Hematopathology Resident / Fellow Manual - Department of ...

DIVISION OF HEMATOPATHOLOGY
HEMATOPATHOLOGY HANDBOOK
FOR
RESIDENTS AND FELLOWS
October 2013
STEVEN H. SWERDLOW, MD
DIRECTOR, DIVISION OF HEMATOPATHOLOGY
GRANT BULLOCK, MD
LYDIA CONTIS, MD
FIONA CRAIG, MD
MIROSLAV DJOKIC, MD
RAYMOND FELGAR, MD/PhD
SARAH GIBSON, MD
LISA ROBINSON, MD
CHRISTINE ROTH, MD
The Division acknowledges the help of Ms. L. Koerbel and Ms. J.
Klimkowicz in putting this handbook together and keeping it up to date.

TABLE OF CONTENTS
(Ctrl +click on blue hyperlink to go to section)
IMPORTANT TELEPHONE NUMBERS LIST 5
GENERAL OUTLINE FOR HEMATOPATHOLOGY ROTATION 7
HEMATOPATHOLOGY PROGRESSIVE GOALS AND OBJECTIVES 11
RESIDENT EVALUATION METHODS AND DOCUMENTATION 18
CONFERENCE SCHEDULE AND RESPONSIBILITIES 19
PEDIATRIC AND GENERAL HEMATOLOGY LABORATORY EXPERIENCE 26
GENERAL/SPECIAL HEMATOLOGY LABORATORY EXPERIENCE CHECKLIST 29
PEDIATRIC HEMATOPATHOLOGY CHECKLIST 41
UPMC PRESBYTERIAN SHADYSIDE AUTOMATED TESTING LABORATORY 49
PATHOLOGIST REVIEW FORM/CHP ATL PATHOLOGIST REVIEW FORM
CLINICAL EXPERIENCE IN HEMATOLOGY 51
CLINICAL HEMATOLOGY/PERFORMANCE OF BONE MARROW EXPERIENCE 52
PERFORMANCE OF BONE MARROW ASPIRATIONS & BIOPSIES 53
HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM 55
FLOW CYTOMETRY LABORATORY EXPERIENCE 56
FLOW CYTOMETRY ROTATION CHECKLIST 58
FLOW CYTOMETRY PANELS, AVAILABLE ANTIBODIES, GUIDELINES, 60
TEST SPECIFICATIONS FOR CLINICAL FLOW CYTOMETRY LABORATORY 71
ICD9 CODES FOR FLOW 73
ADULT BONE MARROW EXPERIENCE 75
GENERAL TRAINEE RESPONSIBILITIES DURING BONE MARROW ROTATION 76
SPECIFIC GUIDELINES FOR RESIDENTS AND FELLOWS ON BONE MARROW SERVICE 78
BONE MARROW ADEQUACY CRITERIA 79
POLICY FOR REVIEW OF BONE MARROW ASPIRATES AND BIOPSIES 80
FORMS AND TEMPLATES FOR BONE MARROW SERVICE 82
RECOMMENDATIONS FOR CONSISTENT TERMINOLOGY 93
AJCC PROTOCOL FOR EXAMINATIOM OF SPECIMINS FROM PATIENTS WITH
HEMATOPOIETIC NEOPLASMS INVOLVING THE BONE MARROW 96
BONE MARROW LABORATORY TEST SPECIFICATIONS 109
SUMMARY OF TEST SPECIFICATION FOR ANCILLARY LABORATORIES 111
BONE MARROW AFTER HOURS PROCEDURES 113

TABLE OF CONTENTS (cont.)
LYMPH NODE EXPERIENCE 117
SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL 118
SURGICAL PATHOLOGY MANUAL: SPLEEN PROTOCOL 127
LYMPH NODE GROSS DICTATION-TEMPLATE 128
POLICY FOR SOLID TISSUE SPECIMENS 129
INSTRUCTIONS FOR FRESH TISSUE BIOPSIES RECEIVED FROM OUTSIDE INSTITUTIONS 130
FRESH CASE LYMPH NODES AND OTHER SOLID TISSUES SENT FOR FLOW CYTOMETRY 131
HELPFUL HINTS FOR HANDLING CONSULT BLOCKS &
SENDING OUTSIDE BLOCKS TO HISTOLOGY 132
RULES FOR HISTOLOGY 133
GENERAL FORMATTING REQUIREMENTS 136
LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL 142
HEMATOPATHOLOGY CASE WORKSHEET 144
LYMPH NODE ROTATION CHECKLIST 149
AJCC PROTOCOL FOR EXAMINTION OF SPECIMENS FROM PATIENT WITH
NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS 158
AJCC PROTOCOL FOR THE EXAMINATION OF SPECIMENS FROM PATIENTS WITH
HODGKIN LYMPHOMA 174
IMMUNOHISTOCHEMISTRY 179
IMMUNOSTAINS/IN-SITU HYBRIDIZATION LABORATORY AND ORDERING INFORMATION 180
STAINS FREQUENTLY USED IN HEMATOPATHOLOGY: CODES AND REACTIVITIES 182
COMPLETE IMMUNOHISTOCHEMICAL STAIN ABBREVIATIONS/CODES 185
IN-SITU HYBRIDIZATION PROBES AVAILABLE 193
IHC/ISH REPORTING TEMPLATES 194
MOLECULAR DIAGNOSTIC AND CYTOGENETICS 197
FLUORESCENCE IN SITU HYBRIDIZATION – PITTSBURGH
CYTOGENETICS LABORATORY 199
COPATH AND DICTATION POINTERS 208
DICTATING & PROOFING TISSUE REPORTS 210
SYNOPTICS 213
WEB-BASED RESOURCES 230

Contents of Supplementary Information
See the following hard copy supplementary information:
1. Schedules
• Master Hematopathology
• Flow Cytometry Conference
• Journal Club
• Patient Safety and Risk Management Hematopathology Conference
• Pediatric Tumor Board
• Conference Schedule
• Hematopathology Core Resident Rotation
2. Forms to turn into Hematopathology Coordinator Linda Koerbel:
• Performance of Marrow Biopsies and Aspirates Form (2)
• Laboratory Hematology Check List
• Flow Cytometry Experience Checklist
• Lymph Node Experience Checklist
• Pediatric Hematology Experience Checklist
• Bone Marrow Experience Checklist
3. Material for Laboratory Hematology
• Red Cell Morphology Classification
• Complete Blood Count Evaluation
• Continuing Education in Clinical Chemistry and Hematology Conference Responsibilities
4. Miscellaneous
• Progressive Goals and Objectives
• Faculty/Fellow Phone List
• Sure-handed Sampling/Easing the Trauma of Bone Marrow Collection
• Resident Evaluation Methods
• Dictating and Proofing Tissue Reports
• CD
• Hematopathology Handbook for Residents and Fellows
• Automated Hematology Instrumentation
• Grossing Fresh Lymph Nodes (PowerPoint Presentation)
• Neutrophil Oxidative Burst Assay (NOBA)
• Hemoglobinopathies (PowerPoint Presentation)
• Chromatin interpretation guide for hemoglobinopathies (PDF)

HEMATOPATHOLOGY
FACULTY
Long Range
Pager
In House
Pager
Office #
Coordinator/Secretary
Grant Bullock, MD 412-958-6254 10356 412-624-7523 Jessica Klimkowicz 412-647-5191
Lydia Contis, MD 412-433-9364 2296 412-647-0264 Jessica Klimkowicz 412-647-5191
Fiona Craig, MD 412-958-2896 2462 412-647-8504 Jessica Klimkowicz 412-647-5191
Miroslav Djokic, MD 412-958-5267 14609 412-692-2128 Jessica Klimkowicz 412-647-5191
Raymond Felgar, MD,
PhD
412-958-6088 2825 412-647-8780 Jessica Klimkowicz 412-647-5191
Sarah Gibson, MD 412-958-5723 13155 412-647-4162 Jessica Klimkowicz 412-647-5191
Lisa Robinson, MD 412-958-8449 10586 412-647-0365 Jessica Klimkowicz 412-647-5191
Christine Roth, MD 412-958-4985 2282 412-692-2090 Jessica Klimkowicz 412-647-5191
Steven H. Swerdlow, MD 412-392-7445 2826 412-647-5191 Linda Koerbel 412-578-9423
FELLOWS
Long Range In House
Pager
Pager
Office #
Coordinator/Secretary
Christopher Cogbill, MD 412-958-7419 8338 412-647-1877 N/A
Bevan Tandon, MD 412-958-7421 8339 412-647-0435 N/A
Charlene Hellman, MD 412-958-7434 8359 412-578-9239 N/A
Lymph Node Assistant
Lisa Fitchwell 412-958-7432 10768 412-647-5869 N/A
Michelle Asturi --------------- --------------- 412-647-0263 N/A
Cytogenetics/Hours of 412-641-6688 (Weekend pager: 412-917-9458-messages will be checked until 3PM)
FISH Lab 412-641-3434
Dr. Urvashi Surti 412-917-9333 --------------- 412-641-4267
Dr. Susanne Gollin --------------- --------------- 412-624-5390 Noel Eisel Harrie
Maureen Sherer --------------- --------------- 412-641-6685 ---------------
Technologist Pager
412-917-9458 (Sat./Sun./Holidays until 3:00pm)
Molecular Diagnostics 412-864-6150 (CLB)
Molec Fellows 412-864-6155
Molec Sign-Out 412-864-6153
Dr. Zoltan Oltvai --------------- --------------- 412-864-6150
Dr. Tim Oury --------------- --------------- 412-648-9659
Dr. Marie DeFrances --------------- --------------- 412-648-8346
Miscellaneous Phone Number Location Supervisor Lead Technologist
Bone Marrow Lab 412-647-0263 G325.1 Celina Fortunato Celina Fortunato 412-802-3272
Bone Marrow Audix 412-802-3273 “Non-Stat” Requests
Bone Marrow Sign Out 412-647-5881 G315 --------------- ------------------
Histology 412-647-7660 CLB
Marina Rahman
412-864-6123
Tisha
Harrison
5am-1:30pm
immunopero
xidase
issues
IPEX 412-647-7663
Lymph Node Sign Out /
Resource Room
412-647-5262 G323 --------------- ------------------
Mike
Swiatkowski
7-3:30
Routine
histology and
special stain
issues
Consult Accessioning 412-864-6175 CLB 9032 Celina Fortunato Celina Fortunato 412-802-3272
Automated Testing Lab
412-647-1022/
heme bench 76199
5 th Fl CLB
SHY Automated Testing
Lab
412-623-1595 WG02.18
Flow Laboratory 412-864-6173
Flow Laboratory Extras 412-864-6182
CLB 9032
Katie Mulvey
412-647-5662
Michael Kaib
412-623-2322
Pager
412-565-9553
Betty Austin 77864 (Heme)
Karen Freilino 412-864-6180
Shadyside Fl
SHY Hematology Lab 412-623-6011
Darla Lower Tammy Garrett
G-Main 412-623-1595
Microlab Adult 412-647-3727 PUH A802 Frances Hardic 412-647-7711
412-692-5325 CHP
Lorraine Heffelfinger 412-692-7611 /
CHP ATL
412-692-5665 Lawrenceville Marianne Riazzi 412-692-9836
Robyn
Darwick 3-
11:30
Evening
routine &
immunopero
xidase issues

GENERAL OUTLINE FOR
HEMATOPATHOLOGY
ROTATION

General Outline for Hematopathology Rotations
Core Rotation for Residents
The approximately three-month core hematopathology rotation offers the resident an
introduction to the many facets of this complex field. It is hoped that the resident will begin to
become familiar with the multiparameter approach to adult and pediatric diagnostic
hematopathology (bone marrows and lymph nodes) as well as with techniques used in general
and special hematology laboratories, and the flow cytometry laboratory. Finally he/she will learn
about major neoplastic and non-neoplastic disease entities that involve the hematopoietic and
lymphoid cell lineage. If interested, more advanced subsequent rotations can be arranged in
one or more areas within the division. It is fully recognized that the resident cannot fully achieve
all of the objectives listed within a period of three months. The different sections within the
rotation are usually, but not always carried out in the order they are listed here. The educational
resources noted below are located in rooms G304 (conference room), G315 (bone marrow signout
room) and G323 (lymph node sign-out room) depending on their subject matter.
Cytogenetics is a separate rotation, but residents will learn how cytogenetic data is used in
diagnostic hematopathology.
Syllabus Statement Concerning Students with Disabilities
If you have a disability for which you are or may be requesting an accommodation, you are
encouraged to contact Dr. Swerdlow, Dr. Roth or their designate prior to your rotation so
reasonable accommodations can be made.
Elective Rotations
This handbook also serves as a resource for upper level resident rotations that can concentrate
on any of the areas in hematopathology.
Fellow Rotations
This handbook also is a major supplement to the fellow handbook as they also follow the basic
procedures outlined here for the rotations that overlap with hematopathology resident rotations.
The expectations are greater for the fellows in terms of their knowledge base, clinical skills and
ability to utilize multiple resources to make specific diagnoses. Accordingly they are given
enhanced responsibilities.
Hematopathology Twelve Week Core Resident Rotation
Week
Activities
1 Orientation with Dr. Roth or designee.
Lymph Node
2 Lymph Node
3 Lymph Node
4 Lymph Node
5 Peds/Wet & ASCP image set/BM tech review
6 Peds/Wet
7 Peds/Wet
8 Days 1-3 AM Shadyside (Go to Hemepath Conference Wed AM)
Days 3 PM – 4,5 Flow Rotation
9 Adult Bone Marrow
10 Adult Bone Marrow
11 Adult Bone Marrow
12 Adult Bone Marrow

1. Lymph Node Pathology (~ 4 weeks)
1. Lymph Node Sign Out.
2. Review of educational materials (See Lymph Node Experience section).
Goals and Objectives:
1. Learn the use of multiparameter approach to diagnostic lymph node pathology as
well as extranodal hematopoietic/lymphoid proliferations.
2. Learn normal nodal histology and basic reactive patterns.
3. Begin to develop a basic understanding of Hodgkin’s Lymphoma, the non-
Hodgkin’s lymphomas and reactive lymphoid hyperplasias. Be able to diagnose
straightforward cases of the above.
4. Complete lymph node rotation checklist.
2. Pediatric Hematopathology and General/Special Hematology Laboratory
Experience (~ 3 weeks)
Trainees should report to the pathologist signing out CHP bone marrows and to Dr. Contis or
her designate after their general rotation orientation or at the start of the rotation. Trainees
should also meet with Dr. Contis or her designate at the midpoint to review progress on the
rotation and at the completion of the rotation. Inform the pathologist covering the general
hematology laboratory as well. The trainee will give one ~15 minute presentation near the end
of this section of the rotation. This period should also be used to review the ASCP image series
on normal and abnormal peripheral blood and bone marrow examinations.
Pediatric Hematopathology Experience
1. Introduction to basic bone marrow/peripheral blood interpretation.
2. Pediatric Bone Marrow Sign out.
3. Observation of pediatric marrow examination procedures.
4. Review pediatric material from Automated Testing Laboratory and Flow
Cytometry Laboratory.
5. Review of educational materials (See Pediatric Hematopathology Experience
section).
Goals and Objectives:
1. Develop basic skills in the interpretation of peripheral blood, bone marrow and
fluid evaluations.
2. Develop familiarity with issues unique to pediatric hematopathology, both
pathologic and clinical.
3. Develop basic skills in hematopathologic ancillary studies.
4. Complete pediatric hematopathology checklist.
5. Complete pediatric bone marrow observation form.

General/Special Hematology Laboratory Experience
1. Automated Testing Laboratory Experience.
2. Special Hematology Testing Experience.
3. Review of educational materials.
4. Presentation to technologists.
Goals and Objectives:
1. Learn the major aspects of non-neoplastic hematology including red blood cell,
white blood and platelet abnormalities and the way in which the laboratory helps
in the diagnosis and follow-up of hematologic/lymphoid neoplasms.
2. Understand the principles of urinalysis and how it is used to help diagnose renal
and systemic disorders.
3. Understand automated hematology and urinalysis instrumentation.
4. Develop understanding of how a large complex patient-oriented clinical
laboratory facility is managed. This includes an appreciation of the scope of the
testing, testing methodology and documentation of test accuracy.
5. Learn the scope and practices of “Special Hematology” testing and how it is
utilized to diagnose hematologic disorders.
6. Complete general/special hematology experience checklist.
3. Clinical experience in Hematology/Performance of Bone Marrows (with
Hematology/Oncology Division) (2 ½ days)
Attend varied clinics at UPMC-Shadyside/Hillman Cancer Center to observe the clinical
aspects of hematology and understand the needs of both patients and their physicians.
Trainees are expected to learn how to perform bone marrow aspirations and biopsies.
They should aim to observe and then perform several marrows. Because it is expected
that during this rotation residents will perform no more that 5 marrows, they should
complete this requirement on their later VA rotation (Dr. M. Melhem). Be sure to
complete the BM performance form that requires signatures of the person who
supervised your marrow examinations and the pathologist who reviewed the slides.
NOTE: Appropriate dress is required to see patients (white coat, men need to wear a
tie).
Goals and Objectives:
1. Gain experience performing bone marrow aspirates and biopsies.
2. Learn more about clinical implications of hematopathology diagnoses and impact
on patients as a person.
3. Provide opportunities to perform bone marrow examinations.
4. Learn what type of consultations clinicians expect from hematopathologists.
5. Complete the bone marrow performance form.

4. Flow Cytometry Laboratory Experience (2½ days)
Understanding of flow cytometric immunophenotypic techniques and interpretation of the
resultant data is an integral part of all the bone marrow and lymph node rotations. In
addition, however there is a brief concentrated exposure to the flow cytometry laboratory
including the technical aspects of flow cytometry and the basic operation of a flow
cytometry laboratory. The resident should report to Karen Freilino or their designate.
Goals and Objectives:
1. Understand sample preparation; basic flow cytometry, quality control, gating on
specific cell populations, and determination of positive versus negative staining
and methods of data presentation.
2. Know indications for testing, taking into account cost effective medicine
3. Complete flow cytometry checklist.
5. Adult Bone Marrow Experience (~ 4 weeks)
A. Limited Sessions with Adult Bone Marrow Technologist.
B. Responsibility for review of selected cases prior to sign-out.
C. Participation in sign-out with staff.
D. Review of educational materials (See Adult Bone Marrow Experience section).
Goals and Objectives:
1. Learn normal and abnormal blood cell morphology.
2. Learn basic approach to bone marrow aspirate, biopsy and particle preparation
interpretation.
3. Begin to become familiar with the use of ancillary studies used in the diagnosis of
bone marrow examinations.
4. Begin to develop a basic understanding of the more common neoplastic and nonneoplastic
disorders which involve the marrow: acute and chronic leukemias,
myelodysplasias, myeloproliferative disorders, anemias, thrombocytopenias,
leukopenias, thrombocytosis, leukocytosis, infections (including HIV), and
metastatic neoplasms. Be able to diagnose straightforward cases of the above.
5. Complete bone marrow rotation checklist.

Hematopathology Progressive Goals and Objectives
Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
Professionalism Reliable, punctual,
appropriate
appearance, ethical
behavior, sensitive to
issues of diversity,
HIPAA compliant
Patient Care
Same as near
beginning of rotation
but projects more
confidence and
handles difficult
situations with
greater ease.
In addition to elements
already noted, can help advise
more junior trainees and serve
as a more senior role model.
Preview marrow
aspirate smears with
Preview marrow
aspirate smears
Write and dictate reports for
most routine cases.
direct faculty guidance. semi-independently,
Review cases, record
observations,
formulate differential
diagnosis.
directly interact with
technologists.
Review cases, record
observations,
formulate more
complete differential
diagnosis
In addition to elements
noted for residents,
functions so that others
perceive fellow more like
a junior faculty member.
Create a professional
CV. Conduct a
successful job search if
not continuing as a
fellow.
Independently work-up
and complete the
majority of cases.
In addition to prior
accomplishments,
interacts with other
faculty and clinicians like
a more confident junior
faculty member, able to
construct and maintain
professional c.v. and
biosketch
Able to provide a
complete diagnostic
report to attending
faculty with minimal
required changes.
Formulate list of
immunohistochemical
stains, cytochemical
stains, flow antibody
combinations to
resolve differential
diagnosis. Review data
from ancillary studies
Formulate more
educated list of
immunohistochemical
stains, cytochemical
stains, flow antibody
combinations to
resolve differential
diagnosis. Review
Independently order ancillary
studies in a resource
conscious way on most
routine cases.
Independently order
ancillary studies in a
resource conscious way
on routine and most
complex cases.
Independently order
ancillary studies in a
resource conscious way
on virtually all cases.

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
and record
interpretation.
data from ancillary
studies and record
more complete
interpretation.
Gross specimens for
lymphoma work-up
with directed
supervision.
With explicit directions,
interact with clinicians
and support staff.
Be able to provide
basic review of
peripheral blood and
interpret most common
hematology tests.
Gross specimens for
lymphoma work-up
with supervision as
needed (after
consulting fellow or
appropriate faculty).
With less explicit
directions, interact
with clinicians and
support staff.
Be able to provide Provide
basic review of
peripheral blood,
fluids and urines and
interpret most
standard hematology
tests.
Gross specimens for
lymphoma work-up with
limited supervision and select
ancillary testing independently
for most routine cases.
Function as a critical
consultant to clinical
physicians and support staff
with some supervision.
consultative/laboratory report
for general and special
hematology tests, peripheral
blood and fluid reviews
working with faculty on more
complex cases and with
limited assistance on less
complex cases.
Gross specimens for
lymphoma work-up with
very limited supervision
and select ancillary
testing independently for
the majority of cases.
Be able to help instruct
junior trainees.
Independently function
as a critical consultant to
clinical physicians.
Provide
consultative/laboratory
report for general and
special hematology
tests, peripheral blood
and fluid reviews on
simple and complex
cases relatively
independently but with
final approval by faculty
member.
Able to gross and triage
specimens
independently and to
supervise and instruct
more junior trainees.
Able to supervise more
junior trainee’s
presentations and
provide guidance for
preparation.
Provide
consultative/laboratory
report for general and
special hematology
tests, peripheral blood
and fluid reviews in all
cases with only limited
supervision.

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
Medical
Knowledge
Observe how others
handle laboratory
management issues.
Present at interdepartmental
CPC
conferences with
extensive supervision.
Knowledge of
morphology and
immunophenotype of
normal lymph node,
spleen, bone marrow
and peripheral blood.
Knowledge of
multiparameter
approach to diagnosis
of hematologic
disorders.
Recognize some of the
more common
neoplastic and nonneoplastic
disorders.
Know basic
immunophenotypic/
genotypic/cytogenetic
features where
Participate with
faculty/senior
technical staff in
laboratory
management issues.
Present at interdepartmental
CPC
Get directly involved in
laboratory management
issues with supervision.
Present at inter-departmental
CPC conferences with limited
conferences with less supervision.
direct supervision.
Know criteria for Know criteria for some of the
major neoplastic and less common
non-neoplastic hematopathologic entities in
hematopathologic addition to those for major
entities.
entities.
Know specific
approach used to
diagnose major
neoplastic and nonneoplastic
hematologic entities.
Recognize additional
common neoplastic
and non-neoplastic
disorders and know
ways in which
specific entities are
further subdivided. In
addition to basic
Recognize most common and
some uncommon neoplastic
and non-neoplastic disorders
of the hematolymphoid system
and know the
immunophenotypic,
cytogenetic and genotypic
characteristics.
Get involved in
laboratory management
issues with more limited
supervision.
Participate in continuing
education of
technologists and
support staff to improve
patient care.
Independently present at Presents cases at
inter-departmental CPC clinical CPC
conferences.
conferences without
supervision.
Have an extensive
knowledge of broad
range of neoplastic and
non-neoplastic
hematopoietic/lymphoid
disorders and other
disorders that involve or
affect the
hematolymphoid system
including the pathologic
and clinical aspects of
these disorders.
Further increase
hematopathology
knowledge base in terms
of rare entities and
variations within more
common entities. Learn
more about the type of
cases that lack a
definitive diagnosis.
Demonstrates ability to
apply and discuss
knowledge learned from
instructional workshops
or conferences attended.
Recognizes broad range Demonstrates an
of hematologic disorders appreciation of the
and recognizes when a
definitive diagnosis
cannot be rendered or
where consultative help
may be required.
limitation(s) of current
diagnostic
schemes/classification
systems (i.e. shows
recognition for “gray
zones” in diagnosis).

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
appropriate.
Know basic
components of
complete blood count
and how they are
obtained.
Practice-based Become familiar with
Learning
basic hematopathology
educational resources.
ancillary data
features, know
pathophysiologic
features of major
entities. Complete
greater than 80% of
resident version of
rotation checklist.
Know basic
components of
complete blood count
and other major
hematology tests and
how they are
obtained including
major pitfalls. Also
know basic principles
of fluid and urinalysis
interpretations.
Know disease
entities where
diagnosis is based in
large part on
hematology
laboratory testing.
Completes more of
appropriate checklists and
sees more entities previously
encountered through reading.
Complete greater than 90% of
resident version of rotation
checklist.
Know full armamentarium of
hematology testing, the
purpose of each test and how
to interpret combinations of
tests. Know new
developments in hematology
instrumentation.
Search literature for Critically analyze literature
information pertaining and other sources of new
to cases and apply it information pertaining to
to diagnostic cases.
appraisals at sign-out
Complete “extended
version” of all rotation
checklists.
In addition to resident
accomplishments, know
details of more esoteric
testing and what is on
the horizon for
laboratory hematology.
Know how to evaluate
new instrumentation.
Be able to teach others
about laboratory
hematology including
factual and interpretive
elements.
Have a broad
Master all skill
knowledge of the expectations listed for
hematopathology more junior residents
resources and literature and first year fellow.
and be able to apply this Use information

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
Start to develop
diagnostic differentials
for some of the more
common neoplastic
and non-neoplastic
disorders with
significant faculty input.
and at conferences.
Knows the differential
diagnoses to
consider for more
commonly
encountered
neoplastic and nonneoplastic
disorders.
Able to construct more
extensive differentials and
apply knowledge by deciding
what stains and ancillary
testing would aid in
distinguishing amongst the
diagnostic possibilities being
considered.
information to daily
practice including
dealing with unusual
cases
Demonstrates ability to
use textbooks and
medical literature to
construct a differential
diagnosis for most cases
and decide what
ancillary testing would
be useful.
independently to alter
personal practice.
Demonstrates ability to
apply knowledge from
medical literature in
constructing a diagnostic
differential or choosing
an appropriate work-up
strategy of stains,
ancillary testing, etc.
Construct reports
based on others’
examples.
Interpersonal/ Present with clarity in
Communication conference settings
Skills with significant faculty
Improve reports
based on comments
received back from
the faculty.
Present with clarity in
conference settings
with minimal faculty
Produce reports based on
comments received back from
the faculty who require few, if
any, changes.
Develop complete
reports that reflect
divisional style based on
continued input from
faculty, integrating the
best suggestions from
varied individuals.
Independently use other
colleagues and faculty
as learning resources.
Have established style
for producing final
reports that reflects an
integration of input from
varied faculty and
integrate additional
suggestions received on
reports.
Demonstrates ability to
utilize other professional
colleagues as learning
resource(s).

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
guidance.
assistance.
System based
Practice
Works well with
technologists and
support staff and
learns from them.
Contact clinicians to
obtain clinical and
other information.
Know and utilize basic
aspects of resources
available in health
system i.e. computer
systems (CoPath,
MARS), laboratories
(hematology,
molecular diagnostics,
cytogenetics,
histology), grossing,
bone marrow
laboratories.
Greater interaction
with technologists,
including
demonstrating an
ability to teach them.
Able to convey
straightforward
information to
clinicians.
Know and more fully
utilize resources
available in health
system.
Can serve as a greater
resource for technical staff.
Discuss preliminary reports
and diagnoses with clinicians
with ease. Able to convey
more complex information to
clinicians and consulting
pathologists.
Learn about outside regulatory Learn about the
agencies/organizations. administrative and
Develop an appreciation of technical functions of
basic healthcare/pathology running the Division of
related financial issues. Hematopathology.
Perform a mock CAP Perform a mock CAP
inspection, if possible. inspection, if possible.
Demonstrates the ability Able to educate
to present information to technologists and
technologists and junior residents with ease in
residents at levels more impromptu settings
appropriate for the as appropriate.
audience.
Proactively seeks
opportunities to educate
others.
Able to convey complex Able to function as a
information to clinicians junior faculty in terms of
and consulting providing consultative
pathologists and can information to staff
answer questions about pathologists at UPMC
diagnoses or work-up. and elsewhere as well
Also able to discuss as with clinicians.
clinical implications of
diagnoses in depth.
Demonstrates
understanding of more
complex personnel
management issues.
Understands the various
components of a
diagnostic
hematopathology
service and the
interaction with other
related, but separate
services, such as

Competency
Core Rotation - 1st to
3 rd Year Resident
Beginning of
Rotation
Core Rotation – 1 st
to 3 rd year Resident
Later in Rotation
Elective Rotation - 3rd and
4th year Resident
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
cytogenetics and
molecular laboratories).
Has basic understanding
of hospital budgetary
issues that may be
specific to
hematopathology or
pathology in general.

RESIDENT EVALUATION METHODS AND DOCUMENTATION
in the Division of Hematopathology
A) Hematopathology Test for Residents:
1. Subject Material:
Images, glass slides and/or laboratory data from areas of rotation that have
been completed:
o Bone marrow
o Laboratory hematology
o Lymph node
2. Evaluation Method:
Review information provided
Examine glass slides and/or images with other laboratory/clinical data
provided
Select best diagnosis from list of choices
3. Dates administered – Approximately 1½ weeks prior to completion of core
hematopathology rotation blocks.
B) Completion of Checklists according to rotation service (Bone Marrow, Lymph Node,
Pediatric Hematopathology, Laboratory Hematology)
C) Department of Pathology Resident Evaluation Forms (covering multiple competencies)
D) Documentation of Observation and Performance of Bone Marrow Aspirates and Biopsies
by Completion of Bone Marrow Performance Form
E) Documentation of Conference Attendance at Journal Club, Interesting Case
Conference, Wednesday morning Hematopathology Conference
F) Faculty and staff observation of performance in conferences and sign-out and
general observations regarding interpersonal relationships, communication skills and
professionalism, including utilization of departmental and extra-departmental resources
G) Personal Meeting with Director or designate at end of core rotation segments

CONFERENCE SCHEDULE
AND RESPONSIBILITIES

Monday
CONFERENCE SCHEDULE
12:00pm Seminars in Laboratory Medicine* Weekly CLB Room 1021
Tuesday
7:00am
8:30 am
9:15am
11:00 am
12:00pm
12:00pm
AP Didactic Conference/Unknown
Surgical Pathology Slide
Conference *
SHY Adult Bone Marrow Review
(BM2 Srvc Fellow or BM3 Srvc
Pathologist)
Continuing Education in Clinical
Chemistry and Hematology
Conference##, ***
Hematopathology Flow
Conference**
Hematopathology Journal Club*,
***,###
Patient Safety & Risk Management
in Hematopathology Conference*,
###
Weekly Totten Room, Scaife 618
Weekly
Weekly;
Hematology
alternates with
Chemistry
~Several
times/month
(see schedule)
Every other
week
Every other
week
Teleconference from PUH
G304 (412-864-7845)
CLB Room 1021
CLB Room 9018
Totten Room, Scaife 618
PUH G323
7:00am CP Didactic Conference* Weekly CLB Room 1021
Wednesday
8:30am
Hematopathology Conference
(case presentation)* ***, ###
Weekly Totten Room, Scaife 618
12:00pm Department Research Seminar + Weekly PUH 11 th Floor
Thursday
12:00pm Shadyside Tumor Board# Intermittent
8:00am Pediatric BM Conference +++ 2 nd and 4 th
Thursday of
each Month
12:00pm
Anatomic Pathology Grand
Rounds *
Weekly
4:00pm
+++, ***
CHP Tumor Board
Leukemia Conference
1 st Thursday of
the month
Shadyside West Wing
Auditorium
Teleconference from PUH
G306
Room 1104 A & B Scaife Hall
Rangos Res. Bldg -
Lawrenceville
* Attendance for residents required either based on this rotation or departmental expectations.
** Attendance at this conference is strongly encouraged for trainees (but not required).
*** The trainees will be expected to present at these conferences.
**** Attendance is strongly encouraged when hematopathology cases are being presented (be sure you are
getting email notifications).
@ Attendance not expected.
+ Attendance optional.
++ Attendance is required for residents on laboratory medical rotation.
+++ Attendance is expected for trainees doing pediatric hematopathology.
# See description concerning attendance obligations.
## Attendance required when on laboratory hematology rotation and encouraged when on other parts of
hematology rotation. One presentation required (see schedule).
### Attendance required for fellows

RESIDENT AND FELLOW CONFERENCE RESPONSIBILITIES
MONDAY
12:00PM (Weekly)
Seminars in Laboratory Medicine are case presentations/lectures by residents, fellows and
faculty. See Conference Schedule from Laboratory Medicine Office for topics.
TUESDAY
7:00AM
The AP Didactic Conference/Unknown Surgical Pathology Slide Conference takes place on
Tuesdays from 7:00 to 9:00 AM in the Totten Room. The slides and clinical history for the
conferences when they occur will be available at PUH, Shadyside and Magee for preview
at least one week prior to the conference. The schedule is available on the resident website
(http://residents.pathology.pitt.edu/default.aspx). Fellows may attend; however it is not
required and hematopathology duties take precedence. Breakfast is served.
8:30AM
SHY Adult Bone Marrow Review takes place Tuesdays from 8:30 – 9 am. A few cases selected
by the Hematology/oncology attending and fellow are presented via teleconference using Go to
Meeting (complete instructions posted in G304). The cases will be presented by the attending
pathologist on BM service 3, or the hematopathology fellow on BM service 2 with the BM3
attending pathologist serving as a mentor.
9:15AM
Continuing Education in Clinical Chemistry and Hematology Conference takes place
Tuesdays at 9:15 -10:15am (following the residents' lectures). The location is usually CLB
room 1021. Each resident on the laboratory hematology rotation will present once.
The sessions are targeted toward technologist education. Discussion between
pathologists/trainees is encouraged. Periodic updating of important basic concepts is
welcome. Please seek input from Dr. Contis when planning your hematology presentation.
11:00AM (several times/month)
The Flow Cytometry Conference is a time when interesting flow cytometry cases selected by
the technologists are reviewed and discussed by one of the hematopathologists. Some
conferences are used for didactic presentations on a specific topic. Generally, other
hematopathologists, residents and fellows attend. No preparation is required. See
schedule for dates of conference. (CLB, Room 9018)
12:00PM
Approximately twice per month, residents doing Hematopathology will be asked to select one (1)
current journal article for presentation at our Journal Club (see separate schedule). The
selection should be of interest to the presenter and others in the group and needs to be
approved by the faculty member or fellow responsible for that date (see schedule for
dates and trainee/faculty assignments). If requested, the faculty member can also offer
suggestions for appropriate articles or offer additional advice in making a selection. The
faculty person or fellow will also choose and present an article. The articles should be
emailed to the hematopathology secretary, Jessica Klimkowicz, no later than Thursday
preceding the Journal Club.
In terms of presentation, it is important to provide enough background information to help explain
why the study was done and /or may be important and how it relates to what is already
known. Any detailed discussion of methodology that may be required should be done

when the results are presented. When presenting the results, it is important to go over the
various tables and figures in the paper and also point out any problems that may be
presented in the data or methodology. Finally, the ultimate significance of the study given
the results found should be discussed. PowerPoint presentations are not at all necessary
and are discouraged!
Everyone attending should also be prepared to comment on the above issues so that a lively
discussion will ensue.
On all other Tuesdays, there will be a Patient Safety and Risk Management Conference (see
separate schedules). Cases are presented and discussed that could potentially raise
patient safety and risk management issues. For example, cases that are particularly prone
to diagnostic errors or cases of entities seen so infrequently that pathologists might not be
familiar with them would be of particular interest. Cases where there have been any types
of errors made within or outside our institution would also be of particular value. Trainees,
along with faculty members, may bring cases to show.
WEDNESDAY
7:00AM
CP Didactic Conference is a set of lectures covering all of laboratory medicine, some
pertinent to hematopathology. The schedule is available on the resident website.
(http://residents.pathology.pitt.edu/default.aspx).
8:30AM
The Hematopathology Conference is entirely the responsibility of our division. The purpose is
to provide a forum to go over morphologic, immunophenotypic, karyotypic, and genotypic
issues together with their clinical correlates. We present 5 cases each week at conference,
ideally 3-bone marrow (including Children’s cases) and 2 lymph nodes. The conference
responsibilities include:
Trainees on the adult bone marrow service will consult with faculty signing out marrows no later
than Friday and choose 3 interesting and /or educational marrows. As at least one
pediatric marrow should be presented if there is a trainee on the service, trainees on the
adult marrow service need to consult with the pediatric service to be sure that 3 bone
marrows/PB/ATL cases are being presented. Please do not add additional cases if there
are already 5.
A. After cases are selected, please sign-up by giving name and number to the bone marrow
technologist or leaving a voicemail message on the Audix line (802-3273). NAMES
MUST BE SUBMITTED BY THE END OF MONDAY.
The trainees will take images using one of the digital camera set-ups in the Division of
Hematopathology (room G304 conference room or G323 lymph node sign-out room) and
find out the case history from the physician or the chart. The images should be imported
into a PowerPoint presentation. At the conference, the trainees will present the case
including a brief history, any prior material and any ancillary studies at the conference. In
addition, some interesting aspects of the case may be discussed briefly (e.g. implications
of an unusual morphologic appearance, significance of unusual phenotype). Don’t give a
lecture. Cytogenetics will be presented by the cytogenetics laboratory faculty or by a
trainee rotating in Cytogenetics. Fellows are expected to present their own cytogenetic
findings as long as the laboratory emails them the karyotypes/FISH images to show and a
cytogeneticist can assist when needed. Genotypic results are usually presented by the
Division of Molecular Diagnostics. If no trainee is on the service, the cases are presented

y the faculty member. Case presentations including all ancillary studies should be less
than 8 minutes to allow time for discussion.
B. Trainees on the lymph node service will consult with the faculty member signing out lymph
nodes and select two lymph node cases to present. In the absence of appropriate current
cases, older educational cases may be selected. The trainees will take images of the case and
if at all possible get the history from the chart or physician. At the conference, using
PowerPoint the trainee will present the case including a brief history, the pathology and any
ancillary studies.
C. Remember case presentations must be relatively brief, to the point and interesting both to
pathology trainees and clinicians. If possible try to present cases in an interactive fashion.
(Totten Room, Scaife 618)
D. If there is >1 trainee on a service, the presenting obligations should be shared.
Guidelines for PowerPoint Presentations
1. Keep the presentation simple. Your time is better spent reading about the case
rather than having multicolored images flying around.
2. Try to limit the number of images shown- make sure that each image makes a point.
3. Photomicrographs should occupy the entire screen.
4. Please use images that are in focus.
5. No more than two flow histograms should be on a single screen (or just use the
electronic overhead projector).
6. Up to 4 immunostains may be presented in a single screen. It is unnecessary to
illustrate all immunostains- you need to choose critical ones or ones that are
necessary to make your point. For example, please don’t show a series of 5
negative stains.
7. Laboratory results can either be discussed or, if presented on a screen, must have
not only the numerical results, but also the units and preferably the normal ranges.
The lab results that are presented visually do not need to include every single
laboratory test that was done on the patient.
8. In at least most cases, there is no need to present a written bone marrow
differential.
12:00PM
Trainees are encouraged, but not required to attend the Departmental Research Conference.
12:00PM
UPMC-Shadyside Tumor Board. Cases are presented by the hematopathology fellow or if
necessary by a hematopathology faculty member at the request of a clinician (detailed
procedure on page 22) (Shadyside West Wing Auditorium). Residents do not attend.
THURSDAY
8:00AM
A Pediatric Bone Marrow Case Conference is held via teleconference to the Children’s
Hospital, Lawrenceville except for the first Thursday of the month. This is attended
primarily by the pediatric hematology/oncology fellows, and the pathology trainees on the
pediatric bone marrow service. The bone marrow technologists will collect the cases from
the prior week to be presented by the attending hematopathologist on service. Fellows

may be expected to present the cases. Complete instructions for using Go-To-Meeting are
in the pediatric bone marrow signout room G304,
12:00PM
Residents doing hematopathology are expected to attend Anatomic Pathology Grand Rounds.
4:00PM
Pediatric Leukemia Tumor Board is held the first Thursday of the month from 4:00 to 5:00 in
Conference Rooms B123 and B124, Floor B, at Children’s Hospital of Pittsburgh. The
hematopathologists and bone marrow technologists are notified by e-mail the week of the
conference as to which cases are to be presented. The bone marrow technologists will
collect the cases for the trainees. The trainees will capture images and prepare a
PowerPoint presentation. The presentations should be brief and succinct and include 1
slide of peripheral smear, 1-2 slides of aspirate, and 1-2 slides of biopsy as well as any
pertinent cytochemical or immunohistochemical stains. Flow images can also be presented
– please check with attending regarding specific images to present. Pertinent results from
the cytogenetics and/or molecular studies should be summarized in 1-2 slides. The
presentation should be approved by the attending prior to presentation.

