WHO Hemato 2008-4Ed.pdf

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Classification of Tumours.

Pathology and Genetics of Tumours

of the Digestive System.IARC Press: Lyon 2000

ISBN 92 832 2410 8

Eble J.N., Sauter G., Epstein J.E.,

Sesterhenn I.A. (Eds.): World Health

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ISBN 92 832 2418 3

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ISBN 92 832 2412 4

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ISBN 92 832 2416 7

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Tumours. Tumours of the Central

Nervous System (4th edition).

IARC, Lyon 2007

ISBN 92 832 2430 2

World Health Organization Classification of Tumours


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World Health Organization Classification of Tumour

International Agency for Research on Cancer (IARC)

4th Edition

WHO Classification of Tumours of

Haematopoietic and Lymphoid Tissues

Edited by

Steven H. Swerdlow

Elias Campo

Nancy Lee Harris

Elaine S. Jaffe

Stefano A. Pileri

Harald Stein

Jürgen Thiele

James W. Vardiman

International Agency for Research on Cancer

Lyon, 2008

WHO OMS


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World Health Organization Classification of Tumours

Series Editors Fred T. Bosman, M.D.

Elaine S. Jaffe, M.D.Sunil R. Lakhani, M.D.

Hiroko Ohgaki, Ph.D.

WHO Classification of Tumours of the Haematopoietic and Lymphoid Tissues

Editors

Layout

Printed by

Publisher

Steven H. Swerdlow, M.D.

Elias Campo, M.D.

Nancy Lee Harris, M.D.

Elaine S. Jaffe, M.D.

Stefano A. Pileri, M.D.

Harald Stein, M.D.

Jürgen Thiele, M.D.

James W. Vardiman, M.D.

Sébastien Antoni

Marlen GrassingerPascale Collard

Participe Présent

69250 Neuville s/Saône, France

International Agency for

Research on Cancer (IARC)

69008 Lyon, France


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This volume was produced with support from the

Associazione S.P.E.S. Onlus, Bologna

Friends of José Carreras International Leukemia Foundation

Leukemia Clinical Research Foundation

Lymphoma and Leukemia Society

MEDIC Foundation

National Cancer Institute, USA

National Institutes of Health Office of Rare Diseases, USA

San Salvatore Foundation

University of Chicago Cancer Research Center

The WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues

presented in this book reflects the views of a Working Group

that convened for an Editorial and Consensus Conference at the

International Agency for Research on Cancer (IARC), Lyon

October 25-27, 2007.

Members of the Working Group are indicated

in the List of Contributors on pages XXX-XXX.


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IARC Library Cataloguing in Publication Data

WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues

Edited Swerdlow S.H., Campo E., Harris N.L., Jaffe E.S., Pileri S.A., Stein H., Thiele J., Vardiman J.W.

1. Haematopoietic System Neoplasms – genetics

2. Haematopoietic System Neoplasms – pathology

I. Swerdlow, Steven H.

ISBN 978-92-832-2431-0

Format for bibliographic citations

Swerdlow S.H., Campo E., Harris N.L., Jaffe E.S., Pileri S.A., Stein H., Thiele J., Vardiman J.W. (Eds.):

WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues.

IARC: Lyon 2008

Published by the International Agency for Research on Cancer (IARC),

150 cours Albert Thomas, 69372 Lyon Cedex 08, France

© International Agency for Research on Cancer, 2008

Distributed by

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distinguished by initial capital letters.

The authors alone are responsible for the views expressed in this publication.

The copyright of figures and charts remains with the authors.

(See source of charts and photographs, page XXX-XXX)


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WHO Classification 9

Summary table 10

Introduction to the classification of tumours of

haematopoietic and lymphoid tissues 14

1 Introduction and overview of the classification of

the myeloid neoplasms

2 Myeloproliferative neoplasms 31

Chronic myelogenous leukaemia, BCR-ABL1 positive 32

Chronic neutrophilic leukaemia 38

Polycythaemia vera 40

Primary myelofibrosis 44

Essential thrombocythaemia 48

Chronic eosinophilic leukaemia, NOS 51

Mastocytosis 54

Cutaneous mastocytosis 57

Systemic mastocytosis 58

Mast cell leukaemia 61

Mast cell sarcoma 61

Extracutaneous mastocytoma 61Myeloproliferative neoplasm, unclassifiable 64

3 Myeloid and lymphoid neoplasms with

eosinophilia and abnormalities of

PDGFRA

PDGFRB

or

FGFR

67

4 Myelodysplastic/myeloproliferative neoplasms 75

Chronic myelomonocytic leukaemia 76

Atypical chronic myeloid leukaemia, BCR-ABL1negative 80

Juvenile myelomonocytic leukaemia 82

Myelodysplastic/myeloproliferative neoplasm,

unclassifiable 85

5 Myelodysplastic syndromes 87

Myelodysplastic syndromes/neoplasms, overview 88

Refractory cytopenia with unilineage dysplasia 94

Refractory anaemia with ring sideroblasts 96

Refractory cytopenia with multilineage dysplasia 98

Refractory anaemia with excess blasts 100

Myelodysplastic syndrome with isolated del(5q) 102

Myelodysplastic syndromes, unclassifiable 103

Childhood myelodysplastic syndrome 104

6 Acute myeloid leukaemia and related precursor

neoplasms 109

AML with recurrent genetic abnormalities 110AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 110

AML with inv(16)(p13.1q22) or

t(16;16)(p13.1;q22);CBFB-MYH11 111

Acute promyelocytic leukaemia with

t(15;17)(q22;q12); PML-RARA 112

AML with t(9;11)(p22;q23); MLLT3-MLL 114

AML with t(6;9)(p23;q34); DEK-NUP214 115

AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2);

RPN1-EVI1 116

AML (megakaryoblastic) with t(1;22)(p13;q13);

RBM15-MKL1 117

AML with mutated NPM1 120

AMLwith mutated CEBPA

AML with myelodysplasia-related changes

Therapy-related myeloid neoplasms

Acute myeloid leukaemia, NOS

AML with minimal differentiation

AML without maturation

AML with maturation

Acute myelomonocytic leukaemia

Acute monoblastic and monocytic leukaemia

Acute erythroid leukaemias

Acute megakaryoblastic leukaemia

Acute basophilic leukaemia

Acute panmyelosis with myelofibrosis

Myeloid sarcoma

Myeloid proliferations related to Down syndrome

Transient abnormal myelopoiesis

Myeloid leudaemia associated with

Down syndrome

Blastic plasmacytoid dendritic cell neoplasm

7 Acute leukaemias of ambiguous lineage

Acute undifferentiated laukaemia

Mixed phenotype acute leukaemia with

t(9;22)(q34;q11.2); BCR-ABL1

Mixed phenotype acute leukaemia with

t(v;11q23);MLL rearranged

Mixed phenotype acute leukaemia, B/myeloid, NOS

Mixed phenotype acute leukaemia, T/myeloid, NOS

Mixed phenotype acute leukaemia, NOS - rare

types

Other ambiguous lineage leukaemias

8 Introduction and overview of the classification of

the lymphoid neoplasms

9 Precursor lymphoid neoplasms

B lymphoblastic leukaemia/lymphoma, NOS

B lymphoblastic leukaemia/lymphoma

with recurrent genetic abnormalities

B Lymphoblasticleukaemia/lymphoma with

t(9:22)(q34;q11.2); BCR-ABL1

B Lymphoblastic leukaemia/lymphoma with

t(v;11q23); MLL rearranged


t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)


hyperdiploidyB Lymphoblastic leukaemia/lymphoma with

hypodiploidy (Hypodiploid ALL)


t(5;14)(q31;q32); IL3-IGH


t(1;19) (q23;p13.3); E2A-PBX1(TCF3-PBX1)

T lymphoblastic leukaemia/lymphoma

10 Mature B-cell neoplasms

Chronic lymphocytic leukaemia /small

lymphocytic lymphoma

B-cell prolymphocytic leukaemia

Contents


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Splenic marginal zone lymphoma 185

Hairy cell leukaemia 188

Splenic lymphoma/leukaemia, unclassifiable 191

Splenic diffuse red pulp small B-cell lymphoma 191

Hairy cell leukaemia-variant 192

Lymphoplasmacytic lymphoma 194

Heavy chain diseases 196

Gamma heavy chain disease 196

Mu heavy chain disease 197Alpha heavy chain disease 198

Plasma cell neoplasms 200

Monoclonal gammopathy of undetermined

significance (MGUS) 200

Plasma cell myeloma 202

Solitary plasmacytoma of bone 207

Extraosseous plasmacytoma 208

Monoclonal immunoglobulin deposition diseases 209

Extranodal marginal zone lymphoma of mucosa-

associated lymphoid tissues (MALT lymphoma) 214

Nodal marginal zone lymphoma 218

Follicular lymphoma 220

Primary cutaneous follicle centre lymphoma 227Mantle cell lymphoma 229

Diffuse large B-cell lymphoma (DLBCL), NOS 233

T cell/histiocyte rich large B-cell lymphoma 238

Primary DLBCL of the CNS 240

Primary cutaneous DLBCL, leg type 242

EBV positive DLBCL of the elderly 243

DLBCL associated with chronic inflammation 245

Lymphomatoid granulomatosis 247

Primary mediastinal (thymic) large B-cell lymphoma 250

Intravascular large B-cell lymphoma 252

ALK positive DLBCL 254

Plasmablastic lymphoma 256

Large B-cell lymphoma arising in HHV8-associated

multicentric Castleman disease 258

Primary effusion lymphoma 260

Burkitt lymphoma 262

B-cell lymphoma, unclassifiable, with features

intermediate between DLBCL and

Burkitt lymphoma 265


intermediate between DLBCL and

classical Hodgkin lymphoma 267

11 Mature T- and NK-cell neoplasms 269

T-cell prolymphocytic leukaemia 270

T-cell large granular lymphocytic leukaemia 272

Chronic lymphoproliferative disorders of NK cells 274Aggressive NK cell leukaemia 276

