Bone marrow biopsy and clinical staging in chronic lymphocytic leukemia

Practical Importance of Routine Paraffin-Embedded Bone Marrow Biopsy in Multiple Myeloma

Paraffin-embedded bone marrow biopsy specimens obtained prior to (37) or after (25) therapy from 62 patients with multiple myeloma (MM) were analyzed with particular reference to infiltration pattern, extent of infiltration, and myeloid to myeloma tissue percentage ratio (MMR) to verify their mutual relationships and clinicopathologic relevance. Fifty-nine biopsies were evaluable for infiltration pattern (diffuse in 27, interstitial in 25, and nodular in 7). Diffuse and interstitial patterns were more common (P < 0.025) in stage III and stage I patients, respectively. A higher (P < 0.001) mean serum paraprotein level was found in patients with’ the diffuse pattern than in those with the interstitial pattern. The average extent of infiltration by myeloma cells in the residual myeloid tissue was higher (P < 0.001) and a high extent (75% or more) was more frequently (P < 0.005) seen in diffuse than in interstitial pattern cases. The average MMR value was lower (P < 0.001) and a MMR value less than 1 was more frequently (P < 0.005) seen in the diffuse pattern group than in the interstitial pattern group. All these differences were present also when a separate analysis was performed for treated and untreated patients. It seems that a diffuse histologic pattern, as opposed to interstitial, would significantly predict a bone marrow extent of infiltration of 75% or more, a MMR lower than 1, a higher serum paraprotein level, and a clinical stage III. Bone marrow biopsy appears thus to play a role in providing parameters of prognostic relevance in MM also in the course of the disease. Prospective studies are needed to establish whether histologic pattern has an independent prognostic value.

Role of ofatumumab in treatment of chronic lymphocytic leukemia

The management of chronic lymphocytic leukemia (CLL) has dramatically improved in the past decade with the addition of anti-CD20 monoclonal antibodies to the treatment armamentarium. Ofatumumab is a novel anti-CD20 monoclonal antibody recently approved in the US and Europe for the treatment of CLL refractory to alemtuzumab and fludarabine. Preclinical data showed improved complement-dependent cytotoxicity and antibody-dependent cellular cytotoxicity compared with rituximab. Clinical studies have shown single-agent activity for ofatumumab in CLL and in other low-grade non-Hodgkin's lymphomas. Combination studies are being conducted to enhance the therapeutic efficacy of ofatumumab. This paper reviews some of the key clinical studies that led to approval of ofatumumab, and future directions.

The significance of the bone marrow biopsy pattern in chronic lymphocytic leukemia: a prognostic dilemma

Although bone marrow biopsy pattern (BMBP) has long been suggested to be an independent prognostic factor in chronic lymphocytic leukemia (CLL), conflicting reports continue to appear in the literature. To investigate this issue we retrospectively reviewed 70 CLL patients who had undergone bone marrow biopsy at the time of diagnosis in a multivariate Cox regression analysis together with other prognostic factors. There were 51 (72.8%) males and 19 (27.2%) females with a median age of 60 years (range, 38-77). The median follow-up time was 24 months (range, 1-76), and median survival was 44 months. Thirtyfour patients (48.6%) had diffuse and 36 patients (51.4%) had nondiffuse BMBP (14 nodular, 11 interstitial, and 11 mixed). The median survival for diffuse and nondiffuse BMBP groups were 17 and 53 months, respectively (P= 0.05). Sixteen patients (22. 9%) had stage A, 28 (40.0%) stage B, and 26 (37.1%) stage C disease according to the Binet system, and four patients (5.7%) had low-risk, 39 (55.7%) intermediate-risk, and 27 (38.6%) high-risk disease according to the modified Rai staging system. The difference between the median survivals of patients in different stages was statistically significant (P < 0.0001). The BMBP and staging systems that are thought to be significant predictors of prognosis were used to build a multivariate Cox proportional hazard model. BMBP was not found to add additional information to the prognostic value of the staging systems. Our results underline two points: first, the significance of BMBP must be investigated in multivariate analysis including the stage, and second, BMBP is not a dynamic prognostic parameter, it is an index of tumor burden and does not add any prognostic information beyond that provided by clinical stage.