Additional information regarding Shadyside Tumor Board Conference
Wednesday Noon
Contact Person SHY: Melissa Forkey 412-648-6466
Contact Person PUH: Celina Fortunato 412-647-0263
1. UPMC – Shadyside will call the UPMC – Presbyterian bone marrow lab at 647-
0263 with a list of patient names NO LATER THAN the Friday preceding the
conference (preferably earlier).
2. The Bone Marrow Technologist will inform the presenter.
a. First inform the 2 nd year fellow if there is one. If the 2 nd year fellow cannot
present (i.e. on a rotation that precludes their availability), the fellow must
inform the bone marrow technologists immediately. Go to step b.
b. Next, inform the 1 st year fellow. If the 1 st year fellow cannot present (i.e. on a
rotation that precludes their availability), the fellow must inform the bone
marrow technologist immediately. Next inform the second 1 st year fellow if
there is one. If there is more than one second year fellow or more than one firstyear
fellow, please ask the one not on a diagnostic signout service first to do
the tumor board (unless they are on another service that would preclude their
being able to attend). If this fellow also cannot present, go to step c.
c. If no fellow can present, the bone marrow technologist will inform the
pathologist on the lymph node service for the week it is to be presented.
This way the bone marrow technologist will know who exactly will be presenting the
conference.
3. The bone marrow technologist will pull the slides and print the reports.
4. If surgical pathology cases are requested, the bone marrow technologist will notify
Melissa Forkey who will make other arrangements for the cases to be presented by
surgical pathologist.
5. The bone marrow technologist will inform the person responsible for the
presentation – prior to the weekend – that the cases are ready.
6. The bone marrow technologist will record on the log sheet that the cases are ready
and the presenter is notified.
The bone marrow technologist will call Melissa Forkey and inform her who will be presenting the case.

Pediatric Hematopathology
and General/Special
Hematology Laboratory
Experience

Pediatric Hematopathology and General/Special Hematology Laboratory
Experience (3 weeks)
Trainees should report to the pathologist signing out CHP bone marrows. The pathologist
covering the general hematology laboratory (“ATL” service) is usually the same person; if this
person is different from the one signing out CHP bone marrows, then contact him or her also.
Also, trainees should touch base with Dr. Contis regarding their continuing education
conference presentation at the beginning of their rotation. Residents also will discuss with Dr.
Contis or her designee how to best apportion their time and how to gain in-laboratory
experience with the technologists.
Pediatric Hematopathology Experience
1. Review Blood Cell Morphology. (Published by the ASCP). RBC, WBC, Normal and Abnormals
(Binders with CDs available in G304 and slides are also on resident’s shared drive, under “CP
Didactic Lectures\Previous CP Didactic Lectures\Hemepath\ASCP Hematology Images.” Each set
is a separate PowerPoint file and the key and reading material for all 6 sets of images is in the
PDF).
2. In the first week, touch base with the lead Celina Fortunato to schedule a teaching session
with the bone marrow technologists (typically Tuesday afternoon is best) to review
peripheral blood and bone marrow aspirate smears
3. Pediatric Bone Marrow Sign out.
A. Preview and sign out cases with hematopathology faculty in a fashion analogous to
procedures followed with adult bone marrows.
• Meet with faculty on service to coordinate these activities.
• See also “Policy for sign-out of CHP marrows that have biopsies”.
4. Review of specimens from Automated Testing Laboratory and Flow Cytometry Laboratory
A. Preview and sign out pediatric and adult abnormal peripheral blood films and body fluid slides
sent for review with faculty hematopathologist. Gather relevant clinical and pathology
information (such as cytology results) prior to sign-out.
B. If there is a case with interesting findings, please give the slide and copy of the ATL review
sheet to Dr. Roth in order to contribute to the study sets.
5. Review of selected cases of Hemoglobinopathies with the CAP textbook
Trainees should pre-review the HPLC tracings that are being faxed weekly to our division
and they should contact Dr. Dobrowolski and meet with him once to review the cases with
him.
6. Review of educational materials
A. Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.

B. Nathan, DG and Orkin, SH, Nathan and Oski’s Hematology of Infancy and Childhood, 7 th
Edition, WB Saunders, 2009.
C. Penchansky L, Pediatric Bone Marrow, Springer, 2004.
D. Glassy EF. Color Atlas of Hematology, CAP 1998
E. Peripheral smear and fluid slide study sets are available for checkout from Office Secretary –
G306.
F. Chromogram information for hemoglobinopathy information (in supplemental materials)
G. Bain BJ. Haemoglobinopathy Diagnosis, 2 nd ed. Blackwell, 2006.
H. Schuman GB, Friedman SK. Wet Urinalysis, ASCP, 2003.
I. Galagan, K. Color Atlas of Body Fluids: An Illustrated Field Guide Based on Proficiency
Testing.
J. Proytcheva, M.A. (Ed), Diagnostic Pediatric Hematopathology, 2011.
7. Review results of ancillary procedures performed on marrows you have reviewed and read
addenda faculty have issued.
Policy for sign-out of CHP marrows that have biopsies
1. Hematopathology signs out biopsies on hematologic disease cases including non-Hodgkin
lymphomas. CHP surgical pathology signs out the biopsies on tumor cases.
2. On all cases with a biopsy, the histologic section must be reviewed by the hematopathologist
even if it is not a case where the hematopathologist is signing out the biopsy. This is to ensure
that it does not conflict with the aspirate smear evaluation.
3. In all cases with a biopsy, where CHP is signing out the biopsy the hematopathologist should
correlate with the CHP pathology report to make sure that the two diagnoses will not conflict. In
some cases, this may involve contacting the CHP pathologist and jointly reviewing the case.
Policy for Assignment of Marrow Cases without Biopsies
Marrow sign-out is the responsibility of the faculty/trainee on the service when the marrow biopsy
typically would come out. However, all cases done on Friday must be pre-reviewed by those on
the service that day. In addition, all marrows, pediatric or adult, with or without flow cytometry that
do not have a biopsy and are received before noon on a Friday, must be signed out by those on
the service that week. They are not the responsibility of those on the following week. Children’s
bone marrow aspirates with biopsies for metastatic tumor evaluation received on Friday will be the
responsibility of the pathologist on service the following week, even though we are only signing out
the aspirate.

General/Special Hematology Experience
1. Meet with Dr. Contis or her designee to review plan for completion of checklist that follows.
2. Plan laboratory presentation (see instructions on Continuing Education in Clinical Chemistry
and Hematology).
3. See checklist for specific activities and educational resources.

General/Special Hematology Laboratory Experience Checklist [Revised 10/2013]
This checklist indicates the areas that need to be covered during the general/special laboratory
experience and the specific activities that are to be performed. This should occupy approximately half
your time when combined with pediatric hematopathology (as in core resident/fellow rotation).
Check boxes to the left of specific activities when the indicated activities are completed
This checklist is also included separately and must be signed by the resident/fellow and turned in to
Dr. Swerdlow’s office at the completion of the rotation.
1. General Activities
Review a spectrum of abnormal peripheral blood and body fluid results. These should include:
o
o
o
o
o
o
Macrocytic and microcytic anemias
RBC changes in autoimmune hemolytic anemia
Thrombocytopenia and inherited platelet disorders
Granulocytosis and granulocytopenia
Blasts in the peripheral blood
Abnormal cytoplasmic inclusions in WBC & RBC as available, either as review specimens or in
the study sets
If cases of each of the above are not available and you are in your last week, be sure to review
teaching slides or other resources (ask Dr. Contis or designee for help if required).
Follow up on patients whose abnormal peripheral bloods and body fluids you have reviewed to
determine the significance of the abnormality on diagnostic and therapeutic decision making and
ultimate clinical outcome.
Keep a list of the following (include relevant clinical information that you have obtained for each
patient):
The laboratory tests (routine and special) that you have observed (or reviewed following
returns by the reference laboratories).
The abnormal peripheral blood films and body fluid smears that you have seen. Also see
section 2B below.
Plan laboratory hematology presentation for Continuing Education in Clinical Chemistry and
Hematology (see detailed instructions in Resident/Fellow Handbook).
2. Specific Activities

General Hematology Laboratory (ATL)
The hematology lead technologist, Betty Austin will help you with orientation to hematology
instrumentation.
A. General
Review procedure manuals in General Hematology, Coagulation and Urinalysis
including the procedures for operating the Iris iQ 200 urinalysis instrument. The
purpose of this review is to learn how a procedure manual is constructed, to
appreciate the CLSI (formally NCCLS) format and to learn how to find a procedure
when needed.
Be sure that the Laboratory Hematology Staff Meeting fellow attendance sheet is
completed with your signature at all the staff meetings/laboratory management
meetings that you attend.
Participate in troubleshooting. This includes analysis of problems with function of
instruments, quality control, or patient data that appear spurious. The problems will
be brought to your attention by the technical staff and/or Dr. Contis or designee.
B. Hematologic Microscopy
Review normal PB morphology, understanding variations between adult and pediatric
values. (Review ASCP sets located in room G315, if not previously reviewed or if further
review is needed).
• See criteria for evaluating red cells on sheet “Red Cell Morphology Classification
(1+, 2+, 3+)” in the hard copy supplement.
Evaluate all abnormal slides referred to the pathologist (ongoing throughout rotation). This
is performed by checking to see if there are slides for review (bone marrow technologists
will usually bring them to you). When slides are designated, the trainee should obtain
clinical information about the patient, including checking CoPath for prior pathologic
evaluations, then review the slide including performing a 100-200 cell differential for
peripheral blood films and a morphologic review of the cytospin slide for a fluid. The
trainee should then formulate a differential diagnosis and then review the case with the
pathologist on the laboratory service (see schedule). This review is an essential part of the
laboratory’s function since the ATL lab is often the first place where an abnormality is
detected.
Peripheral Blood Films
Body Fluid Cytospin slides
Correlate body fluid results from cytology laboratory with hematology findings.

Alert Dr. Christine Roth to interesting peripheral blood films or body fluid slides. Provide
her the slides, a photocopy of the lab values and clinical information.
C. Automated Equipment: Coulter DXH800, Cellavision
Review information provided in your folder
Review procedure manual
Observe:
Setup/Cleaning of instrument
QC/QA Procedures, graphing
Operation of Coulter and Cellavision
Understand principles of instrument. This is discussed in procedure manual and also lead
techs can answer questions.
Review interpretation of Coulter dot plots and causes of spurious results. Use procedure
manual as well as cases you observe in the laboratory.
• See examples on the “Complete Blood Count” in the hard copy supplement.
• See 2 slides explaining histograms and dot plots.
• See up-to-date, “Automated Hematology Instrumentation”.
• Learn to evaluate normal and abnormal patterns.
• Understand meaning of individual flags and mechanisms for evaluating flags.
• Know what a flag is.
• Review CAP & Instrumentation QC/QA date.
Urinalysis
1. AuWi Siemens:
Review information provided in your folder
Review procedure manual
Observe set-up and urinalysis runs
Observe:
Set up, preparation of reagents, samples

QC/QA Procedures, graphing
Running, evaluation of samples
Understand principles of instrument and manual back-up procedures (when and how)
Understand sensitivities and specificity of color reactions and drug interference.
Understand principles of instrument and back-up procedures (when and how).
Review Educational Resources
Crystals and casts
Cells
2. Coagulation automated equipment: STA-R Evolution (Diagnostica Stago, Inc)
Review procedure manual
Observe:
Set up, preparation of reagents, samples
QC/QA Procedures, graphing
Running, evaluation of samples
Understand significance of results for pre-operative screening and monitoring
anticoagulant therapy by reading text materials or original literature and by discussion
of issues with the pathologist on the laboratory service. This should include
understanding the significance and use of the INR.
Observe the D-dimer procedure and understand its clinical usage as a negative
predictor for DVTs and as a positive indicator of DIC.
Administrative Aspects of Laboratory
Attend the weekly Hematology Laboratory meeting during your 3-week rotation.
When: Every other Wednesday at 10:00 AM
Where: CLB 3 rd Floor Room 3018

If the resident’s rotation includes the last week of the month, they can attend the
Shadyside Laboratory Operation meeting at 8:30 AM, at Shadyside Hospital the last
Tuesday of each month in Room 2.15 (ground floor – West wing elevators). Contact
Dr. Contis for information.
3. Special Hematology Laboratory
Many tests are sent out to reference laboratories.
A. General
Review test menu and procedure manual
• Observe any test procedures being performed.
B. Specific Tests:
• Hemoglobin Evaluation
Understand co-migration of hemoglobins and methods for distinguishing them, clinical
significance, relationship to Sickledex.
Understand mechanisms of false positives/negatives, effect of transfusion on findings.
Review HPLC Examples for Variant Hemoglobins, shelved in G315 under Hematology
References.
Review Color Atlas of Hemoglobin Disorders: A compendium based on Proficiency Testing
(located in G315).
Understand principles of HPLC for hemoglobin separation.
Review and interpret tracings that come back from the reference laboratories and from
CHP Laboratories.
Review chromogram information for hemoglobinopathy information (in supplemental
materials)
Contact Dr. Dobrowolski at CHP to arrange a time for review of HPLC and follow-up study
results. Residents are expected to meet with Dr. Dobrowolski twice at CHP.

• Test of RBC function
Know how these tests are performed and how they are useful:
RBC enzymes (G6PD, PK, GPI, etc.)
Teaching case /recent send out file
Read about
Plasma, serum, urine, hemoglobin
Teaching case /recent send out file
Read about
Osmotic fragility
Teaching case /recent send out file
Read about
Heinz bodies
Teaching case /recent send out file
Read about
• Miscellaneous Tests
Acetylcholinesterase (ACHE)
Muramidase
Urine, serum myoglobin
Flow cytometry for PNH (If not reviewed in Flow rotation)
Neutrophil oxidative product formation analysis (If not reviewed in Flow rotation.)
• Staining of bone marrow smears
Routine Stains
Cytochemical and immunocytochemical methods/procedures

• Other Hematology Testing: (Vitamin B12, serum and RBC folate, serum iron
and ferritin)
These tests are now done in chemistry.
Review how they are used in the workup of hematologic disorders.
References:
Color Atlas of Hemoglobin Disorders, A Compendium Based on Proficiency
Testing. James D. Hoyer and Steven H. Kroft, Editors, 2003.
Clinical Diagnosis and Management by Laboratory Methods, 22nd Edition, John
Bernard Henry, 2007
Haemoglobinopathy Diagnosis, 2 nd edition. Barbara Bain, Blackwell Science, 2006.
I have completed the Pediatric Hematopathology Checklist
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________

HEMOGLOBIN ANALYSIS CASE LOG
ACCESSION NUMBER
DIAGNOSIS

PB AND FLUID REVIEW LOG
ACCESSION NUMBER
DIAGNOSIS

PB AND FLUID REVIEW LOG
ACCESSION NUMBER
DIAGNOSIS

Continuing Education in Clinical Chemistry and Hematology
Description:
The Continuing Education Conference is organized around a case discussion (resident) and
scientific issue or laboratory management/quality assurance presentation (faculty). A method or
technical issue may also be presented by a lead technologist. Coordination between the 2-3
presenters is encouraged. The sessions are targeted toward technologist education. Discussion
between pathologists/trainees and technologists is encouraged. Periodic updating of important
basic concepts is welcome. Please seek input from Dr. Contis, or another hematopathologist when
planning your hematology presentation.
Day, time and location:
Tuesdays at 9:15 -10:15 AM (following the residents' lectures), unless the resident lectures times
are changed. The location is usually CLB Room 1021.
Frequency of presentation: Each resident on the laboratory hematology rotation will present
once, usually on the last week of their rotation.
Length of each presentation: 15-20 minutes
Examples of Topics:
1. Case discussion (Resident or fellow).
a. “Atypical lymphocytes,” 9/4/07, Dr. A. Henry
b. “Case of G6PD deficiency,” 9/25/07, Dr. I Batal
c. “Identification of urinary crystals,” 10/16/07, Dr. M. Rollins-Raval
d. “Nucleated Red Blood Cells and the Coulter LH 750 and the Sysmex XE 2100,”
12/16/08, Dr. Hannah Kastenbaum
e. "Scaling the Peaks: High-Performance Liquid Chromatography And the Detection of
Hemoglobin S", 5/5/09, Dr. Milon Amin
f. “Cystine crystals,” 12/12/10, Dr. Kelley Garner
2. Method or technical issue (Lead technologist or other)
a. “Validation of reference ranges for automated ESR method.” 9/4/07, E. Austin
b. “Review and tips for making thick smears for blood parasites,” P. Nowack
c. “Review of PFA-100,” 9/9/08, Dr. S. Monaghan
d. “Review of Bronchoalveolar Lavage (BAL) Analysis for Cell Counts & Differentials,
12/2/08,” Dr. S. Gibson
e. “A Proposed Plan for the Comparison Evaluation of the Coulter DxH 800, Sysmex
XE, and Coulter LH 750,” Dr. S. Monaghan
3. Scientific issue, quality assurance or management (Faculty)
a. Discuss a method, disease, recent literature, QA study, etc.
b. “Immature reticulocyte fraction,” 10/21/08,” Dr. L. Contis
c. “Automated Cell Counts on Pleural Fluid: Review of a Study on the Sysmex XE-
2100, 12/2/08,” Dr. R. Felgar.
d. “Platelet Counting by the Coulter LH 750 and Sysmex XE 2100,” 12/16/08, Dr. S.
Monaghan

Pediatric Hematopathology Checklist
Note: Items indicated in BOLD constitute the basic knowledge expected of residents
rotating in Hematopathology. Additional (non-bolded) items should also be included for
advanced learners including fellows.
Orientation with Hematopathologist on Pediatric Hematopathology service.
Knows how normal pediatric blood and bone marrow differ from those of adults.
Knows special aspects of neonatal hematopathology (see K. Foucar, “Neonatal
Hematopathology: Special Considerations” in Collins RD and Swerdlow SH, eds. Pediatric
Hematopathology).
Knows role of cytogenetic and molecular diagnostic studies in evaluating hematopoietic /
lymphoid disorders in bone marrow and blood.
Learn diagnostic criteria using multiparameter approach and clinical implications for each of
the following:
Diagnosis / Finding
NEOPLASTIC DISORDERS
Observed
Actual Case
Observed
Teaching
File Case
Read About
Acute Lymphoblastic Leukemia
B-lymphoblastic leukemia / lymphoma
T- lymphoblastic leukemia / lymphoma
Acute Myeloid Leukemias
Acute Myeloid Leukemia with 11q23 abnormality
Acute Myeloid Leukemia with recurrent
cytogenetic abnormality, other
Acute Megakaryoblastic Leukemia
AML/MDS associated with congenital marrow
failure syndromes
Acute Myeloid Leukemia, not otherwise
specified
Mixed lineage acute leukemia
Myeloid proliferations associated with Down
Syndrome
Acute Myeloid Leukemia
Transient Abnormal Myelopoiesis

Chronic Myeloproliferative Neoplasms
Chronic Myelogenous Leukemia
Myelodysplastic/Myeloproliferative Disease
Juvenile Myelomonocytic Leukemia
Myelodysplastic Syndromes
Childhood Myelodysplastic Syndromes
Refractory cytopenia of childhood
Mature Lymphoid Neoplasms
Burkitt Lymphoma
Diffuse Large B-cell Lymphoma
Anaplastic Large Cell Lymphoma, ALK+
Pediatric Nodal Marginal Zone Lymphoma
Pediatric Follicular Lymphoma
Systemic EBV+ T-cell LPD of Childhood
Hydroa Vacciniforme-like Lymphoma
Nodular Lymphocyte Predominant Hodgkin
Lymphoma
Classical Hodgkin Lymphoma
Histiocytic Neoplasms
Langerhans cell histiocytosis
Mast Cell Disease
Metastatic Tumors
Neuroblastoma
Rhabdomyosarcoma
Ewing sarcoma
NON-NEOPLASTIC DISORDERS
Congenital Disorders/Syndromes with Prominent
Hematologic Abnormalities (Hereditary bone
marrow failure)
Fanconi Anemia

Diamond Blackfan Syndrome
Congenital Dyserythropoietic Anemia
Congenital Sideroblastic Anemia
Pearson Syndrome
Severe Congenital Neutropenia/Kostmann’s
Syndrome
Cyclic Neutropenia
Shwachman-Diamond Syndrome
Dyskeratosis Congenita
Reticular Dysgenesis
May-Hegglin Anomaly
Bernard-Soulier Syndrome
Wiskott-Aldrich Syndrome
Congenital Amegakaryocytic Thrombocytopenia

Familial Platelet Syndrome with Predisposition to
Acute Myeloid Leukemia
X-linked thrombocytopenia
Thrombocytopenia with Absent Radii (TAR)
Gray Platelet Syndrome
X-Linked Lymphoproliferative Disorder
DiGeorge Syndrome
Severe Combined Immunodeficiency Disease
Red Cell cytoskeletal/membrane abnormalitieshemolytic
anemia
Red Cell enzyme deficiencies-hemolytic anemia
Hemoglobinopathies
Sickle cell disease
Thalassemia
Other
Gaucher Disease
Niemann-Pick
Mucopolysaccharidoses
Other Anemias and Conditions
Transient erythroblastopenia of childhood
Alloimmune hemolytic anemia of newborn
Iron deficiency
B12/folate deficiency
Parvovirus
Thrombocytopenia (see also above)
Autoimmune Thrombocytopenic Purpura
TTP/Hemolytic Uremic Syndrome
Congenital syndromes

Drugs/toxins
Infection-associated
Thrombocytosis
Neutropenia
Immune neutropenia
Neutrophilia/Leukemoid Reaction
Infection/inflammatory disorders
Medications
Eosinophilia
Basophilia
Lymphopenia
Infection
Medication
Autoimmune
Nutritional Deficiency
Congenital Disorders
Lymphocytosis
Epstein Barr Virus (infectious mononucleosis)
Pertussis
Infection, other
Granulomas
Myelofibrosis

Aplastic Anemia
Idiopathic Drugs
Secondary
Infection Associated
Drugs/toxins
Hemophagocytic/Lymphohistocytic Syndromes
Familial lymphohistiocytosis
Secondary hemophagocytic/macrophage
activation syndrome
Immunodeficiencies
Autoimmune Lymphoproliferative Syndrome
Other Primary Immunodeficiencies (see
above)

PRESENTED THE FOLLOWING PEDIATRIC BONE MARROW OR LYMPH NODE CASES
(Fellows should submit presentation in portfolio)
PHB NUMBER
DIAGNOSIS

UTILIZED THE FOLLOWING BONE MARROW RESOURCES
Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.
Orkin, SH, et al., Nathan and Oski’s Hematology of Infancy and Childhood, 7 th Edition.
Penchansky L, Pediatric Bone Marrow, Springer, 2004.
NOTE: Reading is an important component of this rotation. It is recognized that not all of the
above resources can be used nor can most be read in entirety. Use of electronic and other
resources to find and read up-to-date journal articles is also critical.
I have completed the Pediatric Hematopathology Checklist.
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________

UPMC PRESBYTERIAN SHADYSIDE
Automated Testing Laboratory
Pathologist Review Form
Patient Name /Medical Record #
Hospital: PUH/CLB SHY CHP MWH Date:
Patient Diagnosis:
Specimen Type: Peripheral blood smear Pleural fluid Peritoneal fluid CSF Other
Tech Name/ Tech comments:
PATHOLOGIST COMMENTS:
BLID=Blasts are identified
RMCP=Reactive mesothelial cells present
FCSR=Flow cytometry studies recommended GTCBM=Correlation with pending bone
marrow evaluation recommended
AUERP=Auer rods present
INCP=Inflammatory cells present
CBCLDF=Atypical lymphoid population,
worrisome for lymphoproliferative disorder.
Recommend flow cytometric evaluation if clinically
indicated
GTAMC=Clusters of atypical mononuclear cells,
worrisome for malignancy, correlation with
cytology recommended
GTPLC=Plasma cells identified, correlation with
flow cytometry studies recommended
Additional Pathologist comments:
BACIE= Intracellular and extracellular bacteria
present
Correct the Differential? Yes / No
Pathologist comment to tech:
Stain quality: Satisfactory / Unsatisfactory
RESIDENT/FELLOW :
PATHOLOGIST :

Children’s Hospital of Pittsburgh of UPMC
AUTOMATED TESTING LABORATORY
412-692-9836
PATHOLOGIST REVIEW
HEMATOPATHOLOGY DEPARTMENT
Name/Medical Record #:
Date/Accession #:
Patient Diagnosis
Peripheral Blood Smear: Yes / NO
Fluid type: CSF, Synovial, Pleural, Peritoneal, Pericardial, Bronchial Lavage
TECHNOLOGIST COMMENT:
TECH SUBMITTING REVIEW:
PATHOLOGIST COMMENT: To be entered into Sunquest
SEE CORRECTED DIFF
PATHOLOGIST COMMENT: For Technologist only
REVIEW RESIDENT/FELLOW:
REVIEW PATHOLOGIST:

Clinical Experience in
Hematology

Clinical Experience in Hematology at UPMC Shadyside
Clinical Hematology / Performance of Bone Marrow Experience
All activities are based at Hillman Cancer Center, 2 nd Floor unless indicated otherwise. Upon arrival, contact
the on site bone marrow technologist who can help orient you to the facility and facilitate your opportunity to
learn how to perform bone marrow examinations. The bone marrow technologist can either be found in room
A220.36 or paged at (412) 958-8812 or the in-house pager 11443. This can also be facilitated by your seeing
Celina Fortunato, in G325 or one of the bone marrow technologists who can call over to UPMC-Shadyside
the week before you go over there.
MONDAY TUESDAY WEDNESDAY
AM Dr. Redner Clinic
(Hillman Cancer Center,
2 nd Floor Conference Rm.
One).
Learn to perform bone
marrow aspirates /biopsies
with Physician’s Assistant,
Chris Lindberg, or other
Physician’s Assistant
Go with Bone Marrow
Technologist on all marrows if
Chris Lindberg, or other
Physician’s Assistant with
bone marrows to perform are
not available
Dr. R. Smith Clinic, Area A,
Pod 1
Dr. Kiss/Dr. Bontempo’s
Hematology Clinic, Area A,
Pod 3, Rooms 3B,C,D
PM After Dr. Redner’s clinic is
done, go with Bone
Marrow Technologists on
all marrows.
Dr. Raptis/Dr. Agha’s
Clinic, 3rd Floor, Hillman
Cancer Center, Room 16
Learn to perform bone
marrow aspirates /biopsies
with Chris Lindberg, or other
Physician’s Assistant
Begin UPMC-Presbyterian based
flow cytometry laboratory
rotation.
Report to:
Clinical Laboratory Building
9 th Floor, Room 9033
3477 Euler Way
Pittsburgh, PA 15213
412-864-6180
Objectives:
Learn how clinical hematology is practiced including patient concerns and what clinicians need from
pathologists.
Know how to perform bone marrow biopsies and aspirates including actually performing preferably at
least 2 procedures.
Know how bone marrow specimens are processed.

Performance of Bone Marrow
Aspirations & Biopsies

Performance of bone marrow aspirations and biopsies (with hematology/oncology
division)
Trainees are expected to learn how to perform bone marrow aspirations and biopsies. They
should aim to observe and then perform a total of about ten marrows. It is recognized that
this goal may not be met. Some of this must be done while the trainee is on their UPMC-
P/Hillman Cancer Center Hematology rotation. The remainder should be done later in their
training (See below).
A. The trainee will be able to observe and perform marrows as part of the clinical
experience in hematology (see “Clinical Experience in Hematology”).
B. The trainee is required to keep a record of each marrow observed and performed
including the name of the patient, bone marrow number and diagnosis. For the bone
marrows actually preformed, the person supervising the procedure needs to
sign off on the form. In addition, the aspirate smear and biopsy obtained must
be reviewed by a faculty member to assess and document their adequacy. The
form should be completed at the end of the rotation and given to Dr. Swerdlow’s
coordinator in room PUH G333. There is also a hard copy of this form in the red
packet.
C. The trainee should also try to observe several pediatric marrows during the
pediatric/laboratory hematology section of the rotation. These should also be
recorded on the log when noting which are pediatric cases or use a separate sheet
and check off pediatric at the top.
Residents have the opportunity to perform bone marrow aspirates and biopsies at the VA hospital
later in their training.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM
Satisfactory completion of the rotation REQUIRES the return of this form.
Name: Rotation Dates:
AGE OF PATIENTS: ADULT PEDIATRIC
BIOPSIES / ASPIRATES PERFORMED
TO BE COMPLETED BY RESIDENT/FELLOW TO BE COMPLETED BY CLINICAL SUPERVISOR TO BE COMPLETED BY
HEMATOPATHOLOGIST
Patient Name PHB Number Aspirate Biopsy Signature
Satisfactory
Problem INITIALS Aspirate Biopsy
(REQUIRED) (REQUIRED)
S U NA S U NA
(Please use back of form if needed.) S = SATISFACTORY U = UNSATISFACTORY (PUT COMMENT) NA = NOT
APPLICABLE
BIOPSIES / ASPIRATES OBSERVED
Patient Name
(REQUIRED)
PHB Number
(REQUIRED)
Aspirate Biopsy Patient Name
(REQUIRED)
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.
PHB Number
(REQUIRED)
Please get recut H& E and aspirate smear stained. Have attending hematopathologist review and evaluate in section above.
Aspirate
Biopsy
TRAINEE SIGNATURE DATE DIRECTOR (OR DESIGNATE) SIGNATURE DATE
PLEASE RETURN COMPLETED FORM PRIOR TO END OF ROTATION TO DR. SWERDLOW’S COODINATOR, RM G333.

Flow Cytometry Laboratory
Experience

Flow Cytometry Laboratory Experience
Introduction to flow cytometry
Understanding of flow cytometric immunophenotypic techniques and interpretation of
the resultant data is an integral part of all the bone marrow and lymph node
rotations. In addition, however there is a brief concentrated exposure to the flow
cytometry laboratory including the technical aspects of flow cytometry and the basic
operation of a flow cytometry laboratory. In most cases this will occur following the
core pediatric bone marrow rotation (week 4). This is also the opportunity to learn
about flow cytometric DNA content study.
1. Meet with the Flow Cytometry Lab lead technologist or designate for orientation.
2. Become familiar with instrumentation and procedures in laboratory under the guidance
of the lead technologist.
• Immunostaining.
• Acquisition and analysis using flow cytometry.
• Quality control/quality assurance.
• Operation of a large clinical flow cytometry laboratory
3. Complete checklist.
4. Educational materials available:
• Flow Cytometry First Principles. Alice L. Givan.
• Flow Cytometry in Clinical Diagnosis. 4 rd edition, editors: D. Keren, J.P.
McCoy and J.L. Carey.
• Flow cytometric immunophenotyping for hematologic neoplasms. Blood
111(8)3941-3967, 2008.

Flow Cytometry Rotation Checklist
Orientation with the Lead Technologist or her designate.
Understand the principles of flow cytometric immunophenotyping.
Gain familiarity with instrument set –up, compensation and quality
control.
Gain familiarity with procedures for surface and cytoplasmic antibody
staining.
Understand the principles of back-gating and gating using light
scatter and antigen expression
Understand the procedure for DNA / ploidy analysis
Perform additional data analysis using DIVA software on specimens
previously analyzed in the clinical Flow Cytometry Laboratory
Know the immunophenotypic characteristics of the following entities:
Observed Observed
Read
Actual Teaching
Diagnosis/Finding
About
Case File Case
Normal bone marrow
Hematogones
Reactive Lymph Node
Lymphoma
Follicular lymphoma
Chronic lymphocytic leukemia/Small lymphocytic lymphoma
Mantle Cell lymphoma
MALT lymphoma
Diagnosis/Finding
Burkitt lymphoma
T-cell lymphoma
Observed
Actual
Case
Observed
Teaching
File Case
Read
About

Chronic leukemia
Hairy Cell Leukemia
Prolymphocytic Leukemia, B-cell phenotype
Prolymphocytic Leukemia, T-cell phenotype
Sézary Syndrome
Large Granular Lymphocytic Leukemia
Adult T-cell Leukemia / Lymphoma
Acute Myeloid Leukemia
Acute Promyelocytic Leukemia
Acute Myeloid Leukemia associated with t(8;21)
Acute Myeloid Leukemia associated with inv(16)
Acute Myeloid Leukemia with monocytic differentiation
Acute Megakaryocytic Leukemia
Acute Lymphoblastic Leukemia
Precursor B-cell
Precursor T-cell
Minimal Residual Acute Lymphoblastic Leukemia
Paroxysmal Nocturnal Hemoglobinuria
Chronic Granulomatous Disease
Neutrophil Oxidative Burst Analysis
I have completed the Flow Cytometry Checklist.
Name __________________________________________ (printed)
Date
__________________________________________ (signature)
__________________________________________

Flow Cytometry Panels, Available Antibodies, Guidelines,
Test Specifications and Templates
Lymphoproliferative Panel (PB or BM)
FITC PE PerCP-Cy5.5 PE-Cy7 APC APC-H7 V450 V500
CD14 CD13&33 CD45 CD34
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
*cTdT cMPO cCD3 cCD34
*add to Pediatric specimens; “c” = cytoplasmic
Lymphoproliferative Panel (LN)
FITC PE PerCP-Cy5.5 PE-Cy7 APC APC-H7 V450 V500
CD16&57 CD7 CD4 CD5 CD56 CD3 CD2 CD8
Kappa Lambda CD5 CD19 CD10 CD14 CD20 CD45
**cTdT MPO CD3 CD34
*as needed
**add to Pediatric specimens; “c” = cytoplasmic
8 Color CSF Tube
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
Kappa Lambda CD5 CD13/33 CD34 CD14 CD19 CD45

MDS / Cytopenia Panel (BM and PB)
FITC PE PerCP-Cy5.5 PE-Cy7 APC APC-H7 V450 V500
CD36 CD123 CD64 CD33 CD34 CD14 HLA- CD45
DR
CD15 CD56 CD117 CD13 CD11b CD16 HLA- CD45
DR
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
CD7 CD13&33 CD19 CD56
Acute Leukemia Panel (PB and BM)
FITC PE PerCP-Cy5.5 PE-Cy7 APC APC-H7 V450 V500
CD36 CD123 CD64 CD33 CD34 CD14 HLA- CD45
DR
CD15 CD56 CD117 CD13 CD11b CD16 HLA- CD45
DR
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
CD7 CD13&33 CD19 CD56
cTdT cMPO cCD3 cCD34
*CD58 CD123 CD34 CD19 CD10 CD38 CD20 CD45
*add to Pediatric specimens; “c” = cytoplasmic
Myeloma Panel
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD14 CD13&33 CD45 CD34
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
CD3 CD138 CD19 CD56
cLambda CD138 CD19 cKappa
“c” = cytoplasmic

CLL Panel (PB or BM)
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD14 CD13&33 CD45 CD34
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
FMC7 CD23 CD19 CD5
cZAP70 CD19 CD3 CD5
“c” = cytoplasmic
Mini (B) Acute Lymphoblastic Leukemia (PB or BM)
Previous diagnosis of B-lineage acute lymphoblastic leukemia (ALL) established at UPMC-
Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM
submitted for evaluation of ALL. Review previous phenotype for additional aberrant
markers.
FITC PE PerCP-Cy5.5 PE-Cy7 APC APC-Cy7 V450 V500
CD14 CD13&33 CD45 CD34
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
CD58 CD123 CD34 CD19 CD10 CD38 CD20 CD45
cTdT cMPO cCD3 cCD34
”c”= cytoplasmic

Mini (T) Acute Lymphoblastic Leukemia (PB or BM)
Previous diagnosis of T-lineage acute lymphoblastic leukemia (ALL) established at UPMC-
Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM
submitted for evaluation of ALL. Review previous phenotype for additional aberrant
markers.
FITC PE PerCP- PE-Cy7 APC APC-
Cy5.5
Cy7
CD14 CD13&33 CD45 CD34
V450
V500
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
CD16&57 CD7 CD4 CD3 CD56 CD8 CD2 CD45
CD7 CD13&33 CD5 CD56
cTdT cMPO cCD3 cCD34
”c”= cytoplasmic
Mini (AML) Leukemia (PB or BM)
Previous diagnosis of acute myeloid leukemia (AML) established at UPMC-
Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM
submitted for evaluation of AML. Review previous phenotype for additional aberrant
markers.
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD36 CD123 CD64 CD33 CD34 CD14 HLA- CD45
DR
CD15 CD56 CD117 CD13 CD11b CD16 HLA- CD45
DR
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
Basic PB or BM Screen
Limited evaluation of lymphoid and myeloid cells to be used when the following criteria are
met: no significant history, no cytopenias, and no morphologic abnormality e.g. staging for
Hodgkin lymphoma. Also, to follow-up documented CML, or rule-out a myeloproliferative
disorder such as CML, polycythemia vera (PV), essential thrombocythemia (ET). or idiopathic
myelofibrosis.
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD14 CD13&33 CD45 CD34
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45

Mini B-cell Lymphoma Follow-up (PB or BM)
Limited evaluation for follow-up of B-cell lymphoma with previous diagnosis at UPMC-
Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM
submitted for evaluation of lymphoma, and morphology review is consistent with that
diagnosis and does NOT demonstrate another disease process e.g. increased blasts.
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD14 CD13&33 CD45 CD34
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
bcl‐2 testing should be performed on all cases with a history of follicular lymphoma or if the
requisition asks for testing for bcl‐2, bcl‐2 gene rearrangement, or t(14:18) testing (even if this is
indicated in the molecular or cytogenetic area of the requisition).
Mini CLL Follow-up (PB or BM)
Limited evaluation for follow-up of chronic lymphocytic leukemia (CLL) or small lymphocytic
lymphoma (SLL) with previous diagnosis at UPMC-Presbyterian/Shadyside including flow
cytometric evaluation. PB or BM submitted for evaluation of CLL, and morphology review is
consistent with that diagnosis and does NOT demonstrate another disease process e.g.
increased blasts.
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD14 CD13&33 CD45 CD34
FMC-7 CD23 CD19 CD5
CD38 CD19 CD5
Kappa Lambda CD5 CD19 CD10 CD38 CD20 CD45
cZAP-70 CD19 CD3 CD5
”c”= cytoplasmic