EBV+ T-cell lymphoproliferative disorders of

childhood 278

Systemic EBV+ T-cell lymphoproliferative

disease of childhood 278

Hydrovacciniforme-like lymphoma 280

Adult T-cell leukaemia/lymphoma. 281

Extranodal NK/T-cell lymphoma, nasal type 285

Enteropathy-associated T-cell lymphoma 289

Hepatosplenic T-cell lymphoma 292

Subcutaneous panniculitis-like T-cell lymphoma 294

Mycosis fungoides 296

Sézary syndrome

Primary cutaneous CD30 positive T-cell

lymphoproliferative disorders

Primary cutaneous peripheral T-cell lymphomas,

rare subtypes

Primary cutaneous gamma-delta T-cell lymphoma

Primary cutaneous CD8 positive aggressive

epidermotropic cytotoxic T-cell lymphoma

Primary cutaneous CD4 positivesmall/medium T-cell lymphoma

Peripheral T-cell lymphoma, NOS

Angioimmunoblastic T-cell lymphoma

Anaplastic large cell lymphoma (ALCL), ALK+

Anaplastic large cell lymphoma (ALCL), ALK-

12 Hodgkin lymphoma

Introduction

Nodular lymphocyte predominant Hodgkin lymphoma

Classical Hodgkin lymphoma, introduction

Nodular sclerosis classical Hodgkin lymphoma

Mixed cellularity classical Hodgkin lymphoma

Lymphocyte-rich classical Hodgkin lymphomaLymphocyte depleted classical Hodgkin lymphoma

13 Immunodeficiency-associated


Lymphoproliferative diseases associated with

primary immune disorders

Lymphomas associated with HIV infection

Post-transplant lymphoproliferative disorders (PTLD

Plasmacytic hyperplasia and infectious-

mononucleosis-like PTLD

Polymorphic PTLD

Monomorphic PTLD

Classical Hodgkin lymphoma type PTLD

Other iatrogenic immunodeficiency-associated


14 Histiocytic and dendritic cell neoplasms

Introduction

Histiocytic sarcoma

Tumours derived from Langerhans cells

Langerhans cell histiocytosis

Langerhans cell sarcoma

Interdigitating dendritic cell sarcoma

Follicular dendritic cell sarcoma

Other rare dendritic cell tumours

Disseminated juvenile xanthogranuloma

Contributors

Clinical advisory committee

Source of charts and photographs

References

Subject index


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Dr Kenneth C. ANDERSON

Dana Farber Cancer Institute

Boston, MA, USA

Dr Robert ARCECI

Kimmel Comprehensive Cancer Center

Johns Hopkins Oncology Center

Baltimore, MD, USA

Dr James O. ARMITAGE

University of Nebraska Medical Center

Omaha, NE, USA

Dr Tiziano BARBUIHospitals of Bergamo

Bergamo, ITALY

Dr John BENNETT*

University of Rochester Medical Center

Rochester, NY, USA

Dr Peter Leif BERGSAGEL

Mayo Clinic

Scottsdale, AZ, USA

Dr Clara D. BLOOMFIELD*(Myeloid chair)

Ohio State University

Columbus, OH, USA

Dr William CARROLL

NYU School of Medicine

New York, NY, USA

Dr Daniel CATOVSKY*

Institute of Cancer Research

Sutton, U.K.

Dr Franco CAVALLI

San Giovannni Hospital

Bellinzona, SWITZERLAND

Dr Bruce CHESON

Georgetown University Hospital

Washington, DC, USA

Dr Bertrand COIFFIER

Lyon-Sud Hospital

Pierre Bénite, FRANCE

Dr Joseph CONNORS

B.C. Cancer Agency

Vancouver Clinic

Vancouver, CANADA

Dr Theo M. DE WITTEUniversity Hospital Nijmegen

Nijmegen, THE NETHERLANDS

Dr Volker DIEHL

University Hospital of Köln

Köln, GERMANY

Dr Meletios A. DIMOPOULOS

University of Athens

School of Medicine

Athens, GREECE

Dr Hartmut DOHNER

University of Ulm

Ulm, GERMANY

Dr Andreas ENGERT

University Hospital of Köln

Köln, GERMANY

Dr Elihu H. ESTEY

Fred Hutchinson Cancer Research

Center, University of Washington,Seattle, WA, USA

Dr Brunangelo FALINI*

Institute of Hematology, Policlinico Monteluce

Perugia, ITALY

Dr Pierre FENAUX

Avicenne Hospital

University Paris XIIIBobigny, FRANCE

Dr Richard I. FISHER

University of Rochester Medical Center

Rochester, NY, USA

Dr Robin FOA

University “La Sapienza”

Rome, ITALY

Dr Ulrich GERMING*Heinrich Heine University

Duesseldorf, GERMANY

Dr D. Gary GILLILAND*

Brigham and Women’s Hospital

Harvard Medical School

Boston, MA, USA

Dr Peter L. GREENBERG

Stanford University Medical Center

Stanford, CA, USA

Dr Anton HAGENBEEK

Academic Medical Center

Amsterdam, THE NETHERLANDS

Dr Eva HELLSTROM-LINDBERG*

Karolinska Institute

Karolinska University, Hospital Huddinge

Stockholm, SWEDEN

Dr Wolfgang HIDDEMANN

University of Munich

Munich, GERMANY

Dr Richard HOPPE


Palo Alto, CA, USA

Clinical Advisory Committee

Section title

*Also contributors


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Dr Sandra J. HORNING (Lymphoid co-chair)


Palo Alto, CA, USA

Dr Melissa M. HUDSON

St. Jude Children’s Hospital

Memphis, TN, USA

Dr Peter JOHNSON

CR UK Clinical Centre

Southampton General Hospital

School of Medicine, Southampton, UK

Dr Michael J. KEATING

UT M.D. Anderson Cancer Center

Houston, TX, USA

Dr Eva KIMBY

Karolinska Institute

Huddinge University HospitalHuddinge, SWEDEN

Dr Richard A. LARSON*

University of Chicago

Chicago, IL, USA

Dr Michelle M. LE BEAU*

University of Chicago

Chicago, IL, USA

Dr Raymond LIANG

University of Hong Kong

Queen Mary Hospital, Pokfulam

HONG KONG, SAR CHINA

Dr David C. LINCH

University College London

London, UK

Dr Michael LINK

Stanford University School of Medicine

Palo Alto, CA, USA

Dr Alan F. LIST*

H. Lee Moffitt Cancer Center

and Research Institute

Tampa, FL , USA

Dr T. Andrew LISTER

St. Bartholomew’s Hospital

London, UK

Dr Estella MATUTES*

Royal Marsden Hospital/

Institute of Cancer Research

London, UK

Dr Emili MONTSERRAT*(Lymphoid co-chair)

Hospital Clinic

University of Barcelona

Barcelona, SPAIN

Dr Tomoki NAOE

Nagoya University Hospital

Showa-ku, Nagoya, JAPAN

Dr Charlotte Marie NIEMEYER*

University of Freiburg

Freiburg, GERMANY

Dr Michael PFREUNDSCHUH

Saarland University Medical School

Homburg, GERMANY

Dr Kanti R. RAI

Long Island Jewish Medical Center

New Hyde Park, NY, USA

Dr Steven T. ROSEN

Robert H. Lurie Comprehensive Cancer

Center, Northwestern University

Chicago, IL, USA

Dr Gilles André SALLES

Lyon-Sud Hospital

Pierre-Bénite, FRANCE

Dr Kevin SHANNON*

University of California

San Francisco, CA

USA

Dr Margaret A. SHIPP


Boston, MA, USA

Dr Martin TALLMAN

Northwestern University

Feinberg School of Medicine

Chicago, IL, USA

Dr Ayalew TEFFERI*

Mayo Clinic

Rochester, MN, USA

Dr Stephen P. TREON


Boston, MA, USA

Dr Kunihiro TSUKASAKI

Atomic Bomb Disease Institute Nagasa

University, Graduate School of Biomedica

Science, Nagasaki , JAPAN

Dr Rein WILLEMZE*

Leiden University Medical Center

Leiden, The NETHERLANDS

Dr Wyndham H. WILSON*

National Cancer Institute

Bethesda, MD, USA

Dr Motoko YAMAGUCHI

Mie University Graduate School of Medicine

Tsu, Mie, JAPAN

Dr Andrew ZELENETZ

Memorial Sloan Kettering Cancer Cente

New York, NY, USA

Dr Pier-Luigi ZINZANI

Institute of Hematology and Medical Oncolog

L. and A. Seragnoli

University of Bologna, Bologna, ITALY

Dr Emmanuele ZUCCA

“La Carita” Hospital

Locarno, SWITZERLAND

Tumours of the xxxxxx2


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Section title


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1Source of charts and photogra


