
CD3+. CD-I+. and have helper f unction , although
occasionally CD3+. CD8+. suppressor ma rkers and
fu nction may be fo und.

776. Rom anowsky stain: the conspicuous nuclear

con volutions show n on electron microscopy (777) of
the same ce lls arc barely detecta ble as nuclear creasing
by light microsco py.

777. El\1prepa ration from the same case The circulating

Sezarv cells show a 'ce reb rifo rm' nuclea r section, with
striking invaginntions. Glycogen gra nules are con -
spicuous in the cytoplasm,

778. PAS reaction: most cells in this case are negative,

but occasionally fine o r moderat ely coarse gra nular
positivity is present. Nucleoli are well show n in some
of the neoplastic cells, as is the creased or cleft appear-
ance of some nuclei . T he PAS reaction in Seza ry ce lls
is quite variable, some cases having much mo re mar ked
gra nular positivity.

2 ~8
77 9

779. Rom anowsky sta in o n a bu ffy coat prepar ation 78 1

from pe riphe ral bloo d of anot her patien t with SS.
showing six Scza ry cells with typical high nucle ar-
cytoplasmic rati o and deepl y ind ent ed o r clef t nuclei.
more co nsp icuo us tha n in th e previou s case illustrat ed
in 776 . One of these cells shows marked cyto plasmic
baso philia. a fea ture present in only a small mino rity o f
Sczary cells. The field in 779 also conta ins five normal
lymphocytcs. an eosi no phil po lymo rph and 1\\'0
monocytcs .

7g0. 5 B stain on the sa me preparation as in 779.

revealing sudanoph ilia in only one cell. an eosinophi l.
while the rem aining mixture o f the larger Sezary ce lls
and smaller Iymphocytcs sho ws negativ e reactio ns.
Agai n. o nc of the Sczary cells shows de ep cytoplasmic
baso philia.

1. PAS reaction o n the same buffy coat preparation

sho ws coarse blocks and/o r variable gra nules of PAS ·
positive glycogen in most of the Sezary cells. togeth er
with the usual dense positivit y in a neut roph il polymorph
and a less stro ng . finely gra nular and diffuse . reac tio n
in a myelocyte and a stab cell. Th e rem aining lympho-
. tes in this field a rc negat ive .


782 . Rom anowsky sta in on a buffy coat prep ar ati on

from another patient with SS, showing a furth er exa mple
o f the ran ge of cytological appearances in th is diso rder .
Exce pt for th e single neu troph il po lymo rp h at the left ,
all the cells in this field are neop lastic Sezary cells.
mostly with mor e basophilic cytoplasm than in the
previous illustr atio ns. but again with a gene rally high
nuclear-cytopl asmi c ra tio . The ce ntral ce ll has inde n-
tat ion s of the nuclear o utline and th e cell imm ed iately
below it has a dar k line of nucl ear folding across the
upper pa rt of the nucleus.
783 . The PAS reaction in this case agai n shows strong
posltivity in the Sezary cells. with coarse granules and
blocks in many of the m. There are four no rmally
positive ne utrophil polymo rp hs and part of a fifth, and
also a nega tive mon ocyte with folded cyto plasmic edge
at bottom left and a wea kly pos itive myelocyte at the
top right.
784 . Acid phosphatase reaction in this case sho ws
moderately stro ng positivity in two monocytes and a
few scattered granules in th e polymor ph s, while the ~ .
predominating Sezary cells most ly show weak granular
reactions wit h only occas iona lly the pa ra nuclea r dis-
position characterist ic of ma ny T cells . Thi s wea k
sca ttered granule pattern witho ut par an uclear do ts is
the picture most often encountered in SS.
785. This dual esterase stain in the sa me case sho ws
no rm al reac tio ns in monocytes. neu tro phil s and an
eosinophil, but nega tive reaction s in the Seza ry cells.
, .


786. Anothe r variant of ma ligna nt ce ll cytology in SS. 788

In this field , from a Rom an owsky-stain ed buffy coat
smear. all th e ce lls, apa rt from a single stab cell above
the ce ntre. are e ither no rma l Iymphocytcs or Sczary.
The co ntras t in density of nuclear chromatin is striking,
and in this case the deep infolding of the nuclear
membrane can be better envisaged than in 782. perhaps
because the blood sample was kept in anticoagulant for
some hours before the buffy coat preparation was
made . a procedure which tends to exaggerate nuclear
membra ne irregularities .

787. A high-power view of two Seza ry cells from a

fresh peripher al bloo d smear, show ing well-ma rked
nuclear infoldin g but also the ex iste nce of multiple
ma ll nucleoli, especially in th e lower cell. a feature
which is no t usually cons picuous in Seza ry cells .

88. A lower-power view of the same peripheral blood

sample as in 787. showi ng the usual finding in SS of a
positive cell-s u rface me mbrane reaction in the neo-
plastic T cells to an immu nocytochemical A PAAP stain
with the MAh CD4.

7H9 7

789. A nest of mature plasma cells from the marrow o f

a patient with cat-scratch disease, showing some reactive


plasmacytosis. Th e vacuolation and tendency to buddin g
and fragmentation o f the cytoplas m may ind icate en -
hanced activity. Th er e is a central macroph age nucleu s
with filmy ill-defined surro unding cytoplasm. a U-
sha ped residual me gakary ocyte nucleu s with scattere d
platelets bel ow it at th e lower left , and a fragmen t
co ntai ning free iron at th e bo rde r o f th e plasma cell to
the uppe r left o f th e gro up.

790 . A nothe r exa mple o f reactive mature plas ma cells

in the bo ne mar row of a patient with rheumatoid
art hr itis . wher e po lyclona l plasm acytosis is co mmo nly
associated with th e usual hype rgammaglobul inaem ia .

79 1. A low-powe r view of a sec tion of bone ma rro w

trephine biopsy from an elde rly pat ient with a chro nic
infective process and reactive plasmacytosis. Overall
cellularity is low. with man y fat spaces. b ut among the
residual hae mopoietic ma rro w cells sca ttered plasma
cells with their ecce ntric nuclei are freque ntly to be
see n.


• •
794 795

. .,.. ~. 0 ,
. ..• ..

.., .,

.. .,.,.. \

792-797 . A series of paired fields from consecutively 796

stained bo ne marrow sm t'ar prep arations to demonstrate
the presence of free stainable iron in plasma cells. In
each case the first illustration of the pair (792, 794 and
796) shows a Romano wsky -stained field, and the second
(793, 795 and 797) the same field after decolorization
and restaining by the Prussian blue reaction. Th e presence
of free iron in plasma cells may be a result of transfer of
this mat erial from macrophages (two macrophage nuclei
afe present in 794 and 795) via cytoplasm ic bridges.
rather than a consequence of direct phagocytic action .
but it appears 10 be most com monly associated with
alcoholism . although it may also be seen in infective
hep atitis, as in tire present case. The iron has been sh own
bv ultrastructural stud ies to be located in m em brane-
bo und lysosomal vesicles and not in mitochondria. thus
diffe ring fr om the erythroblastic accumulations in 97
sideroblustic anaemia.

.. . '

798, A group of plasma cells with mo re immature

features than those in 789 and 790, from a pati ent with
mult iple myel om a .

799 . Variabilit y in the size . maturity and gene ra l stain-

ing characteristics of plasma cells, in the marrow of a
patient with multiple myelom a .

800 . Bone marrow trephin e biopsy in myeloma . show-

ing the predominance of neopl astic plasm a cells of
va ria ble size and nuclear den sity. with co nside rab le
cyto plasmic fragmentat ion . and' wit h eros ion and
cellular infiltrati on of the tr abecular bo ne at o ne poi nt.



SOl. Circulati ng plas ma ce lls from a case of plasm a cell 8(1.l

leukae mia with predomina ntly mat ure non -nucleolatcd
cells. Note absence ofrouleaux formation .

802. Acid phosphatase reaction in the same case: there

is strong localized positivity, but considerably less
inte nse th an usually scen in typical myelom a cells of
bone marrow (see 825 and 826).

803. Dual esterase reaction : the same case shows only

vcry weak BE positivity in the plasma cells in co m-
pa riso n with th e stro nger reaction for BE or CE or both
enzymes common in typical myelo ma cells of bone
marrow (see 827).

80·1. A re ma rkab le exa mple of inte rnuclear brid ging in

a case of myelo ma . Most myeloma cells had two o r
three linked nuclei.


865. Plasma cells in myeloma. showing a remarkable

tendency to cytoplasmic disruption.

806. A multinucleated plasma cell in myeloma.

807 and 808. The develop ment of flaming cells. The

smooth eosinophil component which makes up the
'flaming' character in certain plasma cells is usually first
seen at the cell periphery. It OrIC'" contrasts sharply
with intense basophilia in the (emaining cytoplasm',


8 11

809. A pai r o f fully de veloped flaming cells. 8 12

HIO and 811. Th e development o f thcsaurocytcs -Iar gc

plasma cells with d ark . so mewha t pycnoti c nuclei and
extensive fibrillary cytoplasm. some times having the
appeara nce of division into compa rtments . These
'storage cells' usually have 'flaming' characteristics in
their rema ining cyto plasm.

812 and 813. Large nuclea r inclusions. PAS-positive .

occasio nally sce n in plasma cells in myeloma (a nd in
o ther co nditions). The ir significance is un known ; they
are less likely tha n cyto plasm ic inclusions to represent
secre tio n or synt hesis prod ucts .



..- ,-

814 a nd 815. Plasm a cells in myelom a , sho wing an

accumu lation of sphe rica l inclu sion s, bluish in co lour .
pro babl y represe nting an abnormal concent ration of
immunog lob ulin precurso r. Ce lls may become full of
the se bod ies (called Russell bo dies by some authorit ies)
and arc then so me times referred to as Mo tt cells .

816 and 817. An other type of sphe rical inclusion .

eosi no phil-sta ining and PAS-positive , found mu ch less
often in smears of plasm a cells. Thi s type of inclusion is
also given th e nam e Ru ssell body. perhap s with more
historic al justifica tion.

818 . A n un usua l form of locul ar degene ration in the

cyto plasm o f a pla sma cell from myel om a.

819. Azurop hilic rod s (rese mbling Aucr rods, but

negative to SR . pe roxidas e and PA S sta ining) are not
rare in plasma cells, but in th is unusual myelom atous
case the majority of the plasm a cells co nta ined many
such rods .

" -

H20 11


820. Three myeloma cells, two with 'flaming' ce ll H23

feat ur es a nd th e third with mu ltipl e small vacuoles
ofte n co nta ining azurophilic materia l. po ssibly irregu lar
deposits of defec tive paraprotein within autop hagic

821 and 822 . An even mor e unu su al case of myeloma .

whe re nearl y all the plasma cells we re d istor ted by lar ge
crystalline inclusion s . having so me resem blan ce to
Charcot-Leyden crystals . and presumably represen ting
the prod uct of diso rde re d synthe tic ac tivity in the ce lls.
T he c~ 1I cytoplasm sho wed wea k PA S positivity. bu t
(he inclu sions were negat ive (822) .

823 and 824. PAS reac tions in plasma cells fro m case s
of mu ltiple myelom a. Reaction s ra nge fro m nega tive to
we akly positive . with occa siona l gran ules against a H2~
we a ke r diffu se ba ckground of faint positive tinge . T he
sphe rical bluish incl usions illustrated in 814 a nd 815
a re PAS-negat ive .


825. The o ne striking cytoche mical characterist ic of

plasma ce lls. no rmal and pat hologi ca l. is their co n-
sistently strong ad d phosp hatase reaction . illustrated
in th is general view of a bone marrow smea r from a
P..uie nr with myelo ma .

826. A seco nd exam ple of acid phosphatase reacti on in

myelom a cells . T he mo re sharply parti culate deposit
arises from the use of naphthol AS-S I phosph oric acid
as substrate , compared with u-naphthyl acid phosphate .
as used for 825.

827. Dual este rase reaction in a marrow smear from

a pat ient with myelom a . Th e cells contain scatte red CE
pcsi ti vny in this case . but no BE as is so me time!'> fo und .




Section of hone marrow trephine biopsy from a

t wit h myeloma . s ho wing typica lly variable
_)', with differences in ce ll size a nd in nuclear
tin co nde nsa tio n. and with con spicuous pale red
Krawc lear inclusions in sever al o f th e myelom a ce lls
nerally more primitive nuclear patt ern s. Th ese
pr umably th e sa me t ype of inclusion as sho wn in
: _ 813.

Anothe r typica l ex ample of myel oma ce ll cy to logy

in histo logical sections o f bone marr ow. Th ere
sional hinucle ated cells and som e var iabil ity in
ty. bu t in ge neral the cell nuclei arc mor e den sely
tic wit h more co nspicuo us clock-face marki ngs
III 28 .

• •• ••
Iyelomato us prolif eration is frequ entl y nodul ar
ribu tio n. and this section from ano the r bo ne
tr ephine biopsy sho ws the mar gin of a foca l
mye loma cell gro wth. at the uppe r righ t. ..
" -\
..• .-11'../•• •<.... ••
~.. .


••• • -
.........._ resid ual nor mal haem opo ietic mar row. with ,:.. ~.. ...,
stic. gra nulocytic an d megak aryocytic co rn-
all visible . at the lower left . Ov er all ccllulariry
ar ea is relative ly low . with num erous fat spaces.
. ::iI

.... . ~ :oX ...
'\.. .. ,. .. ,.

..-... '\.

• •
• ~

K3 \

831-833. Transformati on of myeloma to AML.

831. Myeloma marrow with chiefly mature well-

differentiat ed myeloma ce lls. but with occasion al blast
cells of myc lomonocytic cytology.

832. A higher-pow er view to co ntrast the ra nge o f

myeloma cell morph ology with two nucleolated myeloid
hlast cells.

R33. Marrow smea r fro m th e sa me patien t at a later

stage of transformation, sho wing predo minance of
acute myclo monocytic leuk aemi a (A MML) blast cells
with scanty residu al plasma ce lls and ra re late r grenu -
locyt e stages .



...... ';: .
.I.... ~~ ~':
. ;"':'.; ~ ' .
' •• JII/jt'••' ,:••~'
.....' . .

3-l-8J7. The marrow picture in waldenstrom 's macro - K.l7

ulinuemia is not specific, but appearan ces such as
are \Jery suggestive and wo uld indicate the need fo r
tigation ofthe immunoglobulin patt ern,

A bo ne mar row smear from a patient with macro-

linac mia. Lymphocy tcs , mostly with disrupting or
_ mal cytoplasm, pr edomin at e. Th ere is also a tissue
ce ll prese nt.

.0: . Another exa mple o f bon e marrow cyto logy in

8IICfOglo bulinaemia. Th e red ce lls show cons picuo us
ux formatio n, the lymphocytcs predom inate and
scanty cytoplasm. and there is a plasma cell prese nt
ell as a ve ry den sely gra nu lar tissue mast cell. An
alive name for this last cell. ' baso phil ball cell".
here be descriptively ap t.

Another fie ld from the sa me preparation . wit h

lym phocytcs but a disrupted tissue mast cel l.

The neopJastic cells in this field from the bo ne

_ ....,.. of another case sho w occasional ' Iympho-
cytoid' features. Phagocytic RE cells arc also
_"'PKu O US.

83H. PAS stain in macroglobulinaemia: there is scattered
granular PAS positivity in the cytoplasm of two R E
cells. hut the lymphocytes and plasmacytoid cells in this

disease show little or no reaction .

839. Dual esterase stain in macroglobulin aemia . show-
ing several tissue mast cells with coa rse CE positivity in
a marrow fleck. The neoplastic lymphoi d cells a nd RE
cells in the fleck show only weak scatte red gra nular
pos itivity to both BE and CE .

840. Free-iron stain on bone marr ow smear in macro-

globulinaemia. The e xcessive amount of free iron. both
scatte red and in macroph ages. is evide nt.

841. Romanowsky stain of marrow from macro-

globulinaemia . showing a macroph age heavily laden
with iron .

842. A similar cell to that in 8-11, stained with the

Prussian blue stain for free iron .

... '.::.

.....P7 . " w ~

R43. A high- powe r view of a sectio n of hone marr ow
trep hine hiopsy from a patient with Iymphoplasmacytoid
immunocyto ma and macroglo bulin aemia. providi ng a
clea r demonstration of the mixed lymphocytic. plasma-
eyrie. and inte rmediate cytology of the predom inant
infiltrating cells. Several binucleated plasma ce lls can
he see n.

844. A smear of bone marrow aspir ate from the same

case as in 843. sho wing the much superior cyto logical
detail of such pre parations. There is a central norm o-
blast. but all the re maining cells in this field are of the
Iymphoplasmacytoid ser ies . with a good seq ue nce of
intermediate developmental appearances. from Iympho-
cyte to plasma ce ll.

845 A low po wer view of a section of bone marrow

trephine biopsy from a case of Waldenstrom 's macro-
globulinaemia with lymph nod e invo lvement . where
lymph node biopsy reveal ed the histological features of
Iymphoplasrnacytoid immunocytom a. The field sho ws
the edge of a neoplastic nodule . with a marked 'cosine -
philic' reaction in the immedia tely surrounding residual
marrow. here seen at the up per part of the field. Th e
tumo ur cells appear to have gene rally un iform cytology
at lo w po wer.

lWi •



.. '•

,. .
• •.. •

." •


, , ••

. .•, .
'.: •

•n. • ••

846 A higher power view of the same specime n as in

845. Th e infiltratin g tumour cells are now see n to range
fro m the predo mina nt mature- looking lymphocytic.
ce ntrocytic or plasmacytoid cells. to much less matu re
larger cells with pale-staining nuclei and occasional
nucleo li.

847 and 848. Thin sections fro m plastic-embedded

trephine biopsy mat erial taken from the bon e mar ro w
of another patie nt with macroglo bulin aemia . The low-
powe r view (847) illustrates diffuse invo lvement of

residual marrow with lymp hoplasmacytoid cells and
furthe r 'eosinophilic' mast cells. and also a conspicuo us
scatte red background deposi t of amo rphous eos ino phil
deposit. probably represe nting amyloid mat erial. T he
higher magnificatio n of 848 reveals qu ite clea rly the
Iympho plasmacytoid nat ure of the infiltrate and the
presen ce of various normal myelo id precursors, and
a lso confirms the prese nce of num erous tissue mast

849 xsn

•• •

849-851. Sections from a hone marro w trephine biopsy H51
tak e n from anot her patient with macro globulinaemia .
1149 sta ined by H&E . and 850 and 851 by the PAS
reaction to show various examples of Dut chcr body
formatio n in the neapl astic Iyrnphcplasmacyto id cells.
Th ese are PAS-positive nuclear inclusion bod ies pro-
hab ly derived from cyto plasmic im ·aginations . Similar.
but ge nera lly much smaller. int ra nuclear inclusions
occur in myeloma and less often in reactive plasma
cells. but the lar ge inclusio ns know n as Dutcher bod ies
arc see n especially in macroglobulin aemi a. where they
may be so lar ge . as in 849 , as to ca use fragment ati on of
the nucleus. A PAS-positive body stretching the nuclear
membrane and occupying most of the cell is shown in
850. while in 851 a who le se ries of these bodies , at
vario us stages of deve lopm ent . appears in the lower
pa rt of the field . Th ere is a single PAS · positive poly-
morph near the top.
Part 4

Miscellaneous cells from bone marrow or

blood smears , reticulo-endothelial cells ,
osteoclasts and osteoblasts , foreign cells
and parasites

Reticulo-endoth elial ( RE) cells (re ticulum ce lls. arising in the bon e marrow. and wit h mixed cytol ogical
histiocytes. macrophagcs) are co mmon in the bo ne features of macr op hagcs and dend ritic RE cells.
mar row and have bee n illustr ated several times pre- The Leishman-D ono van bodies . the protozoal
viously in this boo k. Th ey take up foreign particl es. free par asites of Leishmani asis. appea r most prominently in
iro n. fat globules, specific gra nules from disrupted RE macrophagcs.
granulocytes, and o the r cell fragments. and therefore Malignant histioc ytosis is a ra re neopla stic state of the
ofte n co ntai n pha gocytosed mat er ial. Their cyto plasm RE cell and even rarer is histiocytic leuk aemia. Examples
appea rs fragile and is readily broken up in the smea ring of each ar e illustrated in this sectio n.
process o r str etched out between neighbourin g cells - so Apart fro m RE cells . most of the other ce lls illustrated
that the cytoplasmic outlines may be difficult to recog- here ar c less commonly encountered. hut they have
nize. T hey may co ntain various inclusions - sea-blue highly cha racteristic cyto logical features. and o nce these
histiocyte material, pscudo-Gaucher cell bire fringent features are appreciated the cells arc unlikely to be
lipid or blue crystals and gre y-green crystals. In ce rta in co nfused with normal or abn ormal varian ts of more
lipid sto rage disea ses the y appear grossly swollen with common cell lines in the bone marrow or blood.
ahno rmal fibrillary or globular deposits of lipids. A non-malignant form of histioc ytic proliferation with
The nature of this lipid inclusion materi al in the two enhanced phagoc ytosis. arising in var iou s oppo rt unistic
main forms of lipidosis. Ga ucher's disease and Niemann- virus infection s. especially in immun ocomp rom ised
Pick's disease . is illustr at ed in this section and discussed subjects . is virus -associated haem ophagocytic synd rome
in the acco mpanying captions. (VAHS); examples of this co ndi tion in trephine and
Glycogen stor age disease is also associa ted with the aspira tio n marrow biopsies are illust rated here.
accumulatio n of inclusion materi al. parti cularl y in Several different examples of tum o ur cells invadin g
rnacrophages. but 10 a lesser exte nt in man y other the marrow a re shown. Alth ou gh an isolated tumour cell
hae mic ce lls. may rarel y be iden tified as such in the abse nce of more
In chro nic infective or reactive states involving the typical cell clumps, the feature which allows identifica-
bone marrow. rangin g from tuberculosis to sarco idosis. tion in most instances is the occ urrence of ce ll nest s.
macrophage proliferation may lead to forei gn-bod y frequently partially syncytial. of cells not belon ging to
giant-ce ll (or Langhans' ce ll) forma tion . with appea r- any hae mic serie s. The identifi cation cannot often go
ances similar to those encountered in the lymph nod e beyond ' metastasizing tumour ce lls', but comparison
imprints illustrated in 1098 and 1099. with the histology. cytology and cytochemistry of the range
Anothe r group of gra nuloma to us states frequ en tly of illustrative metastascs shown in %(~I024 may provide
involving the bon e marrow a rc those of the ' histiocytosis a suggestive indicat ion of likely origin . Apart from
X: family. including Hand-Sch uller-Chri snnu syn- neuroblastoma. medullobl astoma and chemodectoma -
drome. eosi nop hilic gran uloma and l.cttcrc r-Siwc all relatively rare tum ours with characteristic cytology
disease. A ll arc thou ght to involve proliferation of found in yo ung people the meta sta ses most often found

Langerhans' cells. pro minent in the skin but probably in marrow aspirat es o r trephin e biop sies from o lder

patient s. usually with lcucoery throblastic anaemia. are tropical zones, but their appe arance should be recog-
from primary malignant tumou rs of lung. breast, kidney nized by all haematologists: although what may actually
or thyroid. and examples of all these are shown here. be seen unde r the microscope (as in the photo graphs
Certain of the more common parasites which may be her e) does not always provide detail comparahle with
seen in smears of blood or bone marrow are also the diagrams and painti ngs in parasitology texts.
illustrated. They are found mostly in tropical or sub-

852 . A ph agocytic re ticulo-e ndot helial ( RE) ce ll co n-

ta ining variou s part icles of cellu lar deb ris. These cells
ar c see n o nly rarely in the peripheral blood. altho ugh
they may occas iona lly be found in buffy coat smears in
some chro nic infective sta tes, as in the mo nocyte-
macrophage seq ue nce in 855-857 . but th ey are common
in bo ne marr ow smea rs. as here. where they are
gene ra lly to be found towar ds th e tail of the smear or in
marrow flecks. Their th in flattened lep tochromatic
nuclei, with fine chromat in markings and usually incon-
spicuo us nucleoli. and thei r extensive fragile cytoplasm.
usua lly with inde finite mar gins. as shown here . a rc

853 . T his is prohahly an RE cell with phagocytosed

eos inophil granules from a d isrupted myelocyte . T he
alte rna tive poss ihility is that it represents a pa rtia lly
smeared degen er at ing eos inophil myelocyte .