Validated Extra Tubes:
FITC PE PerCP- PE-Cy7 APC APC-H7 V450 V500
Cy5.5
CD52*
bcl-2 CD10 CD20
bcl-2 CD10 CD19
CD7 CD26 CD3 CD4
TCR a/b TCR g/d CD3 CD25
CD57 CD8 CD3
CD3 CD7 CD4
FMC-7 CD23 CD19 CD5
CD38 CD19 CD5
ZAP-70 CD19 CD3 CD5
CD103 CD11c CD20 CD25
Blkd.K Blkd.L CD20 CD10
Blkd.K Blkd.L CD19 CD5
CD61 CD13/33 CD41a CD34
Tdt CD22 CD79a CD34 CD45
CD52 FITC for consideration for CAMPATH therapy put in combination with previously
tested antibodies
CD123-PE for consideration in new acute leukemias or plasmacytoid
dendritic cell neoplasms

ANTIBODIES AVAILABLE IN THE FLOW CYTOMETRY LABORATORY
FITC PE PerCP PerCP-
CY5.5
PE-
Cy7
APC
APC-
H7
CD1a
X
CD2 X X X X
CD3 X X X X X X X
CD4 X X X
CD5 X X X X
CD7 X X*
CD8 X X X X X
CD10 X X X
CD11b X X
CD11c
X
CD13 X X
CD14 X X X*
CD15 X X
CD16 X* X X
CD18 X
CD19 X X X* X
CD20 X X X X X X
CD22 X X X*
CD23
X
CD24
X
CD25
X
CD26
X
CD33 X X X
CD34 X X X
CD38 X X
CD41A
X
CD43 X
CD45 X X X* X
CD45RA X
CD45RO
X
CD52 X
CD55
CD56 X X
CD57 X*
CD59* X*
CD61 X
CD62L
X
CD79b
X
CD81 X
CD103 X
CD117
X
CD123
X
CD138
X
A/B X
G/D
X
Glyco A X*
(235a)*
BCL2 X
V450 V500 Simulset

FITC PE PerCP PerCP-
CY5.5
X
PE-
Cy7
APC
APC-
H7
FMC7
HLA-DR X* X
MPO
X
TDT X
Zap 70 X
Lambda X X
Kappa X X X
Im Tech
G1
BD G1 X X
BD G2a X X X
V450 V500 Simulset
Sim K/L
Sim 45/14
Sim
G1/G1
X
X
X

Guidelines for Flow Cytometry Staining Decisions
1. Pathologists Decisions. The pathologist who is assigned to the appropriate service
should be called for a decision in any of the following circumstances:
a. Limited specimen. Either there are too few cells to set-up the indicated panel or the
appropriate panel would use the specimen in its entirety. For some limited CSF
specimens technologists can make decision if there is a previous history, with flow
cytometry run in our system, of precursor-B acute lymphoblastic leukemia, acute
myeloid leukemia, CD10 positive B-cell lymphoma, CD5 positive B-cell lymphoid
neoplasm. The Pathologist should be called for limited CSF samples if there is no
history or history of another malignancy.
b. There are questions about any of the information available (including the history,
clinical information, test requested or morphologic appearance).
c. For whatever reason, there is uncertainty regarding the appropriate panel.
d. A technologist who has met the required morphology or decision competency level is
not available.
The following protocol is recommended when calling a pathologist for a decision:
a. Identify yourself and inform the pathologist that you are calling for a flow decision.
b. Notify the pathologist of the following information:
i. Cellularity / adequacy of specimen. Alert the pathologist if the cellularity is low.
Tell them the total number of cells and / or approximately how many tubes can
be set-up.
ii. Specimen Type (peripheral blood, bone marrow, fluid etc.).
iii. Flow-only or In-house.
iv. Test requested (evaluation of lymphocytes or blasts).
v. Clinical Information provided.
vi. Previous pertinent diagnoses in CoPath including the phenotype.
vii. Presence and quantity of abnormal cells including blasts / immature
mononuclear cells, lymphocytes / abnormal lymphocytes, plasma cells, and
unidentifiable cells.
2. Technologist Decisions. Flow decisions can be made by a technologist who has met
the required morphology and decision competency level, in the following circumstances:
a. New Adult Acute Leukemia. A complete “Acute Leukemia Panel” can be set-up if
the smear demonstrates numerous blasts, immature cells, or monocytes. The
designated hematopathologist should be paged with a text message to alert them
about a possible new case of acute leukemia. The pathologist should be called
directly if there are any questions about the tubes that should be set-up, the urgency

of the results, or the morphologic appearance. The pathologist should also receive a
text message when the completed case is being tubed.
b. Full panel. One of the standard complete panels can be set-up if the requisition
indicates the disease entity being evaluated, and both the previous history in CoPath,
and the morphologic review are consistent with that diagnosis. Technologists are
encouraged to be proactive in ordering any additional tubes indicated by previous flow
cytometric results or the information provided on the requisition e.g. the bcl-2 extra in
the evaluation of BM involvement by follicular lymphoma. Novel, untested,
combinations are NOT recommended unless the antibodies have already been
evaluated in their standard combinations.
c. Limited panel. One of the authorized limited panels (see attached list) can be
ordered if the following criteria are met:
i. The patient is being evaluated for a disease entity for which there is a
previous diagnosis at UPMC-Presbyterian/Shadyside including flow
cytometric evaluation (NOT flow only, except for PB evaluation of CLL).
ii.
The requisition indicates follow-up of that disease entity.
iii.
The morphologic findings are consistent with that diagnosis,
or treatment of that entity, and do NOT indicate another disease
process.
d. CSF specimens. If there are only enough cells available for one tube, flow
cytometry technologists can make a decision of which tube to run, based on
the following guidelines:
i. Previous history of precursor-B acute lymphoblastic leukemia with flow cytometry
run in our system:
• CD10 positive - set up CD10 / CD13&CD33 / CD19 / CD34
• CD10 negative - call for decision
• Any questions - call for decision
ii. Previous history of acute myeloid leukemia with flow cytometry run in our system:
• CD34 positive - Set up 8-color CSF tube
• CD34 negative - call for decision
• Any questions - call for decision
iii. Previous history of B-cell lymphoma with flow cytometry or previous diagnostic
evaluation in our system:
i. set up 8-color B-cell tube
iv. No history of a hematolymphoid malignancy, such as leukemia, lymphoma,
myeloma, after review of CoPath and available clinical information:
i. set up 8-color CSF tube (K/L/CD5/CD13&33/CD34/CD14/CD19/CD45).
3. Technologist Ordering of Extra’s. After review of the results from the original panel,
technologists are encouraged to be proactive in ordering any additional tubes indicated,
or text paging the Pathologists to alert them of the possible need for Extra’s. For
example:

a. bcl-2 extra: abnormal CD10 positive B-cell population
b. FMC-7 / CD23 / CD19 / CD5: abnormal CD5 positive B-cell population.
c. CD103 / CD11c / CD20 / CD25: abnormal CD10 negative, CD5 negative B-cell
population.

TEST SPECIFICATIONS: CLINICAL FLOW CYTOMETRY LABORATORY
Leukemia Panels, CLL/Lymphoma Panels, T-Lymphocyte Subset Panels, PNH, NOBA
DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY
Scaife Hall
Room S-763 (7 th floor)
3550 Terrace Street
Pittsburgh, PA 15261
(412) 624-3746
FLOW CYTOMETRY LAB HOURS OF OPERATION
Monday through Friday: 8:00 am to 6:00 pm. In all cases, notify the lab before the specimen is sent
(412- 624-3746). It is recommended that on Friday specimens be received by 5 pm.
Saturday: Emergency specimens can be processed on Saturday. The laboratory must be notified by 12
pm and the specimen must arrive by 1 pm. The hematopathologist on call can be reached through the
UPMC Oakland operator at (412) 647-2345.
Sundays and Holidays: The lab is closed on Sunday and the following holidays: New Year’s Day, Martin
Luther King Day, Memorial Day, July 4, Labor Day, Thanksgiving Day and Christmas. Specimens should
be received by 3 pm on the day before a holiday.
SPECIAL INSTRUCTIONS
Send a completed requisition. In addition FAX the requisition to 412-624-6863 in advance of
sending the specimen.
See specific instructions for storage/transport of specimens.
Use adequate safety measures in transporting specimens.
LEUKEMIA, CLL/LYMPHOMA PANELS
Test Description
These tests utilize a panel of monoclonal antibodies in the immunophenotypic analysis of hematopoietic
and lymphoid proliferation. The panels are used to assess cell lineage and to look for features that
support a neoplastic rather than reactive proliferation.
Specimen Requirements
Bone marrow aspirate: Minimum of 2 ml in a heparinized (green top) tube. Store/transport
specimen at room temperature. If possible send one non-heparinized,
unstained aspirate smear.
Peripheral blood:
One EDTA (preferred; purple top) tube or heparinized (green top) tube
with at least 5 ml of blood. Store/transport specimen at room
temperature.
Lymph nodes:
Preferably 1 cm 3 fresh tissue in RPMI or any other growth media.
Normal saline may be used if RPMI is unavailable and transport time is
kept to a minimum. A small portion of all tissues (or other tissues) will be
processed for histologic sections. Send tissue as soon as possible –
preferably to be received within 24 hours. Store specimen at
2-8 o C if delay in transport.

Body fluids: Preferably should be a minimum of approximately 100,000 cells (e.g. 100
cells/ul x 1 ml; 10 cells/ul x 10 ml). Testing can be attempted even on
very low count specimens. Send specimen as soon as possible.
Store at 2-8 o C if delay in transport.
Fine needle aspirates: Place cores (preferably two) and any additional aspirate in RPMI or other
growth media. Normal saline may be used if RPMI is unavailable and
transport time is kept to a minimum. Send tissue as soon as possible –
preferably to be received within 24 hours. Store specimen at 2-8 o C
if delay in transport.
T-LYMPHOCYTE SUBSET EVALUATION
Test Description
This test may be identified as T Cell Subsets, T and B Cells, CD4:CD8 counts and other synonyms. The
test panel includes a Total T or Pan T antibody, a Total B cell or Pan B antibody, a Total Helper antibody,
a Total Suppressor antibody, the Helper/Suppressor, and a Total Natural Killer antibody. There are no
functional tests associated with these antibodies.
A limited CD4 evaluation can be performed if requested.
Specimen Requirements
One 4 ml EDTA (purple top) tube or two BD microtainer (purple top) pediatric tubes. Store/transport
specimen at room temperature. Testing must performed within 48 hours of specimen collection.
EVALUATION FOR PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH)
Test Description
The flow cytometric test for PNH evaluates the GPI-linked markers: CD59 on RBCs; CD24 and CD16 on
Neutrophils and CD14 on Monocytes. The WBC assay also determines binding of the fluorochrome
labeled toxin Aerolysin.
Specimen Requirements
One 4 ml EDTA (purple top) tube. Store/transport specimen at room temperature. Testing must be
performed within 48 hours of specimen collection.
EVALUATION FOR NEUTROPHIL OXIDATIVE BURST ASSAY (NOBA)
Test Description
This test is a replacement for the Nitro Blue Tetrazolium (NBT) test for Chronic Granulomatous Disease
(CGD). The neutrophil oxidative burst assay measures the respiratory burst of neutrophils following
stimulation with phorbol 12-myristate 13-acetate (PMA). Patients with CGD lack the usual oxidative burst.
Specimen Requirements
One 4 ml EDTA (purple top) tube kept at room temperature. Store/transport specimen at room
temperature. Testing must be performed within 24 hours of specimen collection. In addition a normal
control (from an UNRELATED donor) MUST accompany the specimen.
CONTACTS, DIVISION OF HEMATOPATHOLOGY
Steven H. Swerdlow, M.D. Director, Division of Hematopathology (412) 647-5191
Raymond Felgar, M.D. Co-Director, Flow Cytometry Lab (412) 647-8780
Christine Roth, M.D. Co-Director, Flow Cytometry Lab (412) 692-2090
Karen Freilino Lead Technologist, Flow Cytometry (412) 624-3746
Rev 4/13

ICD9 Codes for Flow
A list of ICD9 Codes commonly received in the Flow Laboratory. This list is to be used as an
aid in interpreting ICD9 codes. It is not to be used to assign ICD9 codes to a case.
IDC9
Disease
78.9 (V78.9) Blood Screen (NOS)
79.99 Viral Infection NOS
172.6 Malignant Melanoma
194.9 Malignant Endocrine Neoplasm (NOS)
201.9 Hodgkin’s Disease (NOS)
202.1 Mycosis Fungoides Unspec Site
202.4 Hairy Cell Leukemia Unspec Site
202.6 Mastocytosis
202.8 Lymphoma Unspec Site
203 Multiple Myeloma No Remission
203.01 Multiple Myeloma In Remission
204.1 CLL - No remission
205 Myeloid leukemia
205.1 CML - No remission
205.11 CML - In remission
207.8 Mast cell leukemia
208.9 Unspecified Leukemia
238.4 Polycythemia Vera
238.7 Lymphoproliferative Chronic (NOS)
238.7 Myeloproliferative Chronic (NOS)
273.3 Macroglobulinemia
284.8 Aplastic Anemia NEC
284.9 Aplastic Anemia NOS
285.6 Lymphadenopathy
285.9 Anemia (NOS)
287.4 Secondary Thrombocytopenia
288 Agranulocytosis
288.1 Function Disorder Neutrophils
288.8 White Blood Disease NEC
289.89 Myelofibrosis
709.9 Skin Disorder NOS
786.5 Chest Pain
789.2 Splenomegaly

Adult Bone Marrow
Experience

Adult Bone Marrow Experience (~4 weeks)
1. Adult Bone Marrow Sign Out
A. Sessions with Adult Bone Marrow Technologists -- if not already done during
pediatric marrow rotation (eg AP only residents), please set up a time to review
peripheral blood and bone marrow aspirate smears with technologists during
your first week.(typically Tuesday afternoon is best)
B. Participation in sign-out with staff. Inform Hematopathologist on BM #1 Service that
you are starting the rotation and review expectations in terms of bone marrow
preview, sign-out, dictation, and proofing ( see “Trainee Responsibilities during
Bone Marrow Rotation”).The trainee should discuss with the faculty the optimal
number of cases to evaluate prior to sign-out. .The number of cases the resident
is expected to evaluate will increase progressively during the rotation.
C. Review results of ancillary procedures performed on marrows you have reviewed
and read addenda that faculty issue (see Special Procedure Review by
Resident/Fellow in CoPath).
D. Review of educational materials.
Blood Cell Morphology. (Published by the ASCP). If not already done during
pediatric marrow rotation (ie AP only residents).. review the RBC, WBC, Normal
and Abnormals Binders with CDs in Hematopathology library (G323) or images
and PDF key are also on shared resident drive, under “CP Lecture
Material\Hemepath\ASCP Hematology Images”
A teaching set of peripheral blood and body fluid smears is available for checkout
from the medical secretary (G306)
A set of cytochemical stains and pb/bm smears is available from the bone
marrow technologists. Individual faculty members also have teaching slides.
Foucar, K. Bone Marrow Pathology, 2 nd Edition, ASCP Press, 2001.
Foucar, K, Viswanatha DS, Wilson S (Eds). Non-neoplastic disorders of bone
marrow. Atlas of non-tumor pathology. AFIP, 2008.
Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele,
J., Vardiman, J. (Eds.): WHO Classification of Tumours Pathology of
Haematopoietic and Lymphoid Tumours, IARC, Lyon, 2008.
Keren DF, McCoy JP Jr, Carey JL (Eds.): Flow Cytometry in Clinical Diagnosis,
4 rd Edition, ASCP, 2007.
Bain, BJ, Clark, DM, Lampert, IA, Wilkins, BS. Bone Marrow Pathology, 3 rd
Edition, Blackwell Science, 2001.
Kjeldsberg CR: Practical Diagnosis of Hematologic Disorders, 4 th Edition, ASCP,
2006.
Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major
Problems in Pathology”), Saunders, 2003.

Stramatoyannopoulos M, Perlmutter V. Molecular Basis of Blood Diseases, 3 rd
Edition, W.B. Saunders, 2001.
Additional Resources:
Knowles DM. Neoplastic Hematopathology, 2 nd Edition, Lippincott Williams &
Wilkins, 2000.
Peterson LC and Brunning RD. Chapter 37. Bone Marrow specimen
Processing, pp1391-1406.
Li C-Y and Yam LT. Chapter 38. Cytochemical, Histochemical and
Immunohistochemical Analysis of the Bone Marrow
See list of web-based resources at end of manual.
NOTE: Reading is an important component of this rotation. It is recognized that not all
of the above resources can be used nor can most be read in entirety. Use of electronic
and other resources to find and read up-to-date journal articles is also critical.
General Trainee Responsibilities during Bone Marrow Rotation
Adequate preparation of a bone marrow prior to sign out includes:
1. Aspirate smears are usually available the day before the biopsy is processed (i.e. the
day before sign-out). Ideally cases should be scanned the day before sign-out in order
to select appropriate cases in which trainees will be expected to assume a greater
degree of responsibility – please coordinate with your attending. On these cases, please
do your own differential counts to see how they compare with the technologists’ counts
on the next day. Particularly once you have some experience, the differentials should be
on the more interesting/difficult cases. Contact physician if necessary (e.g., if after
review with staff pathologists, a new acute leukemia is seen). Trainees will have
increasing responsibility for independent preview, as they are more experienced.
2. Obtain sufficient history from computer, chart or physician’s office to understand reason
for marrow being performed and to understand any coexistent disease process, drug
usage, exogenous toxins, etc. which might affect bone marrow interpretation. Look up
any appropriate laboratory data such as folate, B12, and iron (plus TIBC) in anemias or
macrocytosis, results of SPEP, UPEP, and immunofixation in evaluation of plasma cell
disorders. If possible, this should be obtained prior to initial review with staff pathologist.
The technologist’s history may or may not be sufficient.
3. Preview of peripheral blood smear, marrow aspirate smears and biopsies on all
assigned cases.
4. Gather and interpret any ancillary studies which have been performed such as flow
cytometry.
5. Review prior marrow and surgical pathology specimens where appropriate (e.g.
leukemic marrow case where looking for residual/recurrent disease, extent of prior
disease in follow-up of plasma cell neoplasia).
6. Write down description and diagnosis in pencil on template or indicate agreement or
disagreement with technologist’s comments with a check mark or other notation.
.Discuss the format of bone marrow report with the staff pathologist on service.

7. In consultation with staff pathologist, dictate reports either upon completion of sign-out or
after each case. Please use whatever method will get the cases out ASAP. See specific
guidelines on next page.
8. The staff pathologist may ask you to proof and correct the reports you have dictated. If
you will be doing this, ask the secretary not to send the report to the pathologist’s queue
(i.e. do not “final” the report). Trainee should final the report once it is proofed.
9. With increasing experience, fellows will have a more independent role in bone marrow
evaluations with increasing responsibility as designated by faculty.
10. Bone marrow report:
Peripheral blood smear should focus on morphologic features of (1) red blood
cells, (2) leukocytes and (3) platelets. Any abnormal or atypical features
should be described in detail.
Morphologic description of bone marrow should address the following
features:
‣ Cellularity
‣ Presence of abnormal infiltrates (lymphoid aggregates, clusters of
immature myeloid cells, granuloma, metastatic tumor infiltrates, etc.)
‣ Myeloid-to-erythroid ratio
‣ Maturation of megakaryocytic, erythroid and granulocytic precursors
‣ Presence (and severity) of dysplasia
‣ Bone trabeculae

Specific Guidelines for Residents and Fellows on Bone Marrow Service
.
I. Previewing
a. Urgent cases that faculty should be informed about without delay:
i. New acute leukemias.
ii. Day 14 status post chemotherapy induction for acute myeloid leukemia.
b. Please designate number of cells to be counted; generally 500 cell count if there
is any suspicion for a myeloid neoplasm, 300 cell count for lymphoma/myeloma
staging cases.
c. An iron stain should be ordered if there is anemia, microcytosis, macrocytosis, or
elevated RDW.
i. Please order it on the aspirate smears unless there are no spicules.
ii. If there are no spicules, order it on the touch imprint or core biopsy.
iii. Exception: An iron stain is likely not needed for anemia or abnormal indices
during induction or consolidation for acute leukemia.
II.
III.
Preparation prior to sign-out
a. When applicable, have the most recent bone marrow report and diagnostic
bone marrow report printed out.
b. If available, diagnostic and most recent bone marrow slides should be
pulled out and reviewed and reports printed
c. When applicable, review the prior diagnosis, pertinent immunophenotype and
cytogenetics.
d. Preview the case, including the flow cytometry.
i. Arrange a time to sign-out with a faculty member so that you will have
enough time for previewing, which is very important in resident education.
ii. Be ready to discuss the case and ask questions.
Immunohistochemistry and other studies
a. Order 5-10 blanks to be cut whenever immunohistochemistry studies are
ordered on our bone marrow cases.
b. Order stains through the bone marrow technologists (Audix stain line 412-802-
3273)
c. Please use the table for dictating the results of the immunohistochemistry
studies.
i. Transcriptions know how to format the results in the table
ii. Quick text = “HISTRPT.”
d. Please remember to justify why immunohistochemistry has been performed if
flow has also been performed.
Quick text choices: FLOW/IHC1 or FLOW/IHC2.

IV.
Quality assurance is very important
a. Assess the adequacy of aspirate smears and core biopsy: Adequate,
suboptimal, or inadequate, using the following criteria below:
Bone Marrow Adequacy Criteria:
Biopsy (trephine):
Adequate (A) 15 mm gross length, at least 10 partially preserved intertrabecular
areas (40x)
Suboptimal (S) less than 15 mm length, at least 5 partially preserved
intertrabecular areas
Inadequate (I) less than 5 mm, fewer than 5 partially preserved intertrabecular
areas
Particle/clot:
Adequate (A) at least 10 partially preserved marrow particles/areas (40x)
Suboptimal (S) at least 5 partially preserved marrow particles
Inadequate (I) fewer than 5 partially preserved marrow particles
Aspirate:
Adequate (A) 3 or more spicules, 300 or more cells
Suboptimal (S) 1 or 2 spicules, 100 or more cells
Inadequate (I) no spicules, BM diff. cannot be performed (less than 100 cells)
Touch imprint:
Adequate (A) 300 or more cells
Suboptimal (S) 100 or more cells, less than 300
Inadequate (I) BM diff. cannot be performed (less than 100 cells)
V. Dictations, proof reading, and final sign-out
a. After the initial review of a case with the hematopathologist, please dictate
the report to the best of your ability. Additional studies and final diagnosis
can be added later.
b. After you have dictated the final report, proof read it, and then arrange with the
faculty how they wish you to proceed. Some would like the slides and
paperwork.
c. Faculty specific requests.
Dr. Roth: For normal flow interpretations, please use “CGR_NEG_BM”
and modify appropriately
VI.
Wednesday 8:30 am conference
a. The trainee on the adult bone marrow service is responsible for the 3 cases
for the Wednesday conference for the following week after sign-out with the
faculty member on BM#1 service.
b. If there is a trainee on the pediatric/ATL bone marrow service, then the trainees
should determine if that trainee is presenting a pediatric or ATL case.
c. If the trainee(s) cannot meet this expectation, it is his, her or their
responsibility to make arrangements with someone, such as the faculty
member, so that 3 cases get presented.
d. Discuss the last minute details of your cases to be presented with the
responsible faculty member on Monday, two days before the conference.
Determine if the faculty member needs to review the digital images or any other
details.

VII.
Going off service
a. Please make it clear to the responsible faculty member what the status of a case
is, what is pending, and where you have put it.
b. At the beginning of this last week on service, discuss with the responsible faculty
member who will be presenting at Wednesday 8:30 am conference. In most
cases, you will still be able to present your cases even if on another
hematopathology service.
Policy for Review of Bone Marrow Aspirates, Particle Preparations and Biopsies
Technologists will screen all smears; assess quality of specimen and quality of stain.
Technologist will inform Trainee or if no trainee, faculty when new marrow aspirates with
acute leukemia or day 14 S/P chemotherapy are ready to be reviewed. A worksheet
with the CBC data and morphology comments written in should be printed and made
available for the review with the aspirate smear and PB smear. In addition a working
draft that includes previous cases will be attached. In other cases check review bin in
the sign-out room.
Trainee/Pathologist will review aspirate smears/cases together with the history and other
clinical data on day they are received in the laboratory.
Clinicians performing marrows may also request a marrow differential or iron stain. This
will have been noted by the technologist on the form that is used to record what special
studies are being requested.
Other useful information
1. To order additional immunohistochemical stains, FISH molecular orders and all other non
stat requests on bone marrow cases call the Audix stain line 412-802-3273 and leave a
message. These are routinely picked up during normal working hours.
2. Prior slides:
‣ Bone marrow slides from part of 2009-present are in G325.1.
‣ Bone marrow slides from unknown-part of 2008 are at Iron Mountain.(see table
below)
‣ In the Hematology Lab, the peripheral blood slides are kept for 2 weeks and are filed
by accession number. The CBC results are in Sunquest/Mysis.
‣ Slides to preview for bone marrow service #1 are placed in G315. There is
also a bin for the cases ready for the technologist. Cases ready for sign out
are also placed in G315.
Flow reports are tubed to the bone marrow room G325.1 up to 5:15pm. After that, urgent cases
are delivered directly to the pathologist

APPENDIX C LOCATION OF BONE MARROW RECORDS
CHP UPMC MUH (PRIOR TO MERGER)
SLIDES REPORTS
SLIDES
REPORTS
SLIDES REPORTS
1994 – 2008
(PHB08-2859)
In Iron mountain
PHB08-2860 to
present : see
adult slides
locations.
1996-Present:
In CoPath
Client Server.
Part 2009-Present:
PHB
(09-4561- present)
G325.1 PUH
Bone Marrow Room.
PHB
08-1742 to 09-4560
REPORTS
1990-Present
In Co-path
Client Server.
Starting April, 2009
Surg path reqs
stored in the Scaife
processing area.
1983-1988 asp
1991-1995 asp
and bx:
Iron Mountain.
Unknown-1991 bx:
MUH Surgical
Pathology files
in Iron Mountain.
1990-1995:
As described
for UPMC
In S764 Scaife Hall
(flow processing area)
Unknown-part 2008
(PHB08-1741)
Iron Mountain.
1981-1990:
A Stem 6th floor,
Microfiche files
1967-1982 asp:
Iron Mountain.
Unknown-
1990:
BRM
1976-1994:
Iron Mountain.
Unknown-1976
CHP Pathology
(basement)
1930-1938,
1950-1996:
BRM
1963-1981:
BRM

Forms and Templates for
Bone Marrow Service

ADULT BONE MARROW SERVICE REQUEST FORM
PHB13- Date ADDSYNOPTIC
Name:
Requests:
PB not available
Do full PB Diff and review
Scan PB for morphology, blasts and abnormal cells
Scan PB for blasts and abnormal cells
Scan BM smear for tumor
Do BM Diff with detailed review of smears
300 cell count 500 cell count
*default is 300 cell differential
Order Iron Stain on biopsy/smear
Order the following cytochemical stains:
SB PX PAS CAE DBLE (+/-fl)
NSE (Acetate Esterase +/- fluoride)
NSE (Butyrate Esterase +/- fluoride)
Order the following other stains:
Stain Specimen Date/Time Tech
(Bx,FBM,clot...)
_______________________ ________ ___________________
_______________________ ________ ___________________
Molecular:
Other:__________________________________________________
Print full report
Pull slides
Most recent previous BM
First diagnostic BM
PH__-___________
PH__-___________
_____________________________
Pathologist/Resident
#1 or #2 or #3 or CHP Bone Marrow Service
---------------------------------------------------------------------------------------------------------------------
Quality Assurance Check:
Satisfactory.
Less than optimal:
stain quality:_______________________________
differential count PB _ BM _ : __________
morphology evaluation :______________________
history incomplete/incorrect :__________________
Comment

ADULT BONE MARROW WORKSHEET
OUTSIDE ADULT BONE MARROW WORKSHEET
Technologist: ________________________________________________________________________
Clinical History:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:______________________________________________
______________________________________________________________________________________
DIAGNOSIS:
Part 1) PERIPHERAL BLOOD -_________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE
PREPARATION)-
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________ (See Comment)
COMMENT:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DESCRIPTION:
PERIPHERAL BLOOD:
The following CBC is from ___/___/___, SLIDE # ___________
CBC Patient Typical Normal Reference Range
. Value (Male/Female)
WBC ____________x10E+9/L (4.40 - 11.3)
RBC ____________x10E+12/L (4.50 - 5.90/4.10 - 5.10)
Hgb ____________g/dl (14.0 - 17.5/12.3 - 15.3)
Hct ____________% (41.5 - 50.4/35.9 - 44.6)
MCV ____________fl (80.0 - 96.0)
MCH ____________pg (27.5 - 33.2)
MCHC ____________gm/dl (33.4 - 35.5)
RDW ____________%
PLT ____________x10E+9/L ( 150 - 450 )
Retic ___________% ( 0.5 - 1.5 )
Retic ___________x10E+12/L (0.025 - 0.075)
Polys ___________% __________(ABS) (1.80 - 7.80)
Bands ___________% __________(ABS) (0.00 - 0.70)
Lymphs ___________% __________(ABS) (1.00 - 4.80)
Atyp. lymph _________% __________(ABS)
Monos ___________% __________(ABS) (0.00 - 0.80)
Eos ___________% __________(ABS) (0.00 - 0.45)
Baso ___________% __________(ABS) (0.00 - 0.20)
Blasts ___________% __________(ABS)

Promyel ___________% __________(ABS)
Myelo ___________% __________(ABS)
Meta ___________% __________(ABS)
NRBC/100 WBC ___________
The peripheral blood smear was reviewed as follows:
______________________________________________________________________________
______________________________________________________________________________
RED BLOOD CELL MORPHOLOGY:
___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,
___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,
___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,
___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,
___Unremarkable,
_______________________________________________________________
________________________________________________________________________________
WHITE BLOOD CELL MORPHOLOGY:
_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,
_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,
_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________
_________________________________________________________________________________
PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.
_________________________________________________________________________________
BONE MARROW:
ADEQUACY STATEMENT:
The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for
interpretation precluding a differential). ( ___ aspirate smears and _____ touch
imprints reviewed).
The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.
THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as
well as a PAS stain which is done, in part, to highlight the myeloids and
megakaryocytic elements, further evaluate the myeloid:erythroid ratio and
evaluate the underlying bone marrow stroma.”
BONE MARROW differential (_____ cells counted):
Bone Marrow Patient Adult Normal
Differential Value Mean Range
Blast _____________% 1.0 ( 0.0 - 2.0 )
Promyelocyte _____________% 3.0 ( 2.0 - 4.0 )
Myelocyte _____________% 12.0 ( 8.0 - 16.0 )
Metamyelocyte _____________% 17.0 ( 10.0 - 25.0 )
Band _____________% 12.0 ( 9.0 - 18.0 )
PMN _____________% 9.0 ( 7.0 - 14.0 )
Eos Myelo/Meta _____________% 2.0 ( 1.0 - 4.0 )
Eos Band _____________% 1.0 ( 0.0 - 3.0 )
Eos Seg _____________% 1.0 ( 1.0 - 2.0 )
Basophil _____________% 0.0 ( 0.0 - 0.2 )
Monocytes _____________% 1.0 ( 0.0 - 2.0 )
Pronormoblasts _____________% 1.0 ( 0.0 - 1.0 )
Normoblasts _____________% 24.0 ( 16.0 - 32.0 )

Lymphocytes _____________% 16.0 ( 11.0 - 23.0 )
Plasma Cells _____________% 2.0 ( 0.0 - 3.0 )
Other
_____________%
Myeloid/Erythroid _____________% 2.4 ( 1.5 - 3.3 )
The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,
hypercellular)
(_____% cellular). There is stromal injury/chemotherapy effect.
_____________________________________________________________________________________
_____________________________________________________________________________________
The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,
unremarkable, not evaluable)
_____________________________________________________________________________________
_____________________________________________________________________________________
ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, asynchronous, with dyserythropoietic forms).
_____________________________________________________________________________________
_____________________________________________________________________________________
MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left
shift).
_____________________________________________________________________________________
_____________________________________________________________________________________
MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,
decreased, normal) numbers (with clusters, aggregates, very large aggregates present).
MEGAKARYOCYTES
include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.
____________________________________________________________________________________
____________________________________________________________________________________
STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on
an iron stain performed on the (aspirate smear, biopsy, particle preparation).
There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.
No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,
show osteoclastic resorption, osteoblastic rimming, show new bone formation).
____________________________________________________________________________________
____________________________________________________________________________________
ANCILLARY STUDIES:
FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that
were needed in addition to the flow cytometric immunophenotypic studies for the best
diagnosis possible is as follows:
The flow cytometric studies did not define the precise nature of all the cellular
elements of concern in this specimen.
FLOW/IHC2: Medical necessity justification for the immunohistochemical stains that
were needed in addition to the flow cytometric immunophenotypic studies for the best
diagnosis possible is as follows:
The flow cytometric studies are not clearly representative of all the features
requiring evaluation in this specimen.

ADULT BONE MARROW WORKSHEET
INSIDE ADULT BONE MARROW WORKSHEET
Technologist: ________________________________________________________________________
Clinical History:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:______________________________________________
______________________________________________________________________________________
DIAGNOSIS:
Part 1) PERIPHERAL BLOOD -_________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE
PREPARATION)-
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________ (See Comment)
COMMENT:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DESCRIPTION:
PERIPHERAL BLOOD:
The following CBC is from ___/___/___, SLIDE # ___________
CBC Patient UPMC-Presbyterian Normal Range
. Value (Male/Female)
WBC ____________x10E+9/L (3.8 - 10.6)
RBC ____________x10E+12/L (4.13 - 5.57/3.73 - 4.89)
Hgb ____________g/dl (12.9 - 16.9/11.6 - 14.6)
Hct ____________% (38.0 - 48.8/34.1 - 43.3)
MCV ____________fl (82.6 - 97.4)
MCH ____________pg (27.8 - 33.4)
MCHC ____________gm/dl (32.7 - 35.5)
RDW ____________% (11.8 - 15.2)
PLT ____________x10E+9/L ( 156 - 369 )
Retic ___________% ( 0.8 - 2.0/0.8 - 4.0)
Retic ___________x10E+12/L (0.018 - 0.158)
Polys ___________% __________(ABS) (2.24 - 7.68)
Bands ___________% __________(ABS) (0.10 - 0.80)
Lymphs ___________% __________(ABS) (0.80 - 3.65)
Atyp. lymph _________% __________(ABS)
Monos ___________% __________(ABS) (0.30 - 0.90)
Eos ___________% __________(ABS) (0.00 - 0.40)
Baso ___________% __________(ABS) (0.00 - 0.06)

Blasts ___________% __________(ABS)
Promyel ___________% __________(ABS)
Myelo ___________% __________(ABS)
Meta ___________% __________(ABS)
NRBC/100 WBC ___________
The peripheral blood smear was reviewed as follows:
______________________________________________________________________________
______________________________________________________________________________
RED BLOOD CELL MORPHOLOGY:
___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,
___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,
___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,
___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,
___Unremarkable, _______________________________________________________________
________________________________________________________________________________
WHITE BLOOD CELL MORPHOLOGY:
_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,
_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,
_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________
_________________________________________________________________________________
PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.
_________________________________________________________________________________
BONE MARROW:
ADEQUACY STATEMENT:
The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for
interpretation precluding a differential). (___ aspirate smears and _____ touch
imprints reviewed).
The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.
THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as
well as a PAS stain which is done, in part, to highlight the myeloids and
megakaryocytic elements, further evaluate the myeloid:erythroid ratio and
evaluate the underlying bone marrow stroma.”
BONE MARROW differential (_____ cells counted):
Bone Marrow Patient Adult Normal
Differential Value Mean Range
Blast _____________% 1.0 ( 0.0 - 2.0 )
Promyelocyte _____________% 3.0 ( 2.0 - 4.0 )
Myelocyte _____________% 12.0 ( 8.0 - 16.0 )
Metamyelocyte _____________% 17.0 ( 10.0 - 25.0 )
Band _____________% 12.0 ( 9.0 - 18.0 )
PMN _____________% 9.0 ( 7.0 - 14.0 )
Eos Myelo/Meta _____________% 2.0 ( 1.0 - 4.0 )
Eos Band _____________% 1.0 ( 0.0 - 3.0 )
Eos Seg _____________% 1.0 ( 1.0 - 2.0 )
Basophil _____________% 0.0 ( 0.0 - 0.2 )
Monocytes _____________% 1.0 ( 0.0 - 2.0 )
Pronormoblasts _____________% 1.0 ( 0.0 - 1.0 )
Normoblasts _____________% 24.0 ( 16.0 - 32.0 )
Lymphocytes _____________% 16.0 ( 11.0 - 23.0 )

Plasma Cells _____________% 2.0 ( 0.0 - 3.0 )
Other
_____________%
Myeloid/Erythroid _____________% 2.4 ( 1.5 - 3.3 )
The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,
hypercellular)
(_____% cellular). There is stromal injury/chemotherapy effect.
_____________________________________________________________________________________
_____________________________________________________________________________________
The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,
unremarkable, not evaluable)
_____________________________________________________________________________________
_____________________________________________________________________________________
ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, asynchronous, with dyserythropoietic forms).
_____________________________________________________________________________________
_____________________________________________________________________________________
MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left
shift).
_____________________________________________________________________________________
_____________________________________________________________________________________
MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,
decreased, normal) numbers (with clusters, aggregates, very large aggregates present).
MEGAKARYOCYTES
include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.
____________________________________________________________________________________
____________________________________________________________________________________
STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on
an iron stain performed on the (aspirate smear, biopsy, particle preparation).
There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.
No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,
show osteoclastic resorption, osteoblastic rimming, show new bone formation).
____________________________________________________________________________________
____________________________________________________________________________________
ANCILLARY STUDIES:
FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that
were needed in addition to the flow cytometric immunophenotypic studies for the best
diagnosis possible is as follows:
The flow cytometric studies did not define the precise nature of all the cellular
elements of concern in this specimen.
FLOW/IHC2: Medical necessity justification for the immunohistochemical stains that
were needed in addition to the flow cytometric immunophenotypic studies for the best
diagnosis possible is as follows:
The flow cytometric studies are not clearly representative of all the features
requiring evaluation in this specimen.
ANCILLARY STUDIES:
Cytochemical Stains
Histologic Section Immunohistochemistry/In situ Hybridization

CYTOCHEMICAL STAINS
Interpretation/Diagnosis (for special tests only/addenda):______
________________________________________________________________
________________________________________________________________
Results/Ancillary Studies:
Cytochemical stains were performed on: _________________________
The following results were found:
Stain Usual Reactivity Results
---------------------------------------------------------------------------------------------------------------
Sudan Black gran, mono
---------------------------------------------------------------------------------------------------------------
Peroxidase
gran, mono
----------------------------------------------------------------------------------------------------------------
PAS
diff*-gran, mono
block-lymph
diff +/- block-abnl RBC
-----------------------------------------------------------------------------------------------------------------
CAE
CAE-gran, mast
-----------------------------------------------------------------------------------------------------------------
NSE
NSE-mono, mega
NSE Positivity
Was / was not
inhibited by fluoride
--------------------------------------------------------------------------------------------------------------------

DAY 14 BONE MARROW WORKSHEET
Technologist:
_________________________________________________________________
Clinical History:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:__________________________________________
__________________________________________________________________________________
Specimen adequacy: Aspirate: Adequate/Suboptimal/Inadequate/Not evaluable
Touch imprint: Adequate/Suboptimal/Inadequate/Not evaluable
Biopsy:
Adequate/Suboptimal/Inadequate/Not evaluable
Particle/clot: Adequate/Suboptimal/Inadequate/Not evaluable
Bone marrow blasts: Absent/Present ( %)/Not evaluable
Counted on aspirate/touch imprint:
Cells counted (100, 200, 300, 500, other)
Marrow cellularity: ( %)
Peripheral blood blasts: Absent/Present( %)/Slide not available.
Cells counted(100,200)
Marrow regeneration:
Erythropiesis: Absent/Rare/Present/Not evaluable
Granulopoiesis: Absent/Rare/Present/Not evaluable
Megakaryopoiesis: Absent/Rare/Present/Not evaluable
Additional morphologic findings:
Clusters of immature cells
Lymphoid aggregate(s)
Granuloma(s)
Other:
Immunohistochemical stains performed to better assess marrow findings:
CD34
CD117
TDT
Other
“Medical necessity justification for the immunohistochemical stains that were needed in
addition to the flow cytometric immunophenotypic studies for the best diagnosis possible is

as follows: The flow cytometric studies did not define the precise nature of all the
cellular elements of concern in this specimen”.
Cytochemical stains performed to better assess marrow findings:
Myeloperoxidase
Non-specific (Butyrate) esterase
This report is based on morphologic evaluation of submitted bone marrow specimen and the
following completed ancillary studies:
attached)
Immunohistochemical stains
Cytochemical stains
Flow cytometric analysis (separate report attached)
Classical cytogenetic (karyotypic) analysis (separate report
Cytogenetic FISH analysis (separate report attached)
Molecular analysis (separate report attached)
Other:
The following studies are pending with results to follow:
Immunohistochemical stains
Cytochemical stains
Flow cytometric analysis
Classical cytogenetic (karyotypic) analysis
Cytogenetic FISH analysis
Molecular analysis
Other:
2 bone marrow aspirate smears and 1 touch prep reviewed.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as well as a PAS
stain which is done, in part, to highlight the myeloids and megakaryocytic elements, further
evaluate the myeloid: erythroid ratio and evaluate the underlying bone marrow stroma”.
The following CBC is from ___/___/___, SLIDE # ___________
CBC Patient UPMC-Presbyterian Normal Range
. Value (Male/Female)
WBC ___________ x10E+9/L (3.8 - 10.6)
RBC ___________ x10E+12/L (4.13 - 5.57/3.73 - 4.89)
Hgb ____________g/dl (12.9 - 16.9/11.6 - 14.6)
Hct ____________% (38.0 - 48.8/34.1 - 43.3)
MCV ___________ fl (82.6 - 97.4)
MCH __________ pg (27.8 - 33.4)
MCHC __________ gm/dl (32.7 - 35.5)
RDW __________ % (11.8 - 15.2)
PLT ___________ x10E+9/L ( 156 - 369 )
Retic ___________% ( 0.8 - 2.0/0.8 - 4.0)
Retic ___________x10E+12/L (0.018 - 0.158)
Polys __________% __________(ABS) (2.24 - 7.68)
Bands ___________% __________(ABS) (0.10 - 0.80)
Lymphs ___________% __________(ABS) (0.80 - 3.65)
Atyp. lymph _________% __________(ABS)
Monos ___________% __________(ABS) (0.30 - 0.90)
Eos __________% __________(ABS) (0.00 - 0.40)
Baso __________% __________(ABS) (0.00 - 0.06)

Blasts _________% __________(ABS)
Promyel __________% __________(ABS)
Myelo __________% __________(ABS)
Meta __________% __________(ABS)
NRBC/100 WBC __________
Recommendations for Consistent Terminology in Hematopathology Reports
1. Use the 2008 WHO Classification (see the monograph)
2. Leukemic follow-up marrows
a. History should always state: Day status post chemotherapy (or status post
transplant) for abbreviated disease name e.g. AML, promyelocytic
i. If time unknown, delete “day .”
*Remember day status post chemotherapy refers to days following initiation of therapy.
A. Preferably a similar statement should also be in the diagnosis following the initial diagnostic line
e.g.
Bone marrow, biopsy and aspirate--
A. Markedly hypocellular marrow with chemotherapy effect
B. (Day 7 status post chemotherapy for AML).
B. If history of leukemia is remote, history (and if desired, diagnosis) should state:
“Status post previous diagnosis of _____________________”.
3. Whenever appropriate, state, in comment, how the marrow compares to the immediate previous
one and give the previous marrow number; e.g., “compared to the patient’s previous marrow
(PHB11-XXXX), blasts are not increased.”
4. Whenever any ancillary studies or special stains are reported, be sure to include an interpretation
and not just a statement of the result. On cases without histologic material, be sure to dictate an
interpretation including a summary of the results, which will be typed in the space where diagnosis
usually goes.
For example, if an addendum is issued with the results of a reticulin stain, do not include just,
“The reticulin stain shows a marked increase in reticulin fibers”, also an interpretation
(i.e. “This strongly supports the diagnosis in this case of a myeloproliferative
neoplasm”).
5. Abnormal plasma cell proliferations should be given as specific a diagnosis as possible.