1.01

1.021.03

1.04 Goasguen J.

1.05

1.06

1.07

1.08

2.01 A Vardiman J.W.

2.01 B Vardiman J.W. ???

2.01 C Vardiman J.W.

2.02 Thiele J.

2.03 Thiele J.???

2.04 Vardiman J.W.2.05 Vardiman J.W.

2.06 Thiele J.

2.07 A,B Vardiman J.W.

2.07 C Thiele J.

2.08 Vardiman J.W.

2.09 Vardiman J.W.

2.10 Vardiman J.W.

2.11 Le Beau M.M.

2.12 Melo J.V.

2.13 Vardiman J.W.

2.14 Thiele J.

2.15 Thiele J.

2.16 Thiele J.

2.17 Vardiman J.W.


2.18 B,C,D Thiele J.

2.19 Vardiman J.W.

2.20 Thiele J.

2.21 Thiele J.

2.22 Thiele J.

2.23 Vardiman J.W.


2.24 B,C,D Thiele J.

2.25 Thiele J.

2.26 Vardiman J.W.

2.27 Vardiman J.W.

2.28 Thiele J.

2.29 Thiele J.

2.30 Vardiman J.W.2.31 Vardiman J.W.

2.32 Vardiman J.W.

2.33 Medenica

2.34 Medenica

2.35 Longley

2.36 Horny H.-P.

2.37 Horny H.-P.

2.38 Horny H.-P.

2.39 Brunning R.D.

2.40 Longley

2.41 Vardiman J.W.

2.42 Vardiman J.W.

2.43 A Valent P.

2.43 B Vardiman J.W.2.44 Longley

2.45 Vardiman J.W.

2.46 A Jaffe E.S.

2.46 B Vardiman J.W.

2.47 Vardiman J.W.

2.48 Vardiman J.W.

2.49 Vardiman J.W.

2.50 Brunning R.D.

2.51 Vardiman J.W.

2.52 Vardiman J.W.

2.53 Vardiman J.W.

2.54 Horny H.-P.

2.55 Kvasnicka H.M.

2.56 Kvasnicka H.M.

3.01 Bain B.J.

3.02 Bain B.J.

3.03 Vardiman J.W.

3.04 Vardiman J.W.


4.01 C Orazi A.

4.02 Vardiman J.W.

4.03 Vardiman J.W.

4.04 Vardiman J.W.

4.05 Orazi A.

4.06 Vardiman J.W.

4.07 Vardiman J.W.

4.08 Baumann I.

4.09 Vardiman J.W.

4.10 Vardiman J.W.


4.11 C,D Hussain

4.12 Shannon K.

4.13 Vardiman J.W.

5.01 Brunning R.D.

5.02 Brunning R.D.

5.03 Brunning R.D.

5.04 Brunning R.D.5.05 Brunning R.D.

5.06 Brunning R.D.

5.07 Brunning R.D.

5.08 Brunning R.D.

5.09 Brunning R.D.

5.10 Brunning R.D.

5.11 Brunning R.D.

5.12 A Orazi A.

5.12 B Brunning R.D.

5.13 Brunning R.D.

5.14 Brunning R.D.

5.15 A Brunning R.D.

5.15 B,C Hasserjian R.P.

5.16 Hasserjian R.P.5.17 Brunning R.D.

5.18 Brunning R.D.

5.19 Brunning R.D.


5.20 B Hasserjian R.P.

5.21 Baumann I.

5.22 A Baumann I.

5.22 B ??????

5.22 C Brunning R.D.

5.22 D Baumann I.

6.01 Arber D.A.

6.02 Brunning R.D.6.03 Hirsch

6.04 Flandrin G.

6.05 A Flandrin G.


6.06 Hirsch

6.07 Brunning R.D.

6.08 Falini B.

6.09 Brunning R.D.

6.10 Brunning R.D.

6.11 ???????

6.12 Arber D.A.

6.13 Brunning R.D.

6.14 Falini B.

6.15 Mrozek

6.16 Falini B.

6.17 Falini B.

6.18 Schlenk RF

6.19 Arber D.A.

6.20 Grimwade D.

6.21 Vardiman J.W.

6.22 Vardiman J.W.

6.23 A Flandrin G.


6.24 A Arber ???

6.24 B Flandrin G.

6.25 Brunning R.D.

6.26 Brunning R.D.

6.27 Flandrin G.

6.28 Brunning R.D.6.29 Brunning R.D.

6.30 A Arber D.A.


6.31 Brunning R.D.

6.32 Brunning R.D.

6.33 Falini B.

6.34 Flandrin G.

6.35 Brunning R.D.

6.36 Flandrin G.

6.37 Brunning R.D.

6.38 A Flandrin G.



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2


6.39 B-D Orazi A.

6.40 Pileri S.A.

6.41 ???????

6.42 ???????

6.43 ???????

6.44 Facchetti F.

6.45 Facchetti F

6.46 Facchetti F

7.01 Matutes E.

7.02 Borowitz M.J.

7.03 Borowitz M.J.

7.04 Borowitz M.J.

7.05 Borowitz M.J.

8.01 Jaffe E.S.

8.02 Stein H.

8.03 Jaffe E.S. & Stein H.

8.04 Jaffe E.S.

8.05 Stein H.

8.06 Jaffe E.S.

8.07 Vose ??

9.01 Brunning R.D.

9.02 Brunning R.D.

9.03 Jaffe E.S.

9.04 Brunning R.D.

9.05 Brunning R.D.

9.06 Brunning R.D.

9.07 Carroll A.J.

9.08 Carroll A.J.

9.09 Carroll A.J.

9.10 Hasserjian R.P.

9.11 Brunning R.D.

9.12 Nathwani B.9.13 Jaffe E.S.

9.14 Chan JKC

10.01 Muller-Hermelink H.-K.


10.03 A,B Catovski D.

10.03 C Rozman M.

10.04 Harris N.L.

10.05 Villamor N.

10.06 A Catovski D.

10.06 B Jaffe E.S.

10.07 Isaacson P.G.

10.08 Jaffe E.S.

10.09 Isaacson P.G.10.10 Isaacson P.G.

10.11 Isaacson P.G.

10.12 Isaacson P.G.

10.13 Foucar K.

10.14 Harris N.L.

10.15 Foucar K.

10.16 Foucar K.

10.17 A,B Foucar K.

10.17 C,D Falini B.

10.18 Piris M.

10.19 Piris M.

10.20 Catovski D

10.21 Swerdlow S.H.

10.22 Swerdlow S.H.

10.23 A,B Swerdlow S.H.

10.23 C Pileri S.A.

10.24 Grogan T.

10.25 Rahemtullah A.

10.26 Grogan T.

10.27 Murali M.

10.28 Munshi N.

10.29 A Jaffe E.S.

10.29 B Grogan T.

10.30 A Grogan T.

10.30 B Jaffe E.S.

10.31 McKenna R.W.

10.32 Grogan T.

10.33 Wians F.H.

10.34 Grogan T.

10.35 A McKenna R.W.

10.35 B Grogan T.

10.36 Grogan T.

10.37 Grogan T.

10.38 McKenna R.W.

10.39 Van Wier S.

10.40 Roschke A & Gabrea A.

10.41 Grogan T.10.42 Grogan T.

10.43 Grogan T.

10.44 Grogan T.

10.45 Grogan T.

10.46 Grogan T.

10.47 Grogan T.

10.48 Grogan T.

10.49 Isaacson P.G.

10.50 Isaacson P.G.

10.51 Isaacson P.G.

10.52 Isaacson P.G.

10.53 Isaacson P.G.

10.54 Isaacson P.G.

10.55 Isaacson P.G.10.56 Isaacson P.G.

10.57 Isaacson P.G.

10.58 Isaacson P.G.

10.59 A Campo E & Swerdlow S.H.

10.59 B-E Campo E. & Jaffe E.S.

10.60 Jaffe E.S.

10.61 Nathwani B.N.

10.62 Nathwani B.N.

10.63 De Leval L.

10.64 Nathwani B.N.

10.65 De Leval L.

10.66 De Leval L.

10.67 De Leval L.

10.68 ?????? See ref

10.69 De Leval L.10.70 De Leval L.

10.71 De Leval L.

10.72 Willemze R.

10.73 Willemze R.

10.74 Willemze R. check email

10.75 Willemze R.

10.76 Willemze R.

10.77 Harris N.L.

10.78 Swerdlow S.H.

10.79 Swerdlow S.H.

10.80 Swerdlow S.H.

10.81 Jares P

10.82 Jaffe E.S.

10.83 Jaffe E.S.

10.84 A Harris N.L.

10.84 B,C Warnke R.A.

10.85 Coiffier B.

10.86 De Wolf-Peeters C.

10.87 Graus F.

10.88 Graus F. ????

10.89 Graus F. ????

10.90 Willemze R.

10.91 Willemze R.

10.92 Nakamura S. & Murase T.

10.93 Nakamura S. & Murase T.

10.94 Aozasa K.

10.95 Aozasa K.

10.96 Aozasa K.

10.97 Aozasa K.

10.98 Jaffe E.S.

10.99 Jaffe E.S.

10.100 Jaffe E.S.

10.101 Jaffe E.S.

10.102 A,B Diebold

10.103 Harris N.L.

10.104 Banks P.M

10.105 Diebold10.106 Diebold

10.107 Gaulard P.

10.108 A,B,C Nakamura S & Murase T.

10.108 D Diebold

10.109 Nakamura S & Murase T

10.110 Diebold

10.111 Diebold

10.112 Delsol G.

10.113 Stein H.

10.114 A,B Stein H.

10.114 C Harris N.L.

10.115 Issacson P.G.

10.116 Issacson P.G.

10.117 Issacson P.G.10.118 Issacson P.G.

10.119 Said J.

10.120 Said J.

10.121 Jaffe E.S.

10.122 Jaffe E.S.

10.123 Jaffe E.S.

10.124 Jaffe E.S.

10.125 Leoncini ???

10.126 ??????

10.127 Harris N.L.

10.128 ?????