854 . A gro up of R E cells with poorly o utlined filmy

cytoplasm, from the bone ma rrow in a case of pernicious
anaemia .

._ • ..27J

... .

855. A gro up of three cells of the monocyte-macro-

phage system in buffy coa t of peri pheral blood . from a
patie nt with bacteria l endocarditis. The middle cell is
clearly a macrop hage. whe reas the contiguous mono-
nuclear cells are still of vacuola ted monocytic cyto logy.

856. A similar macroph age in the buffy coat of this

patie nt, stained to show the free-iro n content.

857. Another example of the monocyte-macroph age
seque nce in peri pheral blood . The re are Iymphocytes at
top and boitom of th is field. a nd six neut roph il poly-
morph s. with three cells showing s t agc~ in the monocyte
to macro phage tra nsformation , all having phagocytic
vacuoles and the uppermost showing the most macro-
phagic cytology .



.• ,.
• '"

858-891 . Phagocytic RE cells with various cytochemical 860

reactions and inclusions. ,
858 . Romanowsky stain: a multinucleat ed R E cell
.: '
; ...", .
with remnants or several ingested cells. includ ing a
polymorph . and multiple granules - most probably iron.
859. SB stai n: strong positi vity. probably surroundi ng
phagoc ytose d materi al . including free-iron pa rticles .
Th ere a re scatte red S8 posit ive gra nules in a mon ocyte .

860. PAS reaction: three RE ce lls. on e with scatte red

PAS -positive granules and the other two with weak PAS •'"
reaction but chiefly scattered free-iron particles spreading
across the field diagonally.

861. A lkaline phospha tase reaction . showing strong

positivity in a mar row RE cell.

862. Acid phospha tase reaction : three strongly posi-

tive RE cells. contai ning phagocy tosed cell remnant s
and large particl es of free iron heavily coated with acid
phospha tase .

863. Dual esterase reaction: the phagocytic RE cell

shows the typica l very strongly positive BE reaction .


.. •

. ,,... '

." .


K64 . Fain tly visible blue crysta ls toge ther with coarser 1167
iron gra nules in a distend ed RE ccl l from the marro w in
a case of congenital dyscrythropoietic anaem ia (CDA)
type I. R E cells co ntaining such blue crystals. and
pseudo-Ga ucher cells. RE cells with crumpled swollen
cytoplasm. are found not uncommonly in C DA .

R65 and 866. Increased visibility a nd clear birefringence

of these crystals, with reversal of refringence on 9<r
rotation when the same field as shown in 864 is looked at
unde r po larized light.

867 and 868. A not he r Ga uchcr-like cell with d uplicate

unde r polarized light showing refringence. Th is specimen
was from a case of CML, a co nd itio n in which the
pseudo-Gauche r cell phenomen on is also not infrequent.


. ~
r' •

. #-.,.. ' • •.

.. .. -r . . . ~~


869. A sea-blue histiocyte (SB H) : a n RE cell. bi-

nucleated in this instance. cont aining a mass of blue
granules in the Romanowsky stain. Such cells are seen
particularly in the benign genetic disorder of 'sea-blue
histiocytosis' . and secondarily in myeloid leukaemi a and
in dysmyelopoietic and dyseryrhropoicric slates .
870 and 871. An SBH. stained consecutively by
Lcishma n and free-iron stain s. to demonst rate that the
gra nular material is chiefly negative for iro n.

872 and 873. An iron-laden macroph age with som e SC3-

blue material similarly stained consecutively for CCJrn -
parison. In this case much of the heavier gra nularity
co nta ins free iron .

. " ,,



874. A, thin section of marrow trephine biopsy from a 877

case of MDS with numerous pscudo-Gaucher cells.
histiocytes showing distended granular cytoplasm .
A ltho ugh the H& E stain does not furt her identify the
nat ure of the gra nules . these are the same cells as in 875

and 876 . where the gra nules of man y of them are shown
to be sea-blue by the use of Rom anowsk y staining.

875 and 876. Romanowsky-stained bon e mar row

sme a rs from the same case as illustrat ed in 874 , sho wing
SBHs . with neighbouring ea rly myeloid cells having 'h e
defective gra nularity co mmonly found in the myelodys-
plastic sta tes. In 875 there are three . and in 876 five.
histiocyte or macrophage nuclei visible in the respective
sea-blue cell nests.

877 and 878. Another example of a pseudo-Gauchcr 878

cell. in this case from the bone mar row of a child with
AML. emerging into remission o n che motherapy . Th e
appearance of the striated and chunky cyto plas mic
material is see n un der no rma l microscopic illumin at io n
and the n under polari zed light. Th e inclusion mat erial is
stro ngly birefringent.

879 -


• • •

879. G rey-gree n crystal s in a disrupte d RE cell. Th ese

inclusions occur chiefly in myeloid leuk acm ias and arc
not biref ringent.

880. Anot her exa mple of the non -birefrin gent type of
'grey-green crystal in a macroph age from the bone
marrow of a pat ient with A ML. Th e flat nucleu s and
spread ing cytoplasm of the macro phage are typical. and
the ce ll conta ins othe r phagocytosed mater ial , probably
chiefly iron. in addition to the grey-green crysta l.

881. A genuine Gauche r cell in the bone marrow of a

patie nt with Ga ucher's disease , showing typical coa rse
o nio n-skin lipid inclusion mat erial.


882. Two further Ga ucher cells in the bone marrow -

one typical cell and one heavily vacuolated.

883. Less typical Ga uche r cells from the same speci-

men . The cytoplasm is mor e granular and less fibrillary.

884 and 885. Ga ucher cells under polarized light: the

birefringence is shown in the same cells with the
polarize r turned to a 9()O angle .

886-889 . Marrow trephine sectio ns and aspirate smear
fro m ano ther patient with G auc her's disease . In the low-
po wer field in 886, the nodul ar ap peara nce results from
the pe rsistence of normal hae mopoieti c marrow , with
little infiltrat ion in the vicinity of the bony trabeculum at
the upper left. but elsewhere the Gaucher cell infiltrate
was very extensive in this case , Th e characte ristic
histo logical appeara nce of these cells in marrow sections
stained with H&E is well sho wn in the higher-power
view of 887, with their ample and swollen cyto plasm.
diste nded with fibrill ar mate rial. In the reticulin silver
sta in of 888 a scatt erin g of interl acing ret iculin fibrils,
somewhat increased ove r normal. is revea led. while the
accumulated cytoplasmic materi al has a mo re gran ular
appe arance in this stain a nd there is eve n a suggestion of
weak argyrophilia in the cytoplasm of some hlstioc ytcs.
Th e smear prepa ratio n in 889, with the usu al
Romanowsky stain , shows the same Gaucher cells as in
the preced ing sections. here with a mixed fibrillary and
granular or foa my appearance.
T he striking and highly charac teristic appea ra nce of
Gaucher cells is d ue to the accumulation within ex-
panded Iysosomes o f the lipid glucosy l ccramide. result-
ing from deficiency of the enzyme glucocc rebrosidasc .
890 .. 891

890. R E cells laden with foamy deposits of abnormal 892

• •
lipid iri the hon e marr ow from a patient with Nicmann-
Pick disea se. Th e lipid in these cells is sphi ngomyelin.
• ..
891. Abnorm al cells. probably RE macroph ages. with
variable reticulated cytoplas mic conte nt of abnormal
stor age material. fro m the marrow of a pati ent with a
'histiocytosis' of the eosinophil granuloma-Hand- •
Schuller-Christian disease group . These granul om atous
conditions. including also Letterer-Si we disease. are
someti mes grouped toget her under the name ' Histio-
cytosis X' . They appear to share an origin from
Langerhans' cells which prob ably arise in the bone
marrow, typically express CO l and HLA -DR antige ns. •
and which arc characterized by a mixture of feat ures of
macrophages and immun o-stimulator y de ndritic ce lls.

K92. H& E stai n of tre ph ine biopsy bo ne ma rro w section

from a child with another varia nt of the same disease
gro up. showin g numerous multinucleated histiocytes.

28 1

893 and 894. Lo w- and higher-power views. respect-

ively . of another example of fihrosing granulo ma with
eosinop hilia in a section of bone marrow trephine
biopsy, from a patient with Hodgkin's disease (H D).
The granulo mas were high ly localized in the otherwise
normal marrow shown a t th e lower left part of the field in
893. Th e histiocy tic prolifer at ion and the eosin oph ilic
rea ctio n arc clearl y eviden t in the high-power field of
894. Granulo mas of this so rt arc not diagnostic of bone
marrow involvem ent - and thus of Stage IV d isease - but
are suggestive.

895. A nothe r example of histiocytic proliferation in the

ho ne marrow. with diffuse infiltr ation througho ut the
who le section. from a pati ent with a chronic myelod ys-
plastic state. with refracto ry anaemi a , some incre ase in
blasts and persiste nt mod eratel y severe thr ombocyte-
penia . The histiocy tes appear swollen . with distende d
cytoplas m,

896 897

,. •

Co •

J •

896-898. Furt her fields from the same tr eph ine biops y 89H
of hon e marrow as shown in 895 , with two high-power •
ileitis from an II& E sta in and o ne from a G iemsa-stai ned
prepa ration. Th e histiocyte cyto plasm her e shows so me
• •
•• • • ••
granularity and there is evide nce of phagocytic activity.
especially in 897. where there arc also sever al mult i-
nucleated hisriocytes. In the Gicmsa stain a few of the
histiocy tes show a suggest ion of sea-blue inclusio n
materi al. • • •• •
As scc n previo usly. this appearance is not co nfined to
a single spec ific lysosom al enzyme deficiency as in the • .. •

ma in her editar y lipid sto rage diseases. but appears to
occur most often as a manifestation of myelodysplasia
and perhaps accompanying increased ce ll dest ruct ion • •

invo lving especially the gra nulocyte and th rom bocyte
lines .
e. • •

• •
e. •


90 1


899-904. Smear preparations of bone marrow. and one

of huffy coat, from a child with Pompe's disease.
glycogen storage disease. type 2. Th is is another ex-
ample of a lysosom al sto rage disease arising from the
heredit ary defici ency of a single enzyme. in this instance.
alpha-La-glucosidase . There are commonly vacuolcs
prese nt in pe riphera l blood lyrnphocyres in this disease.
but similar vacuo lcs occ ur in many ot her disorde rs and
the y arc o nly d iagnosticall y helpful in directing atte ntion
to the need for o ther cytoc hemical and biochemical
investigations and bo ne marro w st udies . In this disease.
the PAS reaction gives stro ng pos itivity of vacuolcs and
cytoplasmic gra nules of a very cha racte ristic kind .
In 899 a Rom anowsky sta in of a bo ne ma rro w fleck
shows coarse semi-vac uo lated chu nks of inclusion
material in a macrophage. while in 900 a PAS stain on
the same cell reveals typically st rong positivity of the
chunky inclusions of glycogen-contai ning material. A
more crowded field . including glycogen- laden mega-
karyocyt cs . is illustrated in 901. also a PAS stain. where
the megakaryoc ytes have co nspicuous glycogen in-
clusion bodies.
The Iymphocyte with coarse PA S positivity seen in
902 is from a buffy coat preparation . which first raised
the possibil ity of glycoge n storage disease as a diagnosis
in this case . In 903 and 9()..1. both from the marrow
aspirate , the intensely positive glycogen storage material
is shown in a neutrophil polymorph and in an eosinoph il.

905 906


905-921. Cytology and cytochemistry of bon e marrow 908

smears· from very uncommon cases of histiocytic
leuk aemia or lcukuemic histiocytosis. The cells involved
sho w many fea tures ofactivated macrop huges. including
large size and a m ark ed tendency to sp read over the slide
surface, very conspicuous forma tion of cytoplasmic
pinocytotic vacuoles and peripheral pseudopodia , with
an obvious intense phagocytic activity . Cytochemical/y,
the reactions differ somewhat fro m thOJC of normal
marrow macrophages, with general sudanophobia, un·
expcctedty strong PA S staining. weak acid and alkaline
phosphatases, and almost negative butyrate esterase.
These pa tterns may reflect a neoplastic functional defect
or, possibly, enzy me exhaustion following increased
phagocytic activity .

905. Ma rro w cells fro m an un usual case of histiocytic 909

leukae mia , sho wing gene ral cyto logical similarities to
the ce lls de picted in 891. Phagocytic inclusions are

906and 907. Further field s fro m the marrow of the same

case of histiocytic leuk aemia showing cells of primitive
cyt ology. but with scattered vacuo les, occasional multiple
nuclei and freq uent giant nucleoli.

908 and 909. A nother example of this unus ual type of

histiocytic leukaemia with blast cells again showing very
large size. around 30-40 microns in diameter, irregu lar
and so metimes fragmenting cytop lasmic borders, and
coarse vacuo lation with occasio nal erythrophagocytosis.
910 91


910 and 9 11. SB reaction shows the se primitive cells to

be negative in bo th cases . Th er e is a posit ive neutrophil
in eac h of the illustr ate d fields .

912 and 913. Th e PAS reaction shows rem ark ahl y

stro ng positivit y in virtually eve ry cell in eac h case . It is
clea r that man y. alth ough not all. of the vacuo les
co ntain glycogen. while the inte nsity of the stai n is
emphas ized by the relatively weak . tho ugh normal ,
reac tion in the neutrophil in 913.
914 and 915. Acid pho sphatase is mod erately stro ng in
the blast cells. scatte red ove r the nucl eus. and with local
concen tra tio n in o ne cell at the site of an ingested red cell
in 914 .

,. . '....,
, :::-
'~ ,

:/ y.-

916 917

91K 919

916 and 917. Du al es te rase reaction in smear s fro m 920

eac h o f the two cases o f histiocytic leukaem ia illustrated
o n the pre ceding page. Th e blast ce lls are almos t entire ly
nega tive . with no mo re th an a very weak tinge of
buty rate esterase (BE) positivity and a few fine chloro-
aceta le esterase (Cfi) gra nules in 916. Both fields
co ntai n norm ally reacting Cfi-pos itive neu tr oph ils and
Bfi-po sitive rnacrophages.

91S-920. Free- iro n stains showing a po sitive reaction

in some of the primitive histiocytic cells . The posirivity is
likely to be the result of ingested erythroid cells, and it is
noteworthy th at the single Fe-posi tive blast cell amo ng
eight which ar e ne gative in 920 also co ntains other
cellular debris and has clearl y bee n especially active in
921. Alkaline phos pha tase cytochemistry o n a hone
marrow smear from the seco nd of the two cases shows a
weak tinge of positivity in seven blast ce lls. a co nside r-
ably st ro nge r reaction in an eighth . and a neutrophil
po lymo rph with mod erate cyto plas mic reactio n . Again .
the obvious phagocy tic activity of the mo re strongly
posi tive blast ce ll mak es it see m likely th at at least part of
the alkali ne phosph atase activ ity shown in the histiocytic
blast cells is seco ndary to ingestion of positive neutrophil
cyto plasm. although part ma y be native to th ese unusual
leukae mic cells.


" •
; I


.. •
922. Malignant histiocytosis (histiocytic medullar y
ret iculosis) showing erythro phagocytosis by bon e
marrow RE ce ll (histiocyte).

923. A free -iron stain o n similar malignant phago-

cytos ing RE ce lls.

9U . A furth er ex ampl e of increased phagocy tic activity

in malignant hist iocytosis. Th e whole clu mp of er yth ro-
blasts. showing faint diffuse PAS positivit y. is within the
cytoplasm of a spread RE cell with nucleus to the left of
the clump .

125 926

• ••
• •

•• •

925-927. A se ries of fields at gene ra lly high magnifica- 927

tions, from thin section s of plastic-embedd ed trephine
hiop sy mat erial from anot he r patient with malignant
hist iocytosis. In 925 the exte nsive accumulation of
haem oside rin in many histiocytes is especially notice-
able; in the field chosen in 926. the re are again many
haernosiderin-laden histiocytcs. but the very consid-
erable infiltrate of primitive mon ocyte-macro phage
histiocytes. with palely sta ining leptochr omat ic nuclei
and conspicuo us nucleoli. is also eve n mor e clea rly
evide nt than in 925. All these features ar e visible in the
still higher-power view of 927. whe re the re is also
an exce ptionally dr am ati c example of mu ltip le phago-
cytos is of red cells. Malignan t histiocytosis ma y some-
limes be d ifficult to diffe re ntiate from virus-associated
hacmophagocytic syndrome (928-939). especially when .
as in the prese nt case . ther e is ex te nsive haemoph ago -
cytos is by more mature histiocytcs. eithe r deri ved fro m
less differ enti at ed precursors or perhaps devel oping as a
reactive co mpo ne nt . but the presence o f num erous
primitive ce lls stro ngly suggests the fo rme r malignan t
sta te .


• •
,' ,
, ., •



. •' • f


• •

.' ~. •
, • •
• .. ••
.,- ,
,, -.., . " -

-, . •• • • , ••
, •• J

-" . •

.'" ". • .. , . J:.
' .-~,

• 1•

• •
• •

928-931. Variou sly stained sections from a bone

marrow trephine biop sy. tak en from a pat ient with
virus assoc iate d hacmophagocytic syndro me (V A HS) .
In such pati en ts, ther e is usually an underlying immune
deficie ncy. and the pe ripheral blood often shows pancy-
tope nia . so meti mes with activated Iymphocytes and
monocyte-mac rophagcs detectable . The bone marrow
varies in cellularity, some decrease commonly being
found . as in this specimen . with a reactive increase in
reticuli n a nd fibrob lastic activity (illustrated in the van
Gieson and silver stains of 930 and 931). There is a
widespread increase in histiocytcs in the sections . visible
in bo th the low-power view of 928 and the higher-power
of 929. wher e e rythrophagocytosis is also evide nt. Th ere
may be ingestion of othe r cells or cellular deb ris. but
phagocytic activity is often more readily see n in aspirate
smears than in sections (see 932-939). The histiocytes
are of gene rally mature cytology in VAHS. with non-
nucleolated nuclei and low nuclea r-cytoplasmic ratios.
and are to be distinguished from those of malignant
histiocytosis. which frequen tly show nucleoli and high
nuclear-cytoplasmic ratios . as in 925-927 above . The
distinction may nOI be easy. however . especially in bone
marrow sa mples. since the more prim itive cells of the
neoptasric histiocytosis. though generally much less
actively phagocytic than the histiocytes of VAHS . are
ofte n accompanied by more mature and more stro ngly
phagocytic der ived or reactive histiocytes.

32 933


932-935. Examples o f reactive Iymph ocytes and mo no- 9.'6

cytes . and macrophagic phagocytic activity. in Rom an -
ows ky-s ta ined smears o f bon e marrow as pira te from
anot her pat ien t with VA HS and marked periphe ral
pancytopenia. Various Iymphocytes are seen in 932. that
• ••
o n th e left sho wing activation cha nges ; to th e right are
two monocytcs with progressive transformational change
to wards macroph ages. sho wing pi nocytic vacuoles and
ingestion of platelets. In 933 the macrop hage contains
ma ny inges ted red cells and platelets. while the macro--
phages in 9.,1.4 and 935 show phagocytosis of two early
normoblasts and eight later normobl asts. res pective ly.
T his type of gross and indi scriminat e ph agocytic
activity is more o fte n see n in VA HS than in malignant

936 and 937. Further illustr ation s of massive phage - ~ 937

cytos is by marrow macrophagcs in a pati ent with
refractory anaemia with excess blasts (RAE B) and
immune supp ressio n secondary to chemotherapy. later
develo ping VAH S following an opport unistic viral in-
fectio n. The Rom an owsky stai n in 936 sho ws a cell with
gross accu mulation o f gra nulocyte de bris. includ ing
dark-staining nuclear re mna nts and bo th ne utrophil and
eosi no phil gran ules . To the left a re several somewhat
dys plastic myelocytes, a lymphocyte and an ea rly
eryt hroblast. In 937 the S8 stai n o n a similar cell gro up
reveals the strong sud anophilia of the ingested poly-
morph granules.

.. • ••
. .. • , .•


. • ..;
• • •
. .1#. , "

, •"
'. ..
• .• •

'. • •• • • I
• • • • ••
•• ••
• •
• • • •
,• .,
• \

.'. •• •

• • • •
• • •
• •

• •••

938 and 939, Two furth er eytoehemieally sta ined
field s from the same marrow aspira te as in 936 and 937.
The PAS stain in 938 sho ws a central ph agocyti c
macrophage , aga in with p redo mina ntly polymorph
debris baving the expected PA S po sitivit y. T he field also
co nta ins several early. PAS -negative . gra nulocyte pre -
cursors. The dual esterase reaction shown in 939 is
unu sual , in that the mass of ingested po lymo rp hs
appea rs predominan tly BE-positive rather tha n having
the normal C E positivity sho wn by gra nulocytes . as
man ifest for example in the ne ighbouring myelocytes in
this field . Some residu al CE reac tion ca n still be
made o ut. however. and it see ms likely that this e nzyme
is bei ng ove rridden by high activity o f the endoge no us
BE of the engulfing macrophage,

9~O and ~1. Low- and higher-power fields. respect-

ively. from a trephine biopsy o f bone marr ow tak en
from the same patient at a later stage o f disease . The
specime n now sho ws an oedematous marrow stro ma
with prolifer ati on o f fibrobl asts and development of
fibrosis. perhaps seco nda ry to the earlier chemotherapy.
but also with persiste nt mature cell histiocyt ic increase
and the eme rge nce of some Iymphoplasmacytoi d

reaction to the co nti nuing intrac table viral infection.