A. Plasma cell myeloma (use if possible).
B. Plasma cell neoplasm (if definite neoplasm, but uncertain if myeloma).
C. Plasmacytosis (with qualifier if the diagnosis of a neoplasm cannot be made).
D. Plasmacytoma (a non-myeloma plasma cell neoplasm).
E. Remember, plasma cell dyscrasia includes non-neoplastic disorders as well as plasma cell
neoplasms.

Case number:___________________________
Resident Bone Marrow Differential count Worksheet
(_______ cells counted)
Blasts
Promyelocytes
Myelocytes
Metamyelocytes
Bands/Seg Neutrophils
Erythroid cells
Lymphocytes
Eosinophils
Basophils
Monocytes
Plasma cells
Myeloid:erythroid ratio
Signature____________________________________________________
Date: ___________________________
Pathologist initials ____________

Protocol for the Examination of Specimens From Patients With
Hematopoietic Neoplasms Involving the Bone Marrow
Based on AJCC/UICC TNM, 7 th Edition
Protocol web posting date: June 2012
Procedures
Bone marrow aspiration
Bone marrow core (trephine) biopsy
Authors
Jerry W. Hussong, MD, DDS, FCAP*
Cedars-Sinai Medical Center, Los Angeles, California
Daniel A. Arber, MD
Stanford University School of Medicine, Stanford, California
Kyle T. Bradley MD, MS, FCAP
Emory University Hospital, Atlanta, Georgia
Michael S. Brown, MD, FCAP
Yellowstone Pathology Institute Inc, Billings, Montana
Chung-Che Chang, MD, PhD, FCAP
The Methodist Hospital, Houston, Texas
Monica E. de Baca, MD, FCAP
Physicians Laboratory Ltd, Sioux Falls, South Dakota
David W. Ellis, MBBS, FRCPA
Flinders Medical Centre, Bedford Park, South Australia
Kathryn Foucar, MD, FCAP
University of New Mexico, Albuquerque, New Mexico
Eric D. Hsi, MD, FCAP
Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
National Cancer Institute, Bethesda, Maryland
Michael Lill, MB, BS, FRACP, FRCPA
Cedars-Sinai Medical Center, Los Angeles, California
Stephen P. McClure, MD
Presbyterian Pathology Group, Charlotte, North Carolina
L. Jeffrey Medeiros, MD, FCAP
MD Anderson Cancer Center, Houston, Texas
Sherrie L. Perkins, MD, PhD, FCAP
University of Utah Health Sciences Center, Salt Lake City, Utah
For the Members of the Cancer Committee, College of American Pathologists
* Denotes the primary and senior author. All other contributing authors are listed alphabetically.

Surgical Pathology Cancer Case Summary
Protocol web posting date: June 2012
BONE MARROW: Aspiration, Core (Trephine) Biopsy
Select a single response unless otherwise indicated.
Specimen (select all that apply) (Note A)
___ Peripheral blood smear
___ Bone marrow aspiration
___ Bone marrow aspirate clot (cell block)
___ Bone marrow core (trephine) biopsy
___ Bone marrow core touch preparation (imprint)
___ Other (specify): ___________________________
___ Not specified
Procedure (select all that apply)
___ Aspiration
___ Biopsy
___ Other (specify): ___________________________
___ Not specified
Aspiration Site (if performed) (select all that apply) (Note B)
___ Right posterior iliac crest
___ Left posterior iliac crest
___ Sternum
___ Other (specify): ___________________________
___ Not specified
Biopsy Site (if performed) (select all that apply) (Note B)
___ Right posterior iliac crest
___ Left posterior iliac crest
___ Other (specify): ___________________________
___ Not specified
Histologic Type (Note C)
Note: The following is a partial list of the 2008 World Health Organization (WHO) classification 1 and includes those neoplasms
seen in bone marrow specimens.
___ Histologic type cannot be assessed
Myeloproliferative Neoplasms
___ Chronic myelogenous leukemia, BCR-ABL1 positive

___ Chronic neutrophilia leukemia
___ Polycythemia vera
___ Primary myelofibrosis
___ Essential thrombocythemia
___ Chronic eosinophilic leukemia, not otherwise specified (NOS)
___ Mastocytosis (specify type): ______________________
___ Myeloproliferative neoplasm, unclassifiable
Myeloid and Lymphoid Neoplasms With Eosinophilia and Abnormalities of PDGFRA, PDGFRB and FGFR1
___ Myeloid or lymphoid neoplasm with PDGFRA rearrangement
___ Myeloid neoplasm with PDGFRB rearrangement
___ Myeloid or lymphoid neoplasm with FGFR1 abnormalities
Myelodysplastic/Myeloproliferative Neoplasms
___ Chronic myelomonocytic leukemia
___ Atypical chronic myeloid leukemia BCR-ABL1 negative
___ Juvenile myelomonocytic leukemia
___ Myelodysplastic/myeloproliferative neoplasm, unclassifiable
___ Refractory anemia with ring sideroblasts associated with marked thrombocytosis
Myelodysplastic Syndromes
___ Refractory anemia
___ Refractory neutropenia
___ Refractory thrombocytopenia
___ Refractory anemia with ring sideroblasts
___ Refractory cytopenia with multilineage dysplasia
___ Refractory anemia with excess blasts
___ Myelodysplastic syndrome associated with isolated del(5q)
___ Myelodysplastic syndrome, unclassifiable
___ Refractory cytopenia of childhood
Acute Myeloid Leukemia (AML) With Recurrent Genetic Abnormalities
___ AML with t(8;21)(q22;q22); RUNX1-RUNX1T1
___ AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11
___ Acute promyelocytic leukemia with t(15;17)(q22;q12); PML-RARA
___ AML with t(9;11)(p22;q23); MLLT3-MLL
___ AML with t(6;9)(p23;q34); DEK-NUP214
___ AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
___ AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1
___ AML with mutated NPM1
___ AML with mutated CEBPA
Acute Myeloid Leukemia With Myelodysplasia-Related Changes (select all that apply)
___ Multilineage dysplasia
___ Prior myelodysplastic syndrome
___ Myelodysplasia-related cytogenetic abnormalities
Therapy-Related Myeloid Neoplasms
___ Therapy-related AML
___ Therapy-related myelodysplastic syndrome
___ Therapy-related myelodysplastic/myeloproliferative neoplasm
Acute Myeloid Leukemia, NOS
___ AML with minimal differentiation
___ AML without maturation
___ AML with maturation

___ Acute myelomonocytic leukemia
___ Acute monoblastic/monocytic leukemia
___ Acute erythroid leukemia
___ Acute megakaryocytic leukemia
___ Acute basophilic leukemia
___ Acute panmyelosis with myelofibrosis
___ AML, NOS #
Myeloid Proliferations Related to Down Syndrome
___ Transient abnormal myelopoiesis
___ Myeloid leukemia associated with Down syndrome
Acute Leukemias of Ambiguous Lineage
___ Acute undifferentiated leukemia
___ Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1
___ Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged
___ Mixed phenotype acute leukemia, B/myeloid, NOS
___ Mixed phenotype acute leukemia, T/myeloid, NOS
___ Mixed phenotype acute leukemia, NOS, rare types (specify type): _____________
___ Natural killer (NK) cell lymphoblastic leukemia/lymphoma
Other Myeloid Leukemias
___ Blastic plasmacytoid dendritic cell neoplasm
Precursor Lymphoid Neoplasms
___ B lymphoblastic leukemia/lymphoma, NOS #
___ B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1
___ B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged
___ B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)
___ B lymphoblastic leukemia/lymphoma with hyperdiploidy
___ B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid ALL)
___ B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH
___ B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
___ T lymphoblastic leukemia/lymphoma
Mature B-Cell Neoplasms
___ Chronic lymphocytic leukemia/small lymphocytic lymphoma
___ B-cell prolymphocytic leukemia
___ Splenic B-cell marginal zone lymphoma
___ Hairy cell leukemia
___ Splenic B-cell lymphoma/leukemia, unclassifiable
___ Splenic diffuse red pulp small B-cell lymphoma
___ Hairy cell leukemia-variant
___ Lymphoplasmacytic lymphoma
___ Plasma cell myeloma
___ Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
___ Follicular lymphoma
___ Mantle cell lymphoma
___ Diffuse large B-cell lymphoma (DLBCL), NOS
___ T cell/histiocyte-rich large B-cell lymphoma
___ Primary cutaneous DLBCL, leg type

___ Epstein-Barr virus (EBV)-positive DLBCL of the elderly
___ DLBCL associated with chronic inflammation
___ Lymphomatoid granulomatosis
___ Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma
___ Plasmablastic lymphoma
___ Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
___ Burkitt lymphoma
___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
and Burkitt lymphoma
___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
and classical Hodgkin lymphoma
___ B-cell lymphoma, NOS
___ Other (specify): ____________________________
Mature T- and NK-cell Neoplasms
___ T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
___ T-cell prolymphocytic leukemia
___ T-cell large granular lymphocytic leukemia
___ Chronic lymphoproliferative disorder of NK cells
___ Aggressive NK-cell leukemia
___ Adult T-cell leukemia/lymphoma
___ Extranodal NK/T-cell lymphoma, nasal type
___ Enteropathy-associated T-cell lymphoma
___ Hepatosplenic T-cell lymphoma
___ Mycosis fungoides
___ Peripheral T-cell lymphoma, NOS
___ Angioimmunoblastic T-cell lymphoma
___ Anaplastic large cell lymphoma, ALK-positive
___ Anaplastic large cell lymphoma, ALK-negative
Hodgkin Lymphoma
___ Nodular lymphocyte predominant Hodgkin lymphoma
___ Classical Hodgkin lymphoma
Histiocytic and Dendritic Cell Neoplasms
___ Histiocytic sarcoma
___ Langerhans cell histiocytosis
___ Langerhans cell sarcoma
___ Interdigitating dendritic cell sarcoma
___ Follicular dendritic cell sarcoma
___ Disseminated juvenile xanthogranuloma
___ Histiocytic neoplasm, NOS
Posttransplant Lymphoproliferative Disorders (PTLD) ##
Early lesions:
___ Plasmacytic hyperplasia
___ Infectious mononucleosis-like PTLD
___ Polymorphic PTLD
___ Monomorphic PTLD (B- and T/NK-cell types)
Specify subtype: ________________________

___ Classical Hodgkin lymphoma type PTLD ###
___ Other (specify): ____________________________
Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.
# An initial diagnosis of “AML, NOS” or “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic
results are available or for cases that do not meet criteria for other leukemia subtypes.
## These disorders are listed for completeness, but not all of them represent frank lymphomas.
### Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of American
Pathologists protocol for Hodgkin lymphoma. 2
+ Additional Pathologic Findings
+ Specify: _______________________________________
+ Cytochemical/Special Stains (Note D)
+ ___ Performed
+ Specify stains and results: __________________________________
______________________________________________________
+ ___ Not performed
Immunophenotyping (flow cytometry and/or immunohistochemistry) (Note E)
___ Performed, see separate report: ___________________
___ Performed
Specify method(s) and results: ______________________________
_____________________________________________________
___ Not performed
Cytogenetic Studies (Note F)
___ Performed, see separate report: ___________________
___ Performed
Specify method(s) and results: ______________________________
_____________________________________________________
___ Not performed
+ Fluorescence In Situ Hybridization (Note F)
+ ___ Performed, see separate report: ___________________
+ ___ Performed
+ Specify method(s) and results: ______________________________
_____________________________________________________
+ ___ Not performed

+ Molecular Genetic Studies (Note F)
+ ___ Performed, see separate report: ___________________
+ ___ Performed
Specify method(s) and results: ______________________________
_____________________________________________________
+ ___ Not performed
+ Comment(s)
+ Data elements preceded by this symbol are not required. However, these elements may be
clinically important but are not yet validated or regularly used in patient management.

Explanatory Notes
A. Specimen
Complete evaluation of hematopoietic disorders involving the bone marrow requires integration
of multiple pieces of data, including the clinical history, pertinent laboratory studies (eg,
complete blood count [CBC], serum lactate dehydrogenase [LDH], and beta-2-microglobulin
levels, serum protein electrophoresis, and immunofixation results), and a satisfactory peripheral
blood smear and bone marrow specimen. In most instances, this requires receiving a
peripheral blood smear, bone marrow aspirate specimen, an aspirate clot section (cell block),
and a bone marrow core biopsy. 3 Touch preparations (imprints) of the biopsy specimen are
also very helpful. The World Health Organization (WHO) classification recommends performing
a 200-cell differential count on peripheral blood smears and a 500-cell differential count on bone
marrow aspirate specimens in the evaluation of hematopoietic disorders. 1 This will allow
adequate evaluation of the cellular elements within the peripheral blood and bone marrow.
In addition, submission of bone marrow (usually aspirate) material for flow cytometry
immunophenotyping, cytogenetic studies, fluorescence in situ hybridization (FISH), and
molecular studies is often necessary. The guidelines that follow are suggested for handling of
bone marrow specimens:
The number of stained and unstained peripheral blood, bone marrow aspirate, and bone
marrow core biopsy touch preparation smears should be recorded.
The length of the bone marrow core biopsy(s) should be recorded.
For conventional cytogenetic studies, a bone marrow aspirate specimen received in a
sodium heparin tube is ideal, but fresh specimens submitted in saline or RPMI transport
medium is sufficient.
For immunophenotyping by flow cytometry, a bone marrow aspirate specimen received in an
ACD tube (yellow top tube) or EDTA tube (lavender top tube) is preferred.
Bone marrow core biopsy specimens require decalcification, and care must be taken not to
under- or over-decalcify the specimen, as it will impact the ability to cut and interpret the
histologic sections and may interfere with immunohistochemical staining. Formic acid
decalcification procedures can also degrade DNA, whereas EDTA decalcification may allow
for preservation of DNA for polymerase chain reaction (PCR) studies. EDTA decalcification,
however, is slower than acid decalcification techniques.
Fixation:
o
o
o
Zinc formalin or B5 fixatives produce superior cytologic detail but are not suitable for
DNA extraction and impair some immunostains (eg, CD30). B5 has the additional
limitation of requiring proper hazardous-materials disposal.
Formalin fixation is preferable in many situations, as it allows for many ancillary tests
such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.
Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or
B5) should be avoided for optimal immunophenotypic reactivity.
Care must be taken to ensure that high-quality specimens and sections are obtained for each
bone marrow specimen. Often this requires working hand-in-hand with clinical colleagues to
achieve this goal. In addition to being used for the diagnosis of primary hematopoietic
disorders, bone marrow examination is often utilized as part of the pathologic staging of many
hematopoietic neoplasms, including Hodgkin and non-Hodgkin lymphomas. 3-5 Bone marrow
involvement identified within staging biopsy specimens typically indicates stage IV disease
within the Ann Arbor staging system utilized by the American Joint Committee on Cancer
(AJCC) 6 and the International Union Against Cancer (UICC). 7 For multiple myeloma, the Durie-

Salmon staging system is recommended by the AJCC. 8 Both staging systems are shown
below. In pediatric patients, the St. Jude staging system is commonly used. 9
AJCC/UICC Staging for Non-Hodgkin Lymphomas
Stage I
Stage II
Stage III
Stage IV
Involvement of a single lymph node region (I), or localized involvement of a
single extralymphatic organ or site in the absence of any lymph node
involvement (IE). # , ##
Involvement of 2 or more lymph node regions on the same side of the diaphragm
(II), or localized involvement of a single extralymphatic organ or site in
association with regional lymph node involvement with or without involvement of
other lymph node regions on the same side of the diaphragm (IIE). ## , ###
Involvement of lymph node regions on both sides of the diaphragm (III), which
also may be accompanied by extralymphatic extension in association with
adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or
both (IIIE+S). ## , ### ,^
Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or
without associated lymph node involvement; or isolated extralymphatic organ
involvement in the absence of adjacent regional lymph node involvement, but in
conjunction with disease in distant site(s). Stage IV includes any involvement of
the liver, bone marrow, or nodular involvement of the lung(s) or cerebral spinal
fluid. ## , ### ,^
# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage
IV.
## For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.
### The number of lymph node regions involved may be indicated by a subscript: eg, II 3 . For
stages II to IV, involvement of more than 2 sites is an unfavorable prognostic factor.
^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.
Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence
classification of stage.
AJCC/UICC Staging for Plasma Cell Myeloma
Stage I
Hemoglobin greater than 10.0 g/dL (100 g/L)
Serum calcium 12 mg/dL or less (3.0 mmol/L)
Normal bone x-rays or a solitary bone lesion
IgG less than 5 g/dL (50 g/L)
IgA less than 3 g/dL (30 g/L)
Urine M-protein less than 4 g/24 hours
Test US SI
Hgb >10.0g/dL >100 g/L
Serium calcium 12 mg/dL or less 3.0 mmol/L or less
IgG < 5g/dL

Hemoglobin less than 8.5 g/dL (85 g/L)
Serum calcium greater than 12 mg/dL (3.0 mmol/L)
Advanced lytic bone lesions
IgG greater than 7 g/dL (70 g/L)
IgA greater than 5 g/dL (50 g/L)
Urine M-protein greater than 12 g/24 hours
Test US SI
Hemoglobin 3.0 mmol/L
IgG >7g/dL >70 g/L
IgA >5 g/dL >50 g/L
Stage II
Disease fitting neither stage I nor stage III
Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL (177 mmol/L),
or (B) serum creatinine 2.0 mg/dL (177 mmol/L) or greater. The median survival for stage IA
disease is about 5 years, and that for stage IIIB disease is 15 months. These predicted
survivals, however, may underestimate expected survival for these patient populations with
modern therapy.
B. Aspiration/Biopsy Site
Bone marrow sampling (aspiration and trephine core biopsy) is usually performed at the
posterior iliac crest. 3 Aspirations and biopsies may be unilateral or bilateral, depending on the
indication for the bone marrow biopsy as well as clinician preference. Rarely, a sternal
aspiration may be performed if only a bone marrow aspirate specimen is necessary. Sternal
aspirations should only be considered as a last resort and should be performed only by persons
with extensive experience with this procedure. Occasionally, the anterior iliac crest or tibia may
be the site of the biopsy, depending on patient age and other unique characteristics of the
patient.
C. Histologic Type
This protocol recommends assigning histologic type based on the WHO classification of
lymphoid neoplasms. 1 Originally published in 2001 and revised and updated in 2008, this
classification incorporates the morphologic, immunophenotypic, cytogenetic, and molecular
findings into the final diagnosis. Whereas histologic examination remains of paramount
importance, many neoplasms will require the use of these ancillary studies to arrive at the
correct diagnosis. 10-15 It may not be possible to provide a specific lymphoma diagnosis with
bone marrow examination, particularly for patients in whom the bone marrow is the first
identified site of involvement. Some of the entities provided in the case summary may be
extremely uncommon in the bone marrow or may have not been described but are listed for
completeness.
D. Cytochemical/Special Stains
Numerous cytochemical or special stains may be utilized in the diagnosis of hematopoietic
neoplasms involving the bone marrow. 3 An iron (Prussian blue) stain is paramount in the
evaluation of myelodysplastic syndromes and some myeloproliferative disorders. A reticulin
stain is necessary for the diagnosis of some myeloproliferative disorders but may be valuable in
evaluation of numerous other disorders such as hairy cell leukemia. Cytochemical stain for

myeloperoxidase is rapid, convenient, and helpful for the assessment of myeloid neoplasms.
Cytochemical stains for leukocyte alkaline phosphatase, and naphthol-ASD chloroacetate
esterase provide information related to cell origin or specific disease states. Cytochemical
stains, however, are no longer required for the diagnosis of most disorders.
E. Immunophenotyping by Flow Cytometry and/or
Immunohistochemistry
Immunophenotyping of bone marrow specimens can be performed by flow cytometry 10 or
immunohistochemistry. 11 Each has advantages and disadvantages. Flow cytometry is rapid
(hours), quantitative, and allows multiple antigens to be evaluated on the same cell
simultaneously. Flow cytometry may also allow for the detection of minimal residual disease,
especially in situations in which there is a unique expression pattern. Antigen reactivity,
however, cannot be correlated with architecture or cytologic features. In patients from whom a
dry tap is obtained, an additional bone marrow core biopsy submitted fresh in transport medium
can be disaggregated and utilized for flow cytometry immunophenotyping.
Immunohistochemistry requires hours/days to perform, quantitation is subjective, but importantly
it allows correlation of antigen expression with architecture and cytology. Not all antibodies are
available for immunohistochemistry, particularly in fixed tissues, but one of its advantages is that
it can be performed on archival tissue. Both techniques can provide diagnostic, prognostic, and
therapeutic information. Documentation of expression of antigens such as CD20, CD33, and
CD52 by the neoplastic population can aid the clinician in selection of potential therapeutic
options such as monoclonal antibody therapy. The specific immunophenotypes for individual
hematopoietic disorders involving the bone marrow are readily available within the WHO
Classification of Tumours of Haematopoietic and Lymphoid Tissues as well as many other
hematopathology textbooks. 1,3,5
F. Cytogenetic and Molecular Genetic Studies
Within the WHO classification of hematopoietic disorders, significant emphasis has been placed
on cytogenetic and molecular genetic studies. More than ever before, specific cytogenetic
findings are helpful for the diagnosis of specific neoplasms and disease states. 12-16 In fact,
many acute leukemias are currently defined based upon their specific cytogenetic
abnormalities. 1 Given the importance now placed upon knowing the cytogenetic or molecular
results (as determined by karyotyping, FISH, or PCR results) it is of paramount importance that
care is taken to evaluate the need for these studies at the time of biopsy. FISH studies can be
also performed on air-dried unfixed slides, and in some cases DNA can be scraped off air-dried
unfixed slides for molecular studies. Since karyotyping requires growing viable cells in culture, it
is necessary to submit fresh specimens promptly to help ensure the best opportunity for a
successful study.
References
1. Swerdlow S, Campo E, Harris N, Jaffe E, et al, eds. WHO Classification of Tumours of
Haematopoietic and Lymphoid Tissues. Geneva, Switzerland: WHO Press; 2008.
2. Hussong JW, Arber DA, Bradley KT, et al. Protocol for the examination of specimens
from patients with Hodgkin lymphoma. In: Reporting on Cancer Specimens: Case
Summaries and Background Documentation. Northfield, IL: College of American
Pathologists; 2009.
3. Foucar K, ed. Bone Marrow Pathology. Chicago, IL: ASCP Press; 2001.
4. Zhang Q, Foucar K. Bone marrow involvement by Hodgkin and non-Hodgkin
lymphomas. Hematol Oncol Clin North Am. 2009;23(4):873-902.
5. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone
Elsevier; 2007.

6. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC
Cancer Staging Manual. 7 th ed. New York, NY: Springer; 2009.
7. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant
Tumours. 7th ed. New York, NY: Wiley-Liss; 2009.
8. Durie B, Salmon S. A clinical staging system for multiple myeloma: correlation of
measured myeloma mass with presenting clinical features, response to treatment, and
survival. Cancer. 1975;36(3):842-854.
9. Cairo et al. Non-Hodgkin’s lymphoma in children. In: Kufe P, Weishelbuam R, et al, eds.
Cancer Medicine. 7 th ed. London: BC Decker; 2006:1962-1975.
10. Craig F, Foon K. Flow cytometric immunophenotyping for hematologic neoplasms.
Blood. 2008;111(8):3941-3967.
11. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid
neoplasms: a report from the Association of Directors of Anatomic and Surgical
Pathology. Mod Pathol. 2004;17(1):131-135.
12. Bagg A. Molecular diagnosis in lymphomas. Curr Oncol Rep. 2004;6(5):369-379.
13. Merker J, Arber D. Molecular diagnostics of non-Hodgkin lymphoma. Expert Opin Med
Diagn. 2007;1(1):47-63.
14. Bagg A. Role of molecular studies in the classification of lymphoma. Expert Rev Mol
Diagn. 2004;4(1):83-97.
15. Sen F, Vega F, Medeiros LJ. Molecular genetic methods in the diagnosis of hematologic
neoplasms. Semin Diagn Pathol. 2002;19(2):72-93.
16. Weinberg O, Seetharam M, et al. Clinical characterization of acute myeloid leukemia
with myelodysplastic-related changes as defined by the 2008 WHO classification
system. Blood. 2009;113(9):1906-1908.

Bone Marrow Laboratory
Test Specifications

TEST SPECIFICATIONS: BONE MARROW LABORATORY
Bone Marrow Aspirate Smears, Bone Marrow Particle Preparation, and
Bone Marrow Biopsy
DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY
CLB
Room 9032
3477 Euler Way
Pittsburgh, PA 15213
Phone: 412-864-6173
Fax: 412-864-6102
BONE MARROW LABORATORY HOURS OF OPERATION
Monday through Friday: 8:00am to 5:00pm. The bone marrow specimens can be sent anytime. However
they will be processed the following working day if received after hours of operation. The laboratory is
also closed on the following holidays: New Years Day, Martin Luther King Day, Memorial Day, July 4 th ,
Labor Day, Thanksgiving Day, and Christmas Day.
SPECIAL INSTRUCTIONS
Send a completed requisition.
Call the Clinical Flow Cytometry Laboratory (412-864-6173) first before sending, to make prior
arrangements about where to deliver.
In packaging bone marrows, please:
1. Tightly close the biopsy container. Keep container upright.
2. MARK THE DATE AND TIME THE BIOPSY WAS PLACED IN THE B-PLUS FIXATIVE – on the
container.
3. Package slides separately from the biopsy specimen (to avoid vapor fixation of the slides).
Use adequate safety measures when transporting specimens.
BONE MARROW EXAMINATION TEST DESCRIPTIONS
Bone marrow examinations may include aspiration with smears, particle preparations or clot sections and
biopsies. Aspirate smears are most useful to examine the cytological detail of the marrow elements and
for cytochemical and immunocytochemical stains. The aspirated material may also be used for culture,
flow cytometric immunophenotyping, cytogenetic, molecular, and other special studies.
The particle preparation represents non-decalcified tissue sections of filtered bone marrow aspirate
spicules. This allows for histopathologic analysis of a large volume of marrow with excellent morphology
and an intact architecture so features such as cellularity can be easily assessed. It is suitable for a wide
range of special stains including immunohistologic stains.
Bone marrow core biopsies are decalcified, sectioned, and routinely stained with H&E and PAS stains.
Biopsy specimens are used to evaluate cellularity, hematopoiesis, non-aspirable lesions to see the
topographical relationship of focal lesions to the bony trabeculae, and for evaluation of bone and vessels.
BONE MARROW ASPIRATE SMEAR SPECIMEN REQUIREMENTS
10-20 bone marrow slides should be made at the bedside from the first syringe pulled. Label each
slide with name, date, and time of collection. The number of slides sent will vary depending on the
tests requested. Send the slides in either durable cardboard slide holders or plastic slide holders
accompanied by a requisition.
If bilateral (right and left hips) bone marrows are done, then label slides left or right hip.
Send the slides in either durable cardboard slide holders or plastic slide holders. The number of
slides sent will vary depending on the test requested.
For a basic bone marrow aspirate interpretation based on Wright-Giemsa stains, send two labeled
slides plus a recent CBC/differential result and the corresponding peripheral blood smear.

If cytochemical or iron stains are requested, the following is a list of the minimum required number of
unstained slides that should be sent. Send one additional slide for a Wright-Giemsa stain in all cases.
In addition, extra unstained slides are useful if any stains need to be repeated.
1 SLIDE:
Iron Stain
Naphthyl AS-D Chloroacetate esterase stain (CAE)
Myeloperoxidase cytochemical stain (MPO)
Sudan Black Stain
Periodic Acid Schiff Stain (PAS)
2 SLIDES:
Non-specific Alpha Naphthol Acetate Esterase Stain (NSE)
Double Esterase Stain (NSE+CAE)
If there are any questions regarding cytochemical stains call the Special Testing Laboratory at
(412) 864-6179.
BONE MARROW PARTICLE PREPARATION SPECIMEN REQUIREMENTS
Five milliliters of bone marrow aspirate (preferably from the first or second syringe), placed in a yellow
top (ACD) Vacutainer tube.
Store at room temperature.
The material for the particle preparation will be filtered, fixed, and processed by the bone marrow and
histology laboratories, at UPMC Oakland.
In addition submit two aspirate smears, the most recent CBC/differential and corresponding
peripheral blood smear.
BONE MARROW BIOPSY SPECIMEN REQUIREMENTS
4-6 touch preparations of the biopsy specimen (3 imprints on each slide) made at the bedside. Label
each slide with patient's name, date, and time of collection.
Place the biopsy into B-Plus fixative. MARK THE TIME AND DATE THE BIOPSY WAS PLACED IN
THE B-PLUS FIXATIVE ON THE CONTAINER. The B-Plus fixed biopsy should be delivered to the
laboratory the same day it is done. Prolonged fixation in B-Plus Fixative makes the biopsy difficult to
process.
If performing bilateral (right and left hips) biopsies, each biopsy must be placed in SEPARATE B-Plus
fixative containers and labeled left or right hip.
In addition submit two aspirate smears, the most recent CBC/differential and corresponding
peripheral blood smear.
WARNING: B-Plus fixative contains formaldehyde. Formaldehyde is a carcinogen, irritant, and
highly toxic. Avoid contact with eyes, skin, and clothing. Do not inhale.
CONTACTS, DIVISION OF HEMATOPATHOLOGY
Steven Swerdlow, M.D. Director, Division of Hematopathology (412) 647-5191
Miroslav Djokic, M.D. Director, Adult Bone Marrow Service (412) 692-2128
Celina Fortunato Lead technologist, Bone Marrow Lab (412) 647-0263
Rev 4/13

Summary of Test Specifications for ancillary laboratories (principally for
marrows)
*Flow cytometry (see also detailed test specifications)
-Bone marrow aspirate (2-4 ml) is placed into a heparinized Vacutainer.
Cytogenetics (chromosome analysis)
-Bone marrow aspirate (1 ml) is placed into thawed cytogenetics media. A
heparinized (green top) Vacutainer can be used if there is no media available.
*Gene rearrangement (molecular oncology)
-Bone marrow aspirate (2.5 ml) is placed into an EDTA Vacutainer.
*Cultures
-For bacterial cultures fill 3 small isolator tubes (3-cc total) with bone marrow
aspirate.
-For viral cultures place 1-2 ml of bone marrow aspirate into a heparinized
Vacutainer. (Excluding Parvovirus)
*Parvovirus by PCR
-Place bone marrow aspirate (2.5 ml) into an EDTA Vacutainer.
-This test is sent to Magee Hospital.
*CMV by PCR
-Place bone marrow aspirates (1-5 ml) into ACD Vacutainer.
-Test is performed in virology lab.

Bone Marrow After-Hours
Procedures

AFTER-HOURS PROCEDURES (CHILDREN’S & ADULT BONE MARROWS)
1. The Bone marrow technologist is available Monday through Friday between the hours of
8:00 AM and 4:00 PM. (exclusive of weekends and all UPMC holidays). At all other
times (except on the night shift), a technologist from the Automated Testing Lab (ATL)
will be available to assist with the bone marrow procedure. For assistance at UPMC
Presbyterian, call (412) 647-6199. For assistance at UPMC Shadyside, call (412) 623-
6011. For assistance at UPMC CHP Lawrenceville, call (412) 864-9877.
2. Procedures to follow at UPMC- PUH are located in the Adult Bone Marrow Procedure
Manual (room G325.1) and in the Bone Marrow Procedure Manual of the Hematology
Procedure Manual (Automated Testing Lab).
3. For those weekend bone marrows requiring immediate attention (e.g. acute leukemia)
performed at UPMC-Presbyterian or CHP, the ATL technologist will triage the sample
for ancillary tests, perform a quick stain of the aspirate smears and notify the ‘on call’
Clinical Pathology (CP) resident and hematopathologist.
4. Bone marrow specimen processing:
Aspirate smears (ADULTS):
Emergent cases: Two aspirate smears are stained in the Automated Testing
Laboratory and placed in a folder with requisitions, current peripheral blood slide and
current CBC and differential, for pathologist to review. After pathologist review, place
all material in the G325.1 Bone Marrow Reading room.
Non-emergent cases: Aspirate smears are left in the Automated Testing
Laboratory and sent to the Bone marrow processing area in 9032 CLB the following
working day.
Aspirate smears (CHP):
The CHP hematology technologist is available Monday through Sunday between the
hours of 7 a.m. and 8 p.m. (inclusive all UPMC holidays). CALL 412-864-9877
The technologist will assist with the smears, triage the sample for ancillary tests,
perform a quick stain, and notify the “on call” pathology resident and
hematopathologist.
CHP Aspirate smears on Saturday, Sunday, holidays, and in emergency
situations:
Two aspirate smears are stained at CHP laboratory. One is placed in a folder in the
CHP Heme lab for the Heme/Onc clinician to review. The second BM aspirate, a
current stained peripheral blood slide, current CBC results and a copy of the
Hematopathology requisition are sent to the PUH ATL laboratory 5 th floor CLB, room
5011 to the attention of the lead technologist. The CP resident on call and
hematopathologist should be paged and notified of the case by the CHP
technologist. The PUH Heme lead technologists will be notified by telephone. The
PUH lead technologist will page the pathologist and chief pathology resident when
the specimen arrives. The rest of the bone marrow aspirate smears should be
placed in the plastic containers (after drying) and together with the biopsy sent to the
Flow Cytometry lab, CLB 9032.

Bone Marrow biopsy on cases from UPMC-Presbyterian /Shadyside, UPMC
CHP or outside:
Monday – Thursday evenings: All CHP biopsies designated for hematopathology, all
PUH and SHY adult biopsies are left in the Hematology labs of respective hospitals.
Monday - Friday evenings all outside bone marrow cases are delivered to the Flow
Cytometry area (9032 CLB).
Friday evening after 5:30 pm – Monday morning: the biopsy is kept with the rest of
the case the specimen processing room, CLB 9032. This procedure is also followed
if Monday is a holiday.
Emergent bone marrow biopsies on weekends and holidays:
After the Hematopathologist’s approval, the resident on call will make the biopsy
Same Day Rush Priority. The resident will pick up the bone marrow biopsy from
9032 CLB processing area, indicate this on top of the requisition that is left with the
rest of the specimen in CLB, take biopsy to the Gross room for PA to accession and
gross in. The gross room PA is only available on Saturdays from 8AM-2PM. (For
accessioning and grossing directions of bone marrows see AP procedure manual
located in the PUH Gross Room on 6A or Special Hematology Processing Manual
located in 9032 CLB). Resident on call will contact Histotechnologist on call (pager
12239) about the bone marrow biopsy and take the specimen to the Histology lab.
Histotechnologist will process the specimen on the overnight processor so the
specimen will be ready the next working day.
5. Flow Cytometry:
If specimens cannot be delivered by 5:30 PM Monday through Thursday, leave the
specimen at room temperature at the PUH or CHP Hematology lab. It will be sent to
the Flow Cytometry lab the next working day.
If specimens cannot be delivered by 5:30 PM on Friday, or if there is a specimen
obtained before noon on Saturday, call the Flow Cytometry lab between 8 AM and 1
PM on Saturday at 412-864-6173 to inform them that a specimen is being sent to the
Flow Cytometry lab. Leave an Audix message if the Flow lab is closed.
Specimens from Saturday afternoon, Sunday, Thanksgiving, Christmas and other
holidays after 1 PM, should be held at room temperature and then sent to the Flow
Cytometry lab the following normal working day.
Any holiday that falls on Monday: flow technologist is on call (pager 412-565-9563)
between 9-1 PM for the hematopathologist on call.
Any holiday that falls on a weekday: flow lab is usually closed. However, flow lab is
never closed 2 days in a row. Check with attending if a major holiday is on weekend.
In an emergency on all other Monday holidays before 1:00 PM, clinicians are to
page the clinical pathology resident on-call who will then contact the
hematopathologist on call.