A low blood lymphocyte count is associated with an expansion of activated cytotoxic lymphocytes in patients with B-cell chronic lymphocytic leukaemia

In order to determine the relationships between CD2+ lymphocyte subpopulations and tumour mass, the immunophenotype of natural killer (NK) cells and T lymphocyte subsets was studied in 56 B-chronic lymphocytic leukaemia (B-CLL) patients and 38 healthy subjects. The patients were classified according to their blood lymphocyte count (BLC). Forty patients had BLC<30x10(9)/l (low BLC, less tumour mass) and 16 patients had BLC>30x10(9)/l (high BLC, larger tumour mass). The percentage of CD3- CD56+ cells, as well as of CD8+, CD8+ CD45RO+ and CD3+ CD57+ T subsets in low BLC patients, were higher than those found in high BLC patients. Conversely, the percentages of CD3+ HLA x DR+, CD4+ and CD4+ CD45RO+ lymphocytes were higher in high BLC patients than in low BLC patients. The CD4/CD8 ratio was decreased in low BLC patients while it was increased in high BLC patients and a significant positive correlation was found between their CD4/CD8 ratio and their BLC. We conclude that in low BLC B-CLL patients there is a decreased percentage of activated helper lymphocytes and an increased percentage of NK cells and activated cytotoxic T lymphocytes. These results suggest a role for NK cells, and helper and cytotoxic T lymphocytes in the control of tumour burden in B-CLL patients.

The bone-marrow infiltration pattern in B-cell chronic lymphocytic leukemia is not an important prognostic factor. Danish CLL Study Group

In a multicentre study of 635 consecutive newly diagnosed patients with B-CLL, the histological bone marrow (BM) specimens were reviewed independently by each of 3 pathologists and found evaluable for BM infiltration pattern in 575 patients, 404 of whom had a CD5+, mainly FMC7-, faint surface-membrane immunoglobulin (SIg) fluorescence-intensity ppenotype. In these 404 patients the following BM infiltration patterns were found: mixed nodular-interstitial (30%), moderate interstitial (44%), heavy interstitial (20%) and diffuse packed (6%). In univariate survival analysis, significant differences were found according to BM pattern (p < 0.05), the presence of nodules being a favorable prognostic sign. In multivariate survival analysis in a model including age, clinical stage, BM pattern, BM lymphocytosis, WBC and sex, only age and stage but not BM pattern or BM lymphocytosis had independent prognostic significance. In stage A, progression-free survival was significantly longer in patients with nodular than in patients with non-nodular bone-marrow pattern. The overall survival of these patients, however, did not differ, possibly owing to the prompt and prolonged treatment given to most patients at the time of progression to stage B or C. We conclude that in CD5+, SIg(faint), mainly FMC7-B-CLL, bone-marrow histology may predict unstable disease in early clinical stage but is not important for treatment decisions, when these are based on clinical stage.

The pathology of the chronic lymphoid leukaemias

The chronic lymphoid leukaemias, though they all possess relatively mature lymphoid phenotypes, are a diverse group of diseases at the clinical, morphological, immunophenotypical, and biological levels. Generally accepted entities within this category include B-cell chronic lymphocytic leukaemia of classical and mixed-cell types, B-cell and T-cell prolymphocytic leukaemia, hairy-cell leukaemia and hairy-cell variant, splenic lymphoma with circulating villous lymphocytes, large granular lymphocytic leukaemia, adult T-cell leukaemia/lymphoma syndrome, and leukaemic phases of malignant lymphomas of both B-cell and T-cell types. Recent advances have helped to differentiate these diseases, allowing the development of more specific therapy and more accurate prognostication. In this article, we review the pathological aspects of these diseases.