10.129 Jaffe E.S.

10.130 Jaffe E.S.

10.131 Jaffe E.S.




11.04 Chan W.C.

11.05 A Morice W.

11.05 B Osuji N.

11.06 A,B,C Villamor N.

11.06 D Morice W.

11.07 Chan J.K.C.

11.08 Ko Y.H.

11.09 Ko Y.H.



16/422

3Subject index

11.10 Quintanilla-Martinez L.





11.15 Jaffe E.S.

11.16 Jaffe E.S.

11.17 Jaffe E.S.

11.18 Ohshima K ???

11.19 A Kikuchi

11.19 B Ohshima K ???

11.20 Ohshima K ???

11.21 A,B Ohshima K ???

11.21 C Kikuchi

11.21 D Ohshima K ???

11.22 Jaffe E.S.

11.23 Kikuchi

11.24 Jaffe E.S.

11.25 Ohshima K.

11.26 Chan J.K.C.

11.27 Chan J.K.C.

11.28 Chan J.K.C.

11.29 Chan J.K.C.

11.30 Chan J.K.C.

11.31 Chan J.K.C.11.32 Chan J.K.C.

11.33 Chan J.K.C.

11.34 Chan J.K.C.

11.35 Harris N.L.

11.36 Wright D.H.

11.37 A,B Isaacson P.G.

11.37 C Wright D.H.

11.38 Isaacson P.G.

11.39 Isaacson P.G.

11.40 Isaacson P.G.

11.41 Isaacson P.G.

11.42 Isaacson P.G.

11.43 A Gaulard P.

11.43 B-D Jaffe E.S.11.44 Jaffe E.S.

11.45 Jaffe E.S.

11.46 Jaffe E.S.

11.47 A Willemze R.

11.47 B Ralfkiaer E.

11.48 Ralfkiaer E.

11.49 Ralfkiaer E.

11.50 A Willemze R.

11.50 B Ralfkiaer E.

11.51 Ralfkiaer E.

11.52 Ralfkiaer E.

11.53 Ralfkiaer E.

11.54 Ralfkiaer E.

11.55 Ralfkiaer E.

11.56 Ralfkiaer E.11.57 Willemze R.

11.58 Ralfkiaer E.

11.59 Ralfkiaer E.

11.60 Toro J.

11.61 Jaffe E.S.

11.62 Jaffe E.S.

11.63 Jaffe E.S.

11.64 Willemze R.

11.65 Jaffe E.S.

11.66 Jaffe E.S.

11.67 Willemze R.

11.68 Willemze R.

11.69 A,B Ralfkiaer E.

11.69 C,D Jaffe E.S.

11.70 Ralfkiaer E.

11.71 Pileri S.A.

11.72 Pileri S.A.

11.73 A Dogan A.

11.73 B Jaffe E.S.

11.74 Dogan A.

11.75 Dogan A.

11.76 See ref

11.77 Delsol G.

11.78 Delsol G.

11.79 Delsol G.

11.80 A Ralfkiaer E.

11.80 B Delsol G.

11.81 Delsol G.

11.82 Delsol G.

11.83 Delsol G.

11.84 Delsol G.

11.85 Delsol G.

11.86 Chan J.K.C. ??? see email

11.87 Delsol G.

11.88 Mason D.Y.

11.89 Mason D.Y.

11.90 Mason D.Y.11.91 Mason D.Y.

12.01 Stein H.

12.02 Harris N.L.

12.03 Stein H.

12.04 Stein H.

12.05 Stein H.

12.06 Stein H.

12.07 Stein H.

12.08 Stein H.

12.09 Stein H.

12.10 Stein H.

12.11 Stein H.12.12 Stein H.

12.13 Stein H.

12.14 Stein H.

12.15 Jaffe E.S.

12.16 Stein H.

12.17 Stein H.

12.18 Stein H.

12.19 Stein H.

12.20 Stein H.

12.21 See ref

12.22 Stein H.

13.01 Pittaluga S.

13.02 Jaffe E.S.13.03 Jaffe E.S.

13.04 Jaffe E.S.

13.05 A Harris N.L.

13.05 B Jaffe E.S.

13.05 C Harris N.L.

13.06 Jaffe E.S.

13.07 Jaffe E.S.

13.08 Jaffe E.S.

13.09 ???????

13.10 A,B Raphael M.

13.10 C ???????

13.11 A Jaffe E.S.

13.11 B,C Raphael M.

13.12 Harris N.L.

13.13 Harris N.L.

13.14 A Webber S.

13.14B Swerdlow S.H.

13.15 Swerdlow S.H. & Nelson ??

13.16 A Swerdlow S.H. & Nelson ??

13.16 B Harris N.L.

13.17 A Harris N.L.

13.17 B Swerdlow S.H.

13.17 C,D Harris N.L.

13.18 Harris N.L.

13.19 Swerdlow S.H.

13.20 Harris N.L.

13.21 Harris N.L.

14.01 Pileri S.A.

14.02 Grogan T.

14.03 A,B Weiss L.M.

14.03 C Grogan T.

14.04 Grogan T.

14.05 Jaffe E.S.

14.06 Weiss L.M.

14.07 Weiss L.M.14.08 Weiss L.M.

14.09 A Grogan T.

14.09 B Weiss L.M.

14.10 Falini B.

14.11 Jaffe R.

14.12 Jaffe R.

14.13 Jaffe E.S.

14.14 Grogan T.

14.15 Weiss L.M.

14.16 Grogan T.

14.17 Weiss L.M.

14.18 Weiss L.M.

14.19 Weiss L.M.

14.20 Weiss L.M.14.21 Chan J.K.C.

14.22 A Weiss L.M.

14.22 B Spagnolo V

14.23 Weiss L.M.

14.24 A Kattapuram S.

14.24 B Gonzalez R.G.

14.25 Jaffe R.


17/422

WHO Classification

4th Edition


18/422

WHO Classification of tumours of haematopoietic

and lymphoid tissues

MYELOPROLIFERATIVE NEOPLASMS

Chronic myelogenous leukaemia,

BCR-ABL1 positive 9875/3

Chronic neutrophilic leukaemia 9963/3

Polycythaemia vera 9950/3

Primary myelofibrosis 9961/3

Essential thrombocythaemia 9962/3

Chronic eosinophilic leukaemia, NOS 9964/3

Mastocytosis

Cutaneous mastocytosis 9740/1

Systemic mastocytosis 9741/3

Mast cell leukaemia 9742/3

Mast cell sarcoma 9740/3

Extracutaneous mastocytoma 9740/1

Myeloproliferative neoplasm, unclassifiable 9975/3

MYELOID AND LYMPHOID NEOPLASMS

WITH EOSINOPHILIA AND ABNORMALITIES OF

PDGFRA, PDGFRB OR FGFR1

Myeloid and lymphoid neoplasmswith PDGFRA rearrangement 9965/3

Myeloid neoplasms

with PDGFRB rearrangement 9966/3

Myeloid and lymphoid neoplasms

with FGFR1 abnormalities 9967/3

MYELODYSPLASTIC/MYELOPROLIFERATIVE

NEOPLASMS

Chronic myelomonocytic leukaemia 9945/3

Atypical chronic myeloid leukaemia,

BCR-ABL1 negative 9876/3

Juvenile myelomonocytic leukaemia 9946/3

Myelodysplastic/myeloproliferative neoplasm,

unclassifiable 9975/3

Refractory anaemia with ring sideroblasts

associated with marked thrombocytosis 9982/3

MYELODYSPLASTIC SYNDROMES

Refractory cytopenia with unilineage dysplasia

Refractory anaemia 9980/3Refractory neutropenia 9991/3

Refractory thrombocytopenia 9992/3

Refractory anaemia with ring sideroblasts 9982/3

Refractory cytopenia with

multilineage dysplasia 9985/3

Refractory anaemia with excess blasts 9983/3

Myelodysplastic syndromes

associated with isolated del(5q) 9986/3

Myelodysplastic syndromes, unclassifiable 9989/3Refractory cytopenia of childhood 9985/3

ACUTE MYELOID LEUKAEMIA (AML)

AND RELATED PRECURSOR NEOPLASMS

AML with recurrent genetic abnormalities

AML with t(8;21)(q22;q22);

RUNX1-RUNX1T1 9896/3

AML with inv(16)(p13.1q22)

or t(16;16)(p13.1;q22); CBFB-MYH11 9871/3

Acute promyelocytic leukaemia

with t(15;17)(q22;q12); PML-RARA 9866/3

AML with t(9;11)(p22;q23); MLLT3-MLL 9897/3

AML with t(6;9)(p23;q34); DEK- NUP214 9865/3

AML with inv(3)(q21q26.2)

or t(3;3)(q21;q26.2); RPN1-EVI1 9869/3

AML (megakaryoblastic)

with t(1;22)(p13;q13); RBM15-MKL1 9911/3 AML with mutated NPM1 9861/3

AML with mutated CEBPA 9861/3

AML with myelodysplasia-related changes 9895/3

Therapy-related myeloid neoplasms 9920/3

WHO classification10


19/422

Acute myeloid leukaemia, NOS 9861/3

AML with minimal differentiation 9872/3

AML without maturation 9873/3

AML with maturation 9874/3

Acute myelomonocytic leukaemia 9867/3

Acute monoblastic and monocytic leukaemia 9891/3

Acute erythroid leukaemia 9840/3

Acute megakaryoblastic leukaemia 9910/3

Acute basophilic leukaemia 9870/3

Acute panmyelosis with myelofibrosis 9931/3

Myeloid sarcoma 9930/3

Myeloid proliferations related to Down syndrome

Transient abnormal myelopoiesis 9898/1

Myeloid leukaemia

associated with Down syndrome 9898/3

Blastic plasmacytoid dendritic

cell neoplasm 9727/3

ACUTE LEUKAEMIAS OF AMBIGUOUS LINEAGE

Acute undifferentiated leukaemia 9801/3

Mixed phenotype acute leukaemia

with t(9;22)(q34;q11.2); BCR-ABL 9806/3

Mixed phenotype acute leukaemia

with t(v;11q23); MLL rearranged 9807/3

Mixed phenotype acute leukaemia,

B/myeloid, NOS 9808/3

Mixed phenotype acute leukaemia,

T/myeloid, NOS 9809/3

PRECURSOR LYMPHOID NEOPLASMS


B lymphoblastic leukaemia/lymphoma, NOS 9811/3


with recurrent genetic abnormalities


with t(9;22)(q34;q11.2); BCR-ABL1 9812/3


with t(v;11q23); MLL rearranged 9813/3


with t(12;21)(p13;q22); TEL-AML1

(ETV6-RUNX1) 9814/3

B lymphoblastic leukaemia/lymphomawith hyperdiploidy 9815/3


with hypodiploidy (hypodiploid ALL) 9816/3


with t(5;14)(q31;q32); IL3-IGH 9817/3

B lymphoblastic leukaemia/lymphoma with

t(1;19)(q23;p13.3); E2A-PBX1;

