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Case 1 - FSAK

77 years old gentleman, known case of Acute Myeloid Leukaemia (AML), given Ara-C and Venetoclax. First check marrow post chemotherapy for residual disease assessment.


FBC: Hb 7.1 (moderate anaemia), Platelet 38 (severe thrombocytopaenia), WBC 1.0 (severe leukopenia), ANC 0.3 (severe neutropenia).

FBP: Occasional suspicious-looking cells are seen.

BMA: Normocellular marrow with 27% blast cells. Suggestive of non-remission marrow.

Trephine biopsy:

H&E - Digital Slide 

Reticulin stain - Digital Slide

MPO - Digital Slide

Glyco C - Digital Slide

CD117 - Digital Slide 

CD163 - Digital Slide

CD68 GA - Digital Slide 

CD34 - Digital Slide 

CD61 - Digital Slide

Point of discussion:

  • Identification and quantitation of immature cells (monocytic lineage).

Case 2 - HZH

15 years old boy with no known illness, presented with acute onset of weight loss and loss of appetite for 1 month.


On examination: hepatosplenomegaly and multiple enlarged lymph nodes.


FBC: Hb 10.2 (mild anaemia), Platelet 37 (severe thrombocytopaenia), WBC 1.9 (severe leukopenia), ANC 0.5 (severe neutropenia).

FBP: Pancytopaenia. No blast or abnormal lymphoid cells are seen.

Lymph node biopsy: Suggestive of B-cell lymphoma, unclassifiable with features intermediate in between DLBCL and Classical Hodgkin Lymphoma.

BMA: Hypocellular marrow with trilineage hematopoiesis suppression. No evidence of lymphoma infiltration. Eosinophilic materials seen, possible gelatinous transformation.

Trephine biopsy:

H&E - Digital Slide

H&E (deeper) - Digital Slide

Reticulin stain - Digital Slide

MPO - Digital Slide

Glyco C - Digital Slide

CD3 - Digital Slide

CD20 - Digital Slide

CD68 GA - Digital Slide

TdT - Digital Slide

CD34 - Digital Slide

CD61 - Digital Slide

PAS AB - Digital Slide

AB - Digital Slide

Congo Red - Digital Slide

Point of discussion:

  • Serous atrophy of bone marrow – How to ascertain the diagnosis?

Case 3 - WAWO

58 years old lady with underlying hypertension, feeling unwell for 10 days (fever at night, on and off abdominal pain) associated with bruises over the bilateral upper and lower limb.

On examination: hepatosplenomegaly, 1 left supraclavicular lymph node 4x2cm (LN biopsy reported as myeloid sarcoma).

FBC: Hb 8.7 (moderate anaemia), Platelet 6 (severe thrombocytopaenia), WBC 118 (hyperleukocytosis) with predominant neutrophils, basophils, eosinophils.

FBP: Hyperleukocytosis with neutrophilia (no bimodal peak maturation), eosinophilia, marked basophilia (33%), 6% blast cells. Impression: TRO MPN, ? CML in accelerated phase.

BMA: Haemodiluted, predominant neutrophils, marked basophils and 6 % blast cells. No megakaryocytes.

IPT was sent using peripheral blood: 6% myeloblast, 27% basophils

Trephine Biopsy 

H&E - Digital Slide

H&E 2 - Digital Slide

MPO - Digital Slide 

CD34 - Digital Slide

CD117- Digital Slide

CD99 - Digital Slide

CD33 - Digital Slide

CD20 - Digital Slide

CD3 - Digital Slide

TdT - Digital Slide

CD61 - Digital Slide

E-Cadherin - Digital Slide

Toluidine blue - Digital Slide

CD25 - Digital Slide

Reticulin - Digital Slide

Giemsa - Digital Slide

Point of discussion:

  • Diffuse infiltration of immature cells in trephine biopsy, most lineage markers are negative.

  • The discrepancy of blast count in FBP/BMA vs trephine biopsy (to differentiate accelerated vs blast phase, to decide treatment regime).

  • Diff dx: CML in accelerated vs blast phase or AML with BCR-ABL1

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