Chronic lymphoid leukemias: recent advances in biology and therapy

There exists a wide variety of lymphoid leukemias derived from B and T lymphocytes. These diseases have distinct immunologic and biologic features as well as varied responses to therapeutics. The most common lymphoid leukemia is chronic lymphocytic leukemia (CLL) which is a clonal proliferation of a subset of B cells expressing the CD5 antigen. Prolymphocytic leukemia is usually derived from B cells and shares some features with CLL but is clearly a distinct entity. Hairy-cell leukemia is a B cell malignancy that is uniquely responsive to a variety of biologic and chemotherapeutic agents. Waldenström's macroglobulinemia is a B cell malignancy that secretes immunoglobulin M (IgM) and may present with the hyperviscosity syndrome. Other B cell malignancies that less commonly present as leukemias include non-Hodgkin's lymphomas such as follicular lymphoma or mantle zone lymphoma. Multiple myeloma may rarely present or evolve into a plasma cell leukemia, typically in far advanced disease. T cell malignancies that may present as chronic lymphoid leukemias, and in the past have often been referred to as T cell chronic lymphocytic leukemia, are large granular lymphocytic leukemia, adult T cell leukemia/lymphoma, Sézary cell leukemia and rare cases of non-Hodgkin's lymphoma that are T cell derived and may present or evolve into a leukemic phase. There is also a rare T cell counterpart of prolymphocytic leukemia. Distinguishing these diseases is critical for optimal care of these patients.

Chronic lymphoproliferative disorders: classification and diagnosis

The chronic lymphoproliferative disorders are morphologically, immunologically and clinically heterogeneous. Common features of these processes include T, B or natural killer cell immunophenotypes and terminal deoxy-nucleotidyl transferase negativity. The B cell lymphocytic disorders include B-chronic lymphocytic leukaemia, B cell prolymphocytic leukaemia, chronic lymphocytic leukaemia-prolymphocytic leukaemia, non-Hodgkin's lymphoma (including mantle cell lymphoma) in leukaemic phase, hairy cell leukaemia and splenic lymphoma with villous lymphocytes. The T cell chronic lymphoproliferative disorders include prolymphocytic leukaemia, adult T cell leukaemia-lymphoma, large granulated lymphocyte leukaemia and Sézary syndrome. Occasionally, a lymphocytic proliferation is encountered that does not satisfy the morphological or immunophenotypical criteria for any of the above categories. These processes are best left unclassified.

Progress in chronic lymphocytic leukaemia: a historical perspective

A historical review of gains in the body of knowledge on chronic lymphocytic leukaemia (CLL) reveals a continuous, steady process from the beginning of the century with the pioneering work of scholars to the present era of molecular biology. Several notable hallmarks of this progress have been recognized: (1) the early period of broad, loose grouping of all chronic lymphoproliferative disorders; (2) recognition of CLL as a discrete entity with clinical and cytological identification of different forms of lymphoid neoplasm; (3) development of clinical staging systems and prognostic factors; and (4) use of immunological techniques in the study of CLL. Studies currently in progress using molecular genetic techniques hold promise for future advances in unravelling the biology of leukaemic transformation of lymphocytes in CLL.

Chronic lymphocytic leukaemia: prognostic factors and natural history

In the past 20 years, important progress has been made in the understanding of the natural history and prognosis of chronic lymphocytic leukaemia (CLL). Based on the notion that the clinical manifestations of CLL are due primarily to the progressive accumulation of lymphocytes over time, several prognostic factors have been identified. The prognostic value of parameters reflecting tumour burden (i.e. lymphadenopathy, splenomegaly, anaemia and/or thrombocytopenia due to bone marrow failure), first identified empirically, has been confirmed in multivariate analyses of large series of patients. Furthermore, clinical staging systems that group the most relevant of these factors have also been developed. Patients in early stage (Binet A; Rai 0) have a long survival which, in some cases, may match that of the general population. In contrast, patients with advanced stage (Binet C; Rai III or IV) have a median survival < 2 years. The major limitation of staging systems is that they do not give information about the likelihood of progression for patients in early stage. Nevertheless, haemoglobin level, blood lymphocyte count, lymphocyte doubling time and bone marrow infiltration pattern are useful to identify subsets of patients in early stage with different progression and survival rates, with the 'smouldering' form of the disease being identified fairly accurately. With all these advances, therapy in CLL can now be indicated on a more rational basis. However, further biological insight is needed to elucidate the mechanism accounting for the different forms of the disease.