(TCF3-PBX1) 9818/3

T lymphoblastic leukaemia/lymphoma 9837/3

MATURE B-CELL NEOPLASMS

Chronic lymphocytic leukaemia/

small lymphocytic lymphoma 9823/3

B-cell prolymphocytic leukaemia 9833/3

Splenic marginal zone lymphoma 9689/3

Hairy cell leukaemia 9940/3

Splenic lymphoma/leukaemia, unclassifiable 9591/3

Splenic diffuse red pulp small B-cell lymphoma 9591/3

Hairy cell leukaemia-variant 9591/3

Lymphoplasmacytic lymphoma 9671/3

Waldenström’s macroglobulinemia 9761/3

Heavy chain diseases 9762/3

Alpha heavy chain disease 9762/3

Gamma heavy chain disease 9762/3

Mu heavy chain disease 9762/3

Plasma cell myeloma 9732/3

Solitary plasmacytoma of bone 9731/3

Extraosseous plasmacytoma 9734/3

WHO classification 1


20/422

Extranodal marginal zone lymphoma

of mucosa-associated lymphoid tissue

(MALT lymphoma) 9699/3

Nodal marginal zone lymphoma 9699/3

Paediatric nodal marginal zone lymphoma 9699/3

Follicular lymphoma 9690/3

Paediatric follicular lymphoma 9690/3

Primary cutaneous follicle centre lymphoma 9597/3

Mantle cell lymphoma 9673/3

Diffuse large B-cell lymphoma (DLBCL), NOS 9680/3

T-cell/histiocyte rich large B-cell lymphoma 9688/3

Primary DLBCL of the CNS 9680/3

Primary cutaneous DLBCL, leg type 9680/3

EBV positive DLBCL of the elderly 9680/3

DLBCL associated with chronic inflammation 9680/3Lymphomatoid granulomatosis 9766/1

Primary mediastinal (thymic) large

B-cell lymphoma 9679/3

Intravascular large B-cell lymphoma 9712/3

ALK positive DLBCL 9737/3

Plasmablastic lymphoma 9735/3

Large B-cell lymphoma arising in HHV8-

associated multicentric Castleman disease 9738/3

Primary effusion lymphoma 9678/3Burkitt lymphoma 9687/3


intermediate between diffuse large B-cell

lymphoma and Burkitt lymphoma 9680/3


intermediate between diffuse large B-cell

lymphoma and classical Hodgkin lymphoma 9596/3

MATURE T-CELL AND NK-CELL NEOPLASMS

T-cell prolymphocytic leukaemia 9834/3

T-cell large granular lymphocytic leukaemia 9831/3

Chronic lymphoproliferative disorder of

NK-cells 9831/3

Aggressive NK cell leukaemia 9948/3

Systemic EBV positive T-cell lymphoproliferative

disease of childhood 9724/3

Hydroa vaccineforme-like lymphoma 9725/3

Adult T-cell leukaemia/lymphoma 9827/3

Extranodal NK/T cell lymphoma, nasal type 9719/3

Enteropathy-associated T-cell lymphoma 9717/3

Hepatosplenic T-cell lymphoma 9716/3

Subcutaneous panniculitis-like

T-cell lymphoma 9708/3

Mycosis fungoides 9700/3

Sézary syndrome 9701/3

Primary cutaneous CD30 positive T-cell


Lymphomatoid papulosis 9718/1

Primary cutaneous anaplastic large cell

lymphoma 9718/3

Primary cutaneous gamma-delta


Primary cutaneous CD8 positive aggressive

epidermotropic cytotoxic T-cell lymphoma 9709/3

Primary cutaneous CD4 positive small/medium


Peripheral T-cell lymphoma, NOS 9702/3

Angioimmunoblastic T-cell lymphoma 9705/3

Anaplastic large cell lymphoma, ALK positive 9714/3

Anaplastic large cell lymphoma, ALK negative 9702/3

HODGKIN LYMPHOMA

Nodular lymphocyte predominant

Hodgkin lymphoma 9659/3

Classical Hodgkin lymphoma 9650/3

Nodular sclerosis classical

Hodgkin lymphoma 9663/3Lymphocyte-rich classical


Mixed cellularity classical


Lymphocyte depleted classical


WHO classification12


21/422

HISTIOCYTIC AND DENDRITIC CELL NEOPLASMS

Histiocytic sarcoma 9755/3

Langerhans cell histiocytosis 9751/3

Langerhans cell sarcoma 9756/3

Interdigitating dendritic cell sarcoma 9757/3

Follicular dendritic cell sarcoma 9758/3

Fibroblastic reticular cell tumour 9759/3

Indeterminate dendritic cell tumour 9757/3

Disseminated juvenile xanthogranuloma

POST-TRANSPLANT LYMPHOPROLIFERATIVE

DISORDERS (PTLD)

Early lesions

Plasmacytic hyperplasia 9971/1Infectious mononucleosis-like PTLD 9971/1

Polymorphic PTLD 9971/3

Monomorphic PTLD (B- and T/NK-cell types)*

Classical Hodgkin lymphoma type PTLD*

____________

NOS, not otherwise specified.

The italicized numbers are provisional codes for the 4th

edition of ICD-O. While they are expected to be incorpo-

rated in the next ICD-O edition, they currently remain

subject to changes.

The italicized histologic types are provisional entities, for

which the WHO Working Group felt there was insufficient

evidence to recognize as distinct diseases at this time.

*These lesions are classified according to the leukaemia or

lymphoma to which they correspond, and are assigned the

respective ICD-O code.

WHO classification 1


22/422

CHAPTER 1

Introduction and overview

of the classification

of the myeloid neoplasms


23/422

Introduction and overview of the classification of the myeloid neoplasms18

Introduction and overview of the

classification of the myeloid neoplasms

J.W. Vardiman A. Porwit

R.D. Brunning A. Teffer

D.A. Arber C.D. Bloomfield

M.M. Le Beau J. Thiele

The WHO Classification of Tumours of the

Haematopoietic and Lymphoid Tissues

published in 2001 reflected a paradigm

shift in the approach to classification of

myeloid neoplasms {1039}. For the first

time, genetic information was incorpo-

rated into diagnostic algorithms provided

for the various entities. The publication

was prefaced with a comment predicting

future revisions necessitated by rapidly

emerging genetic information. The current

revision is a commentary on the significant

new molecular insights that have become

available since the publication of the lastclassification.

The first entity described in this mono-

graph, chronic myelogenous leukaemia

(CML) remains the prototype for the iden-

tification and classification of myeloid

neoplasms. This leukaemia is recognized

by its clinical and morphologic features,

and its natural progression is character-

ized by an increase in blasts of myeloid,

lymphoid or mixed myeloid/lymphoid

immunophenotype. It is always associ-

ated with the BCR-ABL1 fusion gene that

results in the production of an abnormal

protein tyrosine kinase (PTK) with en-

hanced enzymatic activity. This protein is

sufficient to cause the leukaemia and also

provides a target for protein tyrosine

kinase inhibitor therapy (PTKI) therapy

that has prolonged the lives of thousands

of patients with this often fatal illness{615}. This successful integration of clini-

cal, morphologic and genetic information

embodies the goal of the WHO classifica-

tion scheme.

In this revision, a combination of clinical,

morphologic, immunophenotypic and

genetic features is used in an attempt to

define disease entities, such as CML, that

are biologically homogeneous and clini-

cally relevant—the same approach used

in the 3rd edition of the classification. Al-

though the previous scheme began to

open the door to including genetic ab-

normalities as criteria to classify myeloid

neoplasms, this revision firmly acknowl-

edges that as in CML, recurring genetic

abnormalities provide not only objective

criteria for recognition of specific entities

but also identification of abnormal gene

products or pathways that are potentiatargets for therapy. One example in this

revised scheme is the addition of a new

subgroup of myeloid neoplasms (Table

1.01) associated with eosinophilia and

chromosomal abnormalities that involve

the platelet-derived growth factor receptor

Disease BM cellularity % Marrow blasts Maturation Morphology Haematopoiesis Blood counts Organomegaly

MPN Usually increased,

often normal in ET

Normal or slightly

increased;


24/422

Introduction and overview of the classification of the myeloid neoplasms 19

alpha (PDGFRA) or platelet derived

growth factor beta (PDGFRB) genes—a

subgroup defined largely by genetic

events that lead to constitutive activation

of the receptor tyrosine kinase, PDGFR,

and that respond to PTKI therapy {131,

466, 812}. Similar examples are found

throughout the classification in each

major subgroup, and include not only

neoplasms associated with microscopi-

cally recognizable chromosomal abnor-

malities but also with gene mutations

without a cytogenetic correlate as well.

On the other hand, the importance of

careful clinical, morphological and im-

munophenotypic characterization of each

myeloid neoplasm and correlation with

the genetic findings cannot be over-

emphasized. The discovery of activating

JAK2 mutations has revolutionized the

approach to the diagnosis of the myelo-

proliferative neoplasms (MPN) {163, 1044,1186, 1288}. Yet JAK2 mutations are not

specific for any single clinical or morpho-

logic MPN phenotype, and are also

reported in some cases of myelodysplas-

tic syndromes (MDS), myelodysplastic/

myeloproliferative neoplasms (MDS/MPN)

and acute myeloid leukaemia (AML).

Thus, an integrated, multidisciplinary

approach is necessary for the classification

of myeloid neoplasms.

With so much yet to learn, there may be

some “missteps” as traditional approaches

to categorization are fused with moremolecularly-oriented classification schemes.

Nevertheless, this revision of the WHO

classification is an attempt by the authors,

editors and the clinicians who served as

members of the Clinical Advisory Com-

mittee (CAC) to provide an “evidence-

based” classification that can be used in

daily practice for therapeutic decisions

and yet provide a flexible framework for

integration of new data.