942 • 943


942. A n osteoclast fro m a smear of nor mal bone 944

marrow. Th e multiple . discrete. round or ova l nuclei,
with their single conspicuo us nucleoli, and the pale blue ,
lightly gran ular cytoplasm are character istic and prevent
conf usion with megak aryocytes.

943. A group of osteo blasts , from a smear of nor ma l

bone marrow. Th ey have a superficial resembl ance to
plasma cells, but are larger , do not sho w the heavy,
'cloc k-face' . nuclear chromatin dispo sition seen in
mature plasma cells, yet have a low nuclear-cytoplasmic
ratio. wit h abunda nt , rath er pale and filmy cytopl asm.

944. A further group of osteo blasts , whose large size is

emphasized by the neighbouring segmented neut rophil.




945. Scatter ed PAS positivity in osteobl asts.

~6 and 9~7. Strong positivity for alkaline phosphata se

in osteoblasts. This provide s another differential point
from plasma cells. which are negative for this e nzyme.

948 and 949. Weak-to-moderate positivity for acid

phosphatase in osteoblasts. This reaction is much
stro nger in plasma cells.


! , ...... ' .
. .. ., .~.

9511 951


95 0-95~ . Low- , intermediat e and high-power views. 952

respect ively. of mixed osteoblasts and osteoclasts, the
former mononu cleated and the latt er multinu cleated .
from an otherwise poo rly cellular ma rrow aspirate tak en
from a patient with Paget 's disease. The detailed
cytolo gy of the bone remodelling cells ca n be seen here.
The re is a similarity between them , especia lly when the
osteoblasts occu r in clusters and form syncytia . as they
arc prone to do when they are very actively proliferating.
as in Paget's disease. This appea rance is revealed in the
predomin antl y osteo blastic field of 950. Osteoclasts
generally show a lighter blue cytoplasm, with many
conspic uous. fine to mode rately coarse. red granules;
the osteoclas t nuclei tend to form a circle or hoo p aro und
the per iphery of the cell, as seen already in 9-12 and again
in 951, in contrast to the overlappin g nuclei . the more
blue than red cytoplasmic gra nula rity. and the freque nt
sepa ration of mononucle ar satellite cells manifest by
syncytial osteoblasts as shown in 952.

• •

953 and 954. Examples of tissue mast cells in bone

marro w smears. These cells have been illustra ted earlier
in macrog lobulinaemia. where they are usually to be
seen , but they also occur in small numbers in normal
marrow and may show an increase in aplastic and
hypoplastic stales. They differ from basophil poly-
morphs in their lack of nuclear lobulation and generally
larger size. and in their absence from normal peripheral
blood and freq uent presence in subc uta neous tissue .
T hey do ap pea r to have their origi n in the bo ne marr ow.
howeve r. and may he involved in a malignant masto-
cytosis which may be fran kly leu kacmi c. Like baso phils.
they show the metachromatic staining of their granules
with toluidine blue produced by acid mucopoly-
saccharides. but this reflects their high content of heparin
sulphate whereas the basophil reaction is due chiefly to
chondroitin sulphate.

955. PAS react ion shows st ro ng positivity in a mast

cell. T his reaction gene rally resem bles that of basophil
polymorphs. although it is less coa rsely gran ular .

956. Dual esterase reaction showing strong chloro-

acetate esterase positivity in a mast cell . The reaction
here diners from that of basophtls. which is essentially
negative for all the cytochemically demonstrable
este rascs.




957-961. Cyto logy and cytoc hemistry of bone marrow 960

as pira te prep ara tion s fro m a patien t with mas t cell
leuk aemi a. As ca n be see n in these illustrations, the
neo plasric mast cells te nd to have relatively higher
nuclea r-cytoplasmic ratio than normal mast cells . with
often less de nse gra nularity and a patch y disposi tion of
gra nules . The nucl eu s is usually round , but may show a
degree of indentation. as in some ce lls in 959 and 961,
while the cytoplasmic ou tline may be elongated and
eve n spind le-shaped . as in 957 and 960. There is a
particul ar tenden cy for malignant mast cells to occu r in ....
clumps and in marrow flecks. where they may be mixed
with fibro blasts, e rythrcblasts . mcga karyocytcs and
gran ulocytcs, and may be difficult to recognize except at
the edges . as in 958. The ce lls may show a rneta -
chro ma tic staining reaction no t o nly with to luidine blue
but also with SR, as see n in 959 , wher e the da rk red 961
co lour o f the mast cell gra nules co ntrasts with the black
stai n o f the neutroph il myelocyte at the right and of a
few sca tte red ne utrophil gra nules. The d ual este rase
reaction of 960 shows stro ng C E pos jtivity, while the
PA S react ion in 961 reveals a weak tinge of positi vity in
most mast ce lls, with peripher al gra nular positivit y in
ma ny.
Of all the cytoc hemical reaction s. the most help ful in
disti ngu ishing neopl astic mast cells fro m the basophils
they may resemble is the este rase reaction , wher e mas t
cells are stro ngly positi ve for chloroacctatc (a nd also
aminoca proate) este rase , . for which bascphils a re
nega tive .

962 • j•

• .
962-966. Examples of vascular endothelial cell clump s
in the peripheral blood . The very regular nuclear
structure and size and the tendency for these cells to
occur in sheets or streaks along the dire ction of spread-
ing of the film assist in recognition. Th ese ce lls arc
for eign to blood, and are lifted from the intima of the
vein during insertion o r withdrawa l of the needle used
for collecting the blood sample. Th e nuclei in 965 both
sho w conspicuous Ban bodies. indicating the presence
of the inactive X-chromosom al materi al of no rmal •
female cells . In 966 can be seen alkaline phosph atase
pos itivity in a strand of vascular endothelium. cross ing a
field of negative immature marrow cells.

7 969

967. Drop let conta mination. A n artefac t produ ced by 970

coughing ove r an unfixed blood smea r before sta ining.

• I
968. A higher magnificat ion reveals a ce ll from the
buccal mucosa, with heavy bacterial contamin ation.

969. Onc int act prom yelocyte a nd two flatt en ed and

parti ally disrupted prom yc locytes. showing exagger ated
nucleoli and open nuclear network . This app earance has •
been known as a ' Ferrata' stage of degeneration.

970. Two buccal mucosal cells with contained bacteria

in a bon e marrow smear.



971. A fat-lade n RE cell or lipoph age from norm al hone


972. A sebaceous skin cell co ntaminating a marro w

smea r.

fJ73 and 974. Stro mal fat cells in bone marrow smears.

5 976
• ,
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7 97H

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. .

975 and 976. Low- and higher-power views. respect-

ivcly. of a thin secti on . stained by H& E . from a bon e
, ... .., . 979

marrow trephine biopsy taken fro m a pa tient with hair y

ce ll leukaemia ( H'Cl.) afte r tre atment with alpha-
interferon . showing a n extensive proli fer ation of fat-
laden foam y macrophages. Th e low-power field
illustrated in, 975 co nta ins a pleom orphic cellular
ad mixture. with foamy macrophages. normoblast nes ts,


• ,
'... ,

megaka ryocy tcs and residua l hairy cells. while the • "
detailed cyto logy o f all th ese ce ll types is seen in 976. The .' ••• • , •••
foamy ce lls a rc d iste nded with lipid . no dou bt derived
fro m dis integrat ing hairy cells. Th ey hea r a supe rficial
resemblance to the sphingo mye lin-lade n rnacro pbagcs

,• •
•• , .....
of Niema nn-Pick disea se. ."
, -, •• •
• ....
977 and 1)78. SB stain and consecutive iron stain on the
same field from a marrow aspirate ta ken from a patient
• .' . C-

with A ML illustrating two cytoplasmic frag ments with
spurious loc aliza tio n of S8 positivi ty on coarse particles
• •••
of free: iron . probably derived from a disrupted macro-
phage. The two blast cells present show the expected • .• ,
...., , •
sudano philia of early grunulocytc precu rsors . - •
979. A thin sectio n fro m a plast ic-em bed ded bo ne
•, •
marro w tr ephine bio psy, showi ng an artefac tual scat-
tering of spherical globules due to the presence of bubbles •
in the embedding medium . T he bubb les ar c con spicuo us •
and rea d ily recognizable o ver e mpty fat spaces. h ut give
rise to co nfusion when over cellular area s.


980 981

9S0 and 981. Examples from two differ ent subjec ts , of

ne uro blasto ma cell nest s in th e bon e marrow . T he cells
have a resemblance individually to Iymphobl asts o f
ac ute leukaem ia . but frequentl y sho w a whorled
ar ra nge me nt in small clumps, as illustrat ed her e.

9H2 . PA S reaction on a clump of neu robl astom a ce lls.

showing a negati ve re act io n, co ntrasting with the usual
co arse positivity enco untered in a pro portion of lympho-
blas ts in ALL.


983-987 . Furth er cytological and cytoche mical features 9l!6

of neur obla stoma cells as seen in bone marrow aspirat es.
Th e high-power view of a Romanowsky-stained smea r
in 983 reveals a clump of neuroblastom a cells with
characte ristic fine nuclear chro matin co nta ining severa l
dense hyper chromatic spo ts, but o nly small and some-
times poo rly distinguishable nucleoli. Th e cytoplasm of
these cells is ofte n frag ile and easi ly disrupted . so that
the cells may appear as naked nuclei.

In 984 the acid phosph at ase reaction in a neuro-
blasto ma cell nest shows the tumo ur ce lls to have o nly •
very weak positivi ty. without any sign of the par anuclear
concentration seen in T Iympho blasts.

Mixed cell clumps with ce ntral neuroblastom a cells
and peri pheral haem ic cells some times occur . whe n they
may be confused with norm al mar row Decks, especially
when dense . Examples are illustr ated sta ined with the 9H7
du al esterase rea ction in 985 and the Prussian blue sta in
for free iron in 986. In 985 there is the usual CE positivit y ,
in granulocytes and so me BE positivity in later norrno-
blasts and a megakaryocyte at the edge s of the cell
clump , while the neuroblastoma cells show moderat ely
strong, finely granular, BE posiiivity . Th ere is no
det ect able free iro n in the tum our cell nest see n in 986.
• ' .
nor in the pe ripheral normobla sts . Th is contrasts with
the finding of norm al qu ant ities of free iron in the >
marro w Deck of haemopoietic tissue from the same , ."'. ,
slide . illustrated in 987, where neuro blastoma cells, if
prese nt. arc no t easily distinguished . , , . •

•• •
• • •• • ...
• •

988-992. Thi n sect ions fro m bo ne marrow tre phine
bio psies showing the histological appearance of neuro-
blasto ma infiltrat ion. In the low-power view of 988. the -,
pale-staining tumo ur cells form swirling colu mns
c, •
.• . - .
between the residual islands of normal hae mic tissue.
and in the higher- power field seen in 989 the typical '
features of these cells arc well shown: their large size .
their flimsy and indefinite cytoplasm, and their pale-
staini ng nuclei without obvious nucleoli but with

characteristic hype rch ro matic nuclear spots-

• ••

• , •
In 990 a more heavily infiltra ted area of bo ne mar row • • •
from another case is sho wn. whe re large clumps of
neuroblastoma cells predominate in an ot herwise poorly , ••
cellular marrow. with scanty residual cry throblasts
around the whorled tu mour masses . Low- and higher-
• .-
power views fro m the same mar row section are see n in
991 and 992. illustratin g the characteristic swirling
whorled pattern of growth and infiltra tion shown by
this turnover against a poorly cellular and oedematous.
weakl y eosino philic hack grou nd . The pa le nuclei with
occasional hyperchromatic dots . and the poorly defined
pinkish cytoplasm arc again well shown .

• . ;

•• ,

• •
~ ..•'. .

, ., .. '"

- ,
• / , • I •


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.0 •

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, • •
••• •

• ••
• t
l , •

993-997 . Thin sectio ns from bo ne marrow tre phine
biopsies from pat ients with medull obl astom a invading
the marrow . Thes e tumour cells bea r some resemb lance
to ne uroblasto ma cells , but they are ge ne rally mo re
stro ngly stai ning , and form sma ller ce ll clumps or chai n-
like co lumns o f single cells in the bo ne marrow. and do
not usually ma n ifest th e swirled or who rled arra ngeme nt
co mmon in ne uroblastoma. The low-power fields of 993
and 994 show th ese cha racteristic gro wth patterns well,
with resid ual no rmal marrow ele men ts in the bac k-
gro und and a sectioned capi llary at the left in 994 . Th e
higher magnification of 995 and 996 reveals the
moderately dense nuclear chromatin and tende ncy to
fo rm ce ll chai ns and small syncytia l clumps . In a still
higher-pow er field (997), th e nuclei o f the medu llo-
blasto ma cells can be see n to have the sa me type of
hyperch rom atic spo ts as previou sly sho wn in neuro- 997
blasto ma ce lls.



• 11

99S-IOO3 . Chemodectoma (paraganglioma) cells in


998 and 999. Leishm an stain : the malignant cells sho w

co nspicuo us nucleoli. somet imes multiple nuclei and
generally a large amou nt of clea r cyto plasm .

1000. SB stain with a norm ally react ing polymo rph and
negative chemod ectoma cells.

1001. PAS reacti on in the same prep arat ion showing

nega tive o r faint diffu sely posi tive reaction in tum our

1002. Alka line phosph atase reaction is negati ve in the

tumo ur cells (in contrast to RE cells). A positive
polymor ph is present.

1003. Acid phosphatase reaction shows moderately

coarse scattered granular positivity in tumour cells.



1001. Clumpe d cells. darkly staining. and unlike any

cells normally found in the marrow. allow a diagnosis of . 1007
tumour ce ll metastasis to be made . This marrow smear
was from a patient with disseminated carcinoma of the

1005 and 1006. Cytological de tail of cell clumps from

the same patient with gastric ca rcinoma . The tendency
to syncytium formatio n is evident.

1007. A part ially syncytia l cell clump of seco ndary

deposi t from carcinoma of the bronchus in a bone
marrow smear .


1008. A fur lher exa mple of bronchial ca rcino ma ce lls in

ma rro w, showing almos t nothing but tum our ce lls (a nd
clumped ery throcy tes). A large multinucleat ed syn-
cyt ium is present . pe rha ps of tumo ur ce lls, but po ssibly
an osteoc last.

1009. Bron chial carcino ma cells in marrow fro m a third

patient, here showing a te nde ncy to rosette forma tio n.

1010- 1012. Examples of malignant cells in bone

marrow asp irates fro m a patient with dissemi nated
carcinoma of the breast.

I 14


1013. A clump of metastat ic tumour cells in a bone

marro w aspirate from a patient with breast carcino ma 1015
and a leucoerythroblastic anaemia . There is conside r-

• •
able variabil ity in cell size and nuclear config uration.
• • •
1014 and 1015. Two different areas from a section of
bone marrow trephine biopsy from the same patient

whose marrow aspirate appeared in 1013. In the firsr. rhe
area chosen has few tumour cells recognizable with •
certai nty. even at this higher power. although two or
three of the larger cells with dark nuclei around the
centre of the field may well be carcino ma cells; bUI the
• .,• • 0 .
main feature shown is a pro minent reactive eosinophilia.
In the lower-power view of another area illustrat ed in 0- 0 • •
1015 there arc several syncytia l clumps of carcino ma
cells with reactive eosinop hils and ncutrop hils aro und, • •
though less conspicuous than in 1014. • -- 0

- •
.-.-• •
•., •

• • 0

• •
•• •
, ,
• ••
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: · u - '•

r t'

.~.- • C :z;;..;: :" ..

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,r ,
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.. 11 • •
.. . ; 1 •

• - .~ .. . , -I if
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1016. A section of bone marrow trep hine biopsy from

another patient with metastasis of breast ade nocar-
cinoma. The tumou r cells appear to be arra nged in a
pseudo-acinar fashion. and have perhaps been secreting
the eosinophilic mucin which occupies the centre of the
lowest acinus. A few fibroblasts are present.

1017 and 1018. Low- and higher-power views. respect- ,

ively. of a section of marrow trephine biopsy heavily
infiltrated with a fibrosing breast carcinoma . The
relative infrequency of epithelial cell nests and the
predominance of dense fibrosis are well shown in 1017.
and the irregular cytology of the malignant cell clumps
amid the surrounding collagen and fibrocytes appears in
grea ter derail in 1018.

• •
• •


. . •
,, : ..

.. ..• 'e.


. •
• •
, , 0

00 0
•,0• •

• t

1019. A nest of tumou r ce lls in a bone mar row aspirate

from a patie nt with bronchia l ca rcino ma . There is wide 1021
vari ability in the size of cells and their nuclei in this
pa rtia lly syncytia l clump.

1020. A high-power view tumour metasta sis in a bo ne ,
mar row sectio n. in this case fro m a pati ent with a thyroid
carcino ma. Th e cytology of the three co mpo ne nts ,
tumou r ce lls. fibrotic reaction , and resid ual marro w .
cells. can be see n in some de tai l.

1021. A case of bo ne mar row metastasis from prostati c

ca rcino ma see n in a tre phine biopsy sec tion. In this low-
power view there is evident erosion of the bo ny
trabecu lae and a conspic uo us fibro tic reaction around
the tumour cell nests.


22 ,..----------~,..------ 1 13

, ~ ". '

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1022. A high-power view of a section from a treph ine

biopsy of bo ne marro w. showing met astatic infiltration
with tumour cells from a clear-cell carcinoma or hyper-
nephro ma of kidn ey. Th e field illustrat ed is almost
devoid of residual haemopoietic ce lls and , apart fro m
the trabecular bone , contains only the polygonal tumour
cells with their variable nuclear chro micity and ample
clear cytoplasm.

1023. A very low-power view of a section of bo ne

, •
marrow trephine biopsy fro m a patient with Paget's
d isease of the bo ne with maligna nt fibroblas tic or
fibrosarcomato us change superveni ng. The fibrob lastic
and fibrocytic proliferation is ove rwhelming and probably
represen ts sarcomatous malignant change. Areas of
exte nsive erosion and destru ction of the trabecular bone
can be see n at the pe riphery. particularly at the upper
edge, while most of the remaining field is occupied by
whor ls of fibrosing tumour cells.

1024. A high-power view of a section of bo ne mar row

trephine biopsy from a patient with Ewing's sarcoma of
bone . sho wing the cyto logy and mitotic activity of the
tumo ur cells. with a multinucleat ed giant tu mo ur cell at
the bottom right. Middl e right of the field is a spur of
normal marrow tissue penetratin g the tumou r mass.



-_... ..



1025-1028, G ia nt cells ( Reed-Ste rn be rg cell s) from the 1t129

bon e marrow o f a pat ient with adv anced HD. Th ey
share the conspicuous lar ge blue nucleoli which are very
cha ra cteristic of HD giant ce lls in smea rs or imprints of
lymph nodes. Duplicat e Rom an owsk y and consecutive
PAS stains showin g the gene rally weak positivity which
mo st R-S cell s.manifest are sho wn in 1027 and 1028.

1029. Involvement of bo th marrow and periph eral

blood in the terminal stage o f HD may produce a
leukaemi a-like picture . Thi s doe s not occ ur commo nly.
but most exa mples reported appe a r to have shown
mon ocytoid primi tive cells. Illustrat ed here is the
periphe ra l blood picture in a term inal leukaemi c tran s-
formation o f HO. wher e the ce lls pro babl y be long to the
same lineage as R-S cell s.


1030 ,
• , • : 100


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. ,.• ,. e.': • •
1030. A very low-power view of a section from a bon e
marrow tr ephine biopsy, showing a rou ghly circul ar
nodule of HD infiltrate in the lower half of the field . T he
,.... ----. •
nature of the infiltra te cannot be det ermined at this
magnification , of co urse, but the field illustr at es how
infiltr ativ e nodul es ca n be det ected by sectio n scanning
at very low power .
1031. A high-power view of a neighbouring nodule to
that in 10~O , from the same section and sho wing the
mixed cyto logy with num erou s Hodgkin 's cells and
reactive eosinophilia. together with lymphocytcs and a •
co nside rab le fibrobl astic reaction ; the latt er is almost
always present in area s of marrow infiltra tion and is not
co nfine d to th e nodular scle ros ing vari an t of HD (which
does not ofte n involve the marrow),

1032. A high-powe r field fro m a section of bon e marrow

• ..
treph ine bio psy, tak en from a patien t with HD and
diffuse marro w invol vement. Th e mixed cyto logy is well • • •
show n - includ ing conspicuo us lar ge Hod gkin's cells and
R-S cells with their characterist ic prominent nucle oli ,

agai nst a background of scattered Iymph ocytes and less
freque nt po lymo rphs and fibroblasts.
Th e type of mar row infiltra tio n illustrated in this
secti on is most ofte n see n in mixed cellularity or
lymph ocyte-deple ted varia nts and carries a poor
prog nostic significance , certai nly requirin g aggressive
chemothera py.


1033. A blood smear in infection with Bartonella 1035

baci lliformis. Many eryt hrocy tes con tain the orga nisms.
with rod-s hape d o r somet imes cocco- bacillary fo rm. The
disease pro duced by this organ ism in man , Bartonello-
sis. Ca rrio n's disease o r Oroya fc is associa ted with
macrocytosis and hae molytic ana emia, and th is smea r
shows some polychromasia.

1034. Yeast-like bod ies of blastom ycosis in a spicule of

bo ne mar row . possibly und ergoi ng phagocytosis by RE

1035. A n RE cell contai ning many Leishrnan-Don ovan

bodies. fro m the ma rrow of a patient with kala-azar.
Variou s other mar row cells. a megakaryocyte. several
myelocytes and a lat c normoblast are also present.


1036. Ano the r exa mple of Leis hma nia, with o rganisms
within a mon ocyte and ot he rs liberated amo ng th e
surrounding cells. Below the monocyte is a clump of
platelets for comparison with the more sharp ly and •
positive ly staining Leishmania bodies.

1037. Furt her Leishmania parasites in a monocyte l


1038 and 1039. Co nsecutive Ro manowsky and PAS

reac tions o n the same field fro m a smear of bo ne mar row
aspirate tak en fro m a pati ent with Leish ma niasis. T he
cen tra l pai r o f macrophag cs contain bet wee n them a
dozen parasites. which can be seen in the PAS stain of
1039 to be weakly PAS-positive. There is a necrotic
Iymphocyte below the macrophages and normally PAS-
positive neutrophils to either side .



• , 'I

1040. Exa mples of leishmania Don ovan i infantum in a 1CJ.I2

group o f macrophagcs from a hon e marrow aspirate
taken from an infected Ethio pian child . Para sites may be
sce n lying free as well as in the macrophagcs.

