PMC9252768_01
Hematoxylin and Eosin (H & E) stained bone marrow biopsy section showing hypercellular marrow with myeloid hypoplasia, erythroid hyperplasia, and increased atypical megakaryocytes (x200). An enclosed picture shows the morphology of the immature cells on a Wright-Giemsa-stained bone marrow aspirate smear (x400).
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fig1
A bone marrow aspirate and biopsy (BMAB1) revealed about 6% immature cells on examination of the aspirate smears, while the biopsy examination showed a hypercellular bone marrow (80% cellularity) with a population of atypical immature B-cells (about 20-25%) together with myeloid hypoplasia, erythroid hyperplasia, atypical megakaryocytes, and marrow fibrosis (MF-2) as shown in Figure 1.
Immunohistochemistry-stained bone marrow biopsy sections showing: A-Positive CD34 staining in immature cells, B- Positive TdT staining in immature cells, C- Positive PAX-5 staining in immature cells, and D- Positive c-MYC staining in immature cells (x200).
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fig2
These cells showed positive expression of CD34, TdT, CD20, PAX-5, and c-MYC by immunohistochemistry as seen in Figure 2.
Flow cytometric immunophenotyping of the immature population in the bone marrow. The blasts express CD45 (heterogenous), CD19, CD34 (heterogeneous), CD38 (moderate), CD58 (bright), CD20, CD10, CD22 (dim), CD24 (heterogenous), CD9 (dim) and are negative for CD13 and CD33. B-lymphoblasts are red, mature B cells are blue.
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fig3
This immature population represented around 1.9% of total cells and was suspicious of a B-lymphoblastic leukemia/lymphoma (Figure 3).
Conventional karyotyping shows positive t(9, 22).
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fig4
FISH showing positive BCR/ABL1 translocation. (a) Fusion signal in a cell with morphologic feature of blast. (b) Fusion signal in a cell with morphologic features of a band neutrophil.
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fig5
Among the BCR/ABL1 fusion positive cells, some have morphologic features of blasts, while cells with features of band neutrophils are also noted (Figure 5). and was negative for immunoglobulin heavy chain (IGH) gene rearrangements.
(a) H&E stained LN needle biopsy section showing a non-necrotizing granuloma with no evidence of lymphoid infiltrate (x200). (b) Immunohistochemically stained lymph node needle biopsy section showing negative staining for TdT (x200).
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fig6
A needle biopsy was taken from the left axillary LN and revealed a non-necrotizing granuloma with no evidence of lymphoid infiltrate (Figure 6).