Post on 06-Jul-2018
8/17/2019 WHO Hemato 2008-4Ed.pdf
1/422
8/17/2019 WHO Hemato 2008-4Ed.pdf
2/422
From all countries
From USA / Canada
WHO PRESS
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
www.who.int/bookorders/
Tel. +41 22 791 3264
Fax +41 22 791 4857
bookorders@who.int
WHO Publications Center
5 Sand Creek Road
Albany, NY 1205-1400
Tel. +1 518 436 9686
Fax. +1 518 436 7433
qcorp@compuserve.com
Renouf Publishing Co. Ltd
http://www.renoufbooks.com/
From USA: Tel. +1 888 551 7470
From Canada: Tel. +1 866 767 6766
Fax. +1 888 551 7471
Fax. +1 613 745 7660
This book and all other volumes of the series can be purchased from:
Hamilton S.R., Aaltonen L.A. (Eds.):
World Health Organization
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
Organization Classification of
Tumours. Pathology and Genetics of
Tumours of the Urinary System and
Male Genital Organs.
IARC Press: Lyon 2004
ISBN 92 832 2415 9
Barnes L., Eveson J.W., Reichart P.,
Sidransky D. (Eds.): World Health
Organization Classification of
Tumours. Pathology and Genetics of
Head and Neck Tumours.
IARC Press: Lyon 2005
ISBN 92 832 2417 5
Fletcher C.D., Unni K.K.,
Mertens F. (Eds.): World Health
Organization Classification of
Tumours. Pathology and Genetics of
Tumours of Soft Tissue and Bone.IARC Press: Lyon 2002
ISBN 92 832 2413 2
Travis W.D., Brambilla E., Müller-
Hermelink H.K., Harris C.C. (Eds.):
World Health Organization
Classification of Tumours. Pathology
and Genetics of Tumours of Lung,
Pleura, Thymus and Heart.
IARC Press: Lyon 2004
ISBN 92 832 2418 3
LeBoit P.E., Burg G., Weedon D.,
Sarasin A. (Eds.): World Health
Organization Classification of
Tumours. Pathology and Genetics of
Skin Tumours.
IARC Press: Lyon 2006
ISBN 92 832 2414 0
Tavassoli F.A., Devilee P. (Eds.):
World Health Organization
Classification of Tumours.
Pathology and Genetics of Tumours
of the Breast and Female GenitalOrgans
IARC Press: Lyon 2003
ISBN 92 832 2412 4
DeLellis R.A., Lloyd R.V., Heitz, P.U
Eng C. (Eds.): World Health
Organization Classification of
Tumours. Pathology and Genetics o
Tumours of Endocrine Organs.
IARC Press: Lyon 2004
ISBN 92 832 2416 7
Louis D.N., Ohgaki H., Wiestler O.D
Cavenee W.K. (Eds.): World Health
Organization Classification of
Tumours. Tumours of the Central
Nervous System (4th edition).
IARC, Lyon 2007
ISBN 92 832 2430 2
World Health Organization Classification of Tumours
8/17/2019 WHO Hemato 2008-4Ed.pdf
3/422
8/17/2019 WHO Hemato 2008-4Ed.pdf
4/422
8/17/2019 WHO Hemato 2008-4Ed.pdf
5/422
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
6/422
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
7/422
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.
8/17/2019 WHO Hemato 2008-4Ed.pdf
8/422
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
WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
(Tel: +41 22 791 3264; Fax: +41 22 791 4857; e-mail: bookorders@who.int).
Publications of the World Health Organization enjoy copyright protection in accordance
with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization
concerning the legal status of any country, territory, city, or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers' products does not imply that they are
endorsed or recommended by the World Health Organization in preference to others of a similar
nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
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)
8/17/2019 WHO Hemato 2008-4Ed.pdf
9/422
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
B Lymphoblastic leukaemia/lymphoma with
t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)
B Lymphoblastic leukaemia/lymphoma with
hyperdiploidyB Lymphoblastic leukaemia/lymphoma with
hypodiploidy (Hypodiploid ALL)
B Lymphoblastic leukaemia/lymphoma with
t(5;14)(q31;q32); IL3-IGH
B Lymphoblastic leukaemia/lymphoma with
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
10/422
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
B-cell lymphoma, unclassifiable, with features
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 disorders
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
lymphoproliferative disorders
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
11/422
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
Stanford University Medical Center
Palo Alto, CA, USA
Clinical Advisory Committee
Section title
*Also contributors
8/17/2019 WHO Hemato 2008-4Ed.pdf
12/422
Dr Sandra J. HORNING (Lymphoid co-chair)
Stanford University Medical Center
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
Dana Farber Cancer Institute
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
Dana Farber Cancer Institute
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
13/422
Section title
8/17/2019 WHO Hemato 2008-4Ed.pdf
14/422
1Source of charts and photogra
Source of charts and photographs
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 A 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 A 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 A,B 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 A,B 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 A 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.