ICJ.II and 1CJ.I2. Co nsecutive photographs of a bi-

nucleated macrophage co ntaining numerous parasites in
a marrow smea r from a patient infected with Leishmania
Brazilien sis, showing the sharp birefr ingence of the
parasites unde r polarized light.
1043 an d 1044. High-p ower and very high-po wer views.
res pec tively , of a field from a section of bo ne marrow
tre phine bio psy tak en from a pat ien t with Leishman-
iasis . In 1043 th e pleom o rph ic cyto logy can be seen. with
co nspicuo us increase in plasma cells and occasional
hisriocytcs amo ng th e normal haem opoiet ic tissue . Th c
Leishm ani a parasites are difficult to d iscern in sections .
of bo ne mar row, but a gro up of extrace llular pa rasi tes •
can just be dist inguished in 1044. a little to th e right and
above the cent re of th e field . Th e cyto logy of th e
predomina nt plasma cells is also well show n at th is

1045. Toxoplasma with in the cytopl asm o f a macro-

phage . T wo free orga nisms are pre sent tow ard s the
bottom right . and othe r single free o rganisms elsewhere.
Their larger size, spindle sha pe and banded nucle us
dist inguis hes the m clea rly from Leis hma nia and fro m
plate lets .

3 18
1 ~7

• •

-, •


1046-1048 . Plasm odium falc iparum infec tion . 1 ~8

1046. Ring form trop hozoites in eryth rocytes. T he

presence of seve ral rings in a single ery throcyte is
strong ly suggestive of P. falc ipar um .

1047. Anot her field showing further ring forms in many

red cells . There is also a mon ocyte in this field .

HMS. Crescentic ga rnetocytes, diagnostic of P. [alci-

paru m . In falcipa rum malaria the schizo nts do not
appear in the per ipher al blood and on ly the ring-shaped
trophozo ites and the cresce ntic gamc tocytes are likely to
be sccn in blood smears.



1049-1052. P. malariae infectio n.

1049. Ring-form tro phozo ites in erythrocytes.

1050. A n example of the coa rse ring forms found in P.

malariae infect io ns (a nd also in P. vivax and P. ovale,
but no t in 1'. [a/ciparum) .

1051. Maturin g troph ozoite.

1052. Schizonts contai ning be twee n six and 12 ro und

merozoi tes, togeth er with clumps of coa rse dark brow n
pigme nt.


;3 105-1

• "

.. ..


1053. Ring for ms in P. vivax infection . 1055

105~ . Ring-form and mo re mature tr op hozoi tes, from

P. o vale infection . Schuffner's dot s in the erythrocy tes
are co nspicuo us. as they may also be in P. vivax
infectio ns.

1055. A schizont in P. l 'i l 'OX infecti on. containing som e

20 merozoites and a quanti ty of den se bro wn pigment.

1056 . P. \-'i\lax infection . Ring-fo rm tro phozoites, a nd

liberation of merozo itcs from a fully deve loped schizont.


• •
•• • " • • • •

• •
". •


1057 and 1058. A nother exa mp le of a schizont in P.

vivax infection. illustr at ing the appea rance of a
Rom an owsky-stained smear under norm al illum inat ion
and then under pola rized light. The pigment dots are
seen to be stro ngly birefringent.

1059 and 1060. Further consecutive stains of the same

schizont as shown in the previous two figures . In 1059 the
slide has been restained by the Prussian blue re action for
free iron . but little or no blue staining can be seen , The
pigment particles do. neve rt heless, contain iron which
C3n be rendered accessib le to the Prussia n blue reaction
by prior trea tme nt with hydroge n perox ide . and in 1060
a blue reaction . albe it faint , can be detected afte r this
sequence of expos ures.

,\ \ 062


. .
1061. Tryp anosoma gumbiense, the most import ant 1063
species causing African trypan osomiasis. Th e kinet o-
plast is much smaller th an the centra l nucleus, the
undul atin g membrane is broad and the contor tions of
shape variable.

1062. T. brucei, present in some areas of Africa, has

generally similar morph ology.

1063. T. cnai. the ca use of Chagas ' disease o r South

Am er ican trypa noso miasis. has a much larger kinet o-
plast , a less conspicuo us undul atin g membrane , and a

more fixed horseshoe configuration.


Part 5

Imprints and sections of lymph nodes and


Cyto logical study of imprin t or needl e aspirate samples immunocy toc he mica l sta ins which fre que ntly re nder
of lymph nodes an d splee n co mp leme nts histo logical them particul arl y co nspicuous . Such stains may hel p in
st udy o f biopsy specimens and is especially va luable in ide ntifying the vari an ts listed above - fibro blastic R E
the diagn osis of infecti ve and reactive lymp hade n- ce lls are describe d as stro ngly positive for alkaline
opat hy, lympho mas and so me ot her metastatic tumo urs . phosph atase bu t o nly weakly so for es terases an d acid
and . in th e case of splenic mat erial. also in lipid oses, phos p hatase; den dr itic ce lls (C D 14 + , C D23 +) , mostly
mali gn an t histiocytosis and so me pri marily haem aro- fro m germina l ce ntres . are negative for phos phatases
logical d isorders with ex tra me du llary haemopoiesis. and weak in es terase ; interdigitating ce lls (C D40+ ).
T he no me ncla ture of lym ph nod e ce lls is confusing and chiefly from extrafollicular T vcel l zones , are nega tive for
several systems exist. In the illustrati on s here , certa in of alka line phos pha tase and react wea kly for acid
the more widely used synonyms are given initially, afte r phos pha tase and es te rase . The aut hors ' impressio n is
which the simple Kicl classification is used chiefly. that the se crite ria are no mor e th an ro ugh guidel ines;
readers bei ng expec ted to tra nslate as necessar y. T he ce rtai nly. the cytoc he mical po sitivity o f clea rly ph ago-
cytological differences between lymphomas, for example, cytic RE cells varies wide ly and is probab ly mu ch
are ge ne ra lly clear in the slides de picted, eve n if influe nced by the nature of the ingested ce llular
se ma ntic d ispute re ma ins . material. T he degree of variability of reaction in the cell
Phagocytic reticu lo-endoth eli al cells (RE cells) in gro up as see n in imprints is illustrated in this sect ion .
bo ne mar row and blood have been illustrate d pre viously We have includ ed illustrations of a wide ran ge of
in thi s volume; simila r cells arc conspicuo us in lymph malign an t disor ders affecti ng lymph no des. fro m
nodes whe re their development fro m mo nocytes Hod gk in's d isease (H D) and non -H od gkin ' s lymp homa
through an inte rme d iate mon ocyte/m acrophage or (N H L) . to seconda ry met astases fro m various tumours
epit he lioid cell may be envisaged . Ce lls o f th e same of non -haem ic cell origi n. Primar y lymph nod e tumou rs
family - perhap s the sa me ce lls in differ ent to pog raphi- are ofte n immedia tely diagn osab le with reason able
cal sites or at differ ent functiona l stages o f activity - ce rtai nty from impri nts mad e at biopsy, and typi cal
have be en separated by histo logists and electron micro- findings for variants of H D and N HL are pro vided .
scopists int o a se ries of type s. A pa rt fro m th e actively Histol ogical appeara nces in lymp h no de sections arc
phagocytic R E ce ll (histiocy te , macrophage , starry sky also incl ude d , par ticul arl y when th e struct ural infor-
cell, histiocytic reticulum cell) (CD 11b/c+) and th e ma tio n th ey pro vide is necessary for , or especially
ep ithe lioid cells, fibrob lastic, dendriti c and inte rdi gi- relevan t to , di agnostic classificati on . Fo r HD , the con-
tating R E or reti cu lum cells have been describ ed . Th ese ventiona lly accepted div ision s into Iymphocyte pre-
latter are no t ofte n clearly distin guishable in imp rint s, do mina nt, nod ular sclerosi ng , mixed cellularity and
perha ps beca use they te nd to rem ain in the suppo rting Iymp hocyte dep leted are followed , while for NH L the
stru cture of the node an d do not easily come free in Kiel classificat ion is gene ra lly used . The table here
tou ch or smear prepara tions . Th e R E cells th at do sho ws the co nd itio ns included in th at class ificatio n.
appear in imp rints are show n in Ro man owsky prep- together with their equivalence to an int ernatio nally
arations and also with va rious cytoche mica l and agree d 'working for mu lati on ' .

Classification of NUL Descriptions o f the histology and cytol ogy of
lymphoid tissu es and cells and of th e reactive and ne o-
\\'o rkin~ Form ulation Kiel Eq uivalent plastic conditions illustrated are given in further de tail in
Low grade Low grade the captions. Chromosome abnormalities frequen tly
A. Sm all lymphocytic. SL A . Lymphocytic: C LL occur in NHL. These include especially t(14 ;18) and
cons istent with CLL. Lymphoplasmacytic t(II ;14) in follicular lymphomas. involving the bel genes
Plasmacytoid Lymphoplasmacytoid on ISq and Ilq with the H-chain locus on 14q : the t(8 ;14)
Lymphocpithelioid of Burkitt's lymp homa and lymphoblastic lymphomas o f
T-zone lymphoma sim ilar cyto logy. involvi ng c-rnyc o n 8q with the sam e H-
B. Fo llicular, sma ll F-SC B .lC. Cc ntrocyticJ chai n locus ; and a ran ge of transloca tions in T-c ell
cleaved ccntroblastic fo llicular lymp homas invo lving th e various tcl ge nes o n lOq. lip
and diffuse and 14q. or the c-myc gene on Sq. with the alpha T-cell
C. Follicular, mixed F-M receptor locus on 14q.
small cleaved and Several examples of sections or imprints from nodes
lar ge ce ll with seco ndary metastases of solid tumours are given ,
interm ediate grade mostl y fro m nod e biopsies made before the primary
D . Ccntroblasridce ntro-
D . Follicular . larg e cell F-L tumo ur had been di agn osed and when lymphoma had
eyrie follirular o r diffuse been suspected . Since haematologists a re frequ ently
E. Diffuse. small cleaved D-SC E . Cenlrocytic . diffu se involved in the interpretation of such node biopsies. an
F. Diffu se. mixed sm all D-M F. Ccntrocytidcentro- appro priate range is illustrated he re .
and large cell +1- blastic diffu se Needle biopsy of the splee n may occasionally be
sclerosis/epit hc lioid diagnostica lly va luab le in co nd itions such as lipidoses
cells High grade and certain tropical d iseases like Leishm ani asis; a few
G . Diffuse lar ge cc ll D-L G . Ccntroblastic. diffuse illustrat ive examp les of the appearances of sp leen
High grade as pirates or imprints are provided .
H . Immunoblastic .largclB H . Immunobl astic Th e occur rence o f Icukaemic or lymphomato us infil-
ce ll (plasmacyto id . (B or T ) tra tio n in pleura , peritoneum or meninges, may lead to
po lymo rpho us. +1- C D 30 (ki - I)+ la rge the presence. o f neoplastic ce lls in pleural. ascitic o r
epithelioid cells) ce ll ana plastic. T o r B ce rebrospina l fluids. The neoplastic cells which may be
I. Lymphoblastic . LB I. Lymphoblastic see n in ce ntrifuge d deposits from these fluids look mu ch
co nvo luted convoluted T -cell as th ey do in buffy coat preparations from blood o r in
non -convoluted unclassified marro w. as illustr ated alrea dy in earlier sections of th is
J . Lymphoblast ic. small SNC J . Lymphoblastic . atlas. They are acco rd ingly not shown again here . bu t
non-cleaved Burkitt Bur kill ce ll type some illustrations are given of pleural lining cells . which
cell -type (B -ce ll) must be differentiated fro m neoplastic ones.
Miscellaneous: Mycosis fungoides and Sezary synd rome
(T< ell). extramedullary plasmacytoma (Bccell), histiocytic
and non -classifiable lymphomas.


1064 . Leis hman stai n: lym ph nod e im print: showing

three lar ge immun obl asts with ample baso philic cyto-
plasm , and ge ne ra lly p rimitive nucle i with nucl e oli more
centrally than peripher ally situated; a somewhat sma ller
cc ntro blas t or lar ge follicula r ce ntre ce ll, top left . with
high er nucl ear-cytopl asmi c ra tio but also with cyto-
plasmi c basophilia a nd three nucl eoli more towar ds th e
pe riphe ry of the nucl eu s ; mature Iyrnph ocytes appear
above a nd be low t he ce n tro blas t nea r the low est
immunob last; there is a single plasma cell near the central
immunobl ast and a mon ocyt e/m acroph age with a sma ll
inclusion a t the left o f the field . Th e rem a ini ng ce lls a re
centrocytes o r sma ll fo llicula r centre ce lls (Fee).

1065. Le ishma n sta in: lymph nod e imprint : seve n

immunoblas ts illustrate th e range o f size and cytology in
this group. Th e re ma ining ce lls in thi s field are mos tly
mature Iymphocytes.

1066 . Leishman sta in: lymph nod e im pr int : a co l-

le ction of ce lls fro m the follicu lar ce nt re a rea of a lymph
no de impri nt in reactive hyperplas ia secondary to infec-
tion . Against a backgroun d of small mature Iym ph ocytes
arc occasiona l small follic u la r"ce nt re ce lls (ce ntrocytcs)
a nd about a dozen large FCCs or centroblasts wit h
nu cleo li a nd so me cytoplas mic basophilia . In the upper
right co rner are seve ral imm unoblasts. a nd to their left a
histi ocyti c R E ce ll a nd a plasma celL


1067. Leishm an sta in: lymph node imprint : field to 1069

illustr ate seven large cells involved in a sequence of
probable developmental cha nges along the mono cyte-
epithelioid cell-macrophage (R E ce ll) line . Th e remain-
ing cells in this field are chiefly small lymphocytes .

1068. Leishman sta in : lymph nod e imprint: an exa mp le

of an epithelioid ce ll cluster in a lymph node showing a
reactive hyperpl asia seco nda ry to toxoplasma infection .
Around the cluster arc chiefly Iymphocytcs but with a
histiocytic RE cell (starry sky cell) at the bottom and six
larg e mon onucl ear cells. o ne in mitosis. at the ce ntre and
lower right of the field. Th ese cells are proh abl y
immunob lasts.

1069. Leishman stai n: lymph nod e imprin t: R E cells,

perhaps of the int erdigitating vari et y. with little evi-
denc e of phagocytosis, but with neighbouring Iympho-
cytes , occupy much of the lower half of this field. Two
are binucleated, the left with a n adja cent prob able tissue
mast cell and the right with a more basoph ilic cyto plasm
th an usual. The upper half shows a mixture of small
Iymph ocytes with dense nuclei and follicular ce ntre ce lls
o r centrocytes with more ope n nuclei . sho wing tran -
sition toward s centroblasts and with a single immuno-
blast toward s the top right corner.

1070 10

1070. SS stain: lymph nod e imprint : Sudan black

po sitivit y is shown in a hist iocyt ic R E cell and in three
cells o f th e monocyte-m acroph age line . All lymphoid
elements are negative.

1071. SB stain: lymph node imprint : positivit y is shown

in a neutrophil polymorph. Th e remainin g cells, including
macrophege s. centrocytes, cent rob lasts and immuno-
blasts, are all S8-negative .

1072. PAS re action : lymph node imprint : thi s pr ep ara-

tion from the same nod e as in 1069 shows fine granular
positivity in a few mononuclear cells o nly. One on the
left is probably an RE cell of th e int erdi git ating type with
granular PAS po sitivit y sprea ding out in the cyto plas mic
prolongation s be tween neighbouring cells. Two oth er
positive cells toward s the top of the field are . respectively.
a ccntro blast and a ce ntrocyte. A ver y occasional
Iymphocytc also shows detecta ble gra nular positivity.

32 '

1073 . PAS reacti on : lymph node imprin t: this prep- 1075

arationshow s no rmall y po sitive reactions in neutrophil
polymorphs but gen er ally negative reacti on s in Iympho-
cytes. centrocytes and ccnt robl asts. alth ou gh ther e is a
single small block of PAS- positive mat eri al in o ne
lymphocyte ju st be low the centre of the field . and weak
diffuse o r finely gra nular reaction s in the nar row cyto-
plasmic rim of eac h of two larger cells. probably
centroblasts, above the centre.

1074 . Alk aline phosphatase : lymph node imprin t: this

prepar ation from a reactive node shows lymphocytes.
ce ntrocytes. ce ntrob lasts and immunoblasts all to be
negat ive for this enzyme . while a single neu trophil
po lymorp h shows + + positivit y and a lar ge phagocytic
RE cell is o nly very weakl y positive - despite its obvious
past ingestion of various o ther cell types . probably
including a neut roph il.

1075. A lkaline phosphatase : lymph node imprint:

strong positivity is manifest in a phagocytic RE cell with
ingested cellular remn ant s: positivel y reactin g fibrils
spread o ut ove r a neighbo uring lymphocy te to give it a
spurious appea ra nce of pos itivity.

, -

1076. Acid pho sphat ase: lymph nod e impr int : very
strong positivity is seen in a phagocytic RE cell contain-
ing much ingested material, while at the opposite corner
of the field a smaller monocyte-m acrophage shows less
intense butstill striking po sitiviry. Most of the remaining
cells are of the lyrnph ocyte , centrocyte, centroblast
familyand show no more than occasional weak granular
'. .

positivity, but betwee n the cells spreads a network of

positively reacting fibrils proba bly deriv ed from the
larger histiocytic RE cell or perhaps from an incon-
spicuous dendritic RE cell.

1077. Acid phosphatase: lymph node imprint: several

strongly positive RE cells of variable size and shape are
seen against a background of Iymphocytes. These show
variable scattered positivity without any clear example
of T-cell type focal paranuclear reaction . There is a
wea kly positive polymo rph at the lower right.

1078. Acid phosphatas e: lymph node imprint: a phago-

cytic or histiocytic RE cell with much ingested material
(sta rry sky cell) shows relatively little acid phosphatase
positivity in contrast to a more strongly positive monocyte
or epithelioid cell. Lymphocytes here show mostly
, .
either negative orscattered granularreactions and there
are two large mononuclear cells, with variable weak
granular posi tivity. which are probably immunoblasts.
At the lower right corner is a positively reacting plasma

9 1080

1079. Du al este rase reacti on : lymph nod e imprint: this 1081

prep ar ation shows chiefly cortical area Tu lymphocytes,
with stro ng localized dots of butyra te esterase ( BE)
positivity, surrounding lar ger ce lls of the monocyte-
macrophage system. only one of which shoe..s moderately
strong BE positivity, the remainder being almost negative
with only a few chloroacetate esterase (Cfi} pos itive
granules . A norma lly CE-positive pol ymorph is present.

1080. Dual esterase reaction : lymph node imp rint: BE

positivity of moderate-to-strong deg ree in epithelioid
cells in this case. One has ingested aCE-positive
neutrophil. Most lymphocytes here do not show the
localized Tit type of BE positivity and are presuma bly
chiefly B cells.

1081 and 1082. Dual esterase reaction : lymph node 11182

imprint: these fields from the same case of reactive
hype rplasia show strong BE posirivity in RE cells
probabl y of the histiocytic o r ph agoc ytic variety. wea ker
reactions in occasional mon ocyte-macroph age ce lls.
and loca lized do t-like positi vity in certain lymph ocytes.
presumab ly of the Tit subset. A probable dendritic RE
cell with lo ng intercellular processes but rather weak BE
positivity is also shown in 1082.


" . •



1083-1096. Sections and imprints from lymph nod e

biopsies taken fro m patients with toxoplasmosis . The
protozoan parasite, although more easily detected in
imprints, is not often identifiable in sections, bur the
histological p icture is suffic iently cha racteristic to suggest
the diagnosis in m ost cases.

1083. A low-power view of a lymph nod e section from a

patie nt with toxopl asma infec tion. Th e histological
picture is a mixed one, with d istended sinuses including a
marked proliferat ion of histiocytes. and with further
histiocytic hyperpl asia in the par aco rtical areas , but also
with follicular hyper plasia and nume rous activated B
cells appearing as immunoblasts and plasm acytoid cells.
In this field the paler areas represen t gro ssly dila ted
sinuses with in the co rtex .

1084. A higher -power field from the same area as shown

in 1083. illust ra ting (he pa raco rt ical lymphocytes to the
left and the dense accum ulatio n of reactive histiocyt es in
the dil ated sinus to the right. The pa le vesicular nuclei of 0.

the mo nocytoid histiocytes and the frequ en t pre sence of

ingested mat erial in their cyt opla sm are clea rly visible
here . while similar large histiocytes are occasiona lly to
be seen amo ng the par acor tical cells.

1085. Anot her high-po wer field fro m a different area in

the sa me node. show ing the edge of a hype rplastic
follicle . sharply de marcate d fro m (he para follicular
lymphoid cuff. but with numerous lar ge histiocytes.


1086-1090. Imp rints from a lymph nod e biopsy ta ke n

from anot her pa tient with toxoplasma infect ion. show- 1089
ing the cytology and cytoc hemist ry of the reactive
process. The cells in the Rom anowsk y prepara tion in
1086 include a macroph age with spreading cytoplas m
and seve ral mo nocytoid ce lls surro unded by a pre-
do minance of Iymph ocytes. In the SB-sta ined field
sho wn in 1087 there is a single nor mally sudanop hilic
neu trophil and a met ach rom atically sta ining tissue mast
cell, while all the remain ing cells. includin g immuno-
blasts and mon ocyto id rnacroph ages. are S8-negativ e .
Th e PAS-st ained field illustrat ed at lower pow er in 1088
again has a mixed cytological con tent. with a few scat-
ter ed PA S-po sitive neutrop hils, includi ng o ne within th e
cyto plasm of a macrop hage. and vario us lympho cytcs.
centrob lasts and immuno blasts, as well as the con-
spicuo us lar ge mon ocyt oid macro phages. Apa rt from
the ncut rophil s. most cells he re appear PA S-negat ive .
or with no mo re th an a weak cytoplas mic tinge of re-
activity . visible in some macrop h ages. In both the du al
este rase and the acid p hos phatase reaction s sho wn in
1089 and 1090 the macrop hages and their monocyti c
precu rso rs are picked o ut by their positive re action s.
that for BE con trasting with th e CE reaction of neutro-
phils in 1089. The majo rity o f th e lymphoid eleme nts ar e
negat ive for bot h reactio ns. in co nfor mity with their
pre do mina ntly B-cell lineage.

