Chapter A5: Atlas of Hematology

Normal bone marrow. Low-power view of normal adult marrow (H&E stain), showing a mix of fat cells (clear areas) and hematopoietic cells. The percentage of the space that consists of hematopoietic cells is referred to as marrow cellularity. In adults, normal marrow cellularity is 35–40%. If demands for increased marrow production occur, cellularity may increase to meet the demand. As people age, the marrow cellularity decreases and the marrow fat increases. Patients >70 years old may have a 20–30% marrow cellularity.

Aplastic anemia bone marrow. Normal hematopoietic precursor cells are virtually absent, leaving behind fat cells, reticuloendothelial cells, and the underlying sinusoidal structure.

Metastatic cancer in the bone marrow. Marrow biopsy specimen infiltrated with metastatic breast cancer and reactive fibrosis (H&E stain).

Lymphoma in the bone marrow. Nodular (follicular) lymphoma infiltrate in a marrow biopsy specimen. Note the characteristic paratrabecular location of the lymphoma cells.

Erythroid hyperplasia of the marrow. Marrow aspirate specimen with a myeloid/erythroid ratio (M/E ratio) of 1:1–2, typical for a patient with a hemolytic anemia or one recovering from blood loss.

Myeloid hyperplasia of the marrow. Marrow aspirate specimen showing a myeloid/erythroid ratio of ≥3:1, suggesting either a loss of red blood cell precursors or an expansion of myeloid elements.

Megaloblastic erythropoiesis. High-power view of megaloblastic red blood cell precursors from a patient with a macrocytic anemia. Maturation is delayed, with late normoblasts showing a more immature-appearing nucleus with a lattice-like pattern with normal cytoplasmic maturation.

Prussian blue staining of marrow iron stores. Iron stores can be graded on a scale of 0 to 4+. A: a marrow with excess iron stores (>4+); B: normal stores (2–3+); C: minimal stores (1+); and D: absent iron stores (0).

Ringed sideroblast. An orthochromatic normoblast with a collar of blue granules (mitochondria encrusted with iron) surrounding the nucleus.

Acute myeloid leukemia. Leukemic myeloblast with an Auer rod. Note two to four large, prominent nucleoli in each cell.

Acute promyelocytic leukemia. Note prominent cytoplasmic granules in the leukemia cells.

Acute erythroleukemia. Note giant dysmorphic erythroblasts; two are binucleate, and one is multinucleate.

Acute lymphoblastic leukemia.

Burkitt’s leukemia, acute lymphoblastic leukemia.

Chronic myeloid leukemia in the peripheral blood.

Chronic lymphoid leukemia in the peripheral blood.

Sézary’s syndrome. Lymphocytes with frequently convoluted nuclei (Sézary cells) in a patient with advanced mycosis fungoides.

Adult T cell leukemia. Peripheral blood smear showing leukemia cells with typical “flower-shaped” nucleus.

Follicular lymphoma in a lymph node. The normal nodal architecture is effaced by nodular expansions of tumor cells. Nodules vary in size and contain predominantly small lymphocytes with cleaved nuclei along with variable numbers of larger cells with vesicular chromatin and prominent nucleoli.

Diffuse large B cell lymphoma in a lymph node. The neoplastic cells are heterogeneous but predominantly large cells with vesicular chromatin and prominent nucleoli.

Burkitt’s lymphoma in a lymph node. Burkitt’s lymphoma with starry-sky appearance. The lighter areas are macrophages attempting to clear dead cells.

Erythrophagocytosis accompanying aggressive lymphoma. The central macrophage is ingesting red cells, neutrophils, and platelets. (Courtesy of Dr. Kiyomi Tsukimori, Kyushu University, Fukuoka, Japan.)

Hodgkin’s disease. A Reed-Sternberg cell is present near the center of the field; a large cell with a bilobed nucleus and prominent nucleoli giving an “owl’s eyes” appearance. The majority of the cells are normal lymphocytes, neutrophils, and eosinophils that form a pleiomorphic cellular infiltrate.

Lacunar cell; Reed-Sternberg cell variant in nodular sclerosing Hodgkin’s disease. High-power view of single mononuclear lacunar cell with retracted cytoplasm in a patient with nodular sclerosing Hodgkin’s disease.

Normal plasma cell.

Multiple myeloma.

Color serum in hemoglobinemia. The distinctive red coloration of plasma (hemoglobinemia) in a spun blood sample in a patient with intravascular hemolysis.