Prerequisites for classification

of myeloid neoplasms by

W O criteria

The WHO classification of myeloid neo-

plasms relies on the morphologic, cyto-

chemical and immunophenotypic features

of the neoplastic cells to establish their

lineage and degree of maturation and to

decide whether cellular proliferation is

cytologically normal or dysplastic or

effective or ineffective. The classification

is based on criteria applied to initial spec-

imens obtained prior to any definitive ther-

apy, including growth factor therapy, for the

myeloid neoplasm. The blast percentage in

the peripheral blood, bone marrow and

other involved tissues remains of practical

importance to categorize myeloid neo-

plasms and to judge their progression.

Cytogenetic and molecular genetic stud-

ies are required at the time of diagnosis

not only for recognition of specific genet-

ically defined entities, but for establishing

a baseline against which future studies

can be judged to assess disease pro-

gression. Because of the multidisciplinary

approach required to diagnose and clas-

sify myeloid neoplasms it is recommended

that the various diagnostic studies be cor-

related with the clinical findings and

reported in a single, integrated report. If

a definitive classification cannot be

reached the report should indicate thereasons why and provide guidelines for

additional studies that may clarify the di-

agnosis.

To obtain consistency, the following

guidelines are recommended for the eval-

uation of specimens when a myeloid neo-

plasm is suspected to be present. It is

assumed that this evaluation will be per-

formed with full knowledge of the clinical

history and pertinent laboratory data.

Morphology

Peripheral blood: A peripheral blood (PB)smear should be examined and corre-

lated with results of a complete blood

count. Freshly made smears should be

stained with May-Grünwald-Giemsa or

Wright-Giemsa and examined for white

blood cell (WBC), red blood cell (RBC)

and platelet abnormalities. It is important

to ascertain that the smears are well-

stained. Evaluation of neutrophil granularity

is important when a myeloid disorder is

suspected; designation of neutrophils as

abnormal based on hypogranular cyto-

plasm alone should not be consideredunless the stain is well-controlled. Manual

200-cell leukocyte differentials of PB

smears are recommended in patients with

a myeloid neoplasm when the WBC count

permits.

Bone marrow aspirate: Bone marrow (BM)

aspirate smears should also be stained

with May-Grünwald-Giemsa or Wright-

Giemsa for optimal visualization of cyto-

plasmic granules and nuclear chromatin.

Because the WHO Classification relies on

percentages of blasts and other specific

cells to categorize some entities, it is rec-

ommended that 500 nucleated BM cells

be counted on cellular aspirate smears in

an area as close to the particle and as

undiluted with blood as possible. Counting

from multiple smears may reduce sam-

pling error due to irregular distribution ofcells. The cells to be counted include

blasts and promonocytes (see definition

below), promyelocytes, myelocytes, meta-

myelocytes, band neutrophils, segmented

neutrophils, eosinophils, basophils, mono-

cytes, lymphocytes, plasma cells, erythroid

precursors and mast cells. Megakary-

ocytes, including dysplastic forms, are

not included. If a concomitant non-

myeloid neoplasm is present, such as

plasma cell myeloma, it is reasonable to

exclude those neoplastic cells from the

count used to evaluate the myeloid neo-plasm. If an aspirate cannot be obtained

due to fibrosis or cellular packing, touch

preparations of the biopsy may yield valu-

able cytologic information, but differentia

counts from touch preparations may not

be representative. The differential counts

obtained from marrow aspirates should

be compared to an estimate of the pro-

portions of cells observed in available

biopsy sections.

Bone marrow trephine biopsy: The contri-

bution of adequate BM biopsy sections in

the diagnosis of myeloid neoplasms can-not be overstated. The trephine biopsy

provides information regarding overal

cellularity and the topography, proportion

and maturation of haematopoietic cells,

and allows evaluation of BM stroma. The

biopsy also provides material for immuno-

histochemical studies that may have di-

agnostic and prognostic importance. A

biopsy is essential whenever there is

myelofibrosis, and the classification of some

entities, particularly MPN, relies heavily on

trephine sections. The specimen must be

Fig. 1.01 Bone marrow trephine biopsy. Bone marrow

trephine biopsies should be at least 1.5 cm in length and

obtained at right angles to the cortical bone.


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adequate, taken at right angle from the

cortical bone and at least 1.5 cm in length

to enable the evaluation of at least 10 par-

tially preserved inter-trabecular areas. It

should be well-fixed, thinly sectioned at

3−4 micra, and stained with haematoxylin

and eosin and/or a stain such as Giemsa

that allows for detailed morphologic eval-

uation. A silver impregnation method for

reticulin fibres is recommended and mar-

row fibrosis graded according to the

European consensus scoring system

{2214}. A Periodic acid-Schiff (PAS) stain

may aid in detection of megakaryocytes.

Immunohistochemical (IHC) study of the

biopsy is often indispensable in the eval-

uation of myeloid neoplasms and is dis-

cussed below.

Blasts: The percentage of myeloid blasts

is important for diagnosis and classification

of myeloid neoplasms. In the PB the blast

percentage should be derived from a200-cell leukocyte differential and in the

BM from a 500-cell count of cellular BM

aspirate smears as described above. The

blast percentage derived from the marrow

aspirate should correlate with an estimate

of the blast percentage in the trephine

biopsy, although large focal clusters or

sheets of blasts in the biopsy should be

regarded as possible disease progression.

Immunohistochemical staining of the BM

biopsy for CD34+ blasts often aids in the

correlation of aspirate and trephine biopsy

findings, although in some myeloid neo-plasms the blasts do not express CD34.

Flow cytometry determination of blast

percentage should not be used as a sub-

stitute for visual inspection. The specimen

for flow cytometry is often haemodilute,

and may be affected by a number of pre-

analytic variables, and as noted for the

biopsy, not all blasts express CD34.

Myeloblasts, monoblasts and megakary-

oblasts are included in the blast count.

Myeloblasts vary from slightly larger than

mature lymphocytes to the size of mono-

cytes or larger, with moderate to abun-

dant dark blue to blue-grey cytoplasm.

The nuclei are round to oval with finely

granular chromatin and usually several

nucleoli, but in some nuclear irregularities

may be prominent. The cytoplasm maycontain a few azurophil granules (Fig 1.03).

Monoblasts are large cells with abundant

cytoplasm that can be light grey to deeply

blue and may show pseudopod formation

(Fig 1.04 A,B). Their nuclei are usually

round with delicate, lacy chromatin and

one or more large prominent nucleoli.

They are usually strongly positive for non-

specific esterase (NSE) but have no or

only weak myeloperoxidase (MPO) activ-

ity. Promonocytes are considered as

“monoblast equivalents” when the requi-

site percentage of blasts is tallied for the

diagnosis of acute monoblastic, acute

monocytic and acute myelomonocytic

leukaemia. Promonocytes have a deli-

cately convoluted, folded or grooved

nucleus with finely dispersed chromatin,a small, indistinct or absent nucleolus,

and finely granulated cytoplasm (Fig 1.04

C, D). Most promonocytes express NSE

and are likely to have MPO activity. The

distinction between monoblasts and

promonocytes is often difficult, but

because the two cell types are summated

Fig. 1.02 Bone marrow biopsy section, H&E. Bone marrow biopsies should be well-fixed and thin sections (3-4 microns)

stained with H&E and/or Giemsa to allow optimal evaluation of histologic details.

Fig. 1.03 Acute myeloid leukaemia. A Agranular myeloblasts. B Granulated myeloblasts.

BA


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as monoblasts in making the diagnosis ofAML, the distinction between a monoblast

and promonocyte is not always critical.

On the other hand, distinguishing

promonocytes from more mature but

abnormal leukaemic monocytes can also

be difficult, but is critical, because the

designation of a case as acute monocytic

or acute myelomonocytic leukaemia ver-

sus chronic myelomonocytic leukaemia

often hinges on this distinction. Abnormal

monocytes have more clumped chromatin

than a promonocyte, variably indented,

folded nuclei and grey cytoplasm withmore abundant lilac-colored granules.

Nucleoli are usually absent or indistinct

(Fig 1.04 E,F). Abnormal monocytes are

not considered as monoblast equivalents.

Megakaryoblasts are usually of medium

to large size with a round, indented or

irregular nucleus with finely reticular chro-

matin and one to three nucleoli. The cyto-

plasm is basophilic, usually agranular,

and may show cytoplasmic blebs (See

Chapter on acute myeloid leukaemia,

NOS). Small dysplastic megakaryocytes

and micromegakaryocytes are not blasts

In acute promyelocytic leukaemia, the

blast equivalent is the abnormal promye-

locyte. Erythroid precursors (erythroblasts)

are not included in the blast count except

in the rare instance of “pure” acute ery-

throid leukaemia, in which case they are

considered as blast equivalents (See

Chapter on acute myeloid leukaemia

NOS).

Cytochemistry and other special stains:

Cytochemical studies are used to deter-

mine the lineage of blasts, although in

some laboratories they have been sup-

planted by immunologic studies using flow

cytometry and/or immunohistochemistry

They are usually performed on PB and

BM aspirate smears but some can be

performed on sections of trephine biop-

sies or other tissues. Detection of MPO

indicates myeloid differentiation but its

absence does not exclude a myeloid lin-eage because early myeloblasts as well

as monoblasts may lack MPO. The MPO

activity in myeloblasts is usually granular

and often concentrated in the Golgi region

whereas monoblasts, although usually

negative, may show fine, scattered MPO+

granules, a pattern that becomes more

pronounced in promonocytes. Erythroid

blasts, megakaryoblasts and lymphoblasts

are MPO negative. Sudan Black B (SBB)

staining parallels MPO but is less spe-

cific. Occasional cases of lymphoblastic

leukaemia exhibit SBB positivity, in whichcase light grey granules are seen rather

than the deeply black granules that char-

acterize myeloblasts. The non-specific

esterases,α naphthyl butyrate (ANB) and

α naphthyl acetate (ANA), show diffuse

cytoplasmic activity in monoblasts and

monocytes. Lymphoblasts may have foca

punctate activity with NSE but neutrophils

are usually negative. Megakaryoblasts

and erythroid blasts may have some mul-

tifocal, punctate ANA positivity, but it is

partially resistant to natrium fluoride (NaF)

inhibition whereas monocyte NSE is totallyinhibited by NaF. The combination of NSE

and the specific esterase, naphthol-ASD-

chloroacetate esterase (CAE), which

stains primarily cells of the neutrophil lin-

eage and mast cells, permits identifica-

tion of monocytes and immature and

mature neutrophils simultaneously. Some

cells, particularly in myelomonocytic

leukaemias, may exhibit NSE and CAE

simultaneously. While normal eosinophils

lack CAE, it may be expressed by neo-

plastic eosinophils. CAE can be performed

Fig. 1.04 Monoblasts, promonocytes and abnormal monocytes from a case of acute monocytic leukaemia.