1091 1091


109 1- 1094. Impri nts from another toxoplasma l lymph

node biopsy . In 1091 there is a central mo nocytoid
macrophage surrounded by imm u nob last s, whic h in turn
arc surrounded by Iymphocytes and centrocytes. Th e
more detailed cyto logy of these cells is shown at higher
power in 1092. wit h two monocytoid macrophages to the
upper right , and with eight immunoblasts around and to
the left of them . plus a centroblast at mid-bottom of the
field . and Iymph ocytes and centrobl asts peripher ally . In
1093 . aga inst a simila r cytological back ground , there are
two mature macrophagcs conta ining inges ted mat eri al
wh ich includes nuclear debris but also elliptical toxo-
plasma prot ozoa . The PAS sta in in 1094 shows two
stro ngly PAS-positiv e neutrophils, most ly ne gat ive
immu no blasts. gra nular cyto plas mic positivi ty in three
centrocy tes to the left of th e field and in a ce ntrob last
be low th e right-h and neutrophil. and pos itivity in a
to xoplasma par asite amo ng ot he r cellul ar debri s in a
macrophage at the to p right corner .

1095 and 1096. Lymph nod e imprints. from a patie nt

with recurrenc e o f lymph ad en opathy te n yea rs after
initial d iagn osis o f toxopl asmosis. Th e presen ce o f
irnmuno blastic and mon ocyte-macroph agc prolifcra-
tio n with num erou s mitoses. a ppare nt in 1095. and th e
mul tinucleated macroph age with mu ch ingested
materi al . incl ud ing a proba ble toxoplasm a o rga nism at
the ext reme right o f the cyto plasm . visib le in 1096 .
co nfirms persistence o r rec ur re nce of the disease .
1097 . .

1097-1099 . Leishman stain: lymph node imprints , 1099

sho wing chronic inflammatory changes. includin g
especially the fo rmation of Langhans giant cells.

1097. A gro up of epithe lio id cells with some phagocytic

activity surro unde d by Iymphocy tes and centroc ytes
from the chronic lymph adenitis of sarcoidosis.

1098. A foreign- body giant cell or Lang hans cell from

the same conditio n.

1099. Anothe r ex ampl e of a Langha ns multinucleated

giant cell from tubercu lous lymp hadenit is.



1100- 1105. Cytoc he mical features of typical Langha ns
giant cells as see n in imprint s of a lymp h node biop sy
fro m a fema le patient with chronic gra nulo matous
disease . Th ese cells a re probably de rived fro m multiple
nuclear division s witho ut cytokinesis occurring in macro-
pha ges . The seque nce o f stains illustr ated her e includes .
first . a Ro manowsky prepar ation . with flat nuclei of
moder ate chro ma tin co nce ntra tion. witho ut clear
nucleoli bu t with single are as o f localized chroma tin
co nde nsation. usually at the pe riphe ry . eac h probab ly
represe nti ng the inac tive X chromo some or Bar r body.
The bluc agra nular cytoplas m is eviden tly fra gile and
eas ily disru pted . In ll Ol the SR stain is esse ntially
negative except for a few scatte red granules probably
derived fro m an ingested neut roph il polymo rp h. T he
haem ato xylin co unte rsta in used in the PAS reaction of 11
1102 again shows the Barr bod ies well. while the cyto-
plasm has weak diffuse PAS-positivity. 'The dual esterase
react ion of 1103 has a modera tely stro ng gran ular
positivity fo r BE in the giant cell. with aCE-pos itive
neutrop hil top left. In 1104 ther e is the strong positive
acid phospha tase reactivity to be expecte d in a cell of
macrop hag ic o rigin. but the alkaline ph osph atase stai n
in 1105 is negative .


1106-1120. A section and a sequence afimpri nts f rom a

lymph node biopsy taken fro m a patient with Leuerer - I HIM
Stwe syndrom e, a form of histiocytosis X . the protife ro-
tin' mix ed granulom atous slate involvin g the nodal
equivalent of epiderm al Lan gerhans cells, perhaps
related 10 or derived fro m dend ritic reticulum cells.

1106. Th is section shows an area of th e co rte x with sinus

expansio n and monon uclea r histiocytic o r Langerh ans
cell hyperpl asia in the lower part. and se veral multi-
nuclea ted giant cells amo ng a prepo nderance of Iympho-
cytc s in the upp er part. Alt hough these giant ce lls bear
some resem blance to Langha ns foreign body giant cells.
they arc gene rally smaller . with fewer and oft en more
cent ra lly placed nuclei .

1107 and 1108 . Imp rints from th e same node biopsy as

in 1106. sho wing at low- and higher -power magnifica -
tion the cyto logy o f th e atypical Xchistio cytcs or
Lan gerhan s cells. Th ey tend to occur in clumps. have a
more irregu lar nucle us and more robu st cytoplas m than
Langhan s foreign body giant cells. alth ou gh with some
tenden cy to exte nd processes. Th ey ofte n appear to
co ntain p hagocyt osed materi al. th ou gh less active in this
respe ct th an th e co mmon histiocyte .

1109 • 11

1111 Ill.

1109- 1114. A sequence ofstains ofimprints f rom lymph 11

node biopsies taken from patients with eosinop hilic
granuloma, another variant of histiocytosis X .

1109. Thi s Rom anowsky-stained preparation shows a

nest of eosino phils surrounde d by a mixtur e of large
monocytoid Langerh ans cells and Iymphocytes.

1110. A similar high-power view of the second case

sho ws the mor e det ailed cytology of the Langer hans
cells and their close resemb lance to monocytoid macro-

1111 and 111 2. Low- and higher -power field s, from

SB-staincd prepa rations from the two cases, illustrating
that the histiocytic cells are generally suda nophobic .
11 -
1113 and 1114. PAS stai ns fro m the two cases . In 1113
there are probably six histiocytes present. two (one of
them with unstained crysta lline inclusions) sho wing
strong PAS-positivity. o ne containing bro wnish
gra nules of free iron . one nega tive except for a small
tetrad of positive mater ial. pe rhaps a phagocytosed
sta rch grain . and the two smaller histiocytes nega tive.
Prob ably only the last three cells are Langerhans ce lls.
the ea rlier ones being phagocy tic macroph ages. Th e
cells from the second case in 1114 are mostly negative .
except for weak gra nular positivity and a diffuse tinge in
o ne large cell to the left of the field. These are pro babl y
all Langerhans cells.
. ";1 • "',
.., .~; .~
,. •,

"'i' . ,. . \-



.•• .. . ....
I .
:;. ,.
,4 / ). .... ,

1115-1120 . Further cytochemical stains from the first of

these {WO cases, where, despite the undoub ted diagnosis 1119
of eosinop hilic granuloma. there is an intense con· •
comitant proliferation of phagocytic macrophages in
parallel with the proliferation of Langerhans cells.

1115 and 1116. Th e immense amo unt of free iron
demonstr able by the Prussian blue reaction in the lymph
nod e macroph agcs from this pa tient is shown in 1115.
Th is accumu lation is no dou bt chiefly in phagocy tic
macrop hages, o ne of which, laden with iron and also
much ingested materi al. includi ng numerou s red cells
from which the iron is derived , is sho wn in 1116.

1117 and 1118. Differ enl fields from the same du al

esterase stai n. In eac h there is a single CE -pos itive
neutrop hil and various negative lyrnphocytes and
centrocy tes . Three weakly BE-positive large ce lls. 1120
possibly La nge rha ns cells . are illust rated in 1117. con-
trastin g with the two much more coa rse ly BE-positive
phagocytic macrop hages in 1118.

1119 and 1120. Acid and alkaline phosphat ase stai ns,
respectively. o n the lymph nod e biop sy materia l, bo th
field s showing positi vity in ph agocyti c macroph ages.
Lan gerh an s cells a re difficult to identify in these pre-
parations but appea r generall y negative for both
pho sph at ases.


1121-1130. A small selection of lymph node biopsy

sections f rom patients with Hodgkin 's disease (HD), to
illus trate features of nodal structure relevant to diagnosis
of pathological variants , not readily apparent fr om

1121 and 1122. Both these fields are taken from an

exa mple o f the lymph ocyte pred omin ant va riant . where
lymp hocytcs and centrocytes grea tly predominate . but "~"~'
wher e both binucleat ed Reed-Sternberg (R-S) cells and
large mononucle ar Hodgkin's ce lls can be distinguished. .... .....- . .,
, \, -
These cells. with their conspicuous large single centrally
placed nucleoli . are quite numerous and promin ent in ...• .1. " ......:; ..... -
'.: .. 1, : ~ .,' .:
.. ~ ,,;.~..,\ J
112t. b ut less frequen t thnugh ea sily eno ugh identified • M It
in 1122. Diagnosis from imprint mat eri al ma y be difficult
when R· S and Hod gkin 's ce lls are few. and th er e may be
confusion with lymphocytic non- Hod gkin 's lymphom a
{l HL ) in the interpre ta tion of bot h imprints and
secti ons.

1123. A very low. power view of a section fro m a nod e

biopsy . illustrating the coa rse ba nds of fibro sis cha rac -
teris ticofthe nodular sclerosing va ria ntof H D (NSH D) .
Eve n at this low magnification . occasional R-S or
Hod gkin's cells surrounded by an empty space . the so -
ca lled lacuna r cells . especially found in NSH D. ca n be
made out. as can the presence of eosi no philia .
-. -~-, .
, ...... " ....
., -... . ':. ; .. .


., .' .

11 26


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

.. '.. . .. - -:..... ..... .:

' .-.--: : :.-:- , "
:- ~ -: ~ ......

, -;
, (
- .....
_ • 4 4

- : , .;

'.. _ 4 .

• ~ · ;-I " .-
-: . "-."

1124-1127. Furt her illustrations of structural pattern s 1127

of nodal and cellular architecture in NSHD . In 1124the
H&E stain shows a coa rse hand of densely fibrotic
mate rial separating islands of neop lastic tissue , includ-
ing a predominance of lacunar cells, conspicu ous among
the surrounding Iymphocytcs. In 1125 and 1126 similar
fields from sectio ns stained with the Mallor y and
Ponceau S methods respectively pick out the collag-
enous tissue with blue and red staining and the nco-
plastic cell nests with nuclei stained red or brown . The
higher-power view of an H&E-stained field in 1127
shows the more derailed cytology of the lacunar cells,
with their nucleolated nuclei and well-defined cytoplasm
contracted within the lacunar space" These cells are
surro unded by lyrnphocyt es with den sely chromatic
nuclei. intersperse d with larger a nd more lightly staining
cent rocytes .

34 1

1128-1130. A low-po wer and two higher-power views 11.

of different areas o f an H&E-st ain ed section of a lymph
nod e biop sy. from a pat ient with th e mixed ce llularity
variant o f HD (MC H D) . The pictu re is a gene ra lly
pleomorphic one . with . in 1128. a pseudofollicular
structure prod uced by an expanding nodule of neop lastic
Hod gkin's cells compressing the surround ing lympho-
cytes into the appea ra nce o f a sheath. but with man y
scatte red Hod gkin 's and R-S cells also present amo ng
the Iymphocytes. In 1129 seve ral of these large neo plastic
ce lls can be d ist ingu ished. an especially conspicuous one
at the lower centre. but there is also a marked eosino-
philic infiltra tio n a nd so me fibro tic activity appare nt
amo ng the ncopl astic tissue and the redu ced lymphocytic
component. An oth er area o f th e section, see n in 1130,
has a high er proport ion o f resid ua l Iym phocytes and
centrocytes bu t agai n a conspicuous pro liferation of R-S
and Hod gkin's cells.

1131-1133. Leishm an stain: lymph node imprints: H D-

mix ed cellularity. 1133

1131 and 1132. Low- and higher -power views. respec t-

ively, of the pleomo rphic picture commonly see n in
node imprint s from the disease . especia lly in the mixed
cellularity variant. Lymph ocytes, centrocytcs, oc-
casional centroblasts and immuno blasts mingle with
plasma cells. eosinop hil and, sometimes , neutrop hil
polymo rphs, and monocyte-macroph agcs. There is a
single large R-S cell with twisted or overlap ping double
nucleu s and large dark violaceo us nucleoli in eac h
figure . The extent of eosinophilia in this exa mple is
unusual , but some cosinop hils can commo nly be found
in most imprint preparat ion s fro m HO.

1133. An other area of the same slide . again showing

lympho cytcs. centrocytes, centrob lasts and an immuno-
blast (top rigbt), togetb er witb a plasma cell and many
eosinop hils. Ce ntrally. there is a macroph age or RE cell
with , on the right . a mononuclear R-S cell or Hodgki n's
cell with cha racte ristic nuclear chro matin and nucleoli.



1134-1136. Leishman stain: lymph node imprints: II D - 11-

lymphocyte predominant .

1134. A low-powe r view providing a more uniformly

lymphocytic and centrocyt ic backgro und. but with
one binuclea ted R-S cell and severa l mononuclear
Hodgkin's cells. Occasio nal monocyte-macrophage
type cells can be secn.

1135. A higher-power view of the same slide in which all

the cell types men tioned abo ve can be more clea rly
ide ntified.

1136. A still higher magnification of an R-S cell from

this specimen , to illustra te the typical reticular nuclear
chromatin and the large da rk violet nucleoli. Th e
surrounding cells a rc mostly lymphocytes.

9 11-10

1137-1139. Lelshm an stain: lymp h node imprint: /ID 1141

<nodular se/erasing to m ixed cel/ularity - m orphological
relation ships of R-S cells.

1137. A field showing various bin uclca ted R-S cells and
mon onu clear Hod gkin's gian t ce lls. A ce ntroblast at th e
lower right corner and a centra l immunoblast show
morphological similarities to the smaller of the Hodgkin's
ce lls and suggest a possible derivation of th e R-S ce lls
from activated B cells.

11 38. A second field from the sa me spec ime n allows

similar parall els to be dr awn : the R-S cell in the upp er
left corn er relat es to the probable mononuclear
Hod gkin ' s ce ll in the lower right. and that in turn to the
immunoblast above it.
1139. Yet anothe r area in th e sa me slide sho ws a
co llection o f histiocytic R E cells. som e with ingested cell
debris. which arc clearly morphologically distinct from
the R-S and Hodgkin 's cells of the previous figures.

11-10-11-15. Leishman stain: lymph node imprints :

variants of giant cells in liD.

1140-1142. Typically binudeated R-S cells. Th er e is

also a monon uclea r Hodgkin's cell in 1142.

1I ~3 11

1I~3 and 1I~ . Mononucle ar Hodgkin's cells, with

characte ristic nuclear and nucleo lar pattern s . In IJ44 a
pai r of these cells, one possib ly with overl apping doub le
nucleus . are se parated by a pair of RE cells o f clea rly
co ntrasting nuclear and cyto plasmic morphol ogy.

1145. A mitotic figure in an R-S ce ll. showing the clearly

intact nucle o li surrounded by separated chromosome s.
To the left of this cell is a macrophage.


• ;'

1146. PA S reactio n: lymph nod e imprint: HD. A

cle arl y binucleated R-S cell and five o ut of six mo no-
nuclear Hod gkin's cells. includ ing o ne in mitosis. show
glob ules or blocks of PA S pos itivity . Although the giant
cells of HD are mos t often PAS -negat ive . the ap-
pearance of glob ules of positivity as in this figure . o r
even coarsely scat te red granular posit ivit y, is by no
mean s rare .

1147. Acid phosphatase stain: lymp h node imprint:

HO . A binucleated R-S ce ll shows strong posuivi ty.

1148. D ual esterase reaction: lymph nod e imprint :

HD. Hod gkin's cells usua lly show little esterase posi-
tivity , as here . where weakly scatte red BE and CE
granules are detectable. in sharp contrast to the stro ng
BE positivity in a neighbouring giant RE cell. An
eos ino phil. a CE -positive neu tro phil and variably BE-
positive lyrnp hocytes co mplete th e field .

3~ 7
1J ~9 11:

1149 a nd 1150. Leishm a n stai n: lym ph nod e imprint : It:

chro nic lymphaden itis . Mult inucleat ed gia nt ce lls. with
flat e pithe lial-type nu clei and re la tive ly sma ll o r incon -
spic uo us nucleoli; no t to be mistake n for HD gia nt ce lls. •

1151 . Dua l es terase reaction from th e same speci men .

One of the mu ltinuclea ted giant cells shows strong BE
positivity, unlike R-S ce lls which are usu ally negative .
Localized dot-like positivity is seen also in some
probable T cells and there is CE positivity in several
ncu trophils and mixed reaction in a plasma cell.

1152-11 57. Lymph node imprints :[ollicular lymphoma. 11 5~

cen trocytic-centrobiastic; mixed small and large [olliculur
cen tre-cell lymphoma.

1152. Leishman stain: lower-power view of a mixtu re

of centrocytcs and centroblasts, with a scattering of
mature Iymphocytcs.

1153 . A higher-power view of the same preparation.

revealing large single o r occasio nally multiple nucleoli
in the larg er cells - ce ntro blasts - which often show
indentation o r cleavi ng of the nucleus. The two varieties
of sma ll-cell. den sely pachych rom ati c Iymphocytes and
more lightly sta ined cen trocytes, ca n be clearl y differ-
entiated .

1154 . SS rea ctio n in this nod e imprint shows all the

lymphoma ce lls to be negative. Th e single positively
reacting ce ll is a neu trophil pol ymorph .

1155 1156


1155. PA S reaction o n the same nod e imprint shows a li S-

little positivity in cyto plasmic fragme nts , and so me tinge
and fine granular react ion in lymph oma cells.

1156. Acid phosph atase reactio n o n this specimen

shows variable + to + + + positivity in lymphom a cells.
scatte red and not part icularly loca lized in the pa ra-
nucl ea r zo ne . There is a st ro ngly positive ij.E cell

1157. Dual este rase react ion here shows CE positivity

in a neutro phil po lymo rp h and in a tissue mast cell. with
BE positi vity of modest degree in an RE cell. possibly
dendritic. with fine processes exte nding bet ween neigh-
bo uring lympho ma cells. Th e lymph oma ce lls arc
essentially negative .

L58 ..,......,.... ..,.......- - - . . - - - - - - - . . , 1159


.... •
z- ... ~
o. •


.' , .:
:. r:

.' . "

1158-11 62. Lymph node sections f rom cem rocyttc- 1161

censroblastic malignant lym ph oma.

IlS8 and 1159. A very low-power view and a higher-

power field fro m an H&E -stain ed section. In 1158 mo st
of th e field is occupied by part of a nod ule of lymphoma
cells. wit h com p ressed norm al pa ra follicula r tissue at th e
upper and left edges. The tum our appears paler th an the
predominantl y lymphocytic surr ounding tissue . Th e
mixed cytology of th e follicular tumour is shown in de tai l
in 1159 ; the ce m roblasts have large and pal el y staining
vesicul ar nuclei wit h periphe ral nucleo li. th e cc nt roc ytcs
are smaller with dar ker nuclei and inco nsp icuo us
nucleoli . and th er e arc one o r two deeply stai ne d small
Iymphoc ytcs. Several mito tic figures ca n be see n .

1160-11 62. Immunocytochemical PAP reaction s on 1162

sec tions from the same biopsy. A negative co nt rol is
see n in 1160. and a reaction with the pan -B f\.lAb C D19
in 1161 - the latter showing stro ng po sitivity in more
matu re residual lymphocytes at the up pe r left and
weaker posi tivity in the ce ntrocytes and ce ntroblasts
co mprising the bulk o f the tumour follicl e in the lowe r
right of th e field . Th e negative T cell s, scanty with in th e
tumour tissue bu t more frequent in the cortical area ,
sta nd o ut clea rly. A rea ction with th e leu cocyt e co mmo n
MAb C D~5 is see n in 1162 wher e all th e cells in the
section sho w positivi ty of grea te r or less inten sity.

1163 11

11 •
1163-1168. Lymph node impr ints: lymphoblastic
lymphoma, B-cell type. I

1163 and 1164. Leishman stain: low- and higher -

power views of the neopl astic lympho blast tumour cells;
they sho w roun ded nuclei with moderately fine
chro matin and nucleoli varying in numb er between one
and thr ee o r four . mostly no t at the nuclear mem brane .
The re is moderately dee p basophilia in the narrow
cytoplasmic rim .

1165. 58 stai n: ther e is a single positive neutrophil

polymo rph. but the Iymphoblasts and occasio nal
Iymphocytcs are all quit e negative.

11 -

1166. PA S reaction: the blast cells are virtually entirely 1168

negative: there is some granular positivity in o ne
lymphocyte and the usual strong reaction in the single
neutrophil present.

11 67. Acid phosphatase: the blast cells are again

negative while a phagocytic RE cell is strongly positive .
A few positive granules are see n in a single plasma cell
above the RE cell.

1168. Dual esterase : the Iymphobl asts show fine

scattered BE positivity. A neutrophil polymorph is CE-

1169 11

1169-1174. Lym ph node imp rints: immunoblastic 1171

lymphoma, B-cell typ e, with some plasmacyto id differ -

1169 and 1170. Leishman stain: low- and high-power

views sho wing large immunobl astic ce lls with mod er ate
amo unts of basophili c cyto plasm and leptochromat ic
nuclei conta ining large but poo rly defined central
nucleoli. Most immunoblasts contain globular inclu-
sions, staining a greyish-green colour. like Russell
bodies, presumably represent ing secreted immuno-
globulin . Thi s feature is o nly occas ionally see n in cases
of immunoblastic lympho ma . but when pre sent
indicat es the secret ory Bccell natu re of the tumour.
Am ong the surro unding small cells , chiefly lymp hocytes
and ce ntrocytes, are som e with plasmacytic morpholo gy
occas ionally containing similar Russell-body inclusion
mate rial. Scatte red cytoplasmic fragments are con-
spicuous. especially in the high-power view. where
multiple small cytop lasmic vacuoles are visible in the
immu nob lasts .

1171. PAS reaction shows the immunob lasts to be

essentially negati ve. as are the globular inclusion s in this
insta nce , altho ugh more ofte n such inclusions sho w
weak PA S positivity. A single pos itive neutrophil ca n be
seen .

2 1173

1172-11 74. Imprints of lymph node biopsies from 1174

another two cases of immunob lastic lymphoma with
gene rally similar cytology but without the globular
inclusions seen in the previous case . In the first , the field
shown in 1172 again illustrates the characteristic
cytology of the immunoblasts and also the presence of
lymphoplasmacytoid cells amon g the lymphocytes and
centrocytes; the immunoblasts from the second case ,
depicted in 1173, have more irregular nuclear outlines,
as may sometimes be see n. The PAS reaction on the cells
from this exampl e. sho wn in 1174, is more variable in
positivit y than was the case in 1171, ranging from
negative to quit e strongly pos itive. with fine or coa rse
granules, as at the top left and lower right . respectivel y.
of this field. An occas ional block of PAS posuivity was
present in the immunobl asts in this case and o ne such
block is seen free from the cytopl asm in the centre of the
field. Variable PAS positivit y of this kind is not
uncomm on in immunoblastic lymphoma.