Sequential changes in the bone marrow trephine biopsy in B-cell chronic lymphocytic leukaemia

BACKGROUND

Trephine biopsy of the bone marrow is integral to both diagnosis and prognosis in B-cell lymphocytic leukaemia (B-CLL), but its usefulness would be enhanced by more information on the type, degree and rate of change that occur over time in histologic pattern and lymphocytic infiltration.

AIMS

To investigate these changes by serial trephine biopsy in totally untreated patients, in treatment-free intervals in treated patients and during intervals of treatment.

METHODS

In 82 patients with predominantly early B-CLL observed for a median of 65 months (13-331), 309 trephine biopsies were carried out, a median of three (two to eight) per patient. The biopsies were classified into nodular, interstitial, mixed and diffuse patterns. Lymphocytic infiltration was subjectively graded into minimal (< 20%), intermediate (20-50%) and majority (> 50%) categories and all changes were compared.

RESULTS

Intensity of infiltration increased through this histologic range, as did the relative risk of death. Survival of patients with > 50% involvement was significantly poorer than those with < 50%. Changes in both lymphocyte numbers and pattern occurred slowly in early disease but quickened as the leukaemia advanced. Under treatment, lymphocytes decreased but the histology did not alter significantly. Examining the marrow for disease progression should be part of regular follow-up. It may help identify the minority of patients with early disease which will run a more active course and in whom early therapy may yet be indicated. We recommend biopsy at two-yearly intervals in early disease, more frequently as the leukaemia advances. The minimal, intermediate and majority classification in addition to the histologic pattern is a useful grading.

Marrow histomorphology and clinical staging of chronic lymphocytic leukemia--a rare disease in India: experience with 26 cases

Chronic Lymphocytic Leukemia is a relatively uncommon hemopoietic malignancy in the Indian subcontinent. We have made an attempt to correlate the morphology of the marrow with staging and clinical course of the disease in 26 cases. Four out of 6 cases in Stage A showed a nodular/interstitial marrow pattern, while 18 out of 20 cases of stage B and C demonstrated a mixed/diffuse involvement of marrow. Cases showing a nodular/interstitial pattern had a relatively benign clinical course even without chemotherapy, while patients with diffuse/mixed marrow pattern required chemotherapy. Trephine histological pattern was found to be a good prognosticator and was useful in segregating cases requiring chemotherapy from those which do not.

Bone marrow histopathologic patterns and immunologic phenotype in B-cell chronic lymphocytic leukaemia

The present work analyzes the clinicobiological and immunological characteristics - the latter hitherto unexplored - of the different bone marrow histopathological patterns of the B-cell chronic lymphocytic leukaemia (B-CLL). In addition, we studied whether any or some of these parameters were able to predict the probability of a particular pattern of bone marrow involvement appearing. Of the 100 B-CLL cases studied 41 had a diffuse pattern and 59 were non-diffuse - interstitial 27, nodular 11 and mixed 21 -. Neither clinical nor immunological differences were observed among the distinct non-diffuse patterns. The patients in the diffuse group displayed an increased incidence of mu+ isotype and a higher proportion of HLA-DR and HAN-PC 1 positive cells while, conversely, reactivity with the FMC 8 McAb was lower. In addition, patients with a diffuse pattern of BM involvement displayed features of a more extensive disease: a higher incidence of adenopathies (p less than 0.05), hepatomegaly (p less than 0.01), splenomegaly (p less than 0.01), anaemia (p less than 0.01) and thrombopenia (p less than 0.01) as well as higher levels of peripheral blood lymphocytosis (p less than 0.05) and a higher percentage of BM lymphocytic infiltration (p less than 0.001). Multiple regression analysis showed that thrombopenia and splenomegaly were the two most important features in predicting the probability of a diffuse pattern.

