PMC4857393_01
A: Karyotype analysis depicting t (9; 22) at the time of initial diagnosis B: FISH for bcr-abl at the time of initial diagnosis. C: Peripheral blood with leukoerythroblastosis and circulating blast (arrow), Wright Giemsa Stain, 40x. D: Bone marrow aspirate smear with erythroid hyperplasia, Wright Giemsa stain, 40x. E: Dysplastic erythroid precursors few blasts, Wright-Giemsa stain, 50x. F: Hyper cellular bone marrow with hyperplastic and left shifted erythroid series, H&E, 40x. G: Bone marrow flow cytometry: increased population of CD33/CD34 positive bone marrow blasts. H: Glycophorin immunostain highlighting the hyperplastic and left shifted erythroid series, 50X. I: CD34 immunostain marks scattered blasts on the biopsy section, 50x. J: Karyotype analysis showing monosomy 7 in the blast phase. K: FISH for bcr-abl and monosomy 7 in the blast phase.
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Further both karyotype and FISH analysis revealed presence of Philadelphia chromosome in nearly all cells (Fig. 1A and B) Based on these findings patient was diagnosed with Chronic myeloid leukemia (CML), chronic phase. CBC done at that time revealed a normal white cell count of 9.1 K/microL with 17.5% circulating blasts, (Fig. 1C) and hemoglobin of 7.5 g/dL. Prominent erythroid hyperplasia was noted on the bone marrow aspirate smears with 69.5% erythroid precursors, several of which showed dysplastic features (Fig. 1D-F). Although only 9% blasts were counted on the bone marrow differential count, flow cytometry revealed 14% cells in the blast gate (Fig. 1G) mostly expressing myeloid markers CD117, CD33, stem cell marker CD34 and with partial aberrant expression of lymphoid marker CD7. Bone marrow biopsy sections revealed marked architectural disarray with prominent erythroid hyperplasia (Fig. 1H) and normal number of megakaryocytes several of which were small and unilobed. Although no solid sheets of blasts were seen, CD34 highlighted scattered blasts throughout the biopsy section with a variable distribution estimated at approximately 10-15% (Fig. 1I). Additionally monosomy 7 was detected in 82% of the cells (Fig. 1J and K) and chromosome 3 anomaly was also noted.