11 -

11 75-1178. Lymph node imprints: hairy eel/leukaemia

tucu .
1175 . Lei shrnan stain: the spec imen is composed
almost entirely of hairy cells (HCs) . Th ere is gross
cyto plasmic fragme ntation but there arc virtua lly no
nor mal lymph node ele ments . A single Iymphocyte can
he seen near the top left-hand corne r. •
11 76. PA S reaction: there is diffuse or finely gra nular
positivity in the background . which is large ly made up
of the fragmen ted cytoplasm of HCs. I

1177. Acid phosp hatase: most cells show moder ately

stro ng granular positivity. and ther e is also conside rable
backgro und scatte red positivity from cyto plasmic
fragmenta tion. O nly four norm al lyrnphocytes can be
de tecte d .
117H. Dual esterase: there is strong BE positivi ty in a
histiocytic RE cell. and weaker reac tion in the cyto-
plasmic rim of many HCs and in the scattered fragme nts
of disru pted He cyto plasm.

79 1180

11 79-1187 . Sections and imprints of lym ph node 118 1

biops ies fro m patients with peripheral T-cell lymp huma s
(Len nen :s lymp homa) . Tslyrnphoblastic lymph oma s.
lik e T-A L L , which they closely resemb le and into which
they usually und ergo transformation. ere regarded as
being derived from precursor T cells. but anothe r group
of lymphomas with diffu se histological distribution and
variable clinical course r eacl with ma ture T-cell markers,
often with CD.J. and do not possess Td T. Their mo, -
pho logy is pleom orphic, with the lymph om atous cells
either mature T cells or T immunoblasts or. more
com m only. a heterogeneous m ixture. but with a m arked
reactive com po nent of epithelioid histiocytes and increased
vascularity , The neap/astir T cells may sho w atypical
surface antigen expression , som etimes failing to react
with the pan · T marker CD 7, fo r example, but their clonal
origin can be confirmed by the demonstration of specific
TCR gene rearrangement in Southern blots.

1179-11 8 1. Successively increasi ng magnifications of

areas from a section of lymph node showing the
character istic features of T-cell lymphom a ; the
increased vascularity and conspicuous epit helioid cell
reaction among the ma lignant Iymphocytes are manifest
in 1179 and 1180. while de tails of the Teccll and
epithelioid-cell cyto logy a re revealed in 1181.

182 11 ,

1182 and 1183. Low- and higher-power views, respect- 11

ively, of a lymph node section from another case of
peripheral T-celllymphoma, again illustrating the mixed
but here chiefly large-cell immunoblastic neoplastic
cytology, the marked vascularity and the epithelioid
histiocytes, although the last component is less con-
spicuous in this case than in the previous one . In 1183
there is a multinucleated giant cell, probably of Langhans
type and derived from the reactive epithelioid histio-
cytes, a finding quite common in this kindof lymphoma .

1184. An immunoperoxidase reaction against the MAb

CD4 , on a section from the same biopsy, showing the
presence of the helper phenotypic antigen on the
malignant T Iymphocytes and immunoblasts. The larger
epithelioid cells and the vascular endothelial cells are
. --
negative. .,


85 11

1185-1187. Romanowsky, PAS and acid phosph atase 1187

stains on imprints made from a lymph node biopsy from
a similar case of periph eral T-cell (Lennert's)
lymphoma . In imprints . the feature o f increased vascu-
larity cannot, of course, be demonstrated, and the
epithelioid histiocytic proliferation is also less easy to
appreciate than in sections, becausethe epithelioidcells
tend to adhere to the cut surface o f the node and no t to
be adequately represe nted in the imprint. The mixed
neoplastic T-cell cyto logy . with a range from mature
lymphocytes to immunoblasts, is apparent in 1185,
however . with a gene rally negative PAS reaction -
exce pt for a single block in o ne immunobl ast (shown in
1186) - but with the strong localized paranuclear acid
phosphatase positivity typically found in T cells (as seen
in 1187).



1188-1 191. Sections and an imprint fr om an example of 1191

true histiocytic lymphoma ( TH L ), a localized variant of
the generalized system ic disease malignant histiocytosis.
Diagnosis usually requires cytochemical or immunocyto-
chemical confirmation of the cell lineage, with acetate or
butyrate esterase and acid ph osphatase staining. or with
positive reactions la CD14, since the neoplastic histio-
cyres in THL often show little ph agocytic activity.

1188-1190. Sections of lymph node biops y from a

localized nodal enlargement without evid en ce of
generalized disease . showing predominance of histio-
cytes, demonstrable as such by cytochemic al stainin g for
the mon ocyte-macrophage en zyme alpha- naphthyl
acetate esterase . as shown at low- and higher-power
magnification in 1188 and 1189, res pective ly. In 1190 an
acid phosph atase sta in o n anoth er sectio n fro m the same
material shows the strong positivity cha racte ristic of
histiocytes .

1191. A high-power field from an imprint preparation

fro m the same nod e biops y. showing an unu sual
example of multiple phagocytosis. Th e large r macro-
phage (histiocyte) contai ns two ingested cells. one
probably a ccntroblast and the ot her an uniden tifiable
cell in metaphase of mitosis. while the smaller macro-
phage below contai ns seve ral fragments of ce llular

92 1193

1192-1194. A lymph nod e imprint : Leishm an sta in: 1194

myelom a. Th e fields illustr ate variable size and staining
characteristics of ' infiltratin g plasma cells. occas ional
mar ked multinuclea rity . and the gene ral contrast
between the plasma cell eleme nts and the backgro und
centrocytcs , with their lighter nuclei and clear cyto -
plasm. In 1194. there is an example of a mitotic figure in
a myelom a cell with probable polyploidy. while ano the r
more norm al mitotic figure can be see n in a neighbour-
ing centrob last.


1195- 1197. A lymph node biopsy : imp rint preparations. 11

Leishman stain. Node infiltration by testicular teratoma.

1195. Three large tumo ur cells among normal and

reactive lymph node cells.

1196 and 1197. Cha racte ristic tumou r cell clumps: the
cytological structure of these teratoma cells is quite
distinct from any normal or lymphomatous component
to be found in lymph nodes .

198 1199


1198-1202 . Lymph nod e imp rints: metastasizing 1201

ov arian carcinoma.

1198and 1199. Two fields from the same Romanowsky-

stained preparation. to illustrate the striking morph -
ology of the ovarian tumourcells. with variability in size
and degree of cytoplasmic baso philia and large deeply
staining nucleoli. The cells are unlike any encountered
in either normal or lymphomatous lymph nodes.

12~1202 . The cytochemical stains shown here - the

PAS reaction in 1200, an acid phosphatase stain in 1201 ,
and an alkaline phosphatase stain in 1202 - all show
strong positive reactions in the tumour cell cytoplasm,
again unlike any cells of haemic origin.


103 12O-a

205 I~


j ...

1203-1208. Lymph node imprints : infiltration with

carcinoma lung.

1203. Rom anowsky staining revea ls replacemen t of 120"

lymphoid tissue by tu mour cells with fragile and
generally poo rly defined cytoplasm, and with smoo th ;.r , -,
structureless nuclei, occasionally mul tiple . T he re are
widespread scatt ered vacuoles . possibly of cytoplasmic r
orig in. .,-, f ,
1204. SB stain shows the lung carcinoma cells to be
sudanopho bic. There is a single SB-positive neutrophil
in this field , but the rema ining cells are probably all
tumou r ce lls.
. •. '~

, .

1205. Th e PAS reaction here shows a group of tumour

,. . ~.

cells with mod erately stro ng granular cytoplasmic posi-

nvi ty . surrounded by normal lymphoid cells with darker
nuclea r stai ning a nd negative PAS reaction .

1206. Th e dua l esterase sta in in this field reveals CE

positivity in a neut roph il and moderatel y stro ng BE
positivity in the larger , more lept ochromatic tumo ur
ce lls. with generally negativ e reactions in the occas ional
small da rk lympho id cells.

1207. Th e acid phosph ata se reaction in this view show s

a strongly pos itive macrophage. but no more than a
weak scattered gra nular reaction in the tumour cells -
with little evide nce of focal localization .

1208. The alkaline phospha tase rea ction is positive in

several of the large r neopla stic cells.

1209and 1210. Lym ph node im prints: cervical node with 1211

secondary gastric carcifl om a.
Low- and higher -power views, respectiv ely, of a
Romanowsky-stained preparation, showing a clump of
tumour cells with large size, high nuclear-cytoplasmic
ratio , irreg ularly cleft and indented nuclei with several
poorl y defined nucleoli. and dee ply basophilic cyto-
plasm. There are two or three degenerating necrobiotic
carcino ma cell remna nts a nd two normal neu trophils in
each field.

1211. Neuroblastoma cells in a lym ph node imprint.

The field shown of th is Romanowsky-stained pre para-
tion contains only two residual Iymphocytes. their
dar kly sta ined nuclei sta nding out in contrast to the paler
generally leptochro matic nucle i of the preponderating
ne urob lastoma cells. Alt hough in this area of the
lymph node imprint the whorled clump ing of neur o-
blastoma cell nests is not apparent. the cells show very
consp icuously the feat ure of dense chro matin spots.
sometimes called chromoccntres or karyocentres. within
many of the nuclei. cha racteristic especially of this type
of tumour and see n in few others except the related
medulloblastoma. ,

1111 120

1212--1215. A clump a/ breast carcinoma cells in a lymph 1214

node imprint.

1212. In this Romanowsky stain the breast carcinoma

cells appear as a largely syncytial clump with over 70
nuclei, many overlapping. and some showing earl y
necrobiotic changes. with an opening and reticula tion of
the nuclear chro matin . Most nuclei have a smooth and
flat appearance , with occasional purple nucleoli visible.
A diagnosis of breast carcinoma secondary could not be
made from this specimen.

I2B-1215. Cytochemical reactions ... to the PAS stain

in 1213, to acid phosphatase in 1214, and to dual
esterases in 1215- all show strong positivity. in the case
of the esterase reaction to BE. It is interesting to note
that each of these cytochemica lly stained cell clumps 1215
shows more clearly defined cytoplasmic outlines and a
less syncytial appea rance than in the Romanowsky stain,
perhaps because the cytochemical reaction products
tend to emphasize the periph ery of the cytoplasm, as is
notably the case in the PAS reaction.

1216-1219. Sections of spleen f rom patients with HCL. 1218

In this disease the spleen is generally moderately
enlarged, with diffuse infiltration with HCs. The splenic
fo llicles, Malpighian bodies, and the whole of the white
pulp are much atrop hied and often no longer visible,
while the red pulp shows Q characteristic combination of
heavy infiltration with HO and areas of marked pseudo-
vascular dilatation engorged with red cells, giving an
app earance resemblin g haemangioma . The pseudo-
sinuses are actually lined chiefly by tartrate-resistant acid
phosphatase (TRA P)-positive HCs rather than vascular
endoth elial cells.

1216 and 1217. Low- and higher-power fields, respect-

ively, from a thin section, showin g an area o f diffuse
infiltration of sple nic co nical tissue with HCs . The
typical halated appea rance of the HCs. with their
centra lly placed nuclei, irregularly marked nucle ar
chromatin, andample cytoplasm against an eosinophilic
background of red ce lls, is well shown .

1218. A low-power view of a thicker secti on from the

spleen of another case of HCL. more strongly staining
with H&E , showing the pseud osinuses eng orged with
red cells in the upper half of the field and the pre-
do minance of HCs in the less vascular lower half.


219 1220

1219. A higher -power view of par t of the same field as 1221

that shown in 1218. where the pscudosinuses with their
evident lining of HCs, and the characteristic nuclearand
cytoplasmic patterns of these ce lls. are shown in more

1220 and 1221. A splenic imprint: He L: Leishman

stain .

1220. Typical appearances of intact HCs in spleen

imprint. The nuclear pattern and moderate amount of
greyish cytoplasm suggest the diagnosis. although hairy
processes cannot be distinguished. A single RE cell is
prese nt. but no monocytes, no granulocytes and almost
no normal small lymphocytes.

1221. A spleen imprint from anot he r case of HCL. with

rather more variable nuclear patternsand a tendency to
cytoplasmic process formation and fragmentation . A
few nonnallymphocytes and neutrophil polymorphs can
be seen and there is a characteristic background of red
cells from the congested pulp.


1222-1229. Splenic imprints : Gaucher's disease. Since 1 22~

one of the most striking clinical features of Gaucher's
disease is splenomegaly , and the diagnos tic cells may not
be found in the bone marrow aspirates or trephin e
biopsies taken in the course of investigating the accom -
panying anaemia or cytopenias. this is one of the fe w
haematological conditions fo r w hich needle biopsy ofthe
spleen may still be diagnos tically valuable.

1222 and 1223. Leishm an stain: various Ga uche r cells

show the granul ar . fibrillar and onion-skin patt erns of
cytoplasmic lipid inclusion mate rial.

1224. 5B stai n: two granulocytes show suda nophilia but

the two Gaucher cells are essentiall y negat ive.



1225 and 1226. PAS reaction: a consecutive pair of

photographs o f the same field containing two Ga uche r
cells; the first shows PAS positivity of diffuse or finely
granular disposition and the seco nd, under polarized
light, shows the refri ngence of the fibrill ar inclusion
material. The brightly refringent PAS·pqsitive 'hot cross
bun' structure at the bottom is a starch granule, from
surgical glove-powder contamination.

1227. Acid phosp hatase: the Ga ucher cells show

strong positiviry.


28 1229

. ,


1228. Dua l esterase: two neutrophil polymorphs show 1230

normal CE positivity, while the group of Gaucher ce lls
show moderately strong BE positivity .

1229. Prussian blue reaction : the Gaucher ce ll in the

ce ntre of the field shows free iron staining of varied
intensity in much of the cytoplasm.

1230 and 1231. Anothe r dupl icate pair of phot ographs

of a field showing starch-powder contamination, similar
to that app eari ng in 1225 and 1226. In this instance. the
contamination is very much heavier and is seen in a
lymph node imprint from a patient with follicular
(centroblastic-centrocytic) lymphoma.


1232 11

1232. A splenic puncture smear: Leishman stain. A 11.:

conspicuous cluster of serosa l cells, picked up as the
needle traverses the pcritoneallining cells of the spleen
surface. The ir flat epithelial nuclear structure and
lanceolate cytoplasm arc very charac teristic.

1233 and 1234. Lcishman stain : splenic puncture

smear. Malignant histiocytosis (histiocytic medullary
reticulosis), showing gross phagocytosis of red cells by
malignant histiocytic RE cells. In 1233there is a mitotic
figure in one such RE cell, which also contains the
remnants of some six or seven erythrocytes, while a
second histiocytic RE cell contains within its cytoplasm
some 20 erythrocytes. In 1234 a similar cell contains
more than 30 erythrocytes .


• ,


r •

1235. PAS reac tion on the same prep aration as the • • •

previous two figures. Th e malignant histiocytic RE cell •
illustrated here contains four erythroblasts and shows
PAS positivity in the surrounding cytoplasm.

1236 and 1237. Prussia n blue reaction on the same

preparation at low and higher magnification to show the
accumulation of free iron in the malignant histiocytes
consequent upon the ingestion and breakdown of •

1238 123

123&-1243. Submaxillary salivary gland imprint: biopsy I'

of a regional lymph node included this material, which is • •
illustrat ed here /0 aid identification ofsimilar unexp ected
cytological biopsy findings.

1238. Leishman stain: clump o f ce lls from a spread and

disrupted salivary-gland acinus.

1239. Leishman stain: a more co mpact clump of acinar


1240. SB stain: several clumps of secretory epithelial

acinar ce lls show strong sudanophilia.

IUI 12-1

• •

• •

1241. PA S rea ctio n: further acinar cell clumps showing 1:2.

stro ng PA S positivity of the mucinous secret ory content.
Th e very dense PAS· positive materi al near the cell
clumps is sta rch from surgical gloves.

1242. Acid phosphat ase prepa ration showing strong

positivity. Th e acco mpanying lymphocyte s give some
impression of the gia nt size of these salivary gland cells.

1243. Dual esterase : the acina r columnar epithe lial cells

show scatte red BE positivity.
2~6 . ---- 124'


1244-1247. Impr int preparations from a post-auricular 12-18

nodular swelling occ urring in a patient with 1(8;21) AML
in haematological remission. A local leuka emic recur-
rence was susp ected , but biopsy revealed only the cerum i-
nous gland cells illustrated here . •
1244. Rom anowsky stain of this imprint material shows
typical ceruminous glandular epithelium , with the cells
containing multipl e dark blue staining granules of

1245. An acid phosphatase stain shows these cells to be

extremely rich in cytoplasmic enzyme.

1246 and 1247. Consecutively stained fields from this

imprint material, 1246 bein g a de color ized Le ishman
prep ar ation rest ained with the Prussian blue reaction for
free iron, and 1247 the same field reph oto graph ed after 12~9
the slide had been furth er stained by the PAS reaction . •
1248. A pleural effusion from a patient with HD :
Leishman stain : the specimen shows pleural lining
epithelial cells, sometimes binucleated (not to be con-
fused with Hodgkin's cells) and a mixed exudate of
ne utrophil polymorphs and Iymphocyte s.

1249. A high-power view of a PAS rea ction on pleural

exudate cells. Th e large cells with stro ng and coa rsely
granular PAS positivity are pleural lining cells. Neutro-
phil polymorp hs and an occasiona l lymphocyte show the •
normal expected positiviry.

Appendix: staining techniques

Purifi ed rea gen t meth od IHeyl! \ 1ay-G rii nwald-Giemsa

R~agents: Reagents:
(a) Azur e Bvthiocyanate (He yl): 1.5 g. in 200 ml. dimeth yl (a) May-Griinwald sta in: Prepare 0.3% so lution of powder in
sulphoxide (DMSO) . methanol by grinding with pestle and mortar . Filter after
(b) Eos in Y (G) (Heyl): 0 .5 g. in 300 ml. methanol. 2-3 days. Befor e use dilute 1:1 with buffer solution
(c) Stock. stai n : Mix: (a) and (b) togeth er. Store in da rk. (phos pha te buffer. pH 7.2) . Diluted so lution should be
(d) Buffer : 2.38 g. HEPES in 1 I. distilled water (O.OI M); pH discarded afte r o ne da y.
adjus ted 10 6.8 with IN NaGH . Store at + 4°C. (b)Gie msa : Add 0.6 g. Gie msa powder to 50 ml. methanol.
(e) Wor king stain: Add 3 ml. stock stain to 41.5 mI. buffer plus Sha ke to dissolve. Add 25 mt. glycerine. Filter after 2-3
2.5 ml. DMSO. Fresh working slain should be made up days . Befor e use dilute 10 ml. stoc k solution with 90 ml . of
dail y. phosph at e buffer (pH 7.2).

Ted nique: Technique:

1. Fix air-dried smea rs for 5 minute s with stock stain. Air-dri ed smea rs of blood or bo ne marrow are used . Coplin
2. Rinse briefly in distilled water . jars a re used throughou t.
3. Cover or immerse in Co plin jar with working stain for 25- I. Fix 15 minutes in metha nol.
35 minutes (for blood or bone marrow smea rs, respect - 2. Tr a nsfer without blotting to diluted May-Griinwald solu-
ively) . lion : 15 minutes .
4. Rinse in distilled water for 2 minutes a nd blot dry . 3. Drain o ff stain o n filter paper without blotting a nd tra nsfer
to diluted G iemsa so lutio n for 30 minutes.
4. Tr an sfer to phosphate buffer (pH 7.2) and agitate for
Lelshman 10- 20 seco nds .
5. Rem ove and blot dry.
(a) Leishman sta in (dry powder ): 0.15 g. in 100 ml. met hanol.
(b) Phosphate buffer pH 7.2 .

Techn ique:
1. Fix.air-dried smears in und iluted Leishman for 3 minutes.
2. Di lutel:2 with phospha te buffer for 8-10 minutes.
3. Wash in distilled wate r or phosphate buffer .
4. BIoI dry .
N.B. 8-/0 minutes staining fo r periph eral blood sm ears is quite
sufficie nt. but bone marrow specimens require 10-20 minutes
dep ending on the cellutarity .
(after MacFadu an and Da vis, 1947) (aftn Sheehan and Storey. 1947)
1. Fix. air-d ried smea rs in formalin vapour for 30 minut es. Reag,nls:
2. Wash in distilled water for 2 minutes. (a) Suda n black B (SB) (Gurr) : 0.3 g. in 100 ml. abso lute
3. Im merse in Co plin jar co ntaining equal parts 2% potas - etha nol.
sium fer rocy anide (Prussian blue) a nd 2% dil ution of pure (b) Buffer : Disso lve 16 g. crys talline phe no l in 30 ml. absolute
(37%) hydr ochloric ac id for I hou r . et ha nol. Add to 100. ml. distilled wat er in which 0.3 g.
4. Rinse with distilled water . hydrated disodium hyd rogen phosph ate (Na2HPO..+ 12H 20 )
5. Counterstain with 0 . 1% nucle ar fast red made up in 5% has been dissolved .
aluminium sulpha te solutio n for 30 minu tes. (c) Work ing stai n: add 40 ml. buffe r to 60 ml. S8 so lution a nd
filte r by suctio n. Kee ps 2- 3 months. Store in refriger ator .
Staining jars must be iro n-free .
- I. Fix a ir-d ried smea rs in formalin vapour for ~IO minutes.
2. Wash briefly in distilled water a nd blot dry .
L fmmerse in work ing sta in for 1 hour.
4. Wash off with 70% e thanol.
5. Co unte rstain with Leishman o r MGG .
-40% wlv fo rm alde hy de saturated filter pap " in bottom of
Copiin jar.

imodified f rom McMonus. /946) Mod ified Graha m-Knetl technique
Rtagt lflS: I. Fix air-d ried smears for 30 seconds (use stopwatch ) in
(a) Peri odi c acid sol ution: Dissolve 5 g. pe riod ic acid crystals 10 ml. -to% form alin a nd 90 ml. ethanol sol ution at room
in 500 ml. dist illed water . Sto re in dark bot tle. Keep s for 3 temperature .
months . 2. Wash with tap water for 10 seco nds and blot dry .
(b) Basic fuchsin: Dissolve 5 g. basic fuchsin in 500 ml. hot 3. Dissolve app rox . 250 mg. of hen zidine or o-t otidine " in
distilled wate r. Filt er when coo l. Saturate with SOl gas by 6 ml. eth anol a nd dilute with 4 ml. distilled wate r- Add
bubbling for 1 hour. Shak e with 2 g. activated cha rcoa l in 0 .02 ml. hydrogen peroxide (20 vol. ). When solution i
conical flask for few minut es unt il j ust clear a nd filter co mplet e. pour o nto slide without filtration a nd a llow to
imme diately through Wha tm an No . I filter into a dark react for 7 minutes .
bottle. Charcoal extraction should be done in fume cup- 4. Wash wi th tap water for 10 seco nds a nd allow to dry in ai r .
boa rd . Solution kee ps for 3--6 mo nths de pending o n how 5. Counters tai n with Lcishm an , diluted immediate lv with
often used. buffer, or use stand ard Ma y-Grunwald-Gi em sa tech niq ue
for co unte rsta ining .
Technique: • N .B. Both these compounds are carcinogenic and should be
1. Fix air-dried sme ars for 10 minutes in IQ ml . 40'Yo forma lin
handled with care.
and 90 ml. e tha nol so lutio n.
2. Wash bri efly in tap wat er .
Diaminohenzidin e ((lAB ) method for peroxid ase
3. Treat with periodic ac id so lutio n for 10 minut es .
4. Wash in distilled water a nd blot dry .
R~agtn ts:
5. Imm er se in Schiff's basic fuchsin in Co plin ja r fo r 30
(a) Fixative : Buffer ed fonnol ace to ne (B FA) - Na 2HPO..
minutes. ( Return fuchsin solu tio n to stoc k bo ttle imm ed i-
40 mg. , KH 2PO.. 200 mg. , ace to ne 90 ml. . co nce ntrat ed
atel y after use. )
form alin 50 ml., distilled water 60 ml. Stor e a t 4°C a nd use
6. Wash in tap wate r for 5-10 minut es .
co ld for fixatio n.
7. Counterstain with aqueous haematoxylin for 10- 15
(b) Stock phosphat e buffer : Dulbecco A , pH 7.3 - NaCl-tO g..
KCl 1 g. . anhydrous Na2H PO .. 5.75 g. , KH 2PO .. I g. .
Co ntro l smears ar e exposed to saliva ry digestion for 30 distilled water I 1.
minutes between stages 2 a nd 3. (c) Working buffer: Dilut e I I. stoc k buffer with 4 1. distilled
(d) Subs tra te : 3.3 'd ia mino benzi dine (D A B) .
(c ) H yd ro gen pe rox ide ( 1(x) vol.).
ALKAI.ISE PH OSI'll,\TASE (f) Working incubatio n solutio n: Dissolve 30 mg. DAB in
60 mt. wo rking bu ffer and add 120 1. of lOO va t. HlO l ; use
Rt agtnLf: immedi at ely.
(a) Stock propanediol buffer . 0.2M: Dissolve 10.5 g. 2- (g) Car azzi's aqueo us haematoxylin : Disso lve 75 g. potassium
amino-I-methyl propane-I I :3)-diol in 5(X) ml. distilled water . aluminium sulphate in 121) ml. warm dist illed water ; add
Store at 4°C; discard after 3 months. 1.5 g. haematoxylin powder dissolved in 3(X) ml. glycerol
(b) Working buffer . 0.05M: Mix 25 ml. stock buffer with by grinding with pestle and mortar ; dissolve 0.3 g. sod ium
5 ml. O. IN HQ and make up to 100 mt. with distilled iod ate in a littl e wat er a nd add grad ually.
water .
(e) Subst rate. to be made up freshl y immediately before use : TtC'hniqut:
Sod ium alpha-na phthyl phosp hate: 35 mg. I. Fix air-dried smea rs in BFA fo r 45 seco nds .
Fa..t Garnet GB C salt: 35 mg. 2. Rinse with distilled water and drain dry .
Working buffer : 35 mt. 3. Incu bat e in working substrat e so lution for 10 minutes.
(d ) Methyl green : 2% in distilled water . freed from co ntamina- 4. Rinse with distilled water.
tion with met hyl violet by extraction with chloroform and 5. Counterstain with Ca razzi' s (or ot her wat er -soluble )
kept free by storage at room temperature in co ntinuo us haematoxylin for I minute .
cont act with chloroform . 6. Rinse with distilled wat er and a ir-d ry.