Interleukin 2 production in bone marrow of normal individuals and patients associated with B-cell chronic lymphocytic leukaemia

T-cells from patients with B-cell chronic lymphocytic leukaemia (B-CLL) have abnormal T4/T8 ratios and functions. Previously, we demonstrated that peripheral blood (PB) mononuclear cells from B-CLL patients secrete significant amounts of interleukin 2 (IL2) with an apparent dysregulation of accessory cells controlling this production. In this study, IL2 production was investigated in PB and in bone marrow (BM) from patients with previously untreated B-CLL, mostly in early stages of the disease, and compared to normal donors. A significant secretion was observed in both PB and BM from B-CLL patients after stimulation by phytohaemagglutinin (PHA), with lower amounts in patients with nodular involvement of BM, as compared to interstitial or diffuse involvements. To explore the role of accessory cells in controlling IL2 production, we added phorbol ester or indomethacin to the culture system or irradiated the cells before culture. Phorbol ester significantly increased the IL2 secretion in both the PB and the BM of B-CLL patients. The irradiation or the addition of indomethacin did not enhance the IL2 production in PB from B-CLL patients. However, IL2 secretion increased in the BM cells from B-CLL patients after addition of indomethacin or prior irradiation, in a similar way to that observed in PB and BM of normal controls, suggesting an apparent normal control of the IL2 production in BM from B-CLL patients. In normal controls, we demonstrated that IL2 secretion per T-cell from BM was 5.4-fold greater than that from normal PB, suggesting a very efficient role of accessory cells controlling IL2 production in normal BM.

Histopathology of canine bone marrow in malignant lymphoproliferative disorders

Bone marrow core biopsies from 63 dogs with malignant lymphoproliferative disorders and leukemic involvement were evaluated. Multicentric lymphoma (44), multiple myeloma (8), chronic lymphocytic leukemia (9), and acute lymphoblastic leukemia (2) were found. Four distinct bone marrow histologic patterns were identified: focal (6), mixed (20), interstitial (28), and packed (9). Of those with focal or mixed patterns, 77% (20/26) had paratrabecular distribution. Stromal changes were infrequent, with 6% (4/63) having necrosis, 3% (2/63) fibrosis, and 6% (4/63) osteolysis. For each condition, the interstitial and mixed patterns were the most common presentations, while focal and packed patterns occurred less frequently. Morphologically, cells of metastatic lesions of lymphoma resembled those of primary sites. Colonization of bone marrow by various cytologic types of lymphoma was independent of the histologic patterns.

B-chronic lymphocytic leukemia. Prognostic implication of bone marrow histology in 120 patients experience from a single hematology unit

The available staging systems for B-chronic lymphocytic leukemia (B-CLL) do not always predict the clinical course and the prognosis of the disease. In these systems, the pattern of bone marrow histology is not incorporated. In the current report we investigate the prognostic value of the diffuse or nondiffuse pattern of bone marrow involvement in 120 B-CLL patients in relation to their actuarial survival, and we compare these results with the actuarial survival based on the International Workshop system. In addition, we analyze the influence of the diffuse or nondiffuse pattern on the actuarial survival, in relation to the individual clinical stages (A, B, C). All patients were diagnosed and followed-up in the same Unit. Our patients were divided into Stage A (64), Stage B (22), and Stage C (34). They were also subdivided into those with a diffuse (46) and those with a nondiffuse (74) pattern of bone marrow histology. The difference in the actuarial survival in relation to their clinical stage (A, B, C) was statistically significant (P less than 0.025). A greater statistical difference (P less than 0.005) was found when the actuarial survival was analyzed in relation to the diffuse or nondiffuse pattern of bone marrow histology. No statistically significant differences could be found (P greater than 0.1), when the actuarial survival was calculated in every stage (A, B, C), on the basis of the diffuse or nondiffuse pattern of bone marrow histology. When our Stage A and B patients were analyzed for disease progression, in relation to the diffuse or nondiffuse bone marrow histology, it was found that 66.6% of the diffuse Stage A patients and 88% of the diffuse Stage B patients had disease progression as compared to only 8.6% for the nondiffuse Stage A patients and 33% for the nondiffuse Stage B patients. Our findings indicate that: the pattern of bone marrow histology in B-CLL patients is the single most important prognostic parameter in this disease; a clinicopathologic staging system for B-CLL may be justified; and the diffuse pattern of bone marrow histology could be considered as the best criterion for initiation of therapy in these patients.