6. Cytogenetics:
Monday through Thursday, specimens that cannot be received by the Cytogenetics
lab before 5:30 PM should be left at room temperature overnight. Specimens are
sent to the Cytogenetics lab the next day.
For specimens obtained Fridays that cannot be received by the Cytogenetics lab by
5:30 PM, leave the specimen at room temperature in the Cytogenetics bin in the
PUH-ATL specimen processing area or CHP-Hematology area for pick up on
Saturday.
Saturday/Sunday/Holiday specimens: Be sure that the specimen gets to the PUH-
ATL specimen processor. The CHP specimen will be delivered to the Cytogenetics
lab directly from CHP hematology. The PUH-ATL specimen processor or CHP
technologists will contact the Cytogenetics lab by page at (412) 917-9458.
Cytogenetic lab personnel arrange for the courier pick up of these specimens.
Alternatively, call (412) 641-6688 and follow Audix instructions.
7. Molecular Diagnostic studies:
Specimens should get to the lab by 4 PM if at all possible. If other arrangements
need to be made or any questions answered, the attending on-call will be available
at pager (412) 433-9591. They may be able to have someone come in on Saturday.
Specimens that have to be held over the weekend or holidays are held as follows:
o DNA testing: Keep the samples at room
temperature.
o RNA testing: Refrigerate the samples at 4 o C.
o DNA and RNA testing: Refrigerate the samples at 4 o C.
o Tissue samples: Freeze the samples at -20 o C.
8. The Flow Cytometry Lab, processing room 9032 CLB is the central receiving area for
bone marrow specimens received from UPMC and non-UPMC affiliated hospitals. The
lab is open from 8:00 AM to 6:00 PM, Monday through Friday and from 8:00 AM to 4:30
PM Saturday. During these hours the flow technologists/processors are responsible for
triaging the specimens they receive (except as noted in numbers 3 and 4). If they
receive a marrow requiring emergency review after 5 p.m. or on the weekend, they will
forward the appropriate material to the ATL lab to the attention of the hematology lead
technologist who will follow the after hour procedures detailed in 4. Any cases that
require triaging or review outside of these hours should be sent to the UPMC-
Presbyterian ATL lab to the attention of the hematology lead technologist.
If a routine bone marrow specimen is delivered to the PUH Gross Room, hold specimen
to the next working day and either send to station #390 or via Medspeed to room 9032
CLB.
Revised 10/2013

Lymph Node
Experience

Lymph Node Pathology Experience (~4 weeks)
Lymph Node Sign Out
A. “On call” for processing of fresh lymph node biopsies.
NOTE: One of the lymph node assistants are available to help gross from 9-5:30/6 pm. The lymph node
assistant pager number is 412-958-7432. They will independently gross most specimens but may require help
either over the telephone with images that can be seen using our gross imaging “telepathology” or you may
need to help them in person in the CLB (Room 9032). If you get called during these hours, be sure to page the
lymph node assistant if they are not already in or on their way to the grossing area in the flow cytometry
laboratory (CLB 9032). After 5:30pm, the Hematopathology fellow or resident on an extended day shift (see
Hematopathology Schedule) can help. On occasion, one of the lymph node assistant should be able to gross
in lymph nodes or help out until 6:00 pm.
Become familiar with detailed lymph node protocol, spleen protocol and consult procedures.
B. Sign out of both fresh and consult lymph nodes and related material with staff. Be sure to meet
with hematopathologist on lymph node service to review organizational aspects of this rotation.
Become familiar with role of the lymph node assistant, use of hematopathology case worksheet,
established procedure for organization of sign-out materials and guidelines for dictating reports.
C. Review of educational materials.
• Checkpath (images, histories and explanations of faculty CME program for Hematopathology)
(PUH G315 and in Dr. Swerdlow’s coordinator’s office).
• Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office).
• Lymph node chapter in Sternberg.
• Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.
(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours,
IARC, Lyon, 2008.
• Ioachim, HL Medeiros, LJ. Ioachim’s Lymph Node Pathology, 4 th edition, 2009.
• Jaffe ES, Harris NL, Vardiman J, Campo E, and Arber D. Hematopathology, 2010
• Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major Problems in
Pathology”), Saunders, 2003.
• Web-based resources.
D. Review results of ancillary studies procedures performed on lymph nodes you have reviewed
and read addenda that faculty issue.

APPENDIX I -SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL
Subject: The protocol is for lymph node or extranodal biopsies with suspected hematopoietic or lymphoid
disorders.
1.0 Principle
Diagnostic lymph node biopsies and other biopsies with suspected lymphoproliferative disorders should be
handled in a standard fashion to optimize histiologic sections and make appropriate ancillary studies
available.
2.0 Specimen
2.1 Criteria:
All tissues where lymphoma is suspected or documented in the patient history as well as all lymph node
biopsies in which the only specimen submitted for study is the nodal tissue, and if performed, a frozen
section has excluded metastatic carcinoma. Cases where post-transplant lymphoproliferative disorders are
suspected are not included unless requested by the Division of Transplant Pathology. Lymph node
excisions performed solely as non-lymphoma staging procedures are not included unless gross, touch
imprint or frozen section studies suggest a hematopoietic/lymphoid neoplasm. The protocol should be
performed under the supervision of a hematopathologist or designate if at all possible.
Emergent lymph nodes on weekends and holidays:
The AP resident should be paged who will determine the most appropriate resident on call to handle the
specimen. After hematopathologist’s approval, the resident on call will make the LN specimen Same Day
Rush Priority. The on-call resident will contact the histotechnologist on call (pager 12239) and take the LN
specimen to the Histology lab located in the CLB room 3018. The Histotechnologist on call will place the
LN specimen on the overnight processor so the specimen will be ready the next working day.
2.2 Fixation:
Fresh or saline moistened tissue. RPMI essential media is used to transport tissue. Formalin or any other
chemically fixed tissue cannot be processed using this protocol and will be handled according to general
cutting manual techniques. Specimens received in formalin in which lymphoma is suspected should have
at least one section post-fixed in B+ fixative.
2.3 Sample size:
Any size tissue can be processed.
3.0 Reagents, Supplies and Equipment
3.1 Reagents:
B+ Fixative
100% formalin
10% formalin
OCT

(Warning: Formalin is a suspected carcinogen. HANDLE WITH CAUTION. DO NOT INHALE. See
MSDS Binder.)
(Warning: B+ fixative contains zinc chloride and formaldehyde. HANDLE WITH CAUTION. DO NOT
INHALE. See MSDS Binder.)
3.2 Supplies:
Lymph Node Gross Dictation Sheet (Appendix E)
Log for freezer (Appendix C)
Liquid nitrogen
Cytocentrifuge cardboard
Slides (Regular and “+” slides)
RPMI essential media
Beam capsules
Marking pens
Tissue processing cassettes
Personal protective supplies
Gloves
Apron
Shield
Plastic freezer box to hold Beam Capsules
Saline solution for Molecular studies
Specimen bags
Sterile containers
Forms for Molecular Diagnostics (Appendix J)
Forms for Cytogenetics Lab (Appendix K)
3.3 Equipment:
Liquid Nitrogen tank
-80° degree freezer
Scalpel
Forceps
4.0 Calibration and Standardization
Not Applicable
5.0 Quality Control
5.1 All problems noted with specimen processing will be entered under the "Adverse Event" section for
each case in CoPath. (See Appendix G.)
6.0 Procedure
6.1 If a frozen section is requested, call the responsible surgical pathologist and resident. The first part of
the gross description should be filled in on the template. The specimen should be kept as intact as

possible and cut as illustrated and described in sections 6.7-6.10. If the frozen section shows
metastatic carcinoma, the case will be handled as per routine, in the surgical pathology division. If
metastatic carcinoma is not identified, continue with protocol. The cassette designation for the
resubmitted frozen section should be filled in on the gross description template—(FS).
NOTE : ALL HEMEPATH SPECIMENS ARE GROSSED IN THE FLOW CYTOMETRY LABORATORY –
CLB Room 9032
6.2 Place tissue in gauze soaked in RPMI in a sealed container labeled with patient name and surgical
number.
6.3 Page the hematopathology LN assistant first. If LN assistant does not answer, page the
hematopathology fellow or resident on call for lymph nodes (See schedule). If any problem, call the
Hematopathology Division Coordinator at 647-5191 and have her contact the Hematopathology resident or
fellow on call. If Coordinator does not answer, call the Hematopathology secretary 412-647-0382 with the
same instructions. If the LN assistant and trainee on call or on the LN service cannot be found, page the
faculty on the LN service or if necessary the faculty on call.
If no one answers, contact any of the hematopathology fellows or any other hematopathology faculty.
6.4 Specimens that arrive in the evening will be handled by the hematopathology fellow or resident on an
extended day shift who will follow this protocol as best they can. Material may be held in RPMI for flow
cytometry but this should only be done if there is enough tissue for 2 good histologic sections plus
enough for 3 snap frozen pieces. No material will go directly to the molecular laboratory. If the
following day is a workday and you are unfamiliar with this protocol, place the entire specimen in RPMI,
place in the refrigerator and notify hematopathology the following morning (See 6.3).
Emergent lymph nodes on weekends and holidays: After hematopathologist’s approval, the resident
on call, assigned by the Chief resident, will make the LN specimen Same Day Rush Priority . The
resident will contact the histotechnologist on call (pager 12239) and take the LN specimen to the
Histology lab; CLB-2 nd Floor. The Histotechnologist on call will place the LN specimen on the overnight
processor so the specimen will be ready the next working day.
6.5 Inform the lymph node service assistant or resident, fellow or, if necessary, the hematopathologist on
lymph node service that tissue has arrived in the Flow Cytometry Laboratory CLB Room 9032.
6.6 Observe tissue grossly and write down brief gross description on template. (Appendix D) Describe
size, color, and consistency.
6.7 Cut lymph node perpendicular to the long axis. Keep tissue moist at all times:
* *

6.8 Cut a small paper thin slice, place on a cytocentrifuge preparation cardboard and make 2 fixed imprints
(done on regular slides) which can be stained immediately with H&E and 3-5 air dried imprints (done on “+”
slides) to be saved at the LN grossing station until the case is completed (for additional special studies, if
appropriate). Unused slides are filed in the slide file drawers. The code TP documents the test.
6.8.1 Look at the touch imprint to make a preliminary assessment of the lymph node. If
performing flow cytometric studies, check if any special studies should be performed (e.g., if the
cells appear blastic, an acute leukemia panel should be run) and about the size of the cells that
are of interest (small, large, mixed) and inform the flow technologist. If no one is present in the
flow lab write the request on the requisition and place it together with the specimen in the
refrigerator located at the flow lab CLB 9 th floor- Room 9032 (See 6.3).
6.9 The central portion of the lymph node should be cut into 2-3 mm slices and if >2 cm in maximum
dimension, hemisected (sometimes it is easier to initially cut 5-6 mm slices and after brief fixation to slice in
half). Include the node capsule in the sections. Be sure to include any focal lesions. No pieces should be
larger than 1.5 x 2 cm.
6.9.1 Fix at least one section in 10% neutral buffered formalin. If tissue is very limited, formalin
fixation takes precedence over B+ fixation.
6.9.2 Each cassette has a unique designation (ACMB/DNA, BB+, C, etc). Be sure to use the
appropriate cassettes. PH White Rule out lymphoma cassettes will be labeled using the
cassette engraver with the surgical pathology number and a unique block designation
[A(CMB/DNA) OR AFS (for frozen section), BB+, C, etc.] by selecting PH White (R/O
Lymphoma). For needle core biopsies or tiny pieces of tissue, specimens should be marked
with eosin and wrapped in filter paper and put into mesh cassettes. Note in your gross
description if you feel the tissue may not survive processing.
6.10 Use end positions (*) for the following (unless focal lesions are present only in
this area or only in the midportion).
6.10.1 Culture, if appropriate, and if the surgeon has failed to do cultures (unless sterile, only
AFB and fungal cultures are generally meaningful).
6.10.2 Cell suspension immunophenotypic studies (flow lab 624-3746). Keep ½ to 1 cm 3 fresh
and moist for this. Place in container with 50 ml RPMI media. Label and place in a biohazard
bag with a copy of the requisition with flow panel decided.
6.10.3 Snap freeze tissue 3+ blocks (approximately 7x4x3 mm) in cryovial capsules (2 without
OCT and 1 with OCT) labeled with the surgical pathology number in the liquid nitrogen tank in
flow lab. If a surgical pathology number is unavailable at the time, print the patient’s full name
and date on the tube. Snap capsules onto cryocane, dip into liquid nitrogen tank for a least 60
seconds. These are to be placed in the –80 o C freezer (place in current capsule box) located in

the CLB room 9032 lymph node grossing area in the designated box and logged in on the log
sheet located on the freezer.
6.10.4 Submit a 7x7x5-mm piece to the Clinical Molecular Diagnostics Laboratory for possible
molecular diagnostic studies. Place tissue in a container with saline labeled with surgical
number and place in a self-sealing biohazard bag. Submit an adjacent piece for routine
processing labeled CMB/DNA to document the nature of piece sent for molecular studies.
Place a copy of the requisition and a filled out Molecular Diagnostics form in the side pouch of
the bag. Place a Molecular Diagnostics sticker on specimen bag. During working hours
(Monday-Friday 7am-3: 45pm) tube to station #370. After hours place in lymph node fridge next
to grossing bench.
6.10.4.1 After hours place specimen in the lymph node refrigerator next to the grossing station on
side door and send it the following day.
6.10.6 If there is a high suspicion of lymphoma and enough tissue after all of the above portions
are taken, place a 7x7x5 mm (or larger) fresh STERILE piece of tissue in RPMI to send to the
Cytogenetic Laboratory for chromosome (karyotype) analysis. Place a Cytogenetics sticker on
specimen bag.
6.10.6.1 The specimen can be tubed to station #417 (Magee
Womens Automated Testing Laboratory) at any time Monday-
Saturday (up until 1:00pm)
6.10.6.2 After 1:00pm on Saturday, place specimen in the lymph node refrigerator
next to the grossing station for it to be tubed to station #417 the following
Monday by the LN assistant.
6.11 Note:
6.11.1 A well-fixed section is the highest priority although almost no node is too small to preclude snap
freezing one piece.
6.11.2 Lymph nodes received in formalin can still be post-fixed in B+
6.12 Once the protocol is completed, the fixed portions are submitted to histology and the completed
gross description template dictated.
6.13 Summary of Lymph Node Protocol
6.13.1 Touch Imprints
6.13.1.1 Quick fix in alcohol and stain with H&E for immediate review
6.13.1.2 Air dry, place in box next to the grossing station.

6.13.2 Fresh tissue for special labs
6.13.2.1 Fresh piece in RPMI for flow lab (give to the flow tech)
6.13.2.2 Fresh piece in saline for molecular diagnostics (See 6.13.4.4)
6.13.2.3 Fresh piece in RPMI for Cytogenetics
6.13.2.4 Fresh piece to Microbiology if required.
6.13.3 Snap freeze 2 pieces of fresh tissue in beem capsules and 1 piece in Beem capsule in
OCT and store in box in -80 freezer located in the LN grossing area. See protocol for details.
6.13.4 Fixed tissue sections
6.13.4.1 If frozen section was performed, submit FS piece in cassette A in
formalin.
6.13.4.2 Cut thin and fix ≥ 1 sections in cassette BB+ after B+ fixative. Put time on
jar.
6.13.4.3 Submit one section of tissue in cassette ACMB/DNA fixed in
formalin that is adjacent to the molecular diagnostics piece.
6.13.4.4 Submit the remainder of tissue in cassettes C, D, E, etc.
6.13.4.5 Use White colored cassettes to be engraved by selecting PH White (Rule out
lymphoma) under ‘Block Detail’ in the Histology section.
6.13.5 Comments
6.13.5.1 If during normal working hours the lymph node assistant/
hematopathology fellow/resident (staff) should be called to perform this protocol.
6.13.5.2 If very little tissue is present, good histologic sections and one snap frozen piece are
generally the highest priorities.
6.13.5.3 A gross dictation template should be used.

6.13.6 Diagram of Summary
B+ and formalin fixed sections
Snap freeze 3-5 pieces
Molecular Lab with
adjacent piece submitted
in fixative “CMB/DNA
If required
--Culture
Cytogenetics
Flow Laboratory
7.0 Calculations
Not Applicable
Touch Preps
Fix and stain
Air dried & Save
8.0 Reporting Results / Normal Values
Not Applicable
9.0 Periodic Maintenance
Not Applicable
10.0 Procedural and QA Notes
Not Applicable
11.0 Limitations
Not Applicable
12.0 References
Banks, PM Technical Aspects of Specimen Preparation and Introduction to Special Studies. In: Jaffe, ES
Surgical Pathology of the Lymph Nodes and Related Organs. pages 1-22, 1995, W.B. Saunders,
Philadelphia.
Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major Problems in Pathology”),
Saunders, 2003.
Revised 7/2004 LF
Revised 1/2010
Revised 3/2010 CF
Revised 10/2013 LF

How to handle very small specimens being submitted for histology*
1. Specimens should be marked with eosin and wrapped in filter paper and put into mesh
cassettes. Note in your gross description if you feel the tissue may not survive processing.
2. The histology lab will contact the responsible house-staff officer and faculty member
immediately if there is a failure to identify tissue in a cassette.
RECUTS OF SMALL PIECES OF TISSUE
Suggestions from Dr. Yousem when you are asking for recuts of very small pieces of tissue. It would be very
worthwhile to alert Histology that the fragments of tissue are small and care must be taken. Instructions in the
stain comment fields are helpful.
1. Tell the lab to "take sections right off the top", "do not face the block"- this alerts them not to aggressively
"face" the block
2. Tell the lab to take "serial sections"-- this way they do not lose sections between the ones obtained for your
stain requests
3. Ask for unstained slides in addition to the required ones-- this allows you to have extras should the stain
not work or tissue fall off the slide
4. If it is a very tough case, ask that an experienced technician handle the case- make this request in the
comment or call the lab
5. Cell blocks in cytology should always contain this type of request, in my opinion.
Pictorial Version of Lymph Node Protocol
(Double click on the link below for the PowerPoint Presentation)
Z:\Linda Koerbel\Fellow LN grossing presentation\Grossing Fresh Lymph
Nodes - LF SHS revision 12 09 updated 02-16-2012.ppt

Submitting Histology After Grossing
When we receive fresh tissue (in saline or RPMI): Submit the cassettes in formalin
filled container appropriately labeled “HISTOLOGY LAB” and they can either be tubed
to station #320 (Histology lab) or if after hours leave on LN grossing bench to be sent
the following day.
NOTE- PLEASE USE YOUR JUDGEMENT

Surgical Pathology Manual: Spleen Protocol
PROCEDURE:
1. Measure the spleen in three dimensions and weigh.
2. Section the spleen transversely at .5 to 1.0-cm intervals. *Photograph any lacerations and/or
surgical tears before transverse sectioning. To take a picture with Nikon digital grossing camera, make
sure all power is turned on as follows: turn on power switch on box next to the PC, turn on power button on
box at camera, and turn on power switches for both lights. ’Place specimen on camera base on table. In
Copath under PHS case no. using Accession Entry Edit or Image entry edit, click on Image gallery,
then click “Import from TWAIN”, and then click on “C” to capture the image.
3. The lymph node protocol for handling lymphomas should be followed in cases of suspected
lymphoma (staging, etc.) and other hematopoietic disorders.
4. Any hilar nodes or accessory spleen should be submitted separately.
5. Photograph one section of spleen.
DESCRIPTION:
1. Weight and dimensions.
2. Hilum: nature of vessels, presence of lymph nodes or accessory spleen.
3. Capsule: color, thickness, focal changes, adhesions, lacerations (location, length and depth).
4. Cut surfaces: color, consistency, malpighian corpuscles (size, color conspicuous), fibrous
trabeculae, nodules or masses, diffuse infiltration, red or white pulp disease.
SECTIONS:
1. If no gross abnormality is seen, and the spleen is taken out as an incidental splenectomy, submit
two to three random sections.
2. If the spleen is grossly lacerated, submit two to three random sections including the area of
laceration.
3. If it is a leukemia or lymphoma case, submit a minimum of five sections (B+ and formalin fixed),
including any distinct nodules. Several nodules should be submitted in cases of focal disease. At
least one section should include the capsule. Sections should be thin and no larger than 1.5 x 2.0
cm.
ANCILLARY STUDIES:
1. Make certain that if a hematopoietic/lymphoid neoplasm is suspected, tissue is processed for all the
potential ancillary studies described for lymph node biopsies.
Revised 10/2013

LYMPH NODE GROSS DICTATION –TEMPLATE
Dictation phone # 802-6706 Work type #9004 For multiple parts use other side>>>
CASE# PHS___: __________________
Protocol to order in
NAME: ______________________________
histology- ‘Rolym’ (select
MEDICAL RECORD #___________________
the ‘load’ box then ‘run
protocol’ button)
PLEASE DICTATE CLINICAL HISTORY AS STATED ON REQUISITION
The specimen is received [fresh in RPMI or formalin] labeled with the patient’s name, initials ___, MRN,
and [specimen site] ”___________________” It consists
of______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Air dried touch preparations are performed, material is snap frozen (__ blocks), and sent for cell
suspension immunophenotypic studies (flow cytometry). A portion is sent to the molecular
diagnostics laboratory with an adjacent section submitted in cassette A (CMB/DNA). Additional
material is sent for cytogenetic studies. The [remainder or representative sections] of the [site
location] is (are) submitted in cassettes BB+ after B+ fixation and in blocks C - ______ after formalin
fixation.
Note: Do not use the B+ fixation if you only are submitting one block, formalin only.
(NOTE: IF a frozen section was submitted by another bench, submit in cassette AFS.) Make sure you
order ‘FRZ1’ in Stain Process for every frozen section block submitted
Write on sides of blocks: B+ fix on B+ fixed blocks
Checklist for specimens: *Make sure all containers, slides, and frozen capsules
are labeled with the case # and patient’s name*
__Touch preps ---2 stained (H&E) on regular
slides to evaluate what type of flow panel to
order
__3 air dried slides on PLUS charge slides
for possible Cytogenetic FISH studies
___ Cassettes are ordered under ‘Block
Detail’ , then select PH White (R/O
Lymphoma) under engraver type
__Put the Date and Time on the formalin
and B+ fixative container
__Snap frozen- 2 capsules without OCT
compound (only if enough tissue available) ,
then 1 capsule with OCT
__Flow cytometry- container with RPMI
(found in refrigerator) w/ copy of requistion
NOTE- On call fellows/ residents: please put
flow specimen on top shelf of flow fridge
(located centrally in lab next to biochemical
hood) and put requisition with flow decision
on staining bench.
_Molecular Diagnostics- container with
Saline (found at grossing bench) fill out MDX
form and tube to station # 370 Hours Mon-
Fri 7am-345pm. After hours, put in LN fridge
to be sent following day.
__Cytogenetics- container with RPMI, fill out
form---- tube to station #417 anytime (but
after 1p Saturday-put in LN fridge).

Policy for solid tissue specimens sent to rule out lymphoma that overlaps with other Centers
of Excellence
In certain circumstances, specimens that fall into a non-Hematopathology Center of Excellence will either be
designated “rule out lymphoma” by the surgeon or have a potential lymphoma discovered either when a frozen
section is performed or when a fresh specimen is examined grossly. For example, a salivary gland may be
removed and a frozen section of a mass demonstrate a dense lymphoid proliferation without evidence of a
carcinoma.
If an intraoperative consultation is requested, the specimen should be handled by the surgical pathology
resident/fellow/pathologist on call at the hospital where the specimen has been removed.
In all cases, following completion of any required intraoperative consultation, both the
resident/fellow/pathologist on service for the Center of Excellence and the Hematopathology “lymph node”
resident/fellow/pathologist should be notified that the specimen is in the gross room. A joint decision
should be made at that time by both parties as to whom the primary pathologist should be based on factors
such as the likelihood of other pathology being present or any concern that a hematopathology protocol
would compromise any aspect of the pathologic examination.
In cases where the Center of Excellence is not located at UPMC-Presbyterian Hospital, the decision as to
whether the specimen should be handled in whole or in part by the Division of Hematopathology should be
made at the originating hospital. This should either be done by members of the Center of Excellence (for
example, if there is a GU specimen at UPMC-Shadyside) or after telephone agreement with the
appropriate AP-related COE pathologist. This will eliminate the possibility of specimens being sent first to
one hospital and then another. The resident/fellow/faculty on lymph node service should be consulted if
questions occur.
The Hematopathology “lymph node” resident/fellow/pathologist will be prepared to accept the responsibility for
processing the entire specimen, for taking a portion of the specimen for a hematopathology workup with
the remainder of the specimen grossed in by an anatomic pathology bench or functioning solely as a
consultant if special procedures are deemed unnecessary (for example, if suspicion for a lymphoma is low
and the tissue sample is very limited).
In cases where the initial triaging to either Hematopathology or one of the AP benches seems inappropriate
after sections are reviewed or ancillary studies become available, if agreeable to all parties, the primary
pathologist will be switched to the pathologist on the more appropriate service. This may involve a Center
of Excellence pathologist signing out a case not accessioned at their Center of Excellence, and ordering
stains that need to be sent by inter-hospital courier.
This model should be applied to all other Centers of Excellence where faculty, fellows or residents should act
to facilitate processing.

Instructions for Fresh Tissue Biopsies Received from Outside Institutions
[Revised 10/2013]
Sometimes tissue specimens from outside institutions are sent to our Flow Cytometry Laboratory for cell
suspension immunophenotypic studies or complete workup. In these cases, as long as sufficient tissue is
available, we try to do a complete lymph node protocol on them, except that tissue is not sent to the
molecular diagnostics or cytogenetics laboratory (except for cases from UPMC-Shadyside, Magee Women’s
or other complete case workups that also get material sent for DNA extraction and, if appropriate, for
cytogenetic studies). One must remember that if the tissue has been sent here for flow cytometric studies,
sufficient tissue must be retained specifically for making a cell suspension. If the tissue submitted is very
small, at a minimum, a touch imprint should be performed, and if possible, a small portion snap frozen. On
cytologic specimens, if material has been retained at the referring institution, do NOT do touch preps unless
there is a lot of material (several good cores) and send the entire specimen to the flow cytometry laboratory.
Run the lymphoma protocol in CoPath but be sure to delete all the items that do not apply. You don’t need a
CMB/DNA block unless molecular is sent. If there are any questions on a given case, please contact the
pathologist covering lymph node biopsies.
Cases from CHP where we are not the primary pathologists traditionally are not sectioned (CHP sections are
reviewed prior to sign-out). Cases from other divisions for flow cytometry may have a section taken if there
is sufficient tissue and if acceptable to the division (to better know what we are actually doing the flow
cytometry on).
All fresh tissue cases from UPMC-Shadyside will arrive in the Flow Cytometry lab and accessioned as UPMC-
Presbyterian cases. All other cases from UPMC hospitals (and rare non-UPMC hospitals) should be
accessioned as UP consults UNLESS we have the entire specimen (with or without a frozen section). If we
have the entire specimen it should be accessioned as a UPMC- Presbyterian case.

Fresh Case Lymph Nodes and Other Solid Tissues Sent to UPMC-Presbyterian for Flow Cytometric
Studies with a non-hematopathology Primary Pathologist [Revised 10/2013]
All non-PB, non-BM, non-fluid outside cases sent to the Division of Hematopathology for flow cytometry, that
are accessioned with a number that is solely being handled by the Division of Hematopathology, need not only
to have the flow cytometry signed out, but a complete report in the usual format. That report should include the
following components:
A History which is amplified from information that is entered when the case is accessioned and should
at least include the information on the requisition. It should also state: “Case received for flow
cytometric consultation.”
A Diagnosis - The diagnosis in cases that do not have a definitive malignant diagnosis can be "Flow
cytometric immunophenotypic studies are non-diagnostic (see comment)”. Other cases may get a
somewhat more definitive diagnosis, but, unless there is an actual disagreement, the diagnosis should
be consistent with what the primary pathologist is calling the case. Hence, the original pathologist on
almost all of these cases should be called. The diagnosis rendered can be a bit more vague than
usual, for example, a follicular lymphoma may be diagnosed without giving the grade.
A Comment - A comment that reiterates the diagnosis and states that the results must be correlated
with the material processed at the institution of origin should be included. It may refer to the
morphologic findings in the tissue processed or in the cytospin.
A Microscopic Description - The description can be of the morphologic findings in the tissue that is
processed or based on the cytospin, if there is nothing else. Or it can state that nothing was
processed for morphological studies.
A Billing code – If only H & E’s and flow are done, BC06. If additional workup or complete consultation
is performed after discussion with the referring pathologist, BC03, BC04, or BC5 (See “Copath and
dictation pointers” .for complete list of billing codes (BC))
In addition, it must be ascertained whether or not the primary pathologist is sending more material on the case
BEFORE the rest of the report is signed out. In general, some institutions do and some do not typically send
additional material. This should be indicated on the requisition but it is not always clear and not always
consistent.
On these "BC06" cases (BC14 for the VA), permission must be obtained to order immunostains, FISH,
molecular diagnostics, etc. If a full consult is requested on the requisition, IHC may be ordered. The primary
pathologist should be asked about doing FISH studies and molecular diagnostics, although if the case is from a
UPMC institution it should be acceptable. If a case is not from a UPMC institution, it is critical to obtain
permission to order anything other than the H&Es.
If you do IHC and flow was done, be sure to put in one of the Flow/IHC comments.
These cases also should have a synoptic if they are lymphomas.

Helpful Hints for Handling Consult Blocks
Ordering H&E slides on Consult Cases
With consult cases you must order the H&E as a recut (RHHE) because the only requests that come on
the Histology Special Request Log are special stains, Ipex, Hblanks, Iblanks and recuts. The slides
that come with the consult case are the original H&E. We cut from the blocks that are sent, therefore it
is a true recut.
When consult blocks are sent for special stains/immunos enter them in Client Server as follows:
-Under Stain/Process Edit/Entry:
-Select the Part that corresponds to Consult Block/s NOT Consult Slide/s
-Select Add Block and enter the block designation as the A, B, C – under block detail go the other
block number and put outside case #.
-Hint #1: An initial H&E is ordered automatically; however, it does not end up on the HISTO
worklog for some reason, so will never ever get it. You must re-order it as a recut (RHHE) to
actually get a slide.
-Hint #2: When you Add Stain/Process to a designated block, be careful to select the correct
block when ordering stains.
-Sometimes you get blank slides instead of a block; check to see what Part they are accessioned and enter a
designation just like a block, as above.
Sending Outside Blocks to Histology
All outside blocks are to be sent in yellow envelopes to Histology via the tube station # 320 with the PUH case
number, patient’s name, Pathologist’s name, and Resident’s or Fellow’s name written with a sharpie pen on
the envelope.

RULES FOR HISTOLOGY
All exceptions must be approved by
Dr. Yousem & Dr. Dhir
WHEN ACCESSIONING:
Pathology staff must be entered in the following order; Pathologist. (P) Fellow or Chief Resident. (R) If there is
no Fellow or Chief Resident on the case enter “none”. If there is no resident, this field can be left blank.
Initial H&E slides will be delivered to the listed pathologist in “reverse rank” order: 1) Resident, 2) Fellow/Chief,
3) Faculty.
New Bench Designations and Color Scheme; Please make sure the proper color cassette is used for
appropriate handling of specimen.
Hemepath – WHITE R/O Lymphoma
Rush Biopsies (PUH/SYS) - PEACH
Rush Neuropath (PUH) - GRAY
Cytology (PUH/SYS) - GREEN
ENT Routine (PUH) - PINK
GI Routine (PUH) - YELLOW
Muscle/Nerve Routine (PUH) - ORANGE
Neuropath Routine (PUH) - BLUE
Thoracic Routine (PUH) - TAN
Transplant Routine (PUH) - PURPLE
Autopsy (PUH) - WHITE
Autopsy Neuropath (PUH) - WHITE
Derm Rush (SYS) - GRAY
GU (SYS) - WHITE
Prostate Routine (SYS) - PINK
Skins Rush (SYS) - BLUE
Bone/Soft Tissue (SYS) - GREEN
STAT cut off times: The cut off time for receiving stats in the histology lab is 11: 00AM. No exceptions, unless
approved by Dr. Yousem and Dr. Dhir.
When accessioning Children’s Hospital bone marrows; they must be accessioned under pediatric bone
marrows, or they will be sent to the Hemepath lab, along with the other bone marrows. There will be no
exceptions.

WHEN ORDERING:
RE-CUTS – Must be ordered under RHHE, and the correct number in the count field. If levels are needed, this
must be entered in the stain comment field when ordering the re-cuts. The cut off time for ordering re-cuts is
1:00PM to be delivered same day by the 5:30 pm courier run. Anything after 1:00PM that day will be cut and
sent the following morning by the 8:30 am courier run. There will be no exceptions unless approved by Dr.
Yousem & Dr. Dhir.
SPECIAL STAINS – Must be ordered with the correct special stain code so there is no delay. Please
remember and take into consideration that some special stains take 2 or 3 DAYS to complete. The cut off time
for ordering Histo stains is 10:00AM and will be delivered on the 2:30PM courier run that day. Anything
ordered after 10:00AM will be stained the following day and delivered on the 8:30 AM courier run the following
day. The only special stains performed on weekends are the Stat Grocott, AFB, and Gram. There will be no
exceptions unless approved by Dr. Yousem or Dr. Dhir.
IMMUNOPEROXIDASE ANTIBODIES – Must be ordered with the correct antibody code so there is no delay.
Most Immunoperoxidase antibodies done in the clinical lab have the prefix A; please make sure the correct
antibody is ordered. Stains ordered before 10:00AM should come out the same day. Stains ordered after
10:00AM should come out by the 8:30am courier the following day.
When ordering special stains, immunos, etc. on blocks that are at Shadyside, order under Shadyside and
put a comment in the stain comment field saying where you want the slides sent.
REPROCESSING TISSUE:
Histology technicians are no longer permitted to decide if a tissue needs reprocessing. The
pathologist reading the case can only make that decision. Histology must send out a suboptimal slide,
which will be highlighted in green. The pathologist needs to determine if the tissue needs
reprocessing. The pathologist must call Histology and give permission to reprocess. A better H&E
will be sent the following morning.
ORDERING BLANKS FOR INSITU:
If the blanks are ordered before 11:00 AM will be sent to ISH on the 11:30AM courier run. Anything ordered
after 11:00AM will be delivered to the ISH lab on the 9:30AM courier run.
WHEN HISTOLOGY SENDS OUT SLIDES:
All lymph node and all bone marrow slides will be sent to the Hemepath lab.
All Transplant H&E slides will be sent to the case pathologist.
All Neuropath H&E slides, including autopsies, will be sent to the case pathologist.
All Transplant TB slides ordered will go to the case pathologist. All non-transplant TB slides will go to the
resident on the case entered in the comment field.
All EM kidney biopsy slides will be sent to the case pathologist.
E slides will go to Cytology. All recuts, special stains, and immunoperoxidase stains will be sent to the hospital
as specified in the stain comment field when ordered.
All dental slides will go to the Dental department.