Tuh niqut:
1. Fix air-dried smears in 10% formalin in absolute methanol
for 30 seco nds (use sto pwatch) at Cl-5°C. AC ID PHOSPHATASE
2. Pour fres hly pr epared substrate directl y on to slides and
incubate for 5- 10 minut es at room temperature. Substrate Reagenu:
must be used with in 5 minutes of preparation . (a) Naphthol AS·B I phosphoric acid : 10 mg .
3. Rinse slides in tap water for 10-15 seco nds . (b ) Fast garn et GB C salt (G urr) : 10 mg .
4 . Counterst ain with meth yl green for 1ll-15 seco nds . (c) Walpolc's acetate buffer , O.IM, pH 5.0: 50 ml.
(d ) Filter freshly prepared substrate into Coplin jar .
Good posi tive co ntrols are provid ed by slides from pol y-
cythae mia. infection. hairy ce ll leukaemia o r Hodgkin's
TeC'h niq u~:
disease .
1. Fix ai r-dried smea rs in forma lin vapour for 4 minut es .
2. Wash briefly in ta p wat er and blot d ry .
3. Incubate in subs trate sol ution a t 3TC for 1-1 '12 ho urs.
4. Wash briefl y in tap water .
5. Co unterstain with aqueous haematoxylin for 11l- 15 minut es.
For assessment of tartrate resistance add HXJ mg. U + )
tartaric acid to the substrare.


Reagents: Techniq ue:

(a) Chlo ro acc tate substrate so lutio n : use at o nce O.JM phos- 1. Fix air-d rie d smea rs in form alin vapour for 4 m inutes .
phate buffer (pH 8 .0) : 10 ml. 2. W ash briefly in di stilled wat er a nd blot dr y.
Alpha-naphthol A S-D chloroaceta te : 0.25 mg. (O.7 x 1O--4 M ) 3. Incubate in freshly prepared chloroacctate substrate solu-
in n.l ml. acetone . tion fo r 5---15minutes at room temperature .
Fast blu e BB salt : 15 mg. (Sx lO-·l M). 4. Wash briefly in d istilled water and blot dr y.
(b) But yrat e substra tc solution: use at once O.IM phosph ate 5. Incubate in freshly prepared butyrate substratc solution for
buffer (pH 8.0): III ml. 15-30 minutes, at room temperature and away from light.
Alpha -naphthyl butyrat e : 0.5 mg. (2.33x IO-" M) . 6. Wash briefly in distilled wate r.
Fast garnet GB C salt: 3 mg. (9 x l~M ). 7. Counterstain in aqu eou s haematoxylin for 5 minut es.
For testin g fluoride inhibition , add NaF 1.5 mg.lml. to 8. Wash in distilled water . blot dry and examine .
buff er .


Immun oper oxidase - indirect PAP Immunoalkaline phosphatase - indirect alkaline

(peroxidase-antiperoxidase) method phosphatase-anti-alkaline phospha tase
(A PAA Pj methnd
(a ) Specific primar y antibodies. e .g. ra bbit ant i-human Ig Reagents:
anti sera . specific for the different heavy and light chains; (a ) Primar y antibodies - any mur ine monoclon al . for example.
mou se monoclon al antibod ies. (b) Appropriate seco ndary an tibodies - anti -mou se immuno-
(b ) Appropriate seco ndary antibodies. e.g. swine anti-rabbit globulin in this case .
immun oglobulin ; goa t anti-mo use immuno globulin. (c) APAAP complex, con sisting of alkaline pho sphatase and
(c) Appropriate rabbit or mou se antipe roxidase- pe rc xidase mou se monoclonal antibody specific for alkaline phos-
co mplex. phatase .
(d) DAB pe roxidase cytoc hemical reag ent s. A solution of (d ) Incubation mediu m for alkaline phosphata se . 2 mg. of
5 mg. DA B in to ml. tr is-salin e solution plus 1 drop of naphthol AS~BI (or AS-MX) pho sphate are dissolved in
100 vol. hydroge n perox ide is freshly prepared and filter ed 0.2 ml. of N ,N-dimeth ylfonnamide , to which 9.8 ml. O.lM
befo re use. T ris-H Cl buffer, pH 8.2. are added . Immediately before
use , add 10 mg. Fast Red TR salt (or ano the r suita ble
Technique: diazonium sa lt) and filter directly on to slides .
I . Fix air-dried smears in methanol for 10 minutes to block When necessary, endogenous alkaline phosph atase activit y
endogenous peroxidase . ean be inhibited by addin g 0.24 mg.lml. (l mmol./I.)
2. Add primary antibody and incub ate for 15-30 minut es. A levam isole to buffer.
titrat ion effect may be achieved by using con centration s
ranging from 1 in 20 to 1 in SW . Technique fo r smears and imprints:
3. Wash in tris-saline solution for 5 minute s. 1. Fix air-dried smears in buffered formalin-acetone
4 . Add seco ndary antibody at 1 in 20 to 1 in I(X) for 15-30
(Na zHP0 4 20 mg. , KH 2 P0 4 100 mg.• aceto ne 45 ml. .
minu tes. co ncentrated formalin 25 ml. , distilled water 30 ml.) for 30
5. Wash as in 3. seconds at room temperatu re. wash briefly in distilled
6. Add PA P oomplex 1 in 20 to 1 in 40 for 15-30 minut es. water and allow to dr y.
7. Wash as in 3. 2. Immerse in 'Iris-buffered saline (TBS ) for 10 minutes, then
8 . Ad d DA B substrate and incubate for 10 minut es. tip off excess.
9. Co unters tain with aqueous haem atox ylin 1 minute . rinse 3. Add primar y mouse rno noclonal antibody and incubate in
and blot dry . moist chamber for 30 minutes at room temp erature.
Optimal di lution of MAb in TBS has to be selected for
individual MAbs .
4. Wash slides in TBS with three changes. 3 minute s each.
5 . Add anti-mouse Ig , diluted 1:25 in TBS. for 15-30 minutes.
6. Wash as in 4 abo ve .
7. Add APAAP co mplex , diluted 1:50 . in TB S, for 15-30
8. Wash as in 4 a bove . Intensity of final staining may be
increa sed by repeating steps 5-8 . with reduced incub ation
9. Add freshly prepared alkalin e phosphatase incub at ion
medium for 15-30 minutes.
10. Wash-briefly in tap water . rinse in distilled water and allow
to dry . .
11. Counterstain with haematoxylin for 2 minute s.
12. Mount slides in an aqueous medium such as glycerine jell)'


Ch loramphe nicol. effect in eryrhro blas ts 75 Hisriocyt es, sea blue 869-873. 898 (see also

Index Chromos omes (see Leukaem ia .

Lymphom a)
RE ce lls)
Histioc ytic medullar y reticulosis ( set'
M alignan t histioc ytosis)
N umbers in light type refe r to page Chronic le uka e mia (see Le ukae mia)
numbers in te xt , th ose in bold to pictu re
Congenit al uyserythr opcietic an aemia H istioc vtosis-X 269 . 891 , 89 2. uos-r 120
and ca ption numbers. (C D A) 7l1-l18 Hod gkin's dise ase (H D) 32-1
Cottage loaf ce lls (see Rcd ce lls) - lymph node sections and imprints in 1121-
A bbrev iati on s 380 1I.l8
Aca mhocyres (st't' Red ce lls) Crenation (see Red ce lls)
Crescent form ation (see Red ce lls) - ma rrow granulom a in 893 . 89-1
Acid phosphatase reaction (see a/so - marrow infilt ra tio n in 1025-1028. 1 0~'O-
ind ivid ua l ce lls and disorders ) Crys tals
- in plasma ce lls 819. 821 . 822 1032
- tec hni que 37H - Reed-Ste rnberg cell le ukae m ia in IU29
Acute leukaemia (st't" leukaem ia) - in RE ce lls 864-8M. 879
Dohle bodies . 69 , 390-393 Ho we ll- l o lly bodies ..... 47. S I , 62. 1-16. 1-17
A du lt T-cellleu kaem iallympho ma (A TL ) - ge nesis of .56
192 Do wn's syndro me
- tran sient mye loprolifer ative d isorder in H ypoc hro m ia (see Re d cells)
A lde r's a nomaly {Alde r-Re illy a nomaly) 70. Immunob lasts ae-t, 649-660. 1~1 066 .
389 566-568
Drep an oc ytes (see Re d ce lls) 107-1. 1078 (set' also Lympho m a. non-
Alk a line phosphat ase re actio n (set" aim Hodgkins. imm uno blastic )
indi vidual ce lls and disorders ) D rum stick a ppendage s 259. 26 1- 263
Dual esterase reaction (see also individua l - acid phosphat ase in 1078
- technique 378 - a lka line phospha tase in 1074
Amyloid materia l in macroglo bulinaemia cells and d isorders)
- techn ique 379 - PA S re action in 656
1147 - pe rox idase reaction in 657
Anaemia Echinocy tes (set' Red cells)
Elliptocy tosis (see Red cells ) - Sudan black re act io n in 1071
- ap lastic and hypo pla stic l-l , 24-27 . Im munocyroc he mical met hod s (see
- co nge nita l d ysery th ro poi e tic (C D A) 14, Endothel ial cells . vascu lar. in blood 962-
966 indiv idu al ce lls an d d isorders)
7l1-l18 - technique s 379
- dimorphi c 8, 9 Eosinoph il (set' Myelocyt e . Polymorp hs)
Eos inophilia 70 Inclusio n bodies
- hae mo lyt ic 13. 19-2 2, 129. 135-137, 15K- - in immu no blasts 1169-1171
160 - in ALL 62 1 ~2-I
- in A ML 292-JO.1 - in leucocyte s 396. 397
- - foetal 37 - in plasma cells 81 2-81 7. 821 . 822
- iron deficienc y 15. 1~IOH . 111. 132. 133 - familial 2H9-29 1
- reactive 283. 8-15 - in macro glo bulinae mia 849-S..lil
- le ucoe ryt hro blasnc 15 . 131 Infect ion (see Leucocytos is of infection )
- macrono rmobla...ti c 11.31- 37 Eos inophilic granuloma 1109-1120
Eosinoph ilic sta ining. diffuse. in myelocyt es Infectiou s mononuc leosis . Iymphocy tes in
- megalobl astic 12. 39-69 6-19-651
- - gran uloc ytes in 12. 69.73.74. 257. 265 560-562
E pithe lioid ce lls 32.... 1097 (see aim Iron , free (see also Pru ssian blue stain) I....
- pe rnicious (see Me ga lo blast ic ) 15. 109-118. sn
- sickle cell 13. 15-1. 155 Mo nocy te-macr o phage system)
Ery rh raemic mye losis a nd ery throleuka emia - ...purious sudanoph ilia on 977, 978
- side ro blasric 15. 112- 116 Kala-a zar 1035-1 ......
An gioimmu noblasuc lymphade no pa thy 1... . 89-105
... acid phosphatase in 103. 10-1 Kle iha uer re action 18
(A IL ) 6I\1-M.l Langerha ns cells 269 . 891. 892. 11(~1120
A nisocytos is (see Red ce lls) - dual esterase in 105
- PAS re act io n in 1JK-102 Langhans ce lls 269. 10'l8. 1099. 1100-1105
A rtefacts La rge granular lym phocytosi s (LGL) 192.
- buccal m UCO!\aI ce lls in a marrow smear - pe roxidase reactio n in 96
- Prussian blue stai n in 118 643. ...
970 LE ce lls 384 . 385
- crescent ce lls (set' Red cell s ) - Su da n black stain in 97
Erythroblasts 11 Leishman stain 3n
- droplet co ntaminati on ofhlood smear Le ishman-D onovan bodies 269. 1035--10+1
967.968 - ab normal 11, 19-69.72 . 73.75-11 8
- in CDA . 78-88 Leis hmaniasis (see Ka la-aza r )
- Ferrata stages of degenera tion 969 Lep tccytes (see Red cells)
- pseudo- elli ptocy tosis (set' Red ce lls) - giant . in eryrhraem ic myelosis 90-9-1. IIN)
- no rm al (see Normobl asts) 11. I-I S Leuere r-Siwe syndrome (see Histiocyt osis-
- se baceous skin cell in a ma rrow smea r 972 X)
- starch granule contamin ation 1225. 1226. - PAS reaction in 36. 37. 84. 98-102. IUS.
118. 1-19. .....9 . -153 Le ucocytcs (see G ra nulocytes .
1230. 1231 Lymphcc yrcs , Mon oc yte . Normal blood
Auer rods . cytology and cytochem istry o f Es te rase (see Du al es terase reactio n)
Fa t cells. stro ma l. in ma rro w smear 973. leucocyte s. No rmal bo ne marrow cells)
199. 200. 202. 203. 205. 208-225.2 29.231. Le ucocytosi s of in fect ion
237-239.2-I1 .2-I2 .~2-I7 . 25 1 .-I 1 5 .41 7
Flamin g ce lls KlI7-809 - ba cte rial
B ce lls (set' also Le ukae mia . chronic - - alkal ine phos phatase in 273
lymphocy tic a nd prolymphocytic. a nd Foe tal haemoglo bi n 18
Foe tal haemolyt ic d isease . PAS rea ct io n in - - Dohle bodies in 390-393
Lym pho ma . non-Hod gki n's) 7.190. 6-13. - - immu noblasrs in 65-1.657. 658
647 erythrobl asts 37
Foll icu la r ce ntre ce lls (see Lym ph node - ... to xic gran ules in 390...392. 658
Bartone lla baci llifo rm is infe ctio n 1033 - viral a nd mycoplas mal
Basophils (see Mye locyt e . Po lymorphs ) imprints and sections. Lymph o ma )
Gauche r 's d isease 269. 881-889. 1222-1 229 - - imm uno blasts in 649-653. 655, 659. 660
Basop hil sti ppling (see Red ce lls) Le ucopenia 69
Birefringe nce (see G a uc he r 's d isease . G lycogen (set' PA S rea ction in specific
condition s) Le ukaemia
Re ticu lo-endo the lia l cells . Starch - acu te lymp ho blastic (A LL) 190. 595-639
gra nu les ) - inclusion bodies in megakary ocytes 465.
-169.470 - - acid phos phatase in 605. 618, 623
Bla stomycosis 10M - - d ual esterase in 606 . 619. 620. 63 2
Brilliant cresy l blue sta in 71. 127. 129. 161. - sto rage disease 269 . 149.899-9 04
GranuI0C )1es.67. IM-W-I (seealso - - cytogene tics of 190
162 - - eos ino ph ilia in 621-62-1
Bu rkitt 's lymph om a . marrow invasion in Met am yelocyte . M yel o blast . M yelocyte .
Po lymo rph s . Pro myelocy tcs. Sta b ce lls) - - FA B class ifica tion of 190
Grumpre cht's shadows 676 - - - L1 . L2 . L3 va ria nts illus tra ted 596.
Burr cells Isee Red cells) 597.610. 612-617. 627
Ca bo t ri ngs 156. 157 H ae mo glo bin-F. Klei ha ue r reaction for 18
Haem o glo bm -H inclu sion s 162 - - imm unocy toch emi stry in 607-609. 628.
Centroblasrs a nd centrccyres (see Lymph
node imprints and sections. Lymphom a) H aem o po iesis . cu rrent concepts . activator s 62"
and inhibitors 7.8 - - immunol ogica l classifica tion of
Ce ru mino us gland cells in post-auri cular ... - - nul l. C- A LL. pre-B . B- a nd T-
nod e biop sy lz.u-I2-I 7 H airy ce lls (see Leukae mia . hai ry ce ll)
H and-Schu ller -Christi an dise ase 269 . 891 vari ants illustr at ed 607-610. 613--617.
Chedia k- Higashi-S teinbrinck anomaly 70. 625-<>29.633-<>39
398 Helmet ce lls (set' Red cells)
He inz bodies 160 - - normoblastic hyperplas ia in 6.'6
Ch e modecto ma ce lls in marro w IJlJK-IOO3

- - PAS reacnon in 600 . 60 1. 603. 6l).S . 615 .