Investigation of cell size and nuclear clefts as prognostic parameters in chronic lymphocytic leukemia

The importance of the size and morphology of peripheral blood lymphocytes has been controversial as prognostic indicators in chronic lymphocytic leukemia (CLL). This study was initiated to specifically examine cell size and morphology with respect to presence or absence of nuclear clefts and the relative importance to survival. Eighty-seven cases of CLL that had not been previously treated were examined. Cleaved cells were considered present in significant numbers when they exceeded 5% of the circulating lymphocytes. Prognosis was not statistically significant when cell size and nuclear clefts were examined individually and in combination. This study confirms that clinical staging is the significant prognostic predictor irrespective of cell size and/or nuclear configuration.

The bone marrow histological pattern has independent prognostic value in early stage chronic lymphocytic leukaemia

The initial diagnostic bone marrow specimens from 90 consecutive, untreated patients with chronic lymphocytic leukaemia were examined for the pattern of lymphocytic infiltration in relation to clinical stage (International Workshop System) and survival. Three non-diffuse (interstitial, nodular, mixed nodular-interstitial) and one diffuse pattern were recognized. Generally, the bone marrow patterns correlated well with clinical stage: a non-diffuse pattern prevailed in early, and a diffuse pattern in later stages. However, with a Cox analysis of the covariate effect of clinical stage and bone marrow pattern on survival, the bone marrow pattern was shown to have independent prognostic significance in the early stage A in which a diffuse pattern carried a fourfold increase in death rate as compared to a non-diffuse pattern. These high risk patients could not be identified by the Rai substages of the International Workshop System.

Patterns of bone marrow involvement in chronic lymphocytic leukemia and small lymphocytic (well differentiated) non-Hodgkin's lymphoma. Its clinical significance in relation to their differential diagnosis and prognosis

Forty-eight patients with chronic lymphocytic leukemia (CLL), and 12 patients with small (well differentiated) lymphocytic lymphoma (WDL) were histologically evaluated for their pattern of bone marrow (BM) involvement. Four different types of BM infiltration were recognized: nodular (N), interstitial (I), nodular and interstitial (mixed) and diffuse (D). The pattern of BM involvement was compared with the clinical, laboratory, and survival status in all patients. The extent of the disease in CLL patients, was determined by the Rai and the International Workshop on CLL Staging Systems, while in WDL patients the Ann Arbor staging system was used. In the CLL group the N pattern was found in 8%, the I in 33%, the mixed in 31%, and the D in 27% of the patients. Based on the International Workshop on CLL Staging System, the I pattern of BM involvement was more frequently found in Stage A (56%), the mixed in Stage B (68%), and the D in Stage C disease (90%). All CLL patients with D pattern required treatment from the beginning, contrary to CLL patients with the other patterns, in whom therapy was required in less than 50%. Similarly, deaths were more common in the D pattern in whom therapy pattern than in the other patterns. In the WDL patients BM involvement was found in 4 of 12, (33%) and its pattern of positivity was always nodular, although most patients (10 of 12) had advanced disease. It is concluded that the frequency of BM involvement may contribute in the differential diagnosis of WDL from CLL. In addition, the pattern of BM infiltration correlates very well with the International Staging System for CLL, and the pattern of BM positivity in CLL patients also has prognostic significance.

Bone marrow histopathologic patterns and immunologic findings in B-chronic lymphocytic leukemia

In 82 patients with B-chronic lymphocytic leukemia, the correlations between the histopathologic bone marrow patterns (interstitial, nodular, mixed, and diffuse), serum immunoglobulin (Ig), and blood B-lymphocyte levels and T-lymphocyte levels have been analyzed. The most commonly lowered Ig class was IgM (43% of cases) followed by IgA (35%), and IgG (10%). There was a trend to a more frequent decrease of Ig levels when "advanced" bone marrow patterns (mixed + diffuse) were compared with the earlier ones (interstitial + nodular). The frequency of such a decrease was statistically significant for IgA class (P less than 0.01). The absolute number of blood T-lymphocytes was increased in the diffuse pattern (P less than 0.01).