A, B Monoblasts are large with abundant cytoplasm that may contain a few vacuoles or fine granules and have round

nuclei with lacy chromatin and one or more variably prominent nucleoli. C, D Promonocytes have more irregular and

delicately folded nuclei with fine chromatin, small indistinct nucleoli and finely granulated cytoplasm. E, F Abnormal

monocytes appear immature, yet have more condensed nuclear chromatin, convoluted or folded nuclei, and more

cytoplasmic granulation (Courtesy of Dr. J. Goasguen).

A B

C D

E F


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on tissue sections as well as PB or mar-

row aspirate smears. In acute erythroid

leukaemia, a PAS stain may be helpful in

that the cytoplasm of the leukaemic

proerythroblasts may show large globules

of PAS positivity. Well-controlled iron

stains should always be performed on the

BM aspirate to detect iron stores, normal

sideroblasts and ring sideroblasts, the lat-

ter of which are defined as erythroid pre-

cursors with 5 or more granules of iron

encircling one-third or more of the

nucleus.

Immunophenotype

Immunophenotypic analysis using either

multiparameter flow cytometry or IHC is

an essential tool in the characterization of

myeloid neoplasms. Differentiation anti-

gens that appear at various stages of

haematopoietic development and in cor-

responding myeloid neoplasms are illus-

trated in Fig. 1.05, and a thorough

description of lineage assignment criteria

is provided in the chapters on mixed phe-

notype acute leukaemia. The techniques

employed and the antigens analyzed may

vary according to the myeloid neoplasm

suspected and the information required to

best characterize it as well as by the

tissue available. Although often important

in the diagnosis of any haematologica

neoplasm, immunophenotyping in myeloid

neoplasms is most commonly required in

AML and in determining the phenotype of

blasts at the time of transformation of

MDS, MDS/MPN and MPN.

Multiparameter flow cytometry is the pre-

ferred method of immunophenotypic

analysis in AML due to the ability to ana-

lyze high numbers of cells in a relatively

short period of time with simultaneous

recording of information about several

antigens for each individual cell. Usually,

Fig. 1.05 Antigen expression at various stages of normal myeloid differentiation.


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rather extensive panels of monoclonal an-

tibodies directed against leukocyte differ-

entiation antigens are applied because

the utility of individual markers in identify-

ing commitment of leukaemic cells into

the different haematopoietic lineages is

limited. Evaluation of expression patterns

of several antigens, both membrane and

cytoplasmic, is necessary for lineage

assignment, to detect mixed phenotype

acute leukaemia, and to detect aberrant

phenotypes allowing for follow-up of min-

imal residual disease.

Immunophenotypic analysis has a central

role in distinguishing between minimally

differentiated acute myeloid leukaemia

and acute lymphoblastic leukaemia, and

in CML, between myeloid blast phase

and lymphoid blast phase. Among AML

with recurrent genetic abnormalities, sev-

eral have characteristic phenotypes. These

patterns, described in the respective sec-tions, can help to plan molecular cytoge-

netic [fluorescence in situ hybridization

(FISH)] and molecular investigations in in-

dividual patients. Immunophenotypic fea-

tures of the other AML categories are

extremely heterogeneous, probably due

to high genetic diversity. Although it has

been suggested that expression of cer-

tain antigens, such as CD7, CD9, CD11b,

CD14, CD56 and CD34 could be associ-

ated with an adverse prognosis in AML,

their independent prognostic value is still

controversial. Aberrant or unusual im-munophenotypes have been found in at

least 75% of cases of AML. These can be

described as cross-lineage antigen

expression, maturational asynchronous

expression of antigens, antigen over-

expression, and the reduction or absence

of antigen expression. Similar aberrancies

have also been reported in MDS as well,

and their presence can be used to support

the diagnosis in early or morphologically

ambiguous cases of MDS (See Chapter 5).

Immunophenotyping by IHC on bone

marrow biopsy sections can be applied ifbone marrow cell suspensions are not

available for flow cytometry analysis. An-

tibodies reactive with paraffin-embedded

bone marrow biopsy tissue are available

for many lineage-associated markers

(e.g. MPO, lysozyme, CD3, PAX5, CD33,

etc.). As noted previously, CD34 staining

of the biopsy can facilitate the detection

of blasts and their distribution, provided

the blasts express CD34 {1650}. For

cases rich in megaloblastoid erythrob-

lasts, immunohistology for glycophorin or

haemoglobin may be helpful in distin-

guishing those cells from myeloblasts

(e.g. in cases of RAEB or acute erythro-

leukaemia), and CD61 or CD42 often aid

in the identification of abnormal mega-

karyocytes.

Genetic studies

The WHO classification includes a num-

ber of entities defined in part by specific

genetic abnormalities, including gene

rearrangements due to chromosomal

translocations and to specific gene muta-

tions, so determination of genetic features

of the neoplastic cells must be performed

if possible. A complete cytogenetic analy-

sis of BM should be performed at the time

of initial evaluation to establish the cyto-

genetic profile, and at regular intervals

thereafter to detect evidence of genetic

evolution. Additional diagnostic genetic

studies should be guided by the diagnosissuspected on clinical, morphologic and

immunophenotypic studies. In some cases,

Reverse transcriptase-polymerase chain

reaction (RT-PCR) and/or FISH may de-

tect gene rearrangements that are pres-

ent in low frequency and not observed in

the initial chromosomal analysis, in cases

with variants of typical cytogenetic

abnormalities, and in cases in which the

abnormality is cryptic, such as the

PDGFRA-FIP1L1 fusion in myeloid neo-

plasms associated with eosinophilia. De-

pending on the abnormality, quantitativePCR performed at the time of diagnosis

may also provide a baseline against

which the response to therapy can be

monitored. A number of gene mutations

detected by gene sequencing, allele-

specific PCR and other techniques have

emerged as important diagnostic and

prognostic markers in all categories of

myeloid neoplasms. Mutations of JAK2 ,

MPL, NRAS , NF1, PTPN11, and KIT in

MPN and MDS/MPN, and NPM1, CEBPA,

FLT3 , RUNX1 and KIT , among others, in

AML are important for diagnosis andprognosis, and some, particularly JAK2 ,

FLT3 , NPM1 and CEBPA figure impor-

tantly in this revised classification. Fur-

thermore, the role of gene over- and

under-expression as well as loss of het-

erozygosity and copy number variants

detected by array-based approaches are

only now being recognized as important

abnormalities that may well influence

diagnostic and prognostic models in the

near future {1531A}. Nevertheless,

microarray profiling studies, although

important in the research setting, have not

yet been tested in clinical practice.

Revised W O classification of

myeloid neoplasms

Table 1.01 lists the major subgroups of

myeloid neoplasms and their characteristic

features at diagnosis. The nomenclature

for the myeloproliferative entities has

been changed from “chronic myeloprolif-

erative diseases” to “myeloproliferative

neoplasms” and the subgroup formerly

designated as “myelodysplastic/myelo-

proliferative diseases” has been changed

to “myelodysplastic/myeloproliferative neo-

plasms” to underscore their neoplastic

nature. Besides the addition of the new

subgroup, “Myeloid and lymphoid neo-

plasms with eosinophilia and abnormali-ties of PDGFRA, PDGFRB and FGFR1,”

new entities have been added and/or

diagnostic criteria updated within each

subgroup.

Myeloproliferative neoplasms MPN)

The MPN (Table 1.02) are clonal haemato-

poietic stem cell disorders characterized

by proliferation of one or more of the

myeloid lineages (i.e. granulocytic, ery-

throid, megakaryocytic and mast cell).

They are primarily neoplasms of adults

that peak in frequency in the 5th to 7thdecade, but some subtypes, particularly

CML and essential thrombocythaemia

(ET), are reported in children as well. The

incidence of all subtypes combined is

6−10/100,000 population annually {1053,

1059, 1060}.

Initially, MPN is characterized by hyper-

cellularity of the marrow with effective

haematopoietic maturation and increased

numbers of granulocytes, red blood cells

and/or platelets in the peripheral blood.

Splenomegaly and hepatomegaly are

Chronic myelogenous leukaemia, BCR-ABL positive

(CML)

Chronic neutrophilic leukaemia (CNL)

Polycythaemia vera (PV)

Primary myelofibrosis (PMF)

Essential thrombocythaemia (ET)

Chronic eosinophilic leukaemia, NOS (CEL, NOS)

Mastocytosis

Myeloproliferative neoplasms, unclassifiable (MPN,U)

Table 1.02 Myeloproliferative neoplasms (MPN)


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common and caused by sequestration of

excess blood cells or proliferation of

abnormal haematopoietic cells. Despite

an insidious onset each MPN has the

potential to undergo a stepwise progres-

sion that terminates in marrow failure due

to myelofibrosis, ineffective haemato-

poiesis or transformation to an acute blast

phase. Evidence of genetic evolution usu-

ally heralds disease progression as may

increasing organomegaly, increasing or

decreasing blood counts, myelofibrosis

and onset of myelodysplasia. The findingof 10−19% blasts in the blood or BM gen-

erally signifies accelerated disease and

20% or more is sufficient for a diagnosis

of blast phase.