- - ptrox)dao;,r reaction in 59'9. 6JO

- pe ro xidase rea ction in 335
- Ph chro moso me in 332
- skin infiltrati on in 329-331
- - T -r-s cppressor ce lls 6-12--6-$.4. 6-16. 647
- - T- ~-hel per ce JJ s ll4.l--6.s8
Lym phoma 192, 32..a
- - Sudan blacL. stai n in 598. 611. 614. 626. - - Sud an black stain in 336-338. 359. 367 - Hod gkin's (st't' Hodgkin's disrObe)
iJ l - chro nic myelomonocytic (C M ML) .wH. - non-lIodgkin's (NHL)
- acute mi xed lympboclas nc-myeloblastic J09 . 588-59" - - acid phosph atase in 721. 1156. 1167
phenotype 19 1. 6JO-632 - emerging re mission in acu te fo rms , - - a lkalin e phosphat ase in 725
- acu te myeloi d (AML) 67 cytologica l fea tures of 536-547 - - Bu rkitt 's , marrow inv asion in 74-1-7..a7
- - acid phosphatase in 2U6. 243. 255. 422. - hairy ce ll (HCL) 191. 7" 8--772 - - centroblastic 702. 70S, 711. 7 12. 7~7J3
' $1 - - acid phosphatase in 75H. 759. 765. 1177 - - ce ntroblastic-cenrrocytic 72l-725. 1152-
- - cyt o ge ne tics of (set' also specific defects - - a typical variant 762-766 1162
below) 68 - - azu ro phil inclusions in 751 - - ce ntrocvr ic 70 1, 70.1, 7 13- 7 15
- - d ua l este rase in 193. 207. 224.225 .229. - - bo ne marrow secti ons in 767-712 - - c1as...ifi~tion o f
2.a.a--2-I7. 256. 303 . JO..&. 3 13• .s2J . 42-1. 427. - - du al este rase in 760. 766. 1178 - - - Kid 32..a, 325
.s42• .s43. 446. 455. 502. 510 - - lymph node impri nts in 1175-11 78 - - - Wo r king formul ation 32..a , 325
- - erythro- I ~ , 89-105 - - ne ut rophil alka line phosph atase in 76 1 - - cytogene tics in 325
- - erythromyeloi d 450-455 - - PAS reaction in 752 . 757. 764. 769. 1176 - - dual esterase in 709. 722. 1157. 1168
- - erythromyetomonocytic ....7-449 - - peroxidase rea ction in 657 - - foJlicular ce nt re ce ll 701. 72l-725. 1152-
- - FA R classificat io n of 68 - - phagocytosis by hair y ce lls 755 1157
- - immunocytochemistry in I'M. 198 - - ribosome-lame lla co mplex in - - histioc ytic , t rue (T H L) II~I 191
- - megakarycblastic .$82--495 - - sple nic sec tion a nd imp rints in 1216- - - immunoblastic 703. 706-7 10. 1169-11 74
- - monoblastic/monocvnc 410-4.0 1221 - - Le nnert's 773-775. 1179-11 87
- - myeloblastic 190-2 15 - - Sudan black sta in in 756. 763 - - lym pho blastic 716-720. 7.w. 741
- - myetomonocyuc 4-$-I.--U6 - - vacuol ated cyt oplasm in 750. 755 - - - B-eelltype 7.w. 741. 74-1-7,,7.11 6l-
- - PAS reaction in 192. 221- - histiocv nc 269 , 905-921 1168
22.\. 228. ~U2 . 2..10.&. 301 • •'02. 312 . - - acid phosphat a se in 9 1" . 915 - - - T-eell type 716-722
419-421 • .s26 .~39-JJI .""9 • .s53.4S7 . - - alka line phosphat ase in 921 - - PA S re actio n in 70-1-706. 720. 724 . 747.
492--495.501 . 519.532 - - d ua l est erase in 916. 9 11 II SS. 1166. 1171
- - peroxidase re action in 200. 2 16. 217. - - fre e iro n in 918--920 - - Sudan black Sla in in 746. 1154. 1165
415• .s16. 5 11-513 - - PA S reaction in 9 12. 913 - - T-cell . peri pheral 77l-775. 1179-1187
- - promy elocy nc ( A PL) wit h I ( 15;17) 226- - - Sudan black sta in in 910. 911 Macroc ytosis (see Red ce lls)
256 - mast ce ll 957-%1 Macro glob ulinae m ia 192, ~51
- - Suda n blac k ..rain in I 'll . 196.202.203. - plasma cell ( PC L) KOI~13 - dual est e ra se in 839 299.300. 311. - prolymphocytic (PLL) 191, 66J--675 - Durcher bodies in 8-19-851
411.413.414.41 7.4.\7.438.445. -148. - - acid phosphatase in 670. 672. 674 - iron-laden macrophages in 84fl...S.t3
452.486.491.499.500. 514-518. 530.53 1 - - B-eell varietv of 664 . 666 . 669. 67" . 675 - mast cell s in 8.14-837. 839
- - Type lfType 11 lineage a nd - - d ual esterase in 671. 673. 675 - PAS reaction in 838 . 8..~. 851
differentiation classification 68 - - PAS reac tion in 6tIS. 669 Macronormoblasu 11, 31-35. 37
- - with basoph ilia J09-3 13 - - Sudan black stain in 667 - PAS re actio n in 37
- - with defec ts of 5q o r 7q 521-523 - - T-cel l variety of 665. 66H. 670-673 Macrophages (see RE ce lls)
- - with inv o r ins 3;3 488-195 Leukaem ic reticuloe ndot hel iosis (L RE ) (see Malari a l pa rasit es 1046-1060
- - with t(6 ;q ) 524-532 le ukaemia , hairy ce ll ( HCL» Malignant histioc ytos is 269, 922-927. 1233-
- - with t(8 ;2 1) 208--225 Lymph node im prints a nd sections 3H .237
- - with triso m y IS 496-502 - cyto lo gy a nd cytochemistry of 1064-11 78 M arr o..... histo lo gy in tre ph ine biopsy
- - wit h cq- 5Ol-520 - - in ca rcino ma sections in
- - wit h Ilq23 ab normalities ~3 - - - br e ast 1212-1215 - Al l
- - with 16q abnormalities 292-J04 - - - gastric 1209. 1210 - - at relapse 637-639
- chronic lymphocytic (CLL) 191 . 676-700 - - - lung I lOl-l 208 - - during remi ssion ind uctio n 6JJ-6J5
- - aci d phosphatase in 681 - - - ovary 1198-1202 - A Ml
- - alkali ne phospbatase in 6IU - - in chronic lymphadenit is 11.s9-1151 - - in assessing n ind uct ion and
- - d ual esterase in 682. 683 - - in HC L 1175-1178 re lap ses 551-559
- - gra nular (G LL) 192,643,64-4 - - in HD - - multilineage 5J4, 535
- - immu nocy toch e m istry in 685. 686 - - - Iymphocy te pred o min ant 1121. 1122. - - - secondary to M DS 533
- - ma rro w histo logy in 687-692 I IJ.l- I 136 - A MonL 428--433
- - ma ligna nt tra nsformati on - Richt er's - - - mixed cellularity 1128--1133 - ang icimm unobtastic lymphadenopathy
svndrome 69l-700 - - - nodula r sclerosing 11~1127 . 1137- (A l l ) 661-663
- - "PA S re act io n in 679. 680 1139 - A Pl :z.l8-251
- - smear ce lls in 676-678 - - - Reed-Sternberg cells in 1131-1 1.&7 - aplastic a nd hy poplastic a na e mia 2.&-27
- - T-cetl va ria nt 686 - - in myeloma 1192-1194 - artefactua l globules in 979
- chronic mye loid (C M L) 68. 320-JSJ - - in neuroblastom a 1211 - ca rci no ma
- - acid phosp hata se in .M7. 361 . 369 - - in non -H od gkin 's lym phoma (NH L) - - breast 1014-1018
- - alka line ph osphat ase in 332-3.M (s!'t'tJb o Lym phoma) 1152-1171 - - kidn ey 1022
- - basopbils in 305, 320. 321. 33 7, 371-37.1 - - in re acti ve hyperplasia 1064-IOH2 - - prost at e 1021
- - bla stic crisis (se!' mal igna nt progr essio n - - in sarcoidosis 1097. 1098 - - thyroi d 1020
be low) - - in secondary testi cul ar terat om a 1195- - Cl l
- - defective ne utro phil gra nu lari ty in .\25 1197 - - foca l a nd d iffuse infiltra tive patterns
- - du al este rase reaction in 348. 362. 370. - - in tox oplasmosis 1083-1096 687-692
3lI2 - - in tubre rculo us lym phadenitis 1099 - - transfo rm a tio n to Rich ter's synd ro me
- - ju ve nile form o f 68 . 375-383 Lymphoblasts 190, 595-639 (see 698--700
- - liver infiltration in J28 Leukaemia, acute lymphoblastic (A LL) . - CML326. 327. ...1
- - malignant progression to Lympboma . fympboblaenc) - - mal ignant progre ssion of 339-.lU• .M9-
- - - lympho blast-type cris is .\63-370 Lymp hocytes 7, 190, 6.atJ-6.I8 357• •\6l-365• .a8J
- - - mye loblast-type crisis 349-362 - azurophil gra nu les in 642 - Ewings sa rcoma 1024
- - - myelofibr osiv megakaryocyuc/ - B-cell fea tures 643. 647 - fibrosa rco ma 1023
myeloprolifera tive state .\.\1J..-.3.sH - bin uclcated 641 - Gauche r 's d isease 886--SS 9
- - ma rro w histology in 326. 327• .\39-JoU. - granu les in A lde r 's a no ma ly 389 - hae mol ytic an aemia 19. 22
349--351 • .l6.\-J6S - reactiv e {see- lmmunoblasts) - HC L 480 . 767-772
- - PA S rea ction in .3-16••160. 368. 373 - T -ce ll fea tures - - fat -lad en macr ophages in 975. Q76

3 2
- histiocytosis-X 892 M velo blast 67. 169. 170. 173-175. 178 (set' ... cytopla...mic disruption in 805
- H od gki n's d isease 283. 893. 894 .10,:40- leukaemia. A ML. myeloblastic) - dua l est er ase in 803. 827
IO~U Mye locy te 67. 169-IU. 178- 180. 185. 188. -- flaming a ppearance of cytopla... m in 807-
- kala-azar 1l}.lJ. IO-U 199 (see leukaemia . C M L) 1lO'I.820
- leucocvtosis . infective a nd reactive 279- - basophi l 305 - inclusions in vacuoles in 820
283 ' - eosinophil .284 - iron . free stai na ble in 792-797
- macroglobulinaemia SoU...S51 - giant 257 - locular degenerati on in 818
- malignant hi...ti0C)1OSis 92$-927 Myelodys plastic synd ro me (M D S) 69 . 7-9. ... multiple nuclei in 806
- M DS 122-124. 167. 168.569-571.575- 119-121.560-565.569-59-1 (seealso - in mveloma 798-83~'
58..' • Leukaemia . C M M L. Refract ory anaem ia - nucl e ar bridging in 804
- - hi...uocvtosi ... in 895-898 (RA). with sideroblasts ( RA S o r RSA ). - nucl ear inclusions in 812. H13. 818
- - pse udo-Gaucher ce lls in 874 with excess blas ts ( RA E B)) - PAS re action in 813. 817. 822-S24
- medullobla...toma 993-997 Mvelofibrosis ... in plasma cell leukaemia 801-803
- megalob lastic a nae mia 39~ 40 - ~arrow histology in se, 339 . J.W. 559. - Russell bodies in 814-817
- myelofibrosis 30. 339. 340. 559. 940. 941 9-10.941 ... the ..a urocv te varian ts of 81U. 811
- mvelo ma SOO. 828-830 - red cellsi n 131 Pla s modi um
- n~uroblastoma 9AA-992 M yelogranular d ysp lasia 560-562 - falcipa rum 1046-1048
-N HL Mvelo ma 192.798-833 (.fet' also Plasm a - malari a e 1049- 1052
- - Bccell. Burkitt ce ll type 742. 743 Cells) -- ovale 1054'
- - cen troblastic 712 - ac ute leu kaemic tran sformation o f 83 1- - viva x 1053. 105.5-1lI60
- - cen troc ytic 7 13-715 lU3 Plat elets 70. 456-459. " 62-1 66
- - cemrocyuccentrob lastic 734-736 - lymp h nod e imprints in 1192-11 94 ... gianl 463
- - immu nobtastic j tu, 711 a-Naphth yl acetate es te rase in ... phagocytosis of 464
- - lymp hocytic-ce ntrocytic 737-739 megakaryccytes 476 Pleural effusion
- - T -cetl . convol uted lymphoblastic 719 a-Naphthyl butyrate es terase (see Dual ... cytology of pleura l linin g ce lls 1248
- - T-cell. periphera l 773-775 este rase) - - PA S reaction in 1249
- normal 166 a -Naphthyl chloroacetat e esterase (see Dual Poikilocytosis (see Red cell s)
-- polycythaemia 23. 28-.\0 esterase ) Pol ychromasia (see Red cell s )
- thrombocvtbaem ia 482 Neurobla..tom a cell.. 9~1J92. 1211 Polycythaemia . primary and secondary. I~ .
-- thrombocytopenia . autoimmune .lS. 472. Normal blood leu cocytes lS-JO
473 -- acid phosphatase in 318 . 6.U . 645 Polym orpbs 67
-- VAHS 928-931 . 940. 941 - dual esterase in 189. 319 . ~ - ag ra nula r 212. 214. 21~. 268. 269. 274. 32.."
Mast cells 953-961 - PAS react io n in 186.314 - basopbil Ixt , 183. 184. IK6. 269. 30.5-308.
- d ual esterase in 960 - peroxidase rea ction in 184.316 31J-316.321.337.3.'8 .371...373 .~24-532
- in macroglobulinaemia 8J.&-.837. 839 - Sudan black Sla in in 181-183.315 ... in emerging rem issio n of ac ute leuk aemi a
- PAS reaction in 961 Normal bone marrow cell s 166 (see also !-46,547
- Suda n black sta in in 9$9 indi vidual ce ll type s ) - eosi nophil 181. IS6. 181- .'ta-l. 31J-JI6.
May-Grun wald Giemsa sta in 377 - acid phosph at ase in 187 1131-1133
May-Hegglin anomaly 70. 394. 395 - d ua l este rase in 188 - multi-lobed in pern icious a naemia 73. 7·1-
Med ullobl asto ma 993-997 - PA S re action in 185 265
Megak ary o bla sts 67 . •\41-348. 460. 484. 4X5 - peroxidase re action in 179 - neutrophil 73. 74. 176.181...184 , 186. 187.
Megakaryoc yt es 67. 456-462. 465--195 - Pru ssian blu e sta in in 110 189.201. 204. 207. 258-2Mt . 262-265 .
-- in e me rg ing remi ssion o f ac ute leukaemia
- fragments in periphe ral blood 345-~\4X .
- Su dan black sta in in 180
No rmoblasts It . 1- 15
- in iro n deficiency a nae mia 106-108
26H. 271-273. 284. 306 . 31J-316. ~'H(~399 .

- - gia nt gran ules in 398

462 - - PA S po... it ivit y in 108 - - phagocytosis of plat ele ts by 46-1
- glycogen inclu..ion bodies in .ui5. 469. 470 - nests around central macrophage 11...15 - - tox ic gra nules in 266. 267. 390-392
- ph agccyrosi... by 4774 79 -- - alkali ne phosphatase in 13 Pompe's d isease (see G lycogen . sto rage
Me gaka ryoc yt ic myelosis 339-.348 . 482-195 - - Prussian blu e sta in in 14. 15 disease )
Megalobla...ts 11. 39--{,9. 72. 73 Nucle ar bridging Pre leukaemic sta tes (set' ~1 D S )
- gigantic .$X - in CDA 78. 79 Proerythroblasts 11. I-S. 22. 41. 42. 62. 7.5-
- ' inte rmed iate ' or ' transit io na l" 63-69 - in myel oma 804 rt
- nuclear extrusion in 60. 61 Nucle~r twinning ... gia nt 76. 77
- rosette formal ion in 53. ~ - in A PL 227. 233-235. 240 - vacuolation in 75
Met amvelocvte 67. 17B-172. 178-180 - 'in myel oma 804 Prolympbocytes 190 (set' aim leuk aemi a .
- eos ino phil'.284 - in neutrophil potymorphs 264 PLL)
- gia nt 69. 545 Osteoblast.. 943-952 Promooocvtes 67 (see also Leuk aemi a.
M icrocytosis (st't" Red cells) - acid phosphatase in 948. 949 AML. monoblasticrmonoc vticj
Micronormoblasts 12. 106-108. III - alka line phos phat ase in 946. 947 Pro mve locvtes . 67 . 169-171 : 176- 178. 187.
- PA S positivity in 1118 - PAS re actio n in 945 25i(st'f' ~lso le ukaemia . A ML. A PL)
- Pru .....ian blue reac tion in I II Os teoclast 942. 950-952 - coarsely gran ular in emerging remission of
Monoblast 67 ( "f(,f' leukaemia . AML. Pap pen he imer body 147 acute leukaemia 543. $44
mon oc yric/mono bla stic . myelcmon ocytic) PA S (periodic acid -Sch iff) reactio n (re- ... eo ...inophil 290
Monocyte 67 . 174. 177.405--107 (St't' indiv id ual ce lls and d isorders ) ... gia nt 257
leukae m ia. A ML. monoc ytic/ - tech niq ue 378 Pr u...sia n blue sta in
mo no bla...tic. mvelomo nocv tic) Pelg er -H uc t anomaly 70. 387 • •'88 ... in C D A 85
... ca rbo n particles' in 399 . Pe ro xidase reac tio n ( "H't ' individua l ce lls and ... in Gaucher's disca...e 1189
- gra nu le.. in 4415-1( 17 disorders) ... in haemolvuc a naemia 159
... vacuoles in 406 - techn ique 378 - in hi...tiOC'o"iic leukaem ia 9 18. 919
Monocyte-macrophages 324 Pe ye r' s patches 1911 - in iron deficiencv ana e mia 111
... in lymph node impri nts 1067. 1070. 1079. Ph (Ph ilad elphia) chro moso me 322 - in macroglobulinaemia SW . 842
1131-1135 Plasma cell ... 19(1. 789-&33 - in mal igna nt bistiocytosi... 923. 12..'\6. 1237
- in peripheral blood from bacterial - acid phosphatase in 802. 82..". 826 - in marrow fleck!" 109- 112
e ndocarditis 855-S57 - in A MonL "12 - in monocyte-macropbages 856
Monocvtosis . rea ctive 70 - azu ro phil rods in 819 - in non -ringed siderobla..ts 117
Men c~lI.. 814. HI5 - in ca t-scra tch disease 789 - in normoblast-macropha ge cell nests 14.
Multinucle a t ed giant cells in chronic - comparison wit h normoblasts 10 15
Iymphade .uis 1149-1151 - crysta lline inclusion... in 821. 822 - in plasma ce lls 792-7'17

- in RE cetb 14. 15. 109. 110. 87 1. 873 - acid phosphatase in 862. 1076-1 078. 11$6. Star ch gran ules. in smears a nd imprints
- in ringed side roblasts 11.1-116 1167 122..~12 Z7. 1230. 1231
- in sea-blue histiocvte, 871 , 873 - a lk.aline pbosphatase in 13. 861. 1074. - birefringence of 1226. 1231
- in sideroblasnc anaemia Ill. 11.1-116, 118 1075 - PAS re act io n in 12~
- technique 3n - in blastomvcosis 103-1 Stem cell s 1R hae mopoiesis 8. 67
Pse udo-elliptocy tosis (see Red ce lls) - blue crys tals in 864-866 Suda n blac k stain (see indi vidual cells and
Pseuco-Ga ucner ce lls 864-868. 87.1-87f, - ce llular de bris in 852-854. 858 d isorders)
Pse uoo-P e tger - Huet phen o men on 215. JX8 - dual esterase in 863. I07 9-WS.2. 1148. - techniqu e 377
Pyruvate-kinase (P K) def iciency 1157 T ce lls
- renculocvt osis in 129 - in emergi ng remission of acu te leukaemia - helper 6-U-6.a8
Re d ce lls' 540-542 - sup presso r n.&2-64-l. 646. 647
- aca m hocyt es or spur ce us 143. 163. 164 - fat -laden ?7J/!, .v : Tart ce ll JM
- anisocytosis 62. 72. 73. 130, I.B. 13-1. 137, - free -iron stain in 1:1. IS. IU'J. 110.871. Terato ma . testi cul a r , in lymph nod e 1195-
I~ 873.923 1197
- basophi l stippli ng 72. 126. 148 - in Gauc he r's d isease 881-889.1222-1227 Th a lassaemi a . re d cells in 150. 151. 153
- bu rr ce lls 13. 141 - - bir efringen ce of 884. K85. 1226 Th e sa uroc ytes 810 , 811
- co-ocy ses (set' tar get ce lls) - grey -gree n crys tals in 879 Th romboc ytopenia 70
- cot tage loaf shape defect 142 - in Ha nd- Scb uller -Chn stian d ise ase 891 - megakaryocytes in 70. 467-a73
- crenation }·n. 142 - interdigitating 1069. 1072 Thrombocvtosi.. a nd th rombocvthaerma 70.
- c re sce nt formation 140 - in kala-azar 1035-100U '477-482 ' .
- dacryoc ytes 131.165 - in lym ph nod e impri nts a nd sections 6 16. Toxoplasma HMS. 1068. 1083-1 0%
- d repanocytes 13. 155 1066-1070.1072-1082.1133,1139.1148, Try pa nosoma
- echi noc yte s 13. 141 1156, 1167 - bruce i l{){i~
elliptocytes 13. 138
helme t ce lls 152. 153
- multinuclea ted 858
- in Nie rna nn- Pick disease 890 .: , ....
" ",
- cruzi 1063
- gambiense 1061
- hypoc hromia 132-13-1. 150 - PA S rea ction in 860 , 92-1. 1072 Tubercu losis . lymp h nod e imp ri nt in 1099
- leptocytes JSO' - as pseudo-Gaucber ce lls sti7. '168. 87~ Tumour ce lls in marrow 269
- M3~TOCVIO'> i s 62. 72-74. 146, 153 1I78 - bre as t carcinoma 1010- 1018
- rmcrcc yrosis 132 - - birefringe nce of 868 - bronchial carcinoma 1007-1009. JOl9
- ·Jrma I 16. 17 - see -blue ma terial in 86473 - chemodectoma (paraganglioma) 99~
- ,>olkllocyt osis 12. 13. 62. 72. 73. 131. 133. - in sp lee n imprint s 1220. 1222-1227 HMI3
13J. ISO. 152. 154 - Sud an bla ck sta in in 859. 1070 - Ewing 's sarcoma of bo ne 10 24
- · '·ar· ,lro p 131. 165 - tox oplasma in 1045 .- fibrosa~rcoma 1023
- pu .. chro-nasia 70. 125. 137 Ried er ce lls 596 - gas tric ca rcino ma 1004-1006
- pseudo-clhptecytosis 13. 139 Romanow sk v stai ns 377 - hyperne phro ma 1022
- -ouleau- I·U . 145 - purified re agent method (Heyl} 377 - med ulloblastoma 993-997
- schis tocyt osis 143. 153. 163. 164 Ro ule au x {see Red ce lls ) ,. - neuroblastoma ~992
- vc; ling Is.! . 155 Rus..o:.ell bodies 814-817. 1169-11 ".pros icca rcinom a 1021
- - rder tic 158. 159 Sa liva ry glan d impri nt 1238-12-13 - thy 1020
- sp her oc ytcs 13. 135-137. 153 Sa rcoidosis. Iymph nod e imp rints.1097. Uraemia. red cell cha nges in 143
- SpUT' cells 13 . 143, 163. 164 1098 Vacu ol ation
"pu, nik ce lls 163. 164 Schistocv tosis (see Red ce lls) ": ~ '-' - in bla st ce lls
- stomatocvt , , 13, 128. 158 Sea- blue histioc ytes 869-873 ... - of AL L 602.603, 613
- target<; j3 . 1$0. IS'. 153. 154. 163. 164 Sebaceous skin cell . in mar row sme ..r 972 - - of A M L 226-228. 30'1-313. 489. 509 .
Reed- Sterub -rg cells Serosal cells (see sple nic imprints) 516
- ac«t ph-spbatase in 1147 Sezary's syndrome 191. 776-788 - in Bur kin lymp homa cells 744-747
- d ual e- ' erase in 1148 Sick le ce lls (see Red cells) - in e . yt hro blasts . as ch loramphenicol or
- Ieu kae mic invol vement 1029 Sideroblasts 12. 114-118 alcohol effect 75
- :n lymp h nod e im pri nt s and tio ns 1121- Siderocyt es (see Red ce lls) - in hairy cells 750. 755
114H Smear ce lls. in e LL 676-678 - in irnmunoblasts 65H
- ill marrow 1025-1029 Splenic aspirates . imprint s a nd sectio ns - in mon cc ytes aee . 649
- PA S re action in 1146 - cyto logy an d cytoc he mis try of 1220- - in mon ocyt e-m acro phage s 855-H57
Re fract o rv anae mia 1237 Vascul ar endothe lial cells . in blood smear
- with excess blasts ( RAE BI SfiO-565. 574. - in G aucher's disease 1222-1229 962-966
577- 587 - in HeL 1216-1221 - lkelinephos phatase in 966
- with sideroblasts ( RAS or RSA ) Il2- U4 - in malignant histiocytosis 1233-1 237 ,infect io n (set' Imm uno bla sts)
Re n culocyt e s 11.12.70. 71. 1~129, 161 - serosal ce lls in 1231 rocytes (see Imm unoblasts )
Reticulo-en dot he lial ( RE) ce lls 269 . 852- Spu r ce lls (set' Re d ce lls) Vi ru s-associ at e d haemo ph agocyti c
924 (seealso Leu kae mia . histiocytic, Sputnik ce lls (see Red ce lls) svnd ro me 269. 92H.-939
M acro ph ages . M alignant histiocy tos is. Stab ce lls 169-171 , 175. 178. 187.258. Wald en strtlm 's ma cro globulina em ia (see
Mo nocyt e-macroph ages) 266 M acro glo bu linaemia )
6 16- 0 7
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