Chronic lymphocytic leukemia

This article reviews, for the internist, recent advances in our understanding of the immunology and clinical characteristics of chronic lymphocytic leukemia (CLL). The method of treatment based on clinical staging of CLL and as practiced in the authors' clinic is detailed. It also provides an outline of possible investigation and therapy that may be expected in the coming years.

Lymphoproliferations in the bone marrow: identification and evolution, classification and staging

Bone marrow biopsies from 3229 patients with lymphoproliferative disorders and 1156 patients with benign or reactive lymphoproliferations were investigated and criteria for distinguishing between them are given. Bone marrow involvement was found in 89% of multiple myeloma, 64% of non-Hodgkin's lymphomas and 8% of Hodgkin's disease. According to the predominant proliferative cell type there were five major entities in multiple myeloma and non-Hodgkin's lymphomas: (1) plasmacytic; (2) lymphocytic; (3) hairy cell; (4) immunocytic; (5) centrocytic. These were further classified into distinct subtypes each of which had independent prognostic significance. The mode of spread of the lymphoproliferative disorders in the bone marrow showed one of six architectural patterns, which together with the quantity of infiltration in the biopsy (reflecting the tumour cell burden) had significant predictive value. These results demonstrate the value of bone marrow biopsies in the identification, classification and staging of lymphoproliferative disorders, as well as in monitoring the course of disease and the response to therapy.

An appraisal of the value of the bone marrow biopsy in the assessment of proliferative lesions of the bone marrow

The diagnostic value of the bone marrow needle biopsy has proved impressive in a variety of disorders. As a complementary procedure to the aspiration smear it adds an invaluable dimension to the examination of haematopoietic tissue. The procedure is easily learned and safe and should be utilized routinely in haematological practice. The usefulness of the bone marrow biopsy is examined in assessing proliferative lesions of the bone marrow.

Nuclear clefts in chronic lymphocytic leukaemia. A light microscopic and ultrastructural study of a new prognostic parameter

Peripheral blood lymphocytes from 48 consecutive, newly diagnosed CLL patients were examined by light- and electron-microscopy for the presence of nuclear cleaving or folding. On this basis, the patients could be subdivided into 2 easily separable morphological groups. In 42 patients the lymphocytes had regular round nuclei. In 6 patients (13%) the lymphocytes of peripheral blood had a highly irregular nuclear outline characterized by pronounced cleaving or folding of the nuclear membrane. In 4 of these 6 patients immunological investigations demonstrated membrane markers consistent with B-cell monoclonality. Age, sex, distribution between stages as well as mode of clinical presentation were all alike in the 2 groups of patients. In spite of this a statistically significant, highly increased mortality was observed in patients with lymphocyte nuclear irregularities. Thus, 50% of all deaths occurred in this small group of patients. These findings indicate that lymphocyte nuclear cleaving or folding represents a stage-independent prognostic parameter, which permits selection of a small but easily identified high-risk group of patients.

Bone biopsy in haematological disorders

Bone marrow biopsies are now widely used in the investigation and follow-up of many diseases. Semi-thin sections of 8216 undecalcified biopsies of patients with haematological disorders were studied. Observations were made on the cytopenias and the myelodysplastic syndromes, the acute leukaemias the myeloproliferative disorders, Hodgkin's disease and the malignant lymphomas including multiple myeloma, hairy cell leukaemia and angioimmunoblastic lymphadenopathy. Bone marrow biopsies are essential for the differential diagnosis of most cytopenias and for the early recognition of fibrosis which most frequently occurred as a consequence of megakaryocytic proliferation in the myeloproliferative disorders. Different patterns of bone marrow involvement were found in the lymphoproliferative disorders and both their type and extent constituted factors of prognostic significance. A survey of the literature is given and the conclusion is drawn that bone marrow biopsies provide indispensible information for the diagnostic evaluation and the follow-up of patients with haematological disorders.