All recuts, special stains, and immunoperoxidase stains will be sent to the doctor ordering them. The doctors
must enter in the stain comment field when ordering, the hospital where that doctor will be located to receive
their slides.
Comments override everything: All slides will be sent to the doctor and hospital specified in the stain comment
field.
For all blocks that need corrections, the appropriate department or person will be notified and they must come to the
Histology lab and make the corrections. Histology will no longer be responsible for making changes to the
cassettes. In addition, a specimen misidentification form must be filled out in histology.
Revised 10/2013

FONT TYPE AND SIZE:
All reports are typed in Arial font, size 9.
GENERAL FORMATTING REQUIREMENTS
GROSS DESCRIPTION
The gross description is typed in sentence style, beginning at the left margin, in paragraph format.
The patient’s initials are typed in all CAPS (i.e. The specimen is received in formalin labeled with the
patient’s name and initials, MSP.)
The label of the specimen is typed within quotation marks (i.e. The specimen is labeled “right upper
lobe lung” and consists….).
When multiple specimen parts are received a new paragraph is started for each part. (i.e. Part 1, Part
2, etc.), using Arabic numerals.
When multiple specimen parts are received each part’s gross description must include the patient's
initials. (i.e. Part 1 is received labeled with the patient’s name and initials, MSP….. Part 2 is received
labeled with the patient’s name and initials, MSP.)
For gross specimens with a cassette listing, a period follows the last submitted description only (see
example below).
EXAMPLE: Gross description for a one-part specimen
Gross Description
The specimen is received in formalin labeled with the patient’s name, initials MSP and “rectal biopsy”. The specimen consists of an unoriented,
irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled A.
VGD/vat
EXAMPLE: Gross description for multiple-part specimens
Gross Description
The specimen is received in formalin in two parts.
Part 1 is labeled with the patient's name, initials MSP and “rectal biopsy”. It consists of an unoriented, irregular, soft, tan, tissue
fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled 1A.
Part 2 is labeled with the patient's name, initials MSP and “antrum”. It consists of an unoriented, irregular, soft, tan, tissue fragment
measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled 2A.
VGD/vat
EXAMPLE: Gross description with cassette listing
Note: When a specimen part is submitted in several blocks, these are indicated by a cassette listing at the end of the gross
description for that part. It is typed flush with the left margin (in the following order: part number, letter designation, a space, a dash, a
space, description of tissue in block). A period follows the last submitted description only. The cassette listing is formatted as follows:
The specimen is submitted as follows:
1A – right upper lobe lung
1B – nodule 20 cm from resection margin
1C – stapled resection margin
1D – lung parenchyma
1E – remainder of tissue
Gross Description
The specimen is received in buffered formalin labeled with the patient’s name, initials MSP and “skin biopsy”. The specimen consists of
an un-oriented, irregular soft tan tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The following sections are submitted:
1A – tips
1B – ends
VGD/vat
EXAMPLE: Gross description for bone marrow biopsy
Gross Description
Received are an aspirate (part 1), biopsy, flow cytometry, cytogenetics and VNTR.
Part 2, bone marrow biopsy, is received in B5 fixative, labeled with the patient's name (MSP) and site. It consists of a single core of tan,
cancellous bone measuring 0.8 x 0.2 cm. The specimen is totally submitted to histology for decalcification in block A.
VGD/vat

EXAMPLE: Consult material description (congross or cons) (may include a gross description)
Consult Material Description
Received for consultation from John Doe, M.D., are eleven (11) consult slides and nine (9) consult slides labeled S05-192; one (1)
consult slide labeled S05-3303 and one (1) consult slide labeled S05-6039 from Memorial Hospital, Pathology Department, 9888
Generic Avenue, Big City, PA 12345, along with an accompanying letter, surgical and cytopathology reports.
VGD/vat
EXAMPLE: Bone marrow biopsy clinical history (preop)
Clinical History
The patient is a 36-year-old male with a history of acute myelogenous leukemia, diagnosed in 04/2003 (PHB03-123456). A bone
marrow performed on 02/200 (PHB05-111111) demonstrated 10% blasts. He is currently day 33 status post allogeneic peripheral
blood stem cell transplant. The bone marrow is for evaluation of engraftment. Medications: Cycloporin, Diflucan, Acyclovir, Synthroid,
Protonix and Magnesium.
VGD/vat
EXAMPLE: Consultation case, one accession number (y and preop)
Clinical History
The patient is a 70-year-old male.
OSS S05-192, 1/7/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS: None given.
POST-OP DIAGNOSIS: None given.
PROCEDURE:
Fine Needle Aspiration right neck.
VGD/vat
EXAMPLE: Consultation case, multiple accession numbers (y and preop)
Clinical History
The patient is a 70-year-old male.
OSS-S05-3303, 04/14/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS: Left vocal cord lesion.
POST-OP DIAGNOSIS: None given.
PROCEDURE:
Left vocal cord stripping.
OSS-05-6039, 07/07/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS: None given.
POST-OP DIAGNOSIS: None given.
PROCEDURE:
Left vocal cord biopsy.
VGD/vat
EXAMPLE: All other surgical clinical histories (preop)
Clinical History
Abdominal pain.
PRE-OP DIAGNOSIS: Abdominal pain.
POST-OP DIAGNOSIS: Same.
PROCEDURE:
Rectal biopsy.
VGD/vat
GROSS ONLY SPECIMEN REPORTS
The clinical history and gross description are typed as described above in the gross description
explanation.
In the microscopic description field type: “No sections are submitted” or “None”.
In the final diagnosis field type (in all CAPS): The specimen line, return and type the dictated final
diagnosis followed by the phrase, “gross diagnosis only; see comment” within parenthesis in lower case
letters (see example below).
In the diagnosis comment field type the quick text code, gross and click on the running man icon to
insert the standard quick text template regarding gross only specimens and further testing. Go to the
pound (#) sign using the keystroke combination [ALT+F] and type in the specimen designation.
INTRAOPERATIVE CONSULTATION
The intraoperative consultation text field is typed in ALL CAPS (similar to the final diagnosis section).
The only exceptions are: 1) the type of intraoperative consultation is typed in parentheses in
lowercase letters (for example: frozen section, gross diagnosis/examination only, touch prep) and 2)
the names of intraoperative staff member(s) performing the intraoperative consultation are entered

within parentheses at the end of the last line of the intraoperative consultation before the period (first
initial of first name in caps and full last name with initial caps and lowercase letters - in the following
order: staff pathologist/fellow/resident/PA including the title, M.D. when applicable) (see examples
below).
EXAMPLE: Single-part intraoperative consultation
Intraoperative Consultation
FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
EXAMPLE: Intraoperative consultation with single-line diagnosis
Intraoperative Consultation
FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
A. BENIGN (T. Pathologist, M.D).
EXAMPLE: Intraoperative consultation with multiple diagnoses
Intraoperative Consultation
FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
A. BENIGN.
B. NO TUMOR SEEN (T. Pathologist, M.D. /C. Resident, M.D./A. Pa).
VGD/vat
EXAMPLE: Intraoperative consultation for multiple parts with multiple diagnoses
Intraoperative Consultation
1AFS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
A. MALIGNANT.
B. SMALL CELL CARCINOMA (T. Pathologist, M.D).
2ATP: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (touch prep) –
A. MALIGNANT (T. Pathologist, M.D.).
3AGD: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (gross diagnosis) –
A. BENIGN (T. Pathologist, M.D.).
VGD/vat
EXAMPLE: Intraoperative consultation for one part with multiple frozen sections/touch preps performed on different blocks
Intraoperative Consultation
1AFS: SUPRAGLOTTIC MASS, LEFT, LATERAL, MEDIAL AND DEEP MARGINS (frozen section) –
A. MALIGNANT.
B. SQUAMOUS CELL CARCINOMA.
C. TUMOR PRESENT AT LATERAL MARGIN. MEDIAL AND DEEP MARGINS FREE OF TUMOR (T. Pathologist, M.D./C.
Resident, M.D.).
1BFS: SUPRAGLOTTIC MASS, LEFT, INFERIOR SHAVE MARGIN (frozen section) –
A. MALIGNANT.
B. SQUAMOUS CELL CARCINOMA.
C. TUMOR PRESENT AT THE MARGIN (T. Pathologist, M.D./C. Resident, M.D.).
1CFS: SUPRAGLOTTIC MASS, ANTERIOR SHAVE MARGIN (frozen section) –
A. MALIGNANT.
B. SQUAMOUS CELL CARCINOMA.
C. TUMOR EXTENDS VERY CLOSE IF NOT TO THE CAUTERIZED MARGIN (T. Pathologist, M.D./C. Resident, M.D.).
VGD/vat
FINAL DIAGNOSIS
The Final Diagnosis is typed in ALL CAPS and bold type. The exception: Any text placed within
parentheses that is non-diagnostic {i.e. (see comment)} is in lowercase bold type.
The specimen line identifies the specimen, identifies the location of the specimen, and indicates the
procedure performed to remove the specimen and is aligned with the left margin. Following the type of
excision, type a space, a dash and then return.
Each diagnosis ends in a period.
A single diagnosis is aligned flush with the left margin and not indented.
For multiple diagnoses, each diagnosis is given a letter designation (A, B, C, etc.).

For multiple parts with one or more diagnoses, each part is labeled as PART # and followed by a colon
mark and a single space and the specimen line (i.e. PART 1: LUNG…). Each diagnosis is given a
letter designation (A, B, C, etc.), with the exception of a diagnosis with only one line. The letter
designation is aligned with the beginning of the specimen header in a hanging indent, (created using
the keystroke combination [CTRL+M]), followed by a period and a space, and then the diagnosis.
Note: When the hanging indent is created, hitting return at the end of the line A diagnosis will create
the appropriate indent for the remaining diagnosis lines.
A blank line is inserted between parts.
For consult diagnoses, place the outside slide number and the accession date of the outside slide
number in parenthesis next to the diagnosis specimen line.
Expand abbreviations in the final diagnosis field. Example: If the dictator says CIN 1 type CERVICAL
INTRAEPITHELIAL NEOPLASIA 1 (CIN 1).
EXAMPLE: Final diagnosis heading - specimen part type, location of specimen, procedure performed
Final Diagnosis
LUNG, LEFT UPPER LOBE, LOBECTOMY –
EXAMPLE: Final diagnosis for one part with one diagnostic line
Final Diagnosis
LUNG, LEFT UPPER LOBE, LOBECTOMY –
BENIGN.
VGD/vat
EXAMPLE: One part, multiple diagnosis lines
Final Diagnosis
SOFT TISSUE KNEE MASS, RIGHT, EXCISION –
A. SKIN AND SUBCUTANEOUS TISSUE WITH FIBROUS-WALLED CYST WITH FOCAL RUPTURE,
B. SYNOVIAL CELL PROLIFERATION AND RARE NON-VIABLE BONY SPICULES OF GANGLION/SYNOVIAL CYST, 11.5 X
3.8 CM (see comment).
C. NEGATIVE FOR MALIGNANCY.
VGD/vat
EXAMPLE: Multiple parts, one or more diagnosis lines
Final Diagnosis
PART 1: GALLBLADDER, CHOLECYSTECTOMY –
CHOLELITHIASIS AND MILD CHRONIC CHOLECYSTITIS.
PART 2: LIVER, RANDOM NEEDLE BIOPSY –
A. NON-CIRRHOTIC LIVER TISSUE WITH MICROVESICULAR AND MACROVESICULAR STEATOSIS INVOLVING 30%
OF THE HEPATOCYTES.
B. MILD NONSPECIFIC PORTAL CHRONIC INFLAMMATION (see microscopic description).
VGD/vat
EXAMPLE: Bone marrow biopsy final
Final Diagnosis
PART 1: PERIPHERAL BLOOD –
WITHIN NORMAL LIMITS.
PARTS 2
AND 3: BONE MARROW, BIOPSY AND ASPIRATE –
TRILINEAGE HEMATOPOIESIS WITH FOCI OF LYMPHOCYTOSIS INCLUDING LYMPHOID AGGREGATES (see
comment).

VGD/vat
EXAMPLE: Consultation diagnosis, one part, one accession number
Final Diagnosis
RIGHT AND LEFT OVARY, BILATERAL SALPINGO-OOPHORECTOMY (OSS S05-6612, 06/14/05) –
A. POORLY-DIFFERENTIATED INTRACYSTIC CARCINOMA WITH FEATURES OF SEROUS AND ENDOMETRIOID
CARCINOMA.
B. ADENOCARCINOMA APPEARS TO BE INTRACYSTIC WITHOUT EVIDENCE OF OVARIAN SURFACE INVOLVEMENT ON
PROVIDED SLIDES.
C. LYMPHOVASCULAR INVASION IS NOT IDENTIFIED.
D. LEFT FALLOPIAN TUBE, HISTOLOGICALLY UNREMARKABLE.
E. RIGHT OVARY AND RIGHT FALLOPIAN TUBE WITH PHYSIOLOGIC CHANGES.
F. DEFINITE ENDOMETRIOSIS IS NOT IDENTIFIED.
VGD/vat
EXAMPLE: Consultation diagnosis, multiple parts one accession number
Final Diagnosis
PART 1: ENDOCERVIX, CURETTINGS (OSS S05-1191, 07/07/05) –
ECTOCERVICAL AND ENDOCERVICAL TISSUE FRAGMENTS WITH NO SIGNIFICANT PATHOLOGIC ABNORMALITY.
PART 2: ENDOMETRIAL CURETTINGS (OSS S05-1191, 07/07/05) –
ATYPICAL COMPLEX HYPERPLASIA IN A BACKGROUND OF SECRETORY PATTERN ENDOMETRIUM WITH TUBAL
AND CLEAR CELL METAPLASIA.
VAT/vat
EXAMPLE: Consultation diagnosis, multiple parts, multiple accession numbers
Final Diagnosis
PART 1: FINE NEEDLE ASPIRATION OF RIGHT NECK (OSS S05-192, 01/07/05) –
A. SATISFACTORY FOR INTERPRETATION.
B. NEGATIVE FOR MALIGNANT CELLS.
C. FRAGMENTS OF FIBROADIPOSE TISSUE.
PART 2: VOCAL CORD, LEFT, STRIPPING (OSS S05-3303, 04/14/05) –
KERATOSIS WITH MILD DYSPLASIA.
PART 3: VOCAL CORD, LEFT, BIOPSY (OSS S05-6039, 07/07/05) –
HYPERPLASTIC, CHRONICALLY INFLAMED SQUAMOUS MUCOSA.
VGD/vat
DIAGNOSIS COMMENT
The diagnosis comment field is typed in sentence style in bold type, aligned with the left margin, in
paragraph format and may contain quick text or free text transcription.
EXAMPLE: Diagnostic comment
Diagnosis Comment
The histologic features seen in this material are consistent with quiescent ulcerative colitis. No dysplasia is seen.
VGD/vat

CLINICAL HISTORY
In the clinical history field, standard quick text templates are used. Type the quick text preop for bone
marrows, consultations and all other surgical cases) and click on the running man icon to insert the
standard quick text template for the patient's clinical history. Go to the pound (#) signs using the
keystroke combination [ALT+F] and type in the dictated information.
The clinical history is typed sentence style (initial uppercase, remainder lowercase; see examples
below).
The patient’s age is typed with hyphens (i.e. The patient is a 24-year-old female).
The first word in the pre-op, post-op and procedure are capitalized and each line ends with a period
(see examples below).
Consultation cases include the outside slide number (OSS), outside slide accession date and the name
of the hospital requesting the consult between the clinical history line and the preoperative diagnosis
line in all capital letters and in bold typeface.
SYNOPTICS
A synoptic should be added to all bone marrow and solid tissue reports when a
hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone marrows, these are
being added on first-time diagnoses only, although they do not need to be limited to those cases.
Instructions for the use of synoptics are available online. The CoPath user guide is posted on the
CoPathPlus website http://copath.upmc.com under the link for CoPathPlus Training Resources. The
Synoptic Data Entry and Reporting Chapter is Chapter 24.
A hard copy is available in rooms G315 and G323.
There are currently four (4) synoptics used in Hematopathology.
o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic
o Gastrointestinal Lymphoma Resection Synoptic
o Hodgkin Lymphoma Biopsy/Staging Synoptic
o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic
OTHER
Never use tabs.
Do not change FONT or center justify header in IHC table.

LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL
(SLIDES, BLOCKS, PAPERWORK)
1.0 Principle
1.1 All material, whether in-house or consult, received fresh or fixed (glass slides and/or blocks)
must be kept in an organized fashion with detailed records to facilitate efficient and accurate
functioning of lymph node/solid tissue hematopathology sign out service.
2.0 Specimen Requirements
2.1 Specimens include all cases designated for hematopathology lymph node/solid
tissue service.
3.0 Reagents, Supplies and Equipment
3.1 Reagents
Not Applicable
3.2 Supplies
Hematopathology Case Worksheets
3.3 Equipment
Computer with Microsoft Office
4.0 Calibration and Standardization
Not applicable
5.0 Quality Control
5.1 All problems noted in terms of special handling, transcription or histology will be entered under
the “Adverse Event” section for each case in CoPath.
(See Appendix G - Adverse Event Recording)
6.0 Procedure
6.1 Throughout the day, all material for the lymph node service is brought into the lymph node sign
out room (G323) to be distributed with the cases.
6.1.1 If formalin fixed H & E stained slides from tissue grossed and submitted the day before
are not received by 4:00PM, follow up with a call to histology laboratory to determine
when the slides will be available (extension 647-7660).
6.2 Whenever slides are received, place on a tray with all other slides on the case together with all
paperwork and place on the microscope table.
6.2.1 If a Hematopathology Case Worksheet (Appendix B) already exists because the case
was handled in the gross room or the sheet was filled out when the consult was
accessioned/received, record which slides were received.
6.2.2 If a case does not already have a Hematopathology Case Worksheet, print one out
in Copath under the “Heme Worksheet” function.

6.2.3 Determine if any slides that should be present are missing by one of the following
methods:
6.2.3.1 Check gross description and current time. Rush formalin fixed and B+ fixed H&E
stains come out by the next day after submission. PAS should be out during the
afternoon on the same day.
6.2.3.2 Check the Hematopathology Case Worksheet for date/time stains were ordered.
Assuming the block is in histology, immunostains ordered before 9AM should be out late
on the same day (does not always happen) and those ordered by 6PM should be out
early the following day. In situ hybridization stains are typically expected in 2 days.
6.2.3.3 Print out the "CoPath Accession Log with stain information by specimen"
(Appendix H) after ordering the stains for the case. Check pending stains noting if all
verified stains have been received. (If not, call histology/immunohistology laboratory ext
7-7663) and if all unverified stains are not overdue (See 6.3.3.1 and 6.3.3.2 for expected
turn-around times and follow-up instructions).
6.2.3.3.1 Directions for CoPath called: “Accession Log with Information by Specimen”
1. Log onto CoPath.
2. Click on FILE in the menu bar.
3. Choose BROWSE ITEMS.
4. Under the Browse Items list, find the report "Accession Log w/Stain Info by
Specimen"
5. Click and drag the “Accession Log w/Stain Info by Specimen” report into your
menu on the left.
6. Double click on it to open the report.
7. The next time you log on, you will be able to directly access the report from
your menu list.
6.2.3.3.2 Directions for bringing up specific "Accession Log w/Stain Information" report:
1. Under Data Field, highlight "Specimen."
2. Choose Individual Items as selection method and type the specimen number
in the "Select a Specimen" Box.
3. Click OK.
4. Under Data Field, for "Retrieval Flag","Stain/Process" and "Request Class",
choose All Values as Selection Method.
5. Click OK and report will appear.
6.2.3.4 Attach copy of print out to Hematopathology Case Worksheet, with notation of
any follow-up performed.
All cases (slides, paperwork, folder) will be kept in one of the following shelves:
Pending flow (inhouse or consult fresh tissue)
Pending IHC cases (keep separated whether out today or the next day)
Pending receipt of requested outside blocks/blanks/slides (Go through at least
every other day.)
Pending H&E’s ONLY
Pending Molecular and Cytogenetic studies
Dictated, to Proof-read
Signed out cases, pending Immunostains/ISH/ MDX/ Cytogenetics for addendums

PHS13-
Blocks in Histology
Hematopathology Case Worksheet
PATIENT:
Blocks sent down to histology
Date/Time
Blanks sent down to histology
Date/Time
Requested Date:
Blocks
Blanks
Other
Contact:
ROUTINE STAINS/BLANKS
Stain Code Block(s) Requested Ordered Received Comments
H & E
RHHE
PAS
HPAS
Grocott
HGRO
AFB
HAFT
Blanks (# ) HBNKNC
Congo Red
HCNR
Steiner
HSTNC
IMMUNOSTAINS * = run stain process group
Stain Code Block(s) Requested Ordered Received Comments
Small B-Cell Panel
CD3, 20,5,10,43
BCL-2,BCL-6,cycD1
SBCP*
MALT Eval
anti-kappa, anti-lambda
CD20, BCL-2, CD43, CD5
BCL-6, CD10, cyclin D1, CD3
DLBCL Eval
CD20, BCL-6, MUM-1
CD3, BCL-2, CD10
Cyclin D1, CD5, MYC, Ki-67
Cytoplasmic Ig-IHC
anti-kappa, anti-lambda
Cytoplasmic Ig-ISH
Kappa, Lambda, MRNA
Myeloma
Kappa BM, Lambda BM
CD138
AMALTe*
ADLBCL*
ACIG*
ICIG*
AMyel*
Double k/lambda IKPLM *
Ig Heavy Chains
AIGH*
anti-IgG,IgA, IgM, IgD
Anti-IgA
Anti-IgD
Anti-IgG
Anti-IgG4
Anti-IgM
CD20/L26
CD22
CD79a
PAX 5
CD21
CD23
CD138
AIGA
AIGD
AIGG
AIGG4
AIGM
AL26
ACD22
ACD79
APAX5
ACD21
ACD23
CD138
UPMC Page 1 of 4

J chain
AJ
BCL2
ABCL2
BCL2 E17
ABCL2E17
MYC
c-MYC
BCL6
ABCL6
CD10
ACD10
IRF4/MUM-1
AMUM1
Cyclin D1
ACYCLD1
SOX-11
SOX11
P27
AP27
LEF-1/TCF-1
LEF-1
Annexin A1
AANNEX
Mini-ALL
AAllm*
TdT, CD34
TdT
ATDT
CD45/LCA
ALCA
Hodgkin's Panel
AHODPP*
CD3, 20, 15, 30
EMA, LCA
HL expanded
AHL*
CD20, CD3, CD45/LCA,
CD30/Ber H2, CD15/Leu M1,
PAX 5, MUM-1,OCT-2, Bob.1, EMA
OCT-2/Bob.1
AOCT*
HL, extras
AHLe*
PAX5, MUM-1, OCT-2
Bob.1
CD15/Leu M1
ALEUM1
CD30/Ber H2
ACD30
EMA
AEMA
ALCL
AALCL*
ALK-1, Clusterin
Alk-1
Clusterin
Pan T-Cell/Basic subset
Hematopathology Case Worksheet
AALK1
ACLUST
APANT*
CD2, CD3, CD4, CD5
CD7, CD8
T-cell subsets other
ATCSS*
Beta-F1, CD57, CD25, Granzyme B,
CD56, TIA1, PD-1, CXCL 13
NK lymphoma
CD20/L26, CD2, CD3, CD5
CD7, Beta-F1, CD56, TIA1
Granzyme B
EBV-ISH (EBER)
CD1a
CD2
CD3
CD4
CD5
CD7
CD8
ANKL*
ACD1a
ACD2
ACD3
ACD4
ACD5
ACD7
ACD8
UPMC Page 2 of 4

CD43/Leu 22
CD279/PD-1
CXCL13
Beta-F1
Gamma TCR
CD56
CD57/Leu 7
TIA1
Granzyme B.
CD25
Myeloblast eval
MPO, Lyso, Neut elast
CD117, CD34, TdT
Myeloblast-limited
MPO, CD117, CD34, TdT
Mini-Myeloblasts
CD117, CD34
BM Lineage
CD68/PGM-1, MPO, CD34
Glycophorin A,Factor VIIIRA
ACD43
PD1
ACXCL13
ABF1
ACD56
ALEU7
ATIA
AGRANZ
ACD25
AMyBe*
AMyBL*
AMyBm*
ABML*
CD68/PGM-1
ACD68
CD123
CD123
TCL-1
TCL-1A
Myeloperoxidase
AMPO
Lysozyme
ALYSO
CD14
CD14
CD163
CD163
CD33
ACD33
Neut. Elast
ANE
CD117
ACKIT
Tryptase
ATRYP
CD34
ACD34
Glycophorin A
AGLYP
Factor VIIIRA
AVWF
CD61
ACD61B
Ki-67/MIB-1
AKi67
P53
AP53
AE1/AE3
AAE13
Cam 5.2
ACAM
Pankeratin
APANKR
S100/S100a
AS100D
CD207 / Langerin
LANG
EBV-ISH (EBER) IEBER *
EBV-LMP
AEBV
Parvovirus
APARVO
CMV
ACMV
HHV8
AHHV8
H.Pylori
HPYL
Bartonella (CSD)
BHENS
Treponema
ATREP
Herpes Simplex 1/2
AHSV12
UPMC

MOLECULAR
DNA/RNA (Already Stored) Frozen Blank Slides Available Order blanks - See PageOne
TEST
Ig heavy chain and light chain gene rearrangment, PCR
T-cell receptor gamma chain rearrangment, PCR
T-cell receptor beta chain gene rearrangment, PCR
JAK2 V617F
BCR-ABL1
PML-RARA
FLT3 & NPM1
CLL sequencing for somatic hypermutation
Req'd Ord'dTissue/Slides Sent(date/time) Comments
CYTOGENETICS Blank Slides Available Order Blanks - See Page One
Break Apart Rearrangement Probes
Other
ALK (2p23) RARA (17q21) ASS deletion (9q34)
AML1 (21q22) TCRB (7q34) ATM deletion (11q22.3)
BCL2 (18q21) TCRG (7p14) CEP X/Y
BCL3 (19q13) TCRAD (14q11) D7S486/CEP7 -7/7q31 I (7q)
BCL6 (3q27) TCR3 (19p13) (D7S522/CEP7) - 7/7q31
BCL10 (1p22) TCL1(14q32.1) Deletion 13q (13q14) D135319
CBFB (16q22)
Deletion 20q (20q12) D205108
CCND1 (11q13) Translocation Probes EGR1 -5/5q-
ETV6 (TEL) (12p13) RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion)
EVI1 (MECOM) (3q26.2) BIRC3-MALT1 (API2-MALT1) t(11;18) CDKN2A (p16) (9p21 deletion)
EWSR1 (22q11.2) BCR-ABL t(9;22) CML/ALL/AML TP53 deletion (17p13.1)
FGFR1 (8p12) IGH - CCND1 (T11:14) Trisomy 5, 9, 15
IGH (14q32) IGH-BCL2 t(14;18) Trisomy 8 D8Z2
IGK (2p11) CBFB-MYH1 (16p13/16q22) t(16;16). inv(16) Trisomy 12 D1273
IGL (22q11)
IGH-FGFR3 t(4;14)
MALT1 (18q21)
IGH-MAF t(14;16)
MLL (11q23)
IGH MALT1 t(14;18)
MYC (8q24)
IGH-MYC t(8;14)
MYCN (2P23-24) (for amp)
PML-RARA t(15;17)
PAX5 (9p13)
TEL-AML1 (ETV6/RUNX1) t(12;21)
PDGFRB (5q33)
Panels
B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21)
CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1)
Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13)
Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21)
Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)]
MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12)
AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)]
[as needed (i.e. if not seen by classical analysis)]
MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12)
Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)
Additional FISH Probes Request (please list) Requested Ordered Blanks Sent
Comments

Filing of Slides
All slides from cases signed out by the Hematopathology Division must be placed for filing in the bone
marrow laboratory (PUH G325.1).
Location of Lymph Node slides
Before 1992 (LN were part of Surgical Pathology Section) - Iron Mountain
SEPT 1992 to PHS11-34754
- Iron Mountain
PHS11- 34813 - present
-G325.1 Bone marrow
Reading room PUH
Starting April, 2009 - LN surgical pathology requisitions are stored in the CLB, the file drawer
behind the grossing station.

Lymph Node Rotation Checklist
Note: Items indicated in BOLD constitute the basic knowledge expected of residents rotating in
Hematopathology. Additional (non-bolded) items should also be included for advanced learners
including fellows.
Orientation with Dr. Swerdlow (Division Director) or his designate.
Done prior rotation
Orientation by experienced trainee.
Done prior rotation
Orientation by Lymph Node Assistant or designate.
Done prior rotation
Competent and comfortable with gross processing and triaging of fresh lymph nodes and
spleens and other specimens with possible hematopoietic/lymphoid disorders.
Competent and comfortable to construct, dictate and proof full reports and to order stains using
CoPath.
Knows normal architecture and immunoarchitecture of lymph node, spleen and Peyer’s Patch.
Knows reactivity of all antibodies used in flow cytometry panel to assess hematopoietic/lymphoid
disorders in lymph node, spleen and all other extranodal sites (panels in resident/fellow
handbook).
Confidently can interpret flow cytometry data including histograms.
Knows role of cytogenetic and molecular diagnostic studies in evaluating
hematopoietic/lymphoid disorder in lymph node, spleen and other extranodal sites.
Learned diagnostic criteria using multiparameter approach and clinical implications for
each of the following in lymph nodes and extranodal sites (residents to
accomplish at least lower case items in bold, fellows to accomplish all over one
year):
Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
NON-NEOPLASTIC DISORDERS (NODAL)
Viral-associated adenitis (infectious mononucleosis,
postvaccinal, herpes zoster, cytomegalovirus,
measles, HIV)
Syphilis
Toxoplasmosis
Cat-scratch disease

Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Granulomatous processes
Whipple’s disease
Bacillary angiomatosis
Autoimmune disorders (Rheumatoid arthritis,
Sjögren’s syndrome, Adults Still’s disease, systemic
lupus erythematosus)
Sarcoidosis
Angiofollicular hyperplasia/Castleman’s Disease
Inflammatory pseudotumor
Dermatopathic lymphadenopathy
Sinus histiocytosis with massive adenopathy
(Rosai-Dorfman)
Histiocytic Necrotizing Lymphadenitis
Kimura’s disease/angiolymphoid hyperplasia with
eosinophilia
Drug reactions (Dilantin, Tegretol)
Hemophagocytic syndrome
Immunodeficiency states (including ALPS, other)
Lymph node infarction
MALIGNANT LYMPHOMAS
B lymphoblastic leukaemia/lymphoma
T lymphoblastic leukaemia/lymphoma
Chronic lymphocytic leukaemia/small
lymphocytic lymphoma
Lymphoplasmacytic lymphoma
Extranodal marginal zone lymphoma of mucosaassociated
lymphoid tissue (MALT lymphoma)
Nodal marginal zone lymphoma
Follicular lymphoma

Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Primary cutaneous follicle centre lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma (DLBCL), NOS
T-cell/histiocyte rich large B-cell lymphoma
Primary DLBCL of the CNS
Primary cutaneous DLBCL, leg type
EBV positive DLBCL of the elderly
DLBCL associated with chronic inflammation
Lymphomatoid granulomatosis
Primary mediastinal (thymic) large B-cell
lymphoma
Intravascular large B-cell lymphoma
ALK positive DLBCL
Plasmablastic lymphoma
Large B-cell lymphoma arising in associated
multicentric Castleman disease
Primary effusion lymphoma
Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features
intermediate between diffuse large B-cell lymphoma
and Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features
intermediate between diffuse large B-cell lymphoma
and classical Hodgkin lymphoma
Adult T-cell leukaemia/lymphoma
Extranodal NK/T cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma

Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Mycosis fungoides
Sézary syndrome
Primary cutaneous CD30 positive T-cell
lymphoproliferative disorders
Lymphomatoid papulosis
Primary cutaneous anaplastic large lymphoma
Primary cutaneous gamma-delta T-cell lymphoma
Primary cutaneous CD8 positive aggressive
epidermotropic
Primary cutaneous CD4 positive small/medium T-cell
lymphoma
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma, ALK positive
Anaplastic large cell lymphoma, ALK negative
Nodular lymphocyte predominant Hodgkin
lymphoma
Classical Hodgkin lymphoma
POST-TRANSPLANT LYMPHOPROLIFERATIVE
Early lesions
Plasmacytic hyperplasia
Infectious-mononucleosis-like PTLD
Polymorphic PTLD
Monomorphic PTLD, B-cell types, T-cell types
Hodgkin lymphoma type PTLD
HISTIOCYTIC AND DENDRITIC CELL
Histiocytic sarcoma
Langerhans cell histiocytosis/sarcoma

Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Interdigitating dendritic cell sarcoma
Follicular dendritic cell sarcoma
OTHER NEOPLASMS
Mastocytosis
Myeloid sarcoma
Blastic Plasmacytoid dendritic cell tumor
Metastatic tumors
Learned diagnostic criteria for the following in the SPLEEN (residents to accomplish at least
items in lower case bold, fellows to accomplish all over one year):
Diagnosis / Finding
BENIGN
Localized lymphoid hyperplasia
Changes in benign systemic and infectious disorders
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Rheumatoid arthritis (Felty’s syndrome)
Autoimmune thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
Hereditary spherocytosis
Acquired immune deficiency syndrome
Bacterial infections including bacillary angiomatosis
Viral infections including infectious
mononucleosis
Castleman disease
Fibrocongestive splenomegaly
Histiocytic proliferations
Lipid histiocytes
Ceroid histiocytosis

Gaucher’s disease
Langerhans cell histiocytosis
Hemophagocytic syndrome
SPLENIC EXPRESSION OF THE FOLLOWING
LYMPHOMAS
Chronic lymphocytic leukemia / Small
lymphocytic lymphoma
Lymphoplasmacytic lymphoma
Mantle cell lymphoma
Splenic and other marginal zone B-cell
lymphomas
Splenic lymphoma/leukaemia, unclassifiable
Follicular lymphoma
Diffuse large B-cell lymphoma
Hepatosplenic T-cell lymphoma
Other non-Hodgkin’s lymphomas
Prolymphocytic leukemia
Large granular lymphocytic leukemia
CHANGES IN LEUKEMIAS AND
MYELOPROLIFERATIVE DISORDERS
Chronic myeloid leukemia
Chronic myeloproliferative neoplasm
Hairy cell leukemia
Acute leukemias
Systemic mastocytosis
NONHEMATOPOIETIC LESIONS
Developmental cysts
Developmental hamartomas
Vascular neoplasms
Hemangiomas
Lymphangiomas
Littoral-cell angiomas

Angiosarcomas
Nonvascular sarcomas
Metastases
Inflammatory pseudotumor

PRESENTED THE FOLLOWING “LYMPH NODE” CASES (Submit Presentation in Portfolio).
PHS NUMBER
DIAGNOSIS

UTILIZED THE FOLLOWING LYMPH NODE RESOURCES
Lymph node chapter in Sternberg. [Highly recommended]
Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.
(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours,
IARC, Lyon, 2008. [Highly recommended]
Checkpath (images, histories and explanations of faculty CME program for Hematopathology)
(PUH G315 and in Dr. Swerdlow’s coordinator’s office).
Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office).
Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major Problems in
Pathology”), Saunders, 2003.
Jaffe, E.S., Harris, N.L., H. Vardiman, J.W., Campo, E., Arber, Daniel A., Hematopathology,
2011 (G323)
O’Malley D.P., George, T.I., Orazi A., Benign and Reactive Conditions of Lymph Node and
Spleen, 2009.
NOTE: Reading is an important component of this rotation. It is recognized that not all of the above
resources can be used nor can most be read in entirety. Use of electronic and other resources to find
and read up-to-date journal articles is also critical.
I have completed the Lymph Node Checklist.
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________

Protocol for the Examination of Specimens From Patients With
Non-Hodgkin Lymphoma/Lymphoid Neoplasms
Protocol applies to non-Hodgkin lymphoma/lymphoid neoplasms involving any site
except the ocular adnexa, bone marrow, mycosis fungoides, and Sezary syndrome.
Based on AJCC/UICC TNM, 7 th Edition
Protocol web posting date: October 2013
Procedures
• Biopsy
• Resection of Lymph Node(s) or Other Organ(s)
Authors
Jerry W. Hussong, MD, DDS, FCAP*
Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Daniel A. Arber, MD
Department of Pathology, Stanford University School of Medicine, Stanford, California
Kyle T. Bradley MD, MS, FCAP
Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia
Michael S. Brown, MD, FCAP
Department of Pathology, Yellowstone Pathology Institute Inc, Billings, Montana
Chung-Che Chang, MD, PhD, FCAP
Department of Pathology, The Methodist Hospital, Houston, Texas
Monica E. de Baca, MD, FCAP
Department of Pathology and Laboratory Medicine, Physicians Laboratory Ltd, Sioux Falls, South Dakota
David W. Ellis, MBBS, FRCPA
Department of Anatomical Pathology, Flinders Medical Centre, Bedford Park, South Australia
Kathryn Foucar, MD, FCAP
Department of Pathology, University of New Mexico, Albuquerque, New Mexico
Eric D. Hsi, MD, FCAP
Department of Clinical Pathology, Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
Hematopathology Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland
Joseph Khoury, MD, FCAP
MD Anderson Cancer Center, Houston, Texas
Michael Lill, MB, BS, FRACP, FRCPA
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Stephen P. McClure, MD
Department of Pathology and Laboratory Medicine, Presbyterian Pathology Group, Charlotte, North
Carolina
L. Jeffrey Medeiros, MD, FCAP
Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
Sherrie L. Perkins, MD, PhD, FCAP
Department of Pathology, Hematopathology, University of Utah Health Sciences Center, Salt Lake City,
Utah
For the Members of the Cancer Committee, College of American Pathologists
* Denotes the primary and senior author. All other contributing authors are listed alphabetically.

Surgical Pathology Cancer Case Summary
Protocol web posting date: October 2013
NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS: Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply) (note A)
Lymph node(s)
Other (specify):
Not specified
Procedure
Biopsy
Resection
Other (specify):
Not specified
Tumor Site (select all that apply) (note B)
Lymph node(s), site not specified
Lymph node(s)
Specify site(s):
Other tissue(s) or organ(s):
Not specified
Histologic Type (note C)
Histologic type cannot be assessed
Precursor Lymphoid Neoplasms
B lymphoblastic leukemia/lymphoma, not otherwise specified (NOS) #
B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1
B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged
B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)
B lymphoblastic leukemia/lymphoma with hyperdiploidy
B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid acute lymphoblastic
leukemia/lymphoma [ALL])
B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH
B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
T lymphoblastic leukemia/lymphoma
Mature B-Cell Neoplasms
B-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
Chronic lymphocytic leukemia/small lymphocytic lymphoma
B-cell prolymphocytic leukemia
Splenic B-cell marginal zone lymphoma
Hairy cell leukemia
Splenic B-cell lymphoma/leukemia, unclassifiable

Splenic diffuse red pulp small B-cell lymphoma
Hairy cell leukemia-variant
Lymphoplasmacytic lymphoma
Gamma heavy chain disease
Mu heavy chain disease
Alpha heavy chain disease
Plasma cell myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
Nodal marginal zone lymphoma
Pediatric nodal marginal zone lymphoma
Follicular lymphoma
Pediatric follicular lymphoma
Primary intestinal follicular lymphoma
Primary cutaneous follicle center lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma (DLBCL), NOS
T cell/histiocyte-rich large B-cell lymphoma
Primary DLBCL of the central nervous system (CNS)
Primary cutaneous DLBCL, leg type
Epstein-Barr virus (EBV)-positive DLBCL of the elderly
DLBCL associated with chronic inflammation
Lymphomatoid granulomatosis
Primary mediastinal (thymic) large B-cell lymphoma
Intravascular large B-cell lymphoma
Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma
Plasmablastic lymphoma
Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
Primary effusion lymphoma
Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
and Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
and classical Hodgkin lymphoma
Other (specify):
Mature T- and NK-Cell Neoplasms
T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
T-cell prolymphocytic leukemia
T-cell large granular lymphocytic leukemia
Chronic lymphoproliferative disorder of NK cells
Aggressive NK-cell leukemia
Systemic EBV-positive T-cell lymphoproliferative disease of childhood
Hydroa vacciniforme-like lymphoma
Adult T-cell leukemia/lymphoma
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Primary cutaneous anaplastic large cell lymphoma

Lymphomatoid papulosis
Primary cutaneous gamma-delta T-cell lymphoma
Primary cutaneous CD8-positive aggressive epidermotropic cytotoxic T-cell lymphoma
Primary cutaneous CD4-positive small/medium T-cell lymphoma
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma, ALK-positive
Anaplastic large cell lymphoma, ALK-negative
Other (specify):
Histiocytic and Dendritic Cell Neoplasms
Histiocytic sarcoma
Langerhans cell histiocytosis
Langerhans cell sarcoma
Interdigitating dendritic cell sarcoma
Follicular dendritic cell sarcoma
Fibroblastic reticular cell tumor
Indeterminate dendritic cell tumor
Disseminated juvenile xanthogranuloma
Posttransplant Lymphoproliferative Disorders (PTLD) ##
Early lesions:
Plasmacytic hyperplasia
Infectious mononucleosis-like PTLD
Polymorphic PTLD
Monomorphic PTLD (B- and T/NK-cell types)
Specify subtype:
Classical Hodgkin lymphoma type PTLD ###
Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.
#
An initial diagnosis of “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic
results are available.
##
These disorders are listed for completeness, but not all of them represent frank lymphomas.
###
Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of
American Pathologists protocol for Hodgkin lymphoma. 1
+ Pathologic Extent of Tumor (select all that apply) (note D)
+ Bone marrow involvement
+ Other site involvement
+ Specify site(s):
+ Additional Pathologic Findings
+ Specify:
Immunophenotyping (flow cytometry and/or immunohistochemistry) (note E)
Performed, see separate report:
Performed
Specify method(s) and results:
Not performed

+ Cytogenetic Studies (note E)
+ Performed, see separate report:
+ Performed
+ Specify method(s) and results:
+ Not performed
+ Molecular Genetic Studies (note E)
+ Performed, see separate report:
+ Performed
+ Specify method(s) and results:
+ Not performed
+ Clinical Prognostic Factors and Indices (select all that apply) (note F)
+ International Prognostic Index (IPI) (specify):
+ Follicular Lymphoma International Prognostic Index (FLIPI) (specify):
+ B symptoms present
+ Other (specify):
+ Comment(s)
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet
validated or regularly used in patient management.

