Hematology Morphology Critique

Survey Slide: 07-11-S History: 60-year-old female presenting with pneumonia

Further Laboratory Data: Hgb : 90 g/L RBC : 2.92 1012/L Hct : 0.25 L/L MCV : 87 fL MCH : 30.8 pg MCHC : 355 g/L RDW : 17.7 % WBC : 2.3 109/L Platelets : 34 109/L Reticulocyte count : 30 109/L WBC Differential Relative (0.00) Acceptable Range (3 SD) Absolute (x 109/L)

Neutrophils 0.36 0.22-0.49 0.8 Lymphocytes 0.48 0.05-0.91 1.1 Monocytes 0.08 0.00-0.19 0.2 Plasma cells 0.08 0.00-0.47 0.2 Morphology: RBC: There is a moderate normochromic, normocytic anemia with an increase in rouleaux

formation and a rare nucleated red blood cell noted. Polychromasia does not appear increased.

WBC: The total white blood cell and absolute neutrophil count are both low with a large number of

plasmacytoid cells present. Platelets: Platelets are present in markedly decreased numbers with normal morphology.

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Hematology Morphology Critique 07-11-S

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Conclusion: This slide was taken from a patient with a history of plasma cell myeloma who presented to the hospital with pneumonia. As is often seen with myeloma patients, there is a moderate normochromic, normocytic anemia with rouleaux formation. The total white cell count is low, with approximately 40% of the circulating white cells appearing as abnormal plasmacytoid cells with prominent nucleoli. These could be considered abnormal plasmacytoid lymphocytes or circulating myeloma (plasma) cells. The finding of plasma cells in the peripheral blood is a rare finding regardless of the underlying disorder. A normal plasma cell is a mature B lymphocyte that is specialized for antibody (immunoglobulin) production. When neoplastic cells are found in circulating blood as in this case, it is termed plasma cell leukemia. Usually plasma cells in this setting are abnormal with prominent nucleoli.Plasma cells are rarely found in the peripheral blood and comprise from 0.2% to 2.8% of the normal bone marrow differential. Mature plasma cells are often oval or fan shaped, measuring 8-15 m. The nucleus is eccentric and oval in shape. The nucleus to cytoplasm ratio is typically 2:1 to 1:1. The perinuclear zone is very distinct, appearing white in the deeply basophilic cytoplasm. Nuclear chromatin is condensed and very patchy, appearing as dark blocks on a reddish-purple background. As the blocks of chromatin may be distributed at the periphery of the nucleus, plasma cells are sometimes said to have a clock-face nucleus. The cytoplasm stains deep blue to gray blue, depending on the stain and the ribosomal content of the individual cell. Plasma cells are seen in increased numbers in multiple myeloma, plasma cell leukemia, Waldenstrm's macroglobulinemia, and MGUS (monoclonal gammopathy of uncertain significance). A marrow plasmacytosis may also be seen in certain benign conditions such as chronic infection. Multiple myeloma and plasma cell leukemia are disseminated plasma cell neoplasms. Multiple myeloma is characterized by the proliferation of myeloma cells in the bone marrow and the secretion of a monoclonal immunoglobulin or immunoglobulin light chain (paraprotein). The monoclonal immunoglobulin is detectable in the serum while the monoclonal light chain, being of low molecular weight is excreted in the urine (Bence-Jones protein). In the majority of cases in which there is a serum paraprotein there is also increased background staining and increased rouleaux formation. In some patients with multiple myeloma, the paraprotein is a cryoglobulin or has cold agglutinin activity. In these cases, precipitated cryoglobulin or red cell agglutinates may be noted on the blood film. Cold agglutinins or cryoglobulins may also cause factitious results with automated cell counters. Rouleaux is best detected using a low power (10X) scan of the peripheral blood film. A review at low power reveals the characteristic stack of coins appearance of red cells, even in the thin edge of the blood film. If the rouleaux extends to the tails of the film it would be considered marked as in this case.

Hematology Morphology Critique 07-11-S

Figure 1: Plasma cell3

Morphological Diagnosis: Marked Thrombocytopenia (with Normochromic/normocytic anemia, rouleaux and circulating plasmacytoid lymphocytes) Significant Diagnostic Features: Markedly decreased platelets Rouleaux Plasmacytoid lymphocytes / Plasma cells / Plasma blasts Summary of Results: 07-11-S

Acceptable : 65 Acceptable with review : 58 Unacceptable : 9 Not Received : 1

References:

1. Glassy, Eric F., ed. - CAP Hematology and Clinical Microscopy Resource Committee. Color Atlas of Hematology. 1998; 235; 242-243

2. Bain, Barbara J. Blood Cells A Practical Guide. Third Edition. 2002; 105-106; 379-380

3. http://image.bloodline.net/stories/storyReader$706

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Hematology Morphology Critique 07-11-S

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Grading Criteria: Accepted without downgrading:

Reporting relative differential values > 3SD for blasts in presence of plasma/lymphoma or abnormal lymphocytic cells

Reporting relative differential values > 3SD for myeloid precursors (0.01-0.05) Reporting moderately decreased platelets (51-100 X 109/L) Reported critically decreased platelets ( 3SD (except where noted) Relative count out by .01 -.03 (.97 - 1.03) Reporting polychromasia (only 14% of respondents and 5% of reference technologists reported) Not reporting rouleaux

Unacceptable (U) Grade assigned for:

Relative count out by .01 -.04 (.96 - 1.04) Reporting relative differential values > 3SD for blasts without presence of plasma/lymphoma

or abnormal lymphocytic cells Reporting a normal differential with no indication of any abnormal / reactive or plasmacytoid

lymphocytes

Hematology Morphology Critique 07-11-S

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Diagnostic Features Reporting Frequency:

(Highlighted codes represent significant diagnostic features) Reporting Codes % Reporting RBC

101 Normal 18.2 104 Polychromasia 14.4 115 Rouleaux 71.2

WBC 210 Toxic changes 86.4 206 Reactive/atypical lymphocytes 48.5

211 Other Leukocyte Abnormality Plasma/Lymphoma/Abnormal lymphocyte cells 43.9

Platelets 306 Markedly decreased (20-50 X 109/L) 88.6

Referral to Pathologist 97.0

Hematology Morphology Critique