Bone Marrow

Patients with chronic phase CML generally have hypercellular bone marrows with 0 to 10 percent fat. However, despite this elevated cellularity, bone marrow is usually easily aspirated. Thinning of the bony cortex and localized erosions of trabecu-lae may occur. The myeloid-erythroid ratio increases to 10-50:1 compared with the normal ratio of 2.5:1. The granulocyte series reveals all stages of development, but generally suggests less maturity than does a simultaneous peripheral blood smear. Mitotic figures are increased four to five times above that of normal marrow. Significant quantities of basophils and eosinophils are usually found. The marrow may be enriched in megakaryocytes, including some with immature or atypical features, such as hypolobation. Evidence of dysplasia, such as coarsely granulated basophils or hypolobated (Pelger-Huet cells) neutrophils is rare (Plate 3-1C-E).

Presumably due to the rapid proliferation and excessive cell death in the marrow with accumulation of membrane contents, lipid-laden benign histiocytes resembling Gaucher cells may become prominent. In addition, well-granulated sea-blue histiocytes can also be observed66 (Plate 3-1F). The morphologic appearance of these reactive reticuloendothelial cells results from phagocytosis of cellular debris, which consists of gluco-cerebrosidase and normal constituents of granulocyte and ery-throid cell membranes.67,68

Myelofibrosis has been reported to accompany the granulocytic hyperplasia of CML in 6 to 22 percent of patients, more commonly late in the course of this disease.64,69 The occurrence of myelofibrosis has been associated with elevation of the LAP score, imminent blastic transformation, and poor prognosis.70 Occasionally, totally fibrotic marrows, indistinguishable from advanced agnogenic myeloid metaplasia, may be observed.61

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