Explanatory Notes
A. Specimen
Any number of specimen types may be submitted in the evaluation of lymphoid neoplasms. Lymph
nodes, skin, gastrointestinal (GI) tract, bone marrow, spleen, thymus, and tonsils are among the most
common. Specimens submitted with a suspected diagnosis of lymphoma require special handling in
order to optimize the histologic diagnosis and to prepare the tissue for molecular and other ancillary
special studies. 2,3 The guidelines detailed below are suggested for specimen handling in cases of
suspected lymphoma.
• Tissue should be received fresh. Unsectioned lymph nodes should not be immersed in fixative, and
care should be taken to make thin slices of the node to ensure optimal penetration of fixative.
• The fresh specimen size, color, and consistency should be recorded, as should the presence or
absence of any visible nodularity, hemorrhage, or necrosis after serial sectioning at 2-mm intervals
perpendicular to the long axis of the lymph node.
• Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol or air
dried.
• For cytogenetic studies or culture of microorganisms: submit a fresh portion of the node (or other
specimen type) sterilely in appropriate medium.
• For immunophenotyping by flow cytometry: submit a fresh portion of the specimen in appropriate
transport medium such as RPMI.
• Fixation (record fixative[s] used for individual slices of the specimen):
o Estimated time from excision to fixation should be noted, if possible, as this may impact
preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed tissues.
o Zinc formalin or B5 produces superior cytologic detail but is not suitable for DNA extraction and
may impair some immunostains (eg, CD30). B5 also has the additional limitation of requiring
proper hazardous-materials disposal.
o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for many
ancillary tests such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.
o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or B5) should
be avoided for optimal immunophenotypic reactivity.
• Snap-frozen tissue is optimal for DNA and RNA extraction.
o Place in aluminum foil or cover in OCT.
o Immerse in dry ice/isopentane slush or liquid nitrogen.
o Store at -80°C until needed.
B. Tumor Site
The anatomic sites that constitute the major structures of the lymphatic system include groups and
chains of lymph nodes, the spleen, the thymus, Waldeyer’s ring (a circular band of lymphoid tissue that
surrounds the oropharynx, consisting of the palatine, lingual, and pharyngeal tonsils), the vermiform
appendix, and the Peyer’s patches of the ileum. 2,3 Minor sites of lymphoid tissue include the bone
marrow, mediastinum, liver, skin, lung, pleura, and gonads. Involvement of extranodal sites is more
common in non-Hodgkin lymphomas (NHL) than in Hodgkin lymphoma. In addition, some NHL, such as
mycosis fungoides and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue
(MALT), occur predominantly or entirely in extranodal sites.
C. Histologic Type
This protocol recommends assigning histologic type based on the World Health Organization (WHO)
classification of lymphoid neoplasms. 4 It was originally published in 2001 and recently was revised and
updated in 2008. 5 This classification encompasses both nodal and extranodal lymphomas and provides
distinction of individual lymphoid neoplasms based upon morphologic, immunophenotypic,
cytogenetic, and clinical features. While histologic examination typically is the gold standard, the
majority of the lymphoid neoplasms will require the utilization of 1 or more other ancillary techniques,

such as immunophenotyping, molecular studies, and/or cytogenetics, to arrive at the correct
diagnosis. 4-10 If the specimen is inadequate or suboptimal for a definitive diagnosis and subtyping, this
information should also be relayed to the clinician with an explanation of what makes the specimen
inadequate or suboptimal.
D. Pathologic Extent of Tumor (Stage)
In general, the TNM classification has not been used for staging of lymphomas because the site of origin
of the tumor is often unclear and there is no way to differentiate among T, N, and M. Thus, a special
staging system (Ann Arbor system) is used for both Hodgkin lymphoma and NHL. 11,12 It was originally
published over 30 years ago for staging Hodgkin lymphoma. The Ann Arbor classification for
lymphomas has been applied to NHL by the American Joint Committee on Cancer (AJCC) 13 and the
International Union Against Cancer (UICC) except for mycosis fungoides and Sezary syndrome. 14
For multiple myeloma, the Durie-Salmon staging system is recommended by the AJCC. 13-15 The
international staging system for multiple myeloma is useful for determining survival. 13 The Ann Arbor
classification and Durie-Salmon staging systems are shown below. It should also be realized that the St.
Jude staging system is commonly used for pediatric patients. 16
Historically, pathologic staging depended on the biopsy of multiple lymph nodes on both sides of the
diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of disease.
Currently, staging of NHL is more commonly clinical than pathologic. Clinical staging generally involves
a combination of clinical, radiologic, and surgical data. Physical examination, laboratory tests (eg,
complete blood examination and blood chemistry studies including lactate dehydrogenase [LDH] and
liver function tests), imaging studies (eg, computed tomography scans, magnetic resonance imaging
studies, and positron emission tomography), biopsy (to determine diagnosis, histologic type, and extent
of disease), and bone marrow examination are often required. In patients at high risk for occult CNS
involvement, cerebrospinal fluid cytology should be performed.
There is almost universal agreement that the stage of the NHL is prognostically significant. 17-20 Correct
diagnosis and staging are the key factors in National Comprehensive Cancer Network treatment
schema that most clinicians utilize. 21
AJCC/UICC Staging for Non-Hodgkin Lymphomas
Stage I Involvement of a single lymph node region (I), or localized involvement of a single
extralymphatic organ or site in the absence of any lymph node involvement (IE) # , ##
Stage II Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or
localized involvement of a single extralymphatic organ or site in association with regional
lymph node involvement with or without involvement of other lymph node regions on
the same side of the diaphragm (IIE) ## , ###
Stage III Involvement of lymph node regions on both sides of the diaphragm (III), which also may
be accompanied by extralymphatic extension in association with adjacent lymph node
involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE+S) ## , ### ,^
Stage IV Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or without
associated lymph node involvement; or isolated extralymphatic organ involvement in
the absence of adjacent regional lymph node involvement, but in conjunction with
disease in distant site(s). Stage IV includes any involvement of the liver, bone marrow, or
nodular involvement of the lung(s) or cerebral spinal fluid. ## , ### ,^
# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV.
## For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.

### The number of lymph node regions involved may be indicated by a subscript: eg, II 3 . For stages II to
IV, involvement of more than 2 sites is an unfavorable prognostic factor.
^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.
Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification of
stage.
AJCC/UICC Staging for Plasma Cell Myeloma
Stage I Hemoglobin greater than 10.0 g/dL
Serum calcium 12 mg/dL or less
Normal bone x-rays or a solitary bone lesion
IgG less than 5 g/dL
IgA less than 3 g/dL
Urine M-protein less than 4 g/24 hours
Stage III One or more of the following are included:
Hemoglobin less than 8.5 g/dL
Serum calcium greater than 12 mg/dL
Advanced lytic bone lesions
IgG greater than 7 g/dL
IgA greater than 5 g/dL
Urine M-protein greater than 12 g/24 hours
Stage II Disease fitting neither stage I nor stage III
Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL or (B) serum creatinine
2.0 mg/dL or greater. The median survival for stage IA disease is about 5 years, and that for stage IIIB
disease is 15 months. 13,14
E. Immunophenotyping and Molecular Genetic Studies
Immunophenotyping can be performed by flow cytometry 8 or immunohistochemistry. Each has its
advantages and disadvantages. Flow cytometry is rapid (hours), quantitative, and allows multiple
antigens to be evaluated on the same cell simultaneously. Antigen positivity, however, cannot be
correlated with architecture or cytologic features. Immunohistochemistry requires hours/days to
perform, quantitation is subjective, but importantly it allows correlation of antigen expression with
architecture and cytology. Not all antibodies are available for immunohistochemistry, particularly in
fixed tissues, but one of its advantages is that it can be performed on archival tissue. Both techniques
can provide diagnostic as well as clinically relevant information (eg, identification of therapeutic targets
such as CD20). Molecular studies now play an increasingly important role in the diagnosis of
hematopoietic neoplasms. They aid not only in helping establish clonality but also in determining
lineage, establishing the diagnosis of specific disease entities, and monitoring minimal residual
disease. 10,22-24
Immunophenotypes and Genetics
The following is to be used as a guideline for the more common immunophenotyping and cytogenetic
findings for each entity. 3,4,8,22-27 It is however, not entirely comprehensive and individual cases may vary
somewhat in their immunophenotypic and cytogenetic profile.
Precursor Lymphoid Neoplasms
B Lymphoblastic Leukemia/Lymphoma, NOS: sIG-, cytoplasmic µ chain (30%), CD19+, CD20-/+, CD22+,
PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene rearrangement +/-, IGL
gene rearrangement -/+, TCR gene rearrangement -/+, variable cytogenetic abnormalities

B Lymphoblastic Leukemia/Lymphoma With t(9;22)(q34;q11.2); BCR-ABL1: sIG-, cytoplasmic µ chain
(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+,
IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(9;22)(q34;q11.2), may have either p190 kd or p210 kd BCR-ABL1 fusion protein.
B Lymphoblastic Leukemia/Lymphoma With t(v;11q23); MLL Rearranged: sIG-, cytoplasmic µ chain
(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10-, CD34+/-, CD13-/+, CD33-/+,
CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(v;11q23)
B Lymphoblastic Leukemia/Lymphoma With t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1): sIG-, cytoplasmic
µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-
/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(12;21)(p13;q22)
B Lymphoblastic Leukemia/Lymphoma With Hyperdiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,
CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene
rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hyperdiploid (>50
chromosomes, often with extra copies of chromosomes 21, X, 4 and 14) without structural abnormalities
B Lymphoblastic Leukemia/Lymphoma With Hypodiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,
CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene
rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hypodiploid with 45
chromosomes to near haploid
B Lymphoblastic Leukemia/Lymphoma With t(5;14)(q31;q32); IL3-IGH: sIG-, cytoplasmic µ chain (30%),
CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-/+, CD15 +/-,
IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(5:14)(q31;q32)
B Lymphoblastic Leukemia/Lymphoma With t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1): sIG-, cytoplasmic
µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-
/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(1;19)(q23;p13.3)
T Lymphoblastic Leukemia/Lymphoma: TdT+, CD7+, CD3+/- (usually surface CD3-), variable expression
of other PanT antigens, CD1a+/-, often CD4 and CD8 double positive or double negative, IG-, PanB-;
variable TCR gene rearrangements; IGH gene rearrangement -/+, chromosomal abnormalities are
common and often involve 14q11-14, 7q35, or 7p14-15
Mature B-Cell Neoplasms
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Faint sIGM+, sIGD+/-,
cIG-/+, panB+ (CD19+, CD20+), CD5+, CD10-, CD23+, CD43+, CD11c-/+; IGH and IGL gene
rearrangements; trisomy 12; del 13q, del(17p), or del(11q) can be seen
B-Cell Prolymphocytic Leukemia: sIgM, sIgD+/-, pan B+ (CD19, CD20, CD22, CD79a, CD79b and FMC-7),
CD5 -/+, CD23-/+, del(17p), t(11;14)(q13;q32), breakpoints involving 13q14
Splenic B-Cell Marginal Zone Lymphoma: sIGM+, sIGD+/-, CD20+, CD79a+, CD5-, CD10-, CD23-, CD43-,
nuclear cyclin D1-, CD103-, allelic loss at 7q31-32 (40%)

Hairy Cell Leukemia: sIG+ (IGM, IGD, IGG, or IGA), PanB+, CD79a+, CD79b-, DBA.44+, CD123+, CD5-,
CD10-, CD23-, CD11c+, CD25+, FMC7+, CD103+ (mucosal lymphocyte antigen as detected by B-ly7),
tartrate resistant acid phosphatase (TRAP)+; IGH and IGL gene rearrangements, no specific cytogenetic
findings
Splenic Diffuse Red Pulp Small B-Cell Lymphoma: sIGG+, sIGD-/+, sIGM+/-, CD20+, DBA.44+, CD5-,
CD103-/+, CD123-, CD25-, CD11c-/+, CD10-, CD23-, t(9;14)(p13;q32) occasionally seen, rarely
abnormalities in TP53 or del 7q
Hairy Cell Leukemia-Variant: sIGG+, PanB+, DBA.44+, CD11c+, CD103+, FMC7+, CD25-, CD123-, Annexin
A1-, TRAP-IHC-, no specific cytogenetic findings
Lymphoplasmacytic Lymphoma: sIGM+, sIGD-/+, cIG+, PanB+, CD19+, CD20+, CD138+ (in plasma
cells), CD79a+, CD5-, CD10-, CD43+/-, CD25-/+; IGH and IGL gene rearrangements, no specific
cytogenetic findings
Alpha Heavy Chain Disease (Immunoproliferative Small Intestinal Disease): cytoplasmic alpha heavy
chain+, CD20+ (lymphocytes), CD138+ (plasma cells), light chain-
Gamma Heavy Chain Disease: IgG heavy chain+, CD79a+, CD20+ (on lymphocytes), CD138+ (in
plasma cells), CD5-, CD10-, light chain-, abnormal karyotype in 50% without recurring abnormalities
Mu Heavy Chain Disease: monoclonal cytoplasmic mu heavy chain+, B-cell antigen+, CD5-, CD10-,
surface light chain-
Plasma Cell Myeloma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-, CD20-,
CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+; IGH
and IGL gene rearrangements; numerical and structural chromosomal abnormalities are common,
including trisomies (often involving odd numbered chromosomes), deletions (most commonly involving
13q14), and translocations (often involving 14q32)
Solitary Plasmacytoma of Bone: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,
CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;
IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in
particular t(11;14)(q13;q32)
Extraosseous Plasmacytoma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,
CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;
IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in
particular t(11;14)(q13;q32)
Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue
(MALT Lymphoma): sIG+ (IGM or IGA or IGG), sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH
and IGL gene rearrangements, BCL1 and BCL2 germline, trisomy 3 or t(11;18)(q21;q21) may be seen
Nodal Marginal Zone Lymphoma: sIGM+, sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH and
IGL gene rearrangements, BCL1 and BCL2 germline
Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-/+, CD23-/+, CD43-,
CD11c-, CD25-; overexpression of BCL2+ (useful to distinguish from reactive follicles), BCL6+; IGH and IGL
gene rearrangements, t(14;18)(q32;q21) with rearranged BCL2 gene (70-95% in adults)

Pediatric Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-, CD23-/+,
CD43-, CD11c-, CD25-; overexpression of BCL2-, BCL6+, t(14;18) with rearranged BCL2 gene -
Primary Cutaneous Follicle Center Lymphoma: CD20+, CD79a+, CD10+/-, BCL2-/+, BCL6+, CD5-, CD43-,
BCL2 gene rearrangement-/+
Mantle Cell Lymphoma: sIGM+, sIGD+, lambda>kappa, PanB+, CD5+, CD10-/+, CD23-, CD43+, CD11c-,
CD25-, cyclin D1+; IGH and IGL gene rearrangements, t(11;14)(q13;q32); BCL1 gene rearrangements
(CCND1/cyclinD1) common
Diffuse Large B-Cell Lymphoma (DLBCL), NOS: PanB+, surface or cytoplasmic IGM>IGG>IGA, CD45+/-,
CD5-/+, CD10+/-, BCL6 +/-, 3q27 region abnormalities involving BCL6 seen in 30% of cases, t(14;18)
involving BCL2 seen in 20-30% of cases, MYC rearrangement seen in 10% of cases
T Cell/Histiocytic-Rich Large B-Cell Lymphoma: PanB+, BCL6+, BCL2-/+, EMA -/+, background comprised
of CD3 and CD5 positive T-cells and CD68+ histiocytes
Primary DLBCL of the CNS: CD20+, CD22, CD79a, CD10-/+, BCL6+/-, IRF4/MUM1+/-, BCL2+/-, BCL6
translocations+/-, del 6q and gains of 12q, 22q, and 18q21 common
Primary Cutaneous DLBCL, Leg Type: sIG+, CD20+, CD79a+, CD10-, BCL2+, BCL6+, IRF4/MUM1+, FOX-
P1+; translocations involving MYC, BCL6, and IGH genes are common
EBV-Positive Diffuse Large B-Cell Lymphoma of the Elderly: CD20+/-, CD79a+/-, CD10-, IRF4/MUM1+/-,
BCL6-, LMP+, EBER+
DLBCL Associated With Chronic Inflammation: CD20+/-, CD79a+/-, CD138-/+, IRF4/MUM1-/+, CD30-/+, T-
cells markers-/+, LMP+/-, EBER+/-
Lymphomatoid Granulomatosis: CD20+, CD30+/-, CD79a-/+, CD15-, LMP+/-, EBER+.
Primary Mediastinal (Thymic) Large B-Cell Lymphoma: sIG-/+, PanB+, (especially CD20, CD79a),
CD45+/-, CD15-, CD30-/+ (weak), IRF4/MUM1 +/-, BCL2+/-, BCL6+/-, CD23+, MAL+; IGH and IGL gene
rearrangements
Intravascular Large B-Cell Lymphoma: Pan B+ (CD19, CD20, CD22, CD79a), CD5-/+, CD10-/+,
IRF4/MUM1+
ALK-Positive Large B-Cell Lymphoma: ALK+, CD138+, EMA+, VS38+, CD45-/+, CD4-/+,
CD57-/+, CD20-, CD79a-, CD3-, CD30-/+, IRF4/MUM1-/+, t(2;17)(p23;q23)+/-, t(2;5)(p23;35)-/+
Plasmablastic Lymphoma: CD38+, CD138+, Vs38c+, IRF4/MUM1+, CD79a+/-, EMA +/-, CD30+/-, CD45-/+,
CD20-/+, PAX5-/+, EBER+/-, EMA+/-, CD30+/-
Large B-Cell Lymphoma Arising in HHV8-Associated Multicentric Castleman Disease: CD20+/-, CD79a-,
CD38-/+, CD138-, EBER-, lambda light chain restricted
Primary Effusion Lymphoma: CD45+/-, CD30+/-, CD38+/-, CD138+/-, EMA+/-, CD19-, CD20-, CD79a-,
CD3-/+, BCL6-, HHV8/KSHV+, EBV+/-, IGH and IGL gene rearrangements
Burkitt Lymphoma: sIGM+, PanB+, CD5-, CD10+, BCL6+, CD38+, CD77+, CD43+, CD23-; Ki-67 (95-100%),
BCL2-; TdT-, IGH and IGL gene rearrangements, t(8;14)(q24;q32) and variants t(2;8)(p12;q24) and

t(8;22)(q24;q11); rearranged MYC gene; EBV common (95%) in endemic cases and infrequent (15-20%)
in sporadic cases, intermediate incidence (30-40%) in HIV-positive cases
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma
and Burkitt Lymphoma: PanB+, CD10+, BCL6+, BCL2-/+, IRF4/MUM1-, Ki-67 (50-100%), 8q24/MYC
translocation (35-50%), BCL2 translocation (15%), and occasionally both translocations (so called double
hit lymphoma)
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma
and Classical Hodgkin Lymphoma: CD45+/-, CD20+/-, CD79a+/-, CD30+/-, CD15+/-, PAX-5+/-, OCT-2+/-,
BOB.1+/-, CD10-, ALK-
Mature T-Cell and NK-Cell Neoplasms
T-Cell Prolymphocytic Leukemia: PanT+ (CD2, CD3, CD5, CD7), CD25-, CD4+/CD8->CD4+/CD8+>CD4-
/CD8-, TCL1+, TdT-, CD1a-; TCR gene rearrangements, 75% show inv 14 with breakpoints at q11 and q32,
10% have a reciprocal tandem translocation t(14;14)(q11;q32)
T-Cell Large Granular Lymphocytic Leukemia: PanT+ (CD2, CD3+, CD5+/-), CD7-, TCR+, CD4-, CD8+,
CD16+, CD56-, CD57+, CD25-, TIA1+, granzyme B+, TdT-; most cases show clonal TCR gene
rearrangements
Chronic Lymphoproliferative Disorder of NK Cells: sCD3-, cCD3+, CD16+, CD56 (weak), TIA1+, granzyme
B+, CD8+/-, CD2-/+, CD7-/+, CD57-/+, EBV-, karyotype is typically normal
Aggressive NK-Cell Leukemia: CD2+, sCD3-, cCD3+, CD56+, TIA+/-, CD16+/-, CD57-, Fas ligand+, EBV+,
del(6)(q21q25) and del(11q) can be seen
Systemic EBV-Positive T-Cell Lymphoproliferative Disease of Childhood: CD2+, CD3+, TIA+, CD8+ (if
associated with acute EBV infection), EBER+, CD56-, TCR gene rearrangements+
Hydroa Vacciniforme-like Lymphoma: Cytotoxic T-cell or less often CD56+ NK-cell phenotype, EBER+/-,
TCR gene rearrangement+
Adult T-Cell Leukemia/Lymphoma (HTLV1+): PanT+ (CD2+, CD3+, CD5+), CD7-, CD4+, CD8-, CD10+,
CD25+, TdT-; TCR gene rearrangements, clonally integrated HTLV1
Extranodal NK/T-Cell Lymphoma: CD2+, CD5-/+, CD7-/+, CD3-/+, granzyme B+, TIA1+, CD4-, CD8-,
CD56+/-, TdT-; usually no TCR or Ig gene rearrangements; usually EBV positive
Enteropathy-associated T-cell Lymphoma: CD3+, CD7+, CD4-, CD8-/+, CD103+, TdT-
Hepatosplenic T-cell Lymphoma: CD2+, CD3+, TCR gamma-delta+, TCR alpha-beta rarely +, CD5-,
CD7+, CD4-, CD8-/+, CD56+/-, CD25-; TCRG gene rearrangements +/-, variable TCRB gene
rearrangements -/+; isochromosome 7q and trisomy 8 common
Subcutaneous Panniculitis-like T-Cell Lymphoma: CD8+, granzyme B+, TIA1+, perforin+, TCR alpha/
beta +, CD4-, CD56-
Lymphomatoid Papulosis: CD4+, CD2-/+, CD3+, CD5-/+, TIA1+, granzyme B+/-, CD30+/-; TCR gene
rearrangements+/-

Primary Cutaneous Anaplastic Large-Cell Lymphoma: CD4+, TIA1+/-, granzyme B+/-, perforin+/-, CD30+,
CD2-/+, CD5-/+, CD3-/+, CLA+, ALK-, EMA-/+; TCR gene rearrangements+/-
Primary Cutaneous Gamma-Delta T-Cell Lymphoma: TCR gamma/delta+, CD2+, CD3+, CD5-, CD56+,
CD7+/-, CD4-, CD8-/+, Beta F1-
Primary Cutaneous CD8-positive Aggressive Epidermotropic Cytotoxic T-cell Lymphoma: CD3+, CD8+,
granzyme B+, perforin+, TIA1+, CD45RA+/-, CD2-/+, CD4-, CD5-, CD7-, EBV-, Beta F1+; TCR gene
rearrangements (alpha/beta)+
Primary Cutaneous CD4-Positive Small/Medium T-Cell Lymphoma: CD3+, CD4+, CD8-, CD30-, TCR gene
rearrangements+
Peripheral T-Cell Lymphoma, NOS: PanT variable (CD2+/-, CD3+/-, CD5-/+, CD7-/+), most cases CD4+,
some cases CD8+, a few cases are CD4-/CD8-, or CD4+/CD8+; TCR gene rearrangements+
Angioimmunoblastic T-Cell Lymphoma: PanT+ (often with variable loss of some PanT antigens), usually
CD4+, PD1+, CXCL13+; TCR gene rearrangements in 75%; IGH gene rearrangements in up to 30%, EBV
often positive in B-cells
Anaplastic Large Cell Lymphoma, ALK Positive: CD30+, ALK+, EMA+/-, CD3-/+, CD2+/-, CD4+/-, CD5+/-,
CD8-/+, CD43+/-, CD25+, CD45+/-, CD45RO+/-, TIA1+/-, granzyme+/-, perforin+/-, EBV-, TCR gene
rearrangements+/-, t(2;5)(p23;35) in 80% of cases, t(1;2)(q25;p23) in 10-15% of cases. Other various
translocations can also be seen.
Anaplastic Large Cell Lymphoma, ALK Negative: CD30+ (strong/intense staining),
CD2+/-, CD3+/-, CD5-/+, CD4+/-, CD8-/+, CD43+, TIA1+/-, granzyme B+/-, perforin +/-, ALK-, TCR gene
rearrangements+
Histiocytic and Dendritic Cell Neoplasms
Histiocytic Sarcoma: CD45+, CD163+, CD68+, lysozyme+, CD45RO+/-, HLA-DR+/-, CD4+/-, S100-/+,
CD1a-, CD21-, CD35-, CD13, CD33, myeloperoxidase-, lack IGH and TCR gene rearrangements
Langerhans Cell Histiocytosis: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+,
most B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities
Langerhans Cell Sarcoma: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+, most
B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities
Interdigitating Dendritic Cell Sarcoma: S100+, vimentin+, CD1a-, langerin-, CD45+/-, CD68+/-,
lysozyme+/-, p53+/-, CD21-, CD23-, CD35-, CD34-, CD30-, myeloperoxidase-, most B and T-cell markers
are negative, lack IGH and TCR gene rearrangements
Follicular Dendritic Cell Sarcoma: Clusterin+, CD21+, CD35+, CD23+, KiM4p+, desmoplakin+, vimentin+,
fascin+, EDGR+, HLA-DR+, CD1a-, myeloperoxidase-, lysozyme-, CD34-, CD30-, CD3-, CD79a-, lack IGH
and TCR gene rearrangements
Disseminated Juvenile Xanthogranuloma: vimentin+, CD14+, CD68+, CD163+, factor XIIIa+/-, fascin+/-,
S100-/+, CD1a-, langerin-, lack IGH and TCR gene rearrangements

F. Clinical Prognostic Factors and Indices
The specific histologic type of the lymphoid neoplasm, stage of disease, as well as the International
Prognostic Index (IPI score) are the main factors used to determine treatment in adults. 13,21,28-33 The 5
pretreatment characteristics that have been shown to be independently statistically significant are: age
in years (≤60 versus >60); tumor stage I or II (localized) versus III or IV (advanced); number of extranodal
sites of involvement (0 or 1 versus >1); patient’s performance status (0 or 1 versus 2 to 4); and serum LDH
(normal versus abnormal). Based on the number of risk factors, patients can be assigned to 1 of 4 risks
groups: low (0 or 1), low intermediate (2), high intermediate (3), or high (4 or 5). Patients stratified by the
number of risk factors were found to have very different outcomes with regard to complete response
(CR), relapse-free survival (RFS), and overall survival (OS). 13 Studies show that low-risk patients had an
87% CR rate and an OS rate of 73% at 5 years compared to high-risk patients who had a 44% CR rate
and a 26% 5-year overall survival rate. 13 A revised IPI (R-IPI) has been proposed for patients with diffuse
large B-cell lymphoma who are treated with rituximab plus CHOP chemotherapy. 34 In pediatric cases,
there is no equivalent of the IPI, and prognosis is based on stage and type of lymphoma. 16
A separate prognostic index has become accepted for follicular lymphoma. The Follicular Lymphoma
International Prognostic Index (FLIPI) appears to provide greater discrimination and stratification among
patients with follicular lymphoma. 35 It evaluates 5 adverse prognostic risk factors including age (>60
years versus ≤60 years), Ann Arbor stage (III to IV versus I to II), hemoglobin level (4 versus ≤4) and serum LDH level (above normal level versus normal or
below). Patients are stratified into 3 risk groups: low risk (0-1 adverse factors), intermediate (2 adverse
factors) and poor risk (≥3 adverse factors).
Prognostic indices are also under development in other lymphoid neoplasms such as mantle cell
lymphoma and T-cell lymphomas.
Although not always provided to the pathologist by the physician submitting the specimen, certain
specific clinical findings are known to be of prognostic value in all stages of NHL. In particular, systemic
symptoms of fever (greater than 38°C), unexplained weight loss (more than 10% body weight) in the
6 months before diagnosis, and drenching night sweats are used to define 2 categories for each stage
of NHL: A (symptoms absent) and B (symptoms present). The presence of B symptoms is known to
correlate with extent of disease (stage and tumor bulk), but symptoms also have been shown to have
prognostic significance for cause-specific survival that is independent of stage. 6,28-33,36
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Wiley-Liss; 2001:689-703.
7. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone Elsevier; 2007.

8. Craig F, Foon K. Flow cytometric immunophenotyping for hematologic neoplasms. Blood.
2008;111(8):3941-3967.
9. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid neoplasms: a
report from the Association of Directors of Anatomic and Surgical Pathology. Mod Pathol.
2004;17(1):131-135.
10. Bagg A. Molecular diagnosis in lymphomas. Curr Oncol Rep. 2004;6(5):369-379.
11. Carbone P, Kaplan H, Musshoff K, et al. Report of the Committee on Hodgkin’s Disease Staging
Classification. Cancer Res. 1971;31(11):1860-1861.
12. Lister T, Crowther D, Sutcliffe S, et al. Report of a committee convened to discuss the evaluation
and staging of patient’s with Hodgkin’s disease: Cotswolds meeting. J Clin Oncol. 1989;7(11):1630-
1636.
13. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC Cancer
Staging Manual. 7 th ed. New York, NY: Springer; 2009.
14. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant Tumours. 7th
ed. New York, NY: Wiley-Liss; 2009.
15. Durie B, Salmon S. A clinical staging system for multiple myeloma: correlation of measured
myeloma mass with presenting clinical features, response to treatment, and survival. Cancer.
1975;36(3):842-854.
16. Cairo, et al. Non-Hodgkin’s lymphoma in children. In: Kufe P, Weishelbuam R, et al, eds. Cancer
Medicine. 7 th ed. London: BC Decker; 2006:1962-1975.
17. Armitage J. Staging non-Hodgkin lymphoma. CA Cancer J Clin. 2005;55(6):368-376.
18. Ansell S, Armitage J. Non-Hodgkin lymphoma: diagnosis and treatment. Mayo Clin Proc.
2005;80(8):1087-1097.
19. Kwee T, Kwee R, Nievelstein R. Imaging in staging malignant lymphoma: a systematic review. Blood.
2008;111(2):504-516.
20. Olsen E, Vonderheid E, Pimpinelli N, et al. Revisions to the staging and classification of mycosis
fungoides and Sézary syndrome: a proposal of the International Society for Cutaneous Lymphomas
(ISCL) and the cutaneous lymphoma task force of the European Organization of Research and
Treatment of Cancer (EORTC). Blood. 2007;110(6):1708-1709.
21. Zelenetz A, Hoppe R. NCCN: non-Hodgkin’s lymphoma. Cancer Control. 2001:8(6 suppl 2):102-113.
22. Arber DA. Molecular approach to non-Hodgkin’s lymphoma. J Mol Diagn. 2000:2(4);178-190.
23. Bagg A. Role of molecular studies in the classification of lymphoma. Expert Rev Mol Diagn.
2004;4(1):83-97.
24. Sen F, Vega F, Medeiros LJ. Molecular genetic methods in the diagnosis of hematologic neoplasms.
Semin Diagn Pathol. 2002;19(2):72-93.
25. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid
neoplasms: a proposal from the International Lymphoma Study Group. Blood. 1994;84(5):1361-1392.
26. Chan JK, Banks PM, Cleary ML, et al. A revised European-American classification of lymphoid
neoplasms: a proposal from the International Lymphoma Study Group: a summary version. Am J
Clin Pathol. 1995;103(5):543-560.
27. Nguyen D, Diamond L, Braylan R. Flow Cytometry in Hematopathology: A Visual Approach to Data
Analysis and Interpretation. Totowa, NJ: Humana Press; 2003.
28. A predictive model for aggressive non-Hodgkin’s lymphoma: The International Non-Hodgkin’s
Lymphoma Prognostic Factors Project. N Engl J Med. 1993;329(14):987-994.
29. Shipp M. Prognostic factors in aggressive non-Hodgkin lymphoma. Blood. 1994;83(5):1165-1173.
30. Hoskins PJ, Ng V, Spinelli JJ, et al. Prognostic variables in patients with diffuse large-cell lymphoma
treated with MACOP-B. J Clin Oncol. 1991;9(2):220-226.
31. Cowan RA, Jones M, Harris M, et al. Prognostic factors in high and intermediate grade non-Hodgkin
lymphoma. Br J Cancer. 1989;59(2):276-282.
32. Gospodarowicz MK, Bush RS, Brown TC, et al. Prognostic factors in nodular lymphomas: a
multivariate analysis based on the Princess Margaret Hospital experience. Int J Radiat Oncol Biol
Phys. 1984;10(4):489-497.

33. Osterman B, Cavallin-Stahl E, Hagberg H, et al. High-grade non-Hodgkin lymphoma
stage I: a retrospective study of treatment, outcome, and prognostic factors in 213
patients. Acta Oncol.
1996;35(2):171-177.
34. Sehn L, Berry B, Chhanabhai M, et al. The revised International Prognostic Index (R-IPI) is
a better predictor of outcome than the standard IPI for patients with diffuse large B-cell
lymphoma treated with R-CHOP. Blood. 2007;109(5):1857-1861.
35. Solal-Celigny P, Roy P, Colombat P, et al. Follicular Lymphoma International Prognostic
Index.
Blood. 2004;104(5):1258-1265.
36. Velasquez WS, Jagannath S, Tucker SL, et al. Risk classification as the basis for clinical
staging of diffuse large-cell lymphoma derived from 10-year survival data. Blood.
1989;74(2):551-557.
18

Protocol for the Examination of Specimens from Patients
with Hodgkin Lymphoma
Protocol applies to Hodgkin lymphoma involving any site. #
Based on AJCC/UICC TNM, 7 th Edition
Protocol web posting date: October 2009
Procedures
Biopsy
Resection of Lymph Node(s) or Other Organ(s)
Authors
Jerry W. Hussong, MD, DDS, FCAP*
Cedars-Sinai Medical Center, Los Angeles, California
Daniel A. Arber, MD
Stanford University School of Medicine, Stanford, California
Kyle T. Bradley MD, MS, FCAP
Emory University Hospital, Atlanta, Georgia
Michael S. Brown, MD, FCAP
Yellowstone Pathology Institute Inc, Billings, Montana
Chung-Che Chang, MD, PhD, FCAP
The Methodist Hospital, Houston, Texas
Monica E. de Baca, MD, FCAP
Physicians Laboratory Ltd, Sioux Falls, South Dakota
David W. Ellis, MBBS, FRCPA
Flinders Medical Centre, Bedford Park, South Australia
Kathryn Foucar, MD, FCAP
University of New Mexico, Albuquerque, New Mexico
Eric D. Hsi, MD, FCAP
Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
National Cancer Institute, Bethesda, Maryland
Michael Lill, MB, BS, FRACP, FRCPA
Cedars-Sinai Medical Center, Los Angeles, California
Stephen P. McClure, MD
Presbyterian Pathology Group, Charlotte, North Carolina
L. Jeffrey Medeiros, MD, FCAP
MD Anderson Cancer Center, Houston, Texas
Sherrie L. Perkins, MD, PhD, FCAP
University of Utah Health Sciences Center, Salt Lake City, Utah
For the Members of the Cancer Committee, College of American Pathologists
*denotes the primary and senior author. All other contributing authors are listed alphabetically.
© 2009 College of American Pathologists (CAP). All rights reserved.
A. Specimen
Any number of specimen types may be submitted in the evaluation of Hodgkin lymphoma.
Lymph nodes, mediastinal masses, bone marrow, spleen, lung, and liver are among the most
common. Specimens submitted with a suspected diagnosis of Hodgkin lymphoma require
special handling in order to optimize the diagnosis. Often, lymph node specimens are submitted
19

where the differential diagnosis includes both Hodgkin and non-Hodgkin lymphomas, and, if
possible, tissue should be obtained for possible molecular and other ancillary studies, which are
often necessary for the diagnosis of non-Hodgkin lymphomas. 1,2 Most flow cytometry,
molecular, and cytogenetic studies will not aid in the diagnosis of Hodgkin lymphoma.
Immunophenotyping by immunohistochemical staining is necessary in the initial diagnosis of
nearly all cases of Hodgkin lymphoma. Because of this, well-fixed sections are of paramount
importance. The guidelines detailed below are suggested for specimen handling in cases of
suspected Hodgkin lymphoma.
Tissue should be received fresh. Unsectioned lymph nodes should not be immersed
in fixative, and care should be taken to make thin (2 mm) slices perpendicular to the long
axis of the node to ensure optimal penetration of fixative.
The fresh specimen size, color, and consistency should be recorded, as should the
presence or absence of any visible nodularity, hemorrhage, or necrosis.
Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol
or air dried. Unstained air-dried imprints can be used for fluorescence in situ hybridization
(FISH) or other studies if necessary.
For microbiology studies: submit a fresh portion of the lymph node (or other specimen type)
sterilely in appropriate medium.
Flow cytometry immunophenotyping is not routinely used in the diagnosis of Hodgkin
lymphoma, but if the differential diagnosis includes non-Hodgkin lymphoma, a fresh portion
of the specimen should be submitted in appropriate transport medium such as RPMI.
Fixation (record fixative[s] used for individual slices of the specimen):
o Estimated time from excision to fixation should be noted, if possible, as this may impact
preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed
tissues.
o Zinc formalin or B+ produces superior cytologic detail but is not suitable for DNA
extraction and may impair some immunostains (eg, CD30). B+ also has the additional
limitation of requiring proper hazardous materials disposal.
o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for
immunohistochemistry as well as many other ancillary tests such as molecular/genetic
studies and in-situ hybridization.
o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or
B+) should be avoided for optimal immunophenotypic reactivity.
B. Tumor Site
Hodgkin lymphomas are nearly always nodal based with cervical lymph nodes more commonly
involved. It can also frequently be seen involving mediastinal, axillary, and paraaortic lymph
nodes. Extranodal Hodgkin lymphoma can rarely be seen. The anatomic distribution of
Hodgkin lymphoma, however, varies depending on the histologic type. 3
C. Histologic Type
This protocol recommends assigning histologic type based on the World Health Organization
(WHO) classification of lymphoid neoplasms. 4 It was originally published in 2001 and more
recently revised and updated in 2008. 4,5 This classification encompasses both Hodgkin and
non-Hodgkin lymphomas and allows distinction of individual lymphoid neoplasms based upon
morphologic, immunophenotypic, cytogenetic, and clinical features. While histologic
examination typically is thought to be the gold standard, the majority of Hodgkin lymphomas will
require immunohistochemical staining, especially at the time of initial diagnoses. 4-9 In addition,
while Hodgkin lymphomas are currently divided into nodular lymphocyte predominant Hodgkin
lymphoma and classical Hodgkin lymphomas (including nodular sclerosis, mixed cellularity,
20

lymphocyte-rich, and lymphocyte-depleted subtypes), it should be recognized that classical
Hodgkin lymphomas may not represent a single disease. In addition, there is overlap between
some cases of Hodgkin lymphoma and non-Hodgkin lymphoma, particularly diffuse large B-cell
lymphomas (so-called gray zone lymphomas). 4,10
D. Pathologic Extent of Tumor (Stage)
The TNM classification is not used for staging Hodgkin lymphomas because the site of origin of
the tumor is often unclear and there is no way to differentiate among T, N, and M. The Cotswold
revision of the Ann Arbor staging classification is used for Hodgkin lymphoma. 11,12 It was
originally published over 30 years ago.
Pathologic staging depends on the biopsy of multiple lymph nodes on both sides of the
diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of
disease.
Currently, staging for Hodgkin lymphoma is more commonly clinical than pathologic. Clinical
staging generally involves a combination of clinical, radiologic, and surgical data. Physical
examination, laboratory tests, imaging studies (eg, computed tomography [CT] scans, magnetic
resonance imaging [MRI] studies, and positron emission tomography [PET]), biopsy (to
determine diagnosis, histologic type, and extent of disease), and bone marrow examination are
often required. Correct diagnosis and staging are the key factors in providing appropriate
treatment. 13-15
Cotswold Revision of the Ann Arbor Staging Classification of Hodgkin
Lymphomas 13,14
Stage I Involvement of a single lymph node region (I), or lymphoid structure (eg, spleen,
thymus, Waldeyer’s ring). #
Stage II Involvement of 2 or more lymph node regions on the same side of the diaphragm
(II) (the mediastinum is considered a single site). ##
Stage III Involvement of lymph node regions on both sides of the diaphragm (III) which
may be accompanied by extralymphatic extension in association with lymph node
involvement (IIIE) or splenic involvement (IIIS).
Stage IV Involvement of extranodal site(s) beyond those designated E.
# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage
IV.
## The number of lymph node regions involved may be indicated by a subscript: eg, II 3 .
E designates involvement of a single extranodal site or contiguous or proximal known nodal site
of disease.
E. Immunophenotyping
Immunophenotyping by flow cytometry and molecular testing by polymerase chain reaction
(PCR) are currently not typically used or are not necessary for the diagnosis of Hodgkin
lymphoma. Immunophenotyping using immunohistochemistry is necessary for the initial
diagnosis of nearly all cases of Hodgkin lymphoma. It requires well-fixed tissue sections for
optimal immunohistochemical staining and interpretation.
21

Immunophenotypes 1,4-8
The following is to be used as a guideline for the more common immunophenotype for each
subtype of Hodgkin lymphoma. It is however, not entirely comprehensive and individual cases
may vary somewhat in their immunophenotypic profile.
Nodular lymphocyte predominant Hodgkin lymphoma: Lymphocyte predominant cells (LP cells;
previously called L&H cells) are CD20+, CD79a+, PAX5+, CD45+, BCL6+, OCT-2+, BOB.1+,
EMA +/-, CD15-, CD30-, CD43-, EBER-.
Nodular sclerosis classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+,
BOB.1-/+, EMA-
Mixed cellularity classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+,
BOB.1-/+, EMA-
Lymphocyte-rich classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+,
BOB.1-/+, EMA-
Lymphocyte-depleted classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+, BOB.1-/+, EMA-
F. Clinical Prognostic Factors and Indices
The International Prognostic Score (IPS) was developed for Hodgkin lymphoma to predict
outcome based on the following adverse factors: serum albumin

3. Shimabukuro-Vornhagen A, Haverkamp H, Engert A, et al. Lymphocyte-rich classical
Hodgkin’s lymphoma: clinical presentation and treatment outcome in 100 patients treated
within German Hodgkin’s Study Group trials. J Clin Oncol. 2005; 23(24):5739-5745.
4. Swerdlow S, Campo E, Harris N, Jaffe E, Pilero S, Stein H, Thiele J, Vardiman J, eds.
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Geneva,
Switzerland: WHO Press; 2008.
5. Jaffe ES, Harris NL, Stein H, Vardiman JW, eds. Pathology and Genetics of Tumours of
Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2001. World Health
Organization Classification of Tumours, Vol. 3.
6. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone
Elsevier; 2007.
7. Zukerberg L, Collins AB, Ferry JA, Harris NL. Coexpression of CD15 and CD20 by Reed-
Sternberg cells in Hodgkin’s disease. Am J Pathol. 1991; 139(3):475-483.
8. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid
neoplasms: a report from the Association of Directors of Anatomic and Surgical Pathology.
Mod Pathol. 2004; 17(1):131-135.
9. Stein H, Marafioti T, Foss H, et al. Down-regulation of BOB.1/OBF.1 and Oct2 in classical
Hodgkin disease but not in lymphocyte predominant Hodgkin disease correlates with
immunoglobulin transcription. Blood. 2001; 97(2):496-501.
10. Mani H, Jaffe E. Hodgkin lymphoma: an update on its biology with new insights into
classification. Clin Lymphoma Myeloma. 2009; 9(3):206-216.
11. Carbone P, Kaplan H, Musshoff K, et al. Report of the Committee on Hodgkin’s Disease
Staging Classification. Cancer Res. 1971; 31(11):1860-1861.
12. Lister T, Crowther D, Sutcliffe S, et al. Report of a committee convened to discuss the
evaluation and staging of patient’s with Hodgkin’s disease: Cotswolds meeting. J Clin
Oncol. 1989;7(11):1630-1636.
13. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC
Cancer Staging Manual. 7 th ed. New York, NY: Springer; 2009.
14. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant
Tumours. 7th ed. New York, NY: Wiley-Liss; in press.
15. Kwee T, Kwee R, Nievelstein R. Imaging in staging malignant lymphoma: a systematic
review. Blood. 2008; 111(2):504-516.
16. Hasenclever D, Diehl V. A prognostic score for advanced Hodgkin’s disease: International
Prognostic Factors Project on Advanced Hodgkin’s Disease. N Engl J Med. 1998;
339(21):1506-1514.
17. Allemani C, Sant M, De Angelis R, et al. Hodgkin disease survival in Europe and the U.S.:
prognostic significance of morphologic groups. Cancer. 2006; 107(2):352-360.
18. Vassilakopoulos T, Angelopoulou M, Siakantaris M, et al. Prognostic factors in advanced
stage Hodgkin’s lymphoma: the significance of the number of involved anatomic sites. Eur
J Haematol. 2001; 67(5-6):279-288.
19. Sup J, Alemany C, Pohlman B, et al. Expression of bcl-2 in classical Hodgkin’s lymphoma:
an independent predictor of poor outcome. J Clin Oncol. 2005;23(16):3773-3779.
20. Rautert R, Schinkothe T, Franklin J, et al. Elevated pretreatment interleukin-10 serum level
is an International Prognostic Score (IPS)-independent risk factor for early treatment failure
in advanced stage Hodgkin lymphoma. Leuk Lymphoma. 2008; 49(11):2091-2098.
21. Rassidakis G, Medeiros LJ, Vassilakopoulos T, et al. Bcl-2 expression in Hodgkin and
Reed-Sternberg cells of classical Hodgkin lymphoma predicts a poorer prognosis in
patients treated with AVBD or equivalent regimens. Blood. 2002; 100(12):3935-3941.
23

Immunohistochemistry

Immunostains/In-Situ Hybridization Laboratory and Ordering
Information
Immunostain Turnaround Time
IHC Routine runs: All orders received before 10:00am should be sent out the same day by
5:30pm (i.e. Monday through Friday) provided the laboratory has the block (or slides). There
are a few stains (e.g. EBER, SV40, TdT, and antibody reactions on frozens) that require longer
incubations and these may be delayed by one day. Orders received after 10:00am will be out
the following morning by the 8:30am courier.
The Immunohistochemistry Laboratory is located at the CLB and personnel can be reached at
647-7663.
A list of the antibodies we use most frequently and a complete list with codes are included in the
manual.
ORDERING OF IMMUNOSTAIN PANELS
It is strongly recommended that the Audix voicemail (412-803-3273) is utilized when ordering
stains in order to facilitate delivery to Hematopathology.
If ordering after hours, the stain panels must now be ordered as Stain/Process Group Protocols
(see separate list).
(Unlike a Histology Protocol, a Stain/Process Group Protocol will not write over stains that have
been previously ordered on the same part)
To order one of the protocols:
1. If you are ordering the panel using the “Accession Entry/Edit” or “Histology Entry/Edit”
activities:
• Go to the Histology tab.
• Select the part (and/or block) on which you wish to order the panel.
• Then click on the “Run Stain/Process Group…” button.
• Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run
Stain/Process Group Protocol” pop up window.
• Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the
“Run Stain/Process Group Protocol” pop up window.