6.05 B Brunning R.D.
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.
6.23 B Brunning R.D.
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.
6.30 B Brunning R.D.
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.
6.38 B Brunning R.D.
8/17/2019 WHO Hemato 2008-4Ed.pdf
15/422
2
6.39 A Brunning R.D.
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.
10.02 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.
11.01 Muller-Hermelink H.-K.
11.02 Muller-Hermelink H.-K.
11.03 Muller-Hermelink H.-K.
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.
Source of charts and photographs
8/17/2019 WHO Hemato 2008-4Ed.pdf
16/422
3Subject index
11.10 Quintanilla-Martinez L.
11.11 Quintanilla-Martinez L.
11.12 Quintanilla-Martinez L.
11.13 Quintanilla-Martinez L.
11.14 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.
8/17/2019 WHO Hemato 2008-4Ed.pdf
17/422
WHO Classification
4th Edition
8/17/2019 WHO Hemato 2008-4Ed.pdf
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
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
B lymphoblastic leukaemia/lymphoma, NOS 9811/3
B lymphoblastic leukaemia/lymphoma
with recurrent genetic abnormalities
B lymphoblastic leukaemia/lymphoma
with t(9;22)(q34;q11.2); BCR-ABL1 9812/3
B lymphoblastic leukaemia/lymphoma
with t(v;11q23); MLL rearranged 9813/3
B lymphoblastic leukaemia/lymphoma
with t(12;21)(p13;q22); TEL-AML1
(ETV6-RUNX1) 9814/3
B lymphoblastic leukaemia/lymphomawith hyperdiploidy 9815/3
B lymphoblastic leukaemia/lymphoma
with hypodiploidy (hypodiploid ALL) 9816/3
B lymphoblastic leukaemia/lymphoma
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
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
B-cell lymphoma, unclassifiable, with features
intermediate between diffuse large B-cell
lymphoma and Burkitt lymphoma 9680/3
B-cell lymphoma, unclassifiable, with features
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
lymphoproliferative disorders
Lymphomatoid papulosis 9718/1
Primary cutaneous anaplastic large cell
lymphoma 9718/3
Primary cutaneous gamma-delta
T-cell lymphoma 9726/3
Primary cutaneous CD8 positive aggressive
epidermotropic cytotoxic T-cell lymphoma 9709/3
Primary cutaneous CD4 positive small/medium
T-cell lymphoma 9709/3
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
Hodgkin lymphoma 9651/3
Mixed cellularity classical
Hodgkin lymphoma 9652/3
Lymphocyte depleted classical
Hodgkin lymphoma 9653/3
WHO classification12
8/17/2019 WHO Hemato 2008-4Ed.pdf
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
22/422
CHAPTER 1
Introduction and overview
of the classification
of the myeloid neoplasms
8/17/2019 WHO Hemato 2008-4Ed.pdf
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;
8/17/2019 WHO Hemato 2008-4Ed.pdf
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.
8/17/2019 WHO Hemato 2008-4Ed.pdf
25/422
Introduction and overview of the classification of the myeloid neoplasms20
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
26/422
Introduction and overview of the classification of the myeloid neoplasms 21
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
8/17/2019 WHO Hemato 2008-4Ed.pdf
27/422
Introduction and overview of the classification of the myeloid neoplasms22
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.
8/17/2019 WHO Hemato 2008-4Ed.pdf
28/422
Introduction and overview of the classification of the myeloid neoplasms 23
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)
8/17/2019 WHO Hemato 2008-4Ed.pdf
29/422
Introduction and overview of the classification of the myeloid neoplasms24
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.
8/17/2019 WHO Hemato 2008-4Ed.pdf
30/422
Introduction and overview of the classification of the myeloid neoplasms 25
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}.
8/17/2019 WHO Hemato 2008-4Ed.pdf
31/422
Introduction and overview of the classification of the myeloid neoplasms26
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