Rationale for the diagnosis and

classification of MPN

In previous classification schemes the

detection of the Philadelphia chromo-

some and/or BCR-ABL1 fusion gene was

used to confirm the diagnosis of CML

whereas the remaining MPN subtypes

were diagnosed by their clinical and

laboratory features with relatively minor

contributions to the diagnosis from mor-

phologic findings. A number of criteria

were required not only to distinguish

subtypes of MPN from each other but

from reactive granulocytic, erythroid and/

or megakaryocytic hyperplasia.

Revisions in the criteria for classification

of MPN in the current scheme have been

influenced by two factors—the recent dis-

covery of genetic abnormalities involved

in the pathogenesis of BCR-ABL1 nega-tive MPN and the wider appreciation that

histologic features (megakaryocytic mor-

phology and topography, marrow stromal

changes, identification of specific cell

lineages involved in the proliferation) cor-

relate with clinical features and can be

used as criteria to identify MPN subtypes

{2177, 2216, 2222}.

Most if not all MPN are associated with

clonal abnormalities involving genes that

encode cytoplasmic or receptor PTKs.

The abnormalities described to date

include translocations or point mutations

of genes that result in abnormal, constitu-

tively abnormal PTKs that activate signal

transduction pathways leading to the

abnormal proliferation. In some cases

these genetic abnormalities, such as the

BCR-ABL1 fusion gene in CML, are asso-

ciated with consistent clinical, laboratory

and morphologic findings that allow them

to be utilized as major criteria for classifi-

cation, whereas others provide proof that

the myeloid proliferation is neoplastic

rather than reactive.Acquired somatic mutations of JAK2 , at

chromosome 9p24, have been shown to

play a pivotal role in the pathogenesis of

many cases of BCR-ABL1 negative MPN

{1044, 1163, 1186, 1287A, 1288}. The

most common mutation, JAK2 V617F, re-

sults in a constitutively active cytoplasmic

JAK2 that activates signal transducer and

activator of transcription (STAT), mitogen

activated protein kinase (MAPK) and

phosphotidylinositol 3-kinase (PI3K) sig-

naling pathways to promote transformation

Fig. 1.06 MPN and other myeloid neoplasms associated with mutation/rearrangement of tyrosine kinase genes.


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and proliferation of haematopoietic pro-

genitors (Fig. 1.07). The JAK2 V617F mu-

tation is found in almost all patients with

polycythaemia vera (PV) and in nearly

one-half of those with primary myelofibrosis

(PMF) and with essential thrombo-

cythaemia (ET). In the few PV patients

who lack the JAK2 V617F, an activating

JAK2 exon 12 mutation may be found,

and in a small proportion of cases of PMF

and ET, an activating mutation of MPL

W515L or W515K is seen. It is important

to note that JAK2 V617F is not specific for

any MPN nor does its absence exclude

MPN. Furthermore, it has been reported

in some cases of MDS/MPN, in rare cases

of AML, and in combination with other

well-defined genetic abnormalities such

as the BCR-ABL1 {1064}. Thus, diagnostic

algorithms for PV, ET and PMF have been

altered to take the mutational status of

JAK2 into account as well as to outline the

additional laboratory and histologic find-

ings required to reach an accurate clas-

sification of cases, regardless of whether

the mutation is or is not present.

In addition to the changes in the criteria

for PV, ET and PMF, information regarding

abnormal PTK function due to rearrange-

ments of the PDGFRA, PDGFRB or FGFR1

genes in patients with myeloid neoplasms

associated with eosinophilia led to reap-

praisal and new diagnostic algorithms for

those syndromes as well (see below). The

appreciation of the role altered PTKs play

in the pathogenesis of CML, PV, ET and

PMF also argues for the inclusion of simi-

lar chronic myeloid proliferations related

to PTK abnormalities under the MPN um-

brella. Thus, systemic mastocytosis, which

has many features in common with other

MPN entities and is almost always asso-

ciated with D816V mutation in the KIT

gene encoding the receptor PTK, KIT, has

been added to this category {2176}. Still

the molecular pathogenesis of nearly half

of all cases of ET and PMF, of all cases of

chronic neutrophilic leukaemia and a

number of myeloid neoplasms associated

with eosinophilia remain unknown. For

these reliance on clinical, laboratory and

morphologic features is essential for

diagnosis and classification.

Summary of major changes in the

classification of MPN

1. The nomenclature, “myeloproliferative

disease” has been changed to “myelo-

proliferative neoplasm”

2. Mastocytosis has been included in theMPN category

3. Some cases previously meeting the

criteria for chronic eosinophilic leukaemia

(CEL) may now be categorized as myeloid

or lymphoid neoplasms with eosinophilia

and abnormalities of PDGFRA, PDGFRB or

FGFR1. If none of these rearrangements

are detected, and there is no BCR-ABL1

fusion gene, they should be categorized

as CEL, not otherwise specified.

4. The diagnostic algorithms for PV, ET

and PMF have been substantially

changed to include information regardingJAK2 and similar activating mutations as

well as pertinent histologic features of the

BM biopsy as diagnostic criteria.

5. The threshold of the platelet count for

the diagnosis of ET has been lowered to

450x109 /L.

6. Criteria for CML in accelerated phase

have been suggested with the caveat that

they have not been fully evaluated in the

era of PTKI therapy; studies to determine

their relevance are in progress and revi-

sions may be necessary.

Myeloid and lymphoid neoplasms with

eosinophilia and abnormalities of

PDGFR , PDGFRB or FGFR

Determining the cause of marked, per-

sistent eosinophilia (>1.5x109 /L) in the

blood can be challenging and is some-

times clinically urgent because of the

potential damage to the heart, lungs, cen-

tral nervous and other organ systems

caused by the eosinophilic infiltration and

release of cytokines, enzymes and other

proteins. The eosinophils may be derived

Fig. 1.07 Mechanism of activation of JAK2 kinase activity by mutations in the JAK2 signaling pathway. A Cytokine

ligands normally bind cytokine receptors, which results in Janus kinase 2 (JAK2) phosphorylation, recruitment of signal

transducer and activator of transcription (Stat) signaling proteins and phosphorylation and activation of downstream

signaling pathways including Stat transcription factors, mitogen activated protein kinase (MAPK) signaling proteins, and

the phosphotidylinositol 3-kinase (PI3K)–Akt pathway. B The JAK2 V617F and JAK2 exon 12 mutant kinases bind

cytokine receptors, are phosphorylated in the absence of ligand and lead to ligand-independent activation of down-

stream signaling pathways. C By contrast, MPL W515L/K mutant thrombopoietin receptors are able to phosphorylate

wild-type JAK2 in the absence of thrombopoietin, and result in the activation of signaling pathways downstream of JAK2.

Negative regulation of JAK2 signaling is normally mediated by suppressor of cytokine signalling (Socs) proteins, most

notably SOCS1 and SOCS3; recent data indicate that the JAK2 V617F allele might escape negative feedback by

SOCS3. Reproduced from {1287A}.


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from the neoplastic clone of a myeloid

neoplasm, such as CEL, CML or AML, or

they may be reactive due to abnormal cy-

tokine release from reactive or neoplastic

T-cells. In a number of cases, no underly-

ing cause can be found and the clonality

of the eosinophils cannot be proven;

these cases are appropriately termed

“idiopathic hypereosinophilic syndrome”

(See Chapter 3?).

Rationale for diagnosis and classification

of myeloid and lymphoid disorders with

eosinophilia and abnormalities of PDGFRA,

PDGFRB or FGFR1

Since the last edition of the WHO classifi-

cation it has been recognized that many

cases of eosinophilia, including a sub-

stantial number considered as “idio-

pathic” are clonal myeloid neoplasms

caused by abnormalities in genes that en-

code the alpha or beta chains of the receptor PTKs, platelet derived growth

factor receptor (PDGFR) or fibroblast

growth factor receptor 1 (FGFR1). Re-

arrangements of PDGFRB at chromo-

some band 5q33 that lead to constitutive

activation of the beta moiety of PDGFR

were first recognized in cases variably re-

ported as CEL or chronic myelomonocytic

leukaemia (CMML) with eosinophilia {131,

812, 2085}. More recently the gene that

encodes the alpha moiety of the PDGFR,

PDGFRA, at chromosome band 4q12,

was found to be involved in cryptictranslocations in CEL and in nearly one-

half of cases reported as idiopathic

hypereosinophilic syndrome {466}. In

addition, rearrangements of the FGFR1

tyrosine kinase gene have also been

implicated in myeloproliferations with

prominent eosinophilia {3, 1354}. How-

ever, the clinical and morphologic

presentations associated with FGFR1

rearrangement are variable, and include

not only presentation as a myeloprolifera-

tive neoplasm with eosinophilia, but also

as AML and they may even present as, orevolve to, precursor T or B lymphoblastic

leukaemia/lymphoma with prominent

eosinophils. Cases associated with

PDGFRA rearrangements can likewise

present as AML or precursor T-cell neo-

plasms {1469}. Although it might seem

most efficient to categorize these cases

as CEL within MPN, this would ignore

cases with PDGFRB abnormalities that

present as CMML as well as cases of

FGFR1 and PDGFRA rearrangements that

may even have a lymphoid component.

To accommodate these translocations, a

new subgroup defined largely by the

genetic abnormalities of PDGFRA,

PDGFRB or FGFR1 has been added

(Table 1.03). Detection of one of these

abnormalities places the case in this cat-

egory, regardless of the morphologic

classification. Cases of myeloid neoplasms

with eosinophilia that lack all of these ab-

normalities and that meet the criteria for

CEL, NOS, in the MPN category shouldbe placed in that group.

Myelodysplastic/myeloproliferative

neoplasms MDS/MPN)

The MDS/MPN (Table 1.04) include clonal

myeloid neoplasms that at the time of ini-

tial presentation have some clinical, labo-

ratory or morphologic findings that

support a diagnosis of MDS, and other

findings more consistent with MPN. They

are usually characterized by hypercellu-

larity of the BM due to proliferation in one

or more of the myeloid lineages. Fre-quently, the proliferation is effective in

some lineages with increased numbers of

circulating cells that may be morphologi-

cally and/or functionally d

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