2. If you are ordering the panel using the “Stain/Process and Block Edit” activity:
• Select the part (and/or block) on which you wish to order the panel.
• Click on the “Add Stain/Process…” button.
• Clinical on the “Run Stain/Process Group…” button.
• Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run
Stain/Process Group Protocol” pop up window.
• Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the
“Run Stain/Process Group Protocol” pop up window.
In the comment field enter” Please deliver to Hematopathology” – otherwise the slides may end
up in your mailbox!!
If you have any questions, please contact AP User Support via e-mail or at 647-9170
ORDERING EXPERIMENTAL STAINS (ANTIBODIES NOT YET IN COMPUTER)
If being done in the routine immunohistology laboratory, order under ABNKNC. Specify desired
stain in the comment of ABNKNC.
If being done in the in situ laboratory order 2 blanks (IBNKNC) and write in comment to sent to
insitu laboratory for_________.
Reporting of Immunostains/in-situ hybridization
The template should always be utilized and follows the general microscopic description.

Stains Frequently Used In Hematopathology: Codes and Reactivities
Here’s a list of markers that are used commonly on the Lymph Node Service and their secret
Client Server code-names. See also the Hematopathology worksheet since its best to order via
panels.
Antigen /
Marker
C/S Codename
Cell-type/s
CD1a ACD1 Thymocytes, Langerhans Cells
CD2 ACD2 T-cells, NK-cells
CD3 ACD3 T-cells, NK-cells
CD4 ACD4 T-cells, Macrophage
CD5 ACD5 T-cells, SLL/CLL & Mantle cell
lymphoma, B-cell subset
CD7 ACD7 T-cells, NK-cells
CD8 ACD8 T-cells, NK-cells
CD10 ACD10 Lymphoblasts, Follicular center
(CALLA)
cells, Granulocytes, Some
epithelial cells/neoplasms,
Follicular T-cells
CXCL-13 ACXCL13 Follicular T helper cells
PD-1 APDT Follicular T helper cells
CD15 (Leu- ALEUM1 R-S cells, CMV-infected cells,
M1)
Some carcinomas
CD20 (L26) AL26 B-cells
CD21 ACD21 Follicular dendritic cells, Some B-
cells
CD22 ACD22 B-cells
CD23 ACD23 Follicular dendritic cells,
SLL/CLL, Normal mantle cells
CD30 (Ki-
1/Ber-H2)
ACD30
R-S cells, Activated T & B-cells,
Some lymphomas, Embryonal
carcinoma
CD31 ACD31 Endothelium
CD33 ACD33 Myeloid
CD34 ACD34 Blasts, Endothelium, Various
mesenchymal neoplasms
CD43 ACD43 T-cells, Myeloid cells, B-cell
subset, SLL/CLL, Mantle cell
lymphoma, Other B-cell
lymphomas, Not most follicular
lymphomas
CD45 (LCA) ALCA All leukocytes
CD45RA
(4KB5)
ACD45R B-cells, Plasmacytoid dendulic
cells
CD45RO AUCHL1 T-cells, Macrophages
(UCHL-1)
CD56 ACD56 NK-cells, “NK-like” T-cells; Some
malignant myeloblasts,
lymphoblasts & plasma cells
(multiple myeloma)
Comment

CD57 (Leu
7)
ALEU7 NK-cells, Neural tissues, T-cell
subset in follicles
CD61 ACD61B Megakaryocytes
CD68 ACD68 Monocyte/Macrophage, Many
Melanomas!
CD79a ACD79 B-cells
CD99 AEWING Blasts, Ewing Sarcoma
CD138 ACD138 Plasma cells, R-S cells, Some
epithelial cells
Alk-1 AALK Anaplastic large cell lymphoma
(systemic)
TIA-1 ATIA T-cells & NK-cells with cytolytic
granules
Granzyme B AGRANZ Cytotoxic T-cells and NK cells
Clusterin ACLUST Positive staining in anaplastic
large cell lymphomas
Bcl-2 ABCL2 Many normal cells but NOT
NORMAL germinal center cells;
Majority of low grade follicular
lymphomas, fewer intermediate
grade ones; Many other
lymphomas
Cyclin-D1
(bcl-1)
ACYCLD
Mantle cell lymphoma, Some
multiple myelomas, Epithelial
cell/neoplasms
Bcl-6 ABCL6 Germinal center B-cells (follicular
center cells); Many diffuse large
B-cell lymphomas
Ki-67 (MIB-
1)
TdT(Termina
l-
deoxynucleo
tidyl
Transferase)
MPO
(Myeloperoxi
dase)
AKI67
ATDT
AMPO
Proliferation marker (G1/S/G2/M
phases)
Lymphoblasts; Sometimes
myeloblasts (

Beta-F1 ABF1 Beta-F1 T-cell receptor chain on
T-cells
Glycophorin- AGLYP RBC’s and their precursors
A
PAX5 APAX5 B-cells (nuclear stain)
EBV EBER-
ISH
IEBER Epstein-Barr Virus Encoded
mRNA (in situ hybridization)
Kappa IRKAP Ig light chain kappa mRNA (in
mRNA-ISH
situ hybridization)
p27 AP27 Pos in indolent B-cell lymphomas
but not MCL
Lambda IRLAM Ig light chain lambda mRNA (in
mRNA-ISH
situ hybridization)
Kappa/Lamb IKPLM Kappa is black /Lambda is redorange
da double
(antibody stain performed
stain
in in-situ hybridization lab)
Bartonella CABART Bartonella henselae
henselae
stain
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group

Complete Immunohistochemical Stain Abbreviations/Codes
See online library for detailed information re: clones, etc
http://aplis.upmc.edu/aplis/resources/index.cfm
Antibody
Actin - Smooth muscle (SMA)
Actin All Muscle
Adenovirus
Adhalin
Adrenocorticotropic Hormone
AE1
AE1/3
AE3
Albumin
Alpha 1 Antichymotrypsin
Alpha 1 Antitrypsin
Alpha-Fetoprotein
Alzheimer beta Amyloid
Amyloid A
Amyloid P
Anaplastic Lymphoma Kinase
androgen receptor
Annexin-1
APP
B72.3/TAG Tumor Glycoprotein
Bartonella Henselae
Bcl-2 Oncoprotein
BCL6
BerEP4
Beta Catenin
BetaF1 T-cell Receptor
BHCG
BK Virus
BOB1
BRACHYURY
Test Code
AACTIN
AMA
Adenovirus
Adhalin
ACTH
AE1
AE1/3
AE3
Albumin
AACT
AAT
AFP
A4G8
Amyloid A
Amyloid P
AALK1
AAR
Annexin-1
APP
ATAG
Bhenselae
ABCL2
ABCL6
ABEREP4
ABCATN
ABF1
ABHCG
ABKV
ABOB1
BRACHYURY

BRAF
BRAF-GI
C1Q Complement
AC1Q
C4d
AC4D
C4d Frozen
AC4Df
C5B-9 Membrane Complex
APMAC
CA125
ACA125
CA19.9
YCA199
CA9
ACA9
Calcitonin
ACALCI
Caldesmon
ACALDES
Calponin
ACALP
Calretinin
ACALRET
CAM 5.2 CAM 5.2
Caveolin-1
ACAVEOLIN-1
CD10 (CALLA)
ACD10
CD117 C-KIT
CD117
CD138
ACD138
CD15
ACD15
CD1a
ACD1A
CD2
ACD2
CD20 - L26
CD20
CD21
CD21
CD22
CD22
CD23
CD23
CD25 INTERLEUKIN2
ACD25
CD3
CD3
CD30
CD30
CD31
ACD31
CD33
CD33
CD34
CD34
CD4
CD4
CD4 Frozen
CD4f
CD43
CD43
CD45RA
CD45RA
CD45RO - OPD4
CD4

CD5
CD5
CD56
CD56
CD57
CD57
CD61
CD61
CD68
CD68
CD7
CD7
CD79a
CD79a
CD8
CD8
CD99 - Ewing
CD99
CDX2
CDX2
CEA
ACEA
CEA-M
CEAM
Chromogranin
ACHROMO
CITED-1
ACITED-1
CKIT - CD117
ACKIT
CLUSTERIN
ACLUST
COLLAGEN IV
ACOL4
Connexin 43
COX2 - Cyclooxygenase-2
ACOX2
CRP
CRP
CXCL13 CXCL 13
Cyclin D1 - BCL-1
ACYCLD1
Cytokeratin - Pan Keratin
APANKLAM
Cytokeratin 19
ACK19
Cytokeratin 20 - CK20
ACK20
Cytokeratin 5
CK5
Cytokeratin 5/6 - CK5/6
ACK5/6
Cytokeratin 7 - CK7
ACK7
Cytokeratin AE1/AE3 - CK AE1/3
AE1/3
Cytomegalovirus
ACMV
D2-40 AD240
Desmin
ADESMIN
DOG1
DOG1
Dysferlin
ADYSF
Dystrophin1
DYS1

Dystrophin2
DYS2
E-Cadherin
ECAD
EGFR
AEGFR
EMA
AEMA
Epstein Barr virus - EBV
AEBV
ER
AER
ERG
ERG
Ewing sarcoma - CD99
AEWING
Factor 8 - vonWildebrand
AVWF
Factor XIIIa
AXIII
Fibrinogen
FIBRINOGEN
FLI1
FLI-1
Fmac
AFMAC
Follicle Stim. Hormone
FSH
FUMARATE HYDRATASE
FUM-HYD
Galectin-3
Galectin-3
Gastrin
Gastrin
GCDFP15
AGCDFP
Glial Fibrillary Acidic Protein - GFAP AGFAP
Glucagon
GLUC
Glut-1
AGLUT1
Glutamine Synthetase
AGLUTSYNTH
Glycophorin A
AGLYP
Glypican-3
GPC-3
Granzyme B
AGRANZB
Growth Hormone
AGH
H. pylori HPYL
HBME-1
AHBME
Hemoglobin
AHEMO
Hepatitis B Core
AHBCOR
Hepatitis B Surface
AHBS
Hepatitis C
AHEPC
HepPar 1 Hepatocytes
AHEPAR
Her-2/neu c-erb
ANEU
Herpes Simplex Virus I & II
AHSV12

HHV8
HMB45 Melanoma
HPV Papilloma Virus
HSP70
HSV1
HSV2
IDH1
IgA
IgD
IgG
IgG4
IgM
Inhibin Alpha
Insulin
Interleukin2 - CD25
J chain of IgA+IgM
Kappa amyloid
Kappa Light Chain
KI67 Proliferating Cells
KI67 Proliferating Cells
LAM/PANK
Lambda BM
Lambda Light Chain
Laminin
LAMY
Langerin
LCA, CD45 Monoclonal
Leu M1 - CD15
LN3 HLADR
Lutenizing Hormone
Lysozyme
LYVE1 BROWN
Mac 387 macrophage
Mammaglobin
MCPyV
HHV8ip
AHMB45
AHPV
AHSP70
HSV1
HSV2
IDH1
AIGA
AIGD
AIGG4
AIGG4
AIGM
AINHIB
AINSU
ACD25
AJ
AKAPY
AKAPPA
Ki67
Ki67
APANKLAM
LAMBDABM
ALAMBDA
ALAM
ALAMY
LANG
LCAMH
ACD15
ALN3
ALH
ALYSO
LYVE1 BROWN
AMC387
AMAMA
MCPYV

Melan A/Melanoma
MELANA
Merosin Frozen
MHC1
AMHC1
MITF DAB
AMITFD
Mitochondrial
MITOC
MLH1 Homolog
MLH1
MOC-31
MOC31
MSH2
MSH
MSH6
AMSH6
MUC-1
AMUC1
MUC-2
AMUC2
MUC-4
AMUC4
MUC-5AC
AMUC5AC
MUC-6
AMUC6
MUM-1
AMUM1
Myeloperoxidase
AMPO
Myogenin
AMYOGN
Myoglobin
AMYO
Myosin Heavy Chain
ASMYOS
N-Cadherin
Napsin A
ANAPA
NEUN
ANEUNUC
Neurofilament
ANFIL
Neuron Specific Enolase
ANSE
Neutrophil Elastase
ANEUNUC
NKIC3 melanoma
ANKIC3
OCT_2
Oct_2
OCT3/4
OCT3/4
OPD4 (CD45RO)
AOPD4
Osteocalcin
AOC
Osteonectin
AON
P16
AP16
P21, WAF1 AP21
P27
AP27
P40
AP40

P501S
P504S
P53 Tumor Suppressor Protein
P63 Tumor Suppressor Protein
P75 NGF
P903
Pan Cytokeratin
Pancreatic Polypeptide
PANK (for PANK/LAM DS)
Parathyroid Hormone
Parvalbumin
Parvovirus
Pax-5, B-cell Specific Activator Protein
PAX-8
PD1
PGP 9.5 Neuroendocrine
PIN4
Plakoglobin
PLAP
PMAC P5B
PMS2
Pneumocystis carinii
PPARgamma
PREA ATTR
Progesterone Receptor
Prolactin
Prostate Specific Acid Phosphatase
Prostatic Specific Antigen
Prostate Specific Membrane Antigen
PSTAT3
Renal Cell Carcinoma
Respiratory Syncytial Virus
S100
Sarcomeric Actin
Serotonin
P501S
AP504S
AP53
AP63
P75
AP903
CKPAN
APP
APANKLAM
APTH
APARV1
APARVO
APAX5
PAX8
PD1
APFP
APIN4
PLAP
PMAC
PMS2
APCAR
PPARg
ATTR
APR
APRO
APAP
APSA
PSMA
APSTAT
ARCC
ARSV
AS100
ASACT
ASERO

SMAD4
Smoothelin
Somatostatin
SOX11
Surfactant Protein A
SV40 papova virus
Synaptophysin
TAG-72
TAU
Terminal Deoxynucleotide Transferase - TdT
TDP43
TFE3
Thrombomodulin
Thyroglobulin
TIA1 granzyme
Toxoplasma
Treponema pallidum
Trypsin
TRYPTASE
TSH
TTF-1
Tyrosinase
Ubiquitin
UCHL1 CD45RO
Ulex Europaeous Lectin
UP III
Varicella zoster
VEGF, Vascular Endothelial Growth Factor
Vimentin
WT-1
SMAD4
SMOOTHELIN
ASOMAT
SOX11
ASPA
ASV40
ASYNP
ATAG
TAU
TDT
TDP-43
TFE3
ATHROMBO
ATHYRO
ATIA1
ATOXO
ATREP
TRYP
TRYPTASE
ATSH
TTF1
ATYROS
AUBQ
AUCHL1
AULEX
AUPIII
AVZV
AVEGF
AVIMEN
AMESO

CODES FOR DOUBLE LABELING
ICKDE
AE1/AE3 and desmin
ICKAC
ICKMI
AE1/AE3 and actin (HHF35)
AE1/AE3 and MIB-1
In all cases cytokeratin staining will be red (AEC) and the second antibody will be black (Nickel enhanced
DAB).
IKPLM
Kappa (black) and Lambda (red)
IBT
T-cell (CD3-black) and B-cell (L26/CD20-red)
IN-SITU HYBRIDIZATION PROBES AVAILABLE
Insitu (Brightfield)
iADV Adenovirus
iBKV BKV insitu
iCMV CMV insitu
iEBER EBER probe for EBV mRNA (Ventana)
iHPV HPV probe panel (manual method)
i1618 HPV 16,18,31,33,35,39,45,51,52,56,58,66 subtype (high)(Ventana)
i611
HPV 6+11 subtype (low) (Ventana)
iHSV HSV probe
iJCV
JC virus probe
iRLAM mRNA for Lambda light chain restriction (Ventana)
iRKAP mRNA for Kappa chain restriction (Ventana)
IHC testing in ISH Laboratory
aMIT Mitochondrial antibody
aPALABU Kidney
aBAPP Neuropathology

IHC/ISH Reporting
Templates

PHS/B:______________________
PARAFFIN SECTION IMMUNOHISTOCHEMISTRY/IN-SITU HYBRIDIZATION
Name:______________________
In order to characterize ___________________, paraffin section immunohistologic/in-situ hybridization studies were performed on
___________________.
The following results were found:
Antigen/Antibody
anti-kappa
kappa mRNA-ISH
anti-lambda
lambda mRNA-ISH
anti-IgG
anti-IgG4
anti-IgA
anti-IgM
anti-IgD
CD20/L26
CD22
CD79a
PAX 5
CD21
CD23
CD138
J chain
BCL2
BCL2 E17
MYC
BCL6
CD10
IRF4/MUM-1
Cyclin D1
SOX-11
P27
LEF-1/TCF-1
Annexin A1
TdT
CD45/LCA
CD15/Leu M1
CD30/Ber H2
EMA
OCT-2
Bob.1
ALK-1
Clusterin
CD1a
CD2
CD3
CD4
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cell subset
B-cells
B-cells
B-cells
B-cells
Follicular dendritic cells
B-cell subset, follicular dendritic cells
Plasma cells, other
Plasma cells, other
Lymphocyte subset, other
Lymphocyte subset, other
MYC protein
Follicular center cells, other
B-cell subset
B-cell subset
Mantle cell lymphoma, other
Mantle cell lymphoma, other
Lymphoid subset
CLL/SLL, T-cells, other
Hairy cell leukemia, myeloid, T cell
subset
Lymphoblasts, some myeloblasts
Leukocytes
Reed-Sternberg cells, myeloid
RS cells, activated lymphs
Epithelium, lymphocyte subset
B-cells, other
B-cells, other
Anaplastic large cell lymphoma kinase
ALCL, other
Thymocytes, Langerhans-type cells
T and NK-cells
T and NK-cells
T-helper/inducer cells
Result

CD5
CD7
CD8
CD43/Leu 22
CD279/PD-1
CXCL13
Beta-F1
Gamma TCR
CD56
CD57/Leu 7
TIA1
Granzyme B
CD25
CD68/PGM-1
CD123
TCL-1
Myeloperoxidase
Lysozyme
CD14
CD163
CD33
Neutrophil elastase
CD117
Tryptase
CD34
Glycophorin
E-cadherin
T-cells, B-cell subset
T and NK-cells
T-cytotoxic/suppressor cells
T-cells, some B-cells, myeloid
T-follicular helper cells, other
T-follicular helper cells, other
TCR-beta chain
TCR gamma
T-cell subset and NK-cells
T and NK cell subsets
Cytotoxic cells
Activated cytotoxic cells
Activated lymph, other
Myeloid, macrophages
Plasmacytoid dendritic cells,
Hairy cell leukemia, other
Plasmacytoid dendritic cells, T-PLL,
B-cell subset, other
Myeloid
Myeloid, macrophages
Monocytic cells/macrophages
Monocytic cells/macrophages
Myeloid, macrophages, mast cells
Myeloid
Mast cells, myeloid precursors, other
Mast cells
Progenitor cells, endothelial cells, other
Erythroid
Immature erythroid, other
Factor VIIIRA Megakaryocytes, endothelial cells
CD61
Megakaryocytes
Ki-67/MIB-1 Proliferating cells
P53
Tumor suppressor gene
AE1/AE3
Cytokeratin
Cam 5.2
Cytokeratin
Pankeratin
Cytokeratin
S100/S100a Neural, melanoma & other
CD207/Langerin Langerhans cells
EBV-ISH (EBER) Epstein-Barr virus
EBV-LMP
Epstein-Barr virus
Parvovirus
Parvovirus
CMV
Cytomegalovirus
HHV8
Human herpes virus-8
H.Pylori
H. Pylori
B. henselae Bartonella henselae
HSV 1/2 Human herpes viruses 1 & 2

Molecular Diagnostic and Cytogenetic Testing
MOLECULAR DIAGNOSTIC TEST ORDERING:
MOLECULAR DIAGNOSTICS WEBSITE:
http://path.upmc.edu/divisions/mdx/diagnostics.html
printable requisition form
information on required sample types for each test
frequently asked questions are answered
Request on BM specimens should be given to BM technologists – message can be left on the Audix line (802-
3273). On lymph node service, please fax requisition and save with fax “receipt” in notebook in room G323. It
is also preferred that you call to inform them a fax is coming. Lymph node assistant or backup should help.
The molecular oncology testing schedule (after DNA/RNA preparation) is as follows (updated 1/2012; subject
to change per MDX policy)
Monday/Thursday: TCR, IgH, JAK2, BCL-2 PCR testing is started and results out the next day
Wednesday: Quantitative BCR-ABL and Quantitative PML testing is started and results out Thursday or Friday
Wednesday: TCR, IgH, BCL-2 Southern blot testing is started and results out the following Tuesday
Please see below for example of requisition form.
Additional Testing Information: Specialty labs will do PCR for B. henselae from frozen specimens or
paraffin sections (test is not validated for paraffin sections). Their number is 800-421-7110, Pacific
Time, if you have specific questions. The samples should be sent through Molecular Diagnostics, as
for TB. Testing for Whipple disease can be arranged through the molecular diagnostics laboratory
also.
CYTOGENETICS TEST ORDERING: Please be sure that the pathology requisition is attached to the
cytogenetics requisition and that the cytogenetic requisitions have at least the following information:
• Name of the patient and numerical identifier
• Pathologist’s name
• Clinician’s name (if clear on requisition not necessary to repeat)
• Reason for sending specimen (“r/o lymphoma” should be fine for all of our specimens unless
you have different or more specific information to provide)
Please see below for example of cytogenetics requisition form as well as testing menu

PITTSBURGH CYTOGENETICS LABORATORY
Oncology Cytogenetic Study Requisition form
PATIENT INFORMATION (Please Print)
REFERRING PHYSICIAN (Please Print)
Last Name: First: M.I.: Name:
Address:
City, State, Zip:
Birthdate: ___________________ Sex: ______ Male ______
Female
Social Security #: ___________________
Address:
City, State, Zip:
Telephone:
Medical Record #:
Account#:
Inpatient? _____ Location: _______________ Outpatient? _____
Specimen information:
Date/Time of Collection: _______________ Amount Drawn: ________
Type of Specimen:
_____ Bone Marrow
_____ Peripheral Blood (unstimulated)*
_____ Tumor type (location)__________________________
_____ Lymph Node (location)_________________________
* Peripheral blood may be submitted for unstimulated studies only if
circulating blast count is above 5%.
____Pre-Bone Marrow Transplant Sex of Donor: ____Male ____
Female
____ Post-Bone Marrow Transplant #days _____
Fax:
Additional Report To:
Address:
City, State, Zip:
Phone:
Fax:
Clinical History/Pertinent Physical Findings (include
chemotheraphy and radiation therapy dates/drugs):
Signature of Requesting Physician (REQUIRED!):
INDICATION FOR STUDY: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *
Anemia Thrombocytopenia Leukocytosis Leukopenia Pancytopenia Lymphoma Other (Specify)
Diagnosis: Tentative Confirmed New Diagnosis? Remission Sample? Relapse Sample?
CML: Chronic Phase Blast Phase ALL: B-ALL T-ALL CLL MM MPD (Specify)
MDS AML Other (Specify)
TEST(S) REQUESTED: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *
Chromosome Analysis (Karyotype) Yes No
Fluorescence in-situ hybridization (FISH) panels requested: * CIRCLE ALL THAT APPLY *
MDS Panel MPD Panel AML Panel CLL Panel MM Panel Children’s ALL
Panel
FLUORESCENCE IN SITU HYBRIDIZATION (FISH)
B-Cell lymphoma
Panel
Monosomy/Trisomy Translocation/fusion Break-apart rearrangement Solid tumors
___5q- ___BCR/ABL t(9;22) ___ALK (2p23) ___MLL (11q23) ___12CEP/12p
___Monosomy 7/ 7q- ___BIRC3/MALT t(11;18) ___AML1 (21q22) ___MYC (8q24) ___1p36/19q
___Trisomy 8 ___CBFβ/MYH1 inv(16) ___BCL2 (18q21) ___PAX5 (9p13) ___ALK (2p23)
___Trisomy 9 ___ETV6/RUNX1 t(12;21) ___BCL3 (19q13)
___Trisomy 12 ___IGH@/FGFR3 t(4;14) ___BCL6 (3q27))
___PDGFRB (5q33)
___RARA (17q21)
___TCF3 (19p13)
___TCL1 (14q32)
___CHOP (12q13)
___ERBB2/CEP17
___13q- ___IGH@/BCL2 t(14;18) ___BCL10 (1p22) ___TCRAD (14q11) ___EWSR1 (22q12)
___20q-
___Hyperdiploidy 5, 7, 9
___ATM (11q-)
___CMYB (6q-)
___P16(CDKN2A)
(9p21)
___IGH@/CCND1 t(11;14)
___CCND1 (11q13)
___EVI1 (MECOM) (3q26)
___TCRB (7q34)
___FKHR(FOXO1)
(13q14)
___IGH@/MAF t(14;16) ___FGFR1 (8p12) ___TCRG (7p14) ___MONOSOMY 3
___IGH@/MALT1 t(14;18) ___IGH (14q32) ___TEL(ETV6) (12p13) ___N-MYC
___IGH@/MYC t(8;14) ___IGK (2p11) ___TLX1 (10q24) ___SYT (18q11.2)
___PML/RARA t(15;17) ___IGL (22q11) ___TLX3 (5q35) ___TLS(FUS) (16p11.2)

PITTSBURGH CYTOGENETICS LABORATORY
Oncology Cytogenetic Study Requisition form
___P53 (del 17p13.1)
___RUNX1T1/RUNX1
t(8;21)
___MALT1 (18q21
___PAX5 (del 9p13)
___XX/XY
Updated: 3/25/13 JH
___CHIC2/FIP1L1-
PDGFRA (4q12)
Others (Specify):_______________________________________________________________________________
Magee-Womens Hospital of UPMC
300 Halket St., Rm. 1225
Pittsburgh, PA 15213
(412)641-5558 PHONE (412)641-2255 FAX

Cytogenetics Test Menu
CYTOGENETICS Blank Slides Available Order Blanks - See Page One
Break Apart Rearrangement Probes
Other
ALK (2p23) RARA (17q21) ASS deletion (9q34)
AML1 (21q22) TCRB (7q34) ATM deletion (11q22.3)
BCL2 (18q21) TCRG (7p14) CEP X/Y
BCL3 (19q13) TCRAD (14q11) D7S486/CEP7 -7/7q31 I (7q)
BCL6 (3q27) TCR3 (19p13) (D7S522/CEP7) - 7/7q31
BCL10 (1p22) TCL1(14q32.1) Deletion 13q (13q14) D135319
CBFB (16q22)
Deletion 20q (20q12) D205108
CCND1 (11q13) Translocation Probes EGR1 -5/5q-
ETV6 (TEL) (12p13) RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion)
EVI1 (MECOM) (3q26.2) BIRC3-MALT1 (API2-MALT1) t(11;18) CDKN2A (p16) (9p21 deletion)
EWSR1 (22q11.2) BCR-ABL t(9;22) CML/ALL/AML TP53 deletion (17p13.1)
FGFR1 (8p12) IGH - CCND1 (T11:14) Trisomy 5, 9, 15
IGH (14q32) IGH-BCL2 t(14;18) Trisomy 8 D8Z2
IGK (2p11) CBFB-MYH1 (16p13/16q22) t(16;16). inv(16) Trisomy 12 D1273
IGL (22q11)
IGH-FGFR3 t(4;14)
MALT1 (18q21)
IGH-MAF t(14;16)
MLL (11q23)
IGH MALT1 t(14;18)
MYC (8q24)
IGH-MYC t(8;14)
MYCN (2P23-24) (for amp)
PML-RARA t(15;17)
PAX5 (9p13)
TEL-AML1 (ETV6/RUNX1) t(12;21)
PDGFRB (5q33)
Panels
B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21)
CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1)
Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13)
Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21)
Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)]
MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12)
AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)]
[as needed (i.e. if not seen by classical analysis)]
MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12)
Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)
Additional FISH Probes Request (please list) Requested Ordered Blanks Sent
Comments

FISH panels for Hematologic Malignancies
CLL Panel
DNA Probe
Chromosome Breakpoint
1. D13S319/LAMP2 13q14.3
2. CEP 12 12p11.1-q11.1
3. ATM 11q22.3
4. p53 17p13.1
5. CMYB 6q23
6. IGH 14q32.3*
*If IGH is positive, we may recommend a few translocation probes involving 14q32
a. IGH/BCL2 t(14;18)(q32;q21)
b. IGH/CCND1 t(11;14)(q13;q32)
Multiple Myeloma (MM) Panel
DNA Probe
Chromosome Breakpoint
1. IGH 14q32.3
2. IGH/CCND1 14q32/11q13
3. TP53/CEP17 17p13.1
4. D13S319/LAMP1 13q14.3
5. D5S23/D5S721,9q34,CEP7 5p15.2, 9q34, 7p11.1-q11.1
(hyperdiploidy)
If IGH is + and IGH/CCND1 is -, then we will do FISH for:
IGH/FGFR3 t(4;14)(p16;q32)
IGH/MAF t(14;16)(q32;q23)
If classical chromosome analysis is normal and the above MM FISH panel is negative, then the
following FISH will be performed reflexively:
ALL panel
DNA Probe
Chromosome Breakpoint
1. BCR/ABL 9q34/22q11.2
2. MLL 11q23
3. ETV6/RUNX1 12p13/21q22
(TEL/AML1)
4. CEP4 4p11-q11
5. CEP10 10p11.1-q11.1
6. CEP17 17p11.1-q11.1

B-Cell Lymphoma Panel
DNA Probe
Chromosome Breakpoint
1. BCL6 3q27
2. MYC 8q24
3. IGH 14q32
4. BCL2 18q21
MDS Panel
DNA Probe
Chromosome Breakpoint
1. EGR1 5q31
2. CEP 7 7p11.1-q11.1
3. D7S486 7q31
4. CEP 8 8p11.1-q11.1
5. D20S108 20q12
MPD Panel
DNA Probe
Chromosome Breakpoint
1. BCR/ABL 9q34/22q11.2
2. CEP 8 8p11.1-q11.1
3. CEP 9 9p11-q11
4. D20S108 20q12
AML Panel
DNA Probe
Chromosome Breakpoint
1. D7Z1/D7S486 7p11.1-q11.1/7q31
2. EGR1 5q31/5p15.2
3. RUNX1T1/RUNX1 8q22/21q22
(ETO/AML1)
4. CBFB 16q22 [inv(16)]
5. MLL 11q23
MALT Lymphoma Strategy
DNA Probe Chromosome Breakpoint
1. MALT1 18q21*
*If MALT1 is positive, we will recommend a few translocation probes involving
18q21
a. IGH/MALT1 t(14;18)(q32;q21)
b. API2/MALT1 t(11;18)(q21;q21)

CML Strategy
ES probe
1. BCR/ABL ES t(9;22)(q34;q11.2)*
*If the extra signal is not observed using the BCR/ABL ES DNA probe and the cells are
positive for the fusion signal in a considerable proportion of cells, perform FISH using the
LSI ASS (9q34) DNA probe to detect a deletion of 9q.
*If there is suspicion for the acute phase or blast phase of CML, we may suggest the
following FISHes to detect trisomy 8 and/or i(17q) using the following DNA probes:
a. CEP 8 8p11.1-q11.1
b. RARA/CEP17 17q21

CoPath and Dictation
Pointers

COPATH Related Instructions for Dictation of Final Reports
1. At time of dictating any report, the patient name, the CoPath pathology report number,
the medical record number should be stated in all instances except the occasional
consult in which this information is not available. With the exception of the other cases,
the number put in the dictaphone should be the MR number. At the end of the dictation,
state that this is the end of the dictation on ____________ (given patient’s name).
2. The trainee dictating at the end of the final diagnosis can state “do not mark this case
complete.” In this instance, the transcriptionist will not finalize the case by marking it
“complete” during the transcription process. If the report is dictated before noon, within
two hours it will be available for correction by the trainee. If it is dictated afternoon, four
hours later, the report will be available for corrections. In all instances, reports dictated
before the four o’clock cut-off would be transcribed on the same day. The trainee then
can go into the report and edit the final diagnosis and microscopic (as well as the gross
and clinical history they choose) and when finished they must mark the case as
“complete” which will then sent to the physician’s electronic sign-out queue. During this
process the trainee is to verify that the final diagnosis matches that written on the hard
copy during sign-out. If a report is not ready, contact the secretarial supervisor. The
trainee should then give the paperwork including a printed final copy to the staff
pathologist.
The trainee should ask the faculty person if the above is what they want. If not, be sure to
given the faculty person all paperwork.
3. All “UP” cases (white or yellow sheet consults) must have a billing code dictated. These
consult cases have either a white or yellow sheet on the folder containing the consult
case. Blue sheet consults (usually performed at request of clinician) do not need a
billing code dictated.
4. Cut off times:
Cases dictated by 5:00 PM Monday – Friday will be typed that day
Cases dictated after 5:00 PM Monday – Friday will be typed by 10:00 AM the
next day
Saturday: cases dictated by 12 Noon will be typed that day
BILLING CODES FOR “UP” CASES (“WHITE” OR “YELLOW” SHEET CONSULTS)
BC#
Consultation Type
1 Level I Consult (very simple review, no extra stains)
2 Level II Consult (greater than 4 H&E, or up to 3 IHC stains)
3 Level III Consult (4-7 IHC stains)
4 Level IIII Consult (complex with 8-11 IHC stains)
5 Level V Consult (complex with ≥12 IHC stains)
6 Lymph Nodes with Flow Cytometry and No Immunostains
14 No Charge (including VA flows)
15 Stains, only

FLOW/IHC cases -- coded comments for discussion
Coded comments to add to end of microscopic description after immunostain table or if
there is no immunostain table (because it will be in an addendum) under “Ancillary
Studies.”
FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that were
needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis
possible is as follows: The flow cytometric studies did not define the precise nature of all the
cellular elements of concern in this specimen.
[to be used for example if a cyclin D1 stain with other markers is needed or if flow didn't
evaluate a plasma cell or possible RS population]
FLOW/IHC2: Medical necessity justification for the immunohistochemical stains that were
needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis
possible is as follows: The flow cytometric studies are not clearly representative of all the
features requiring evaluation in this specimen.
[To be used for example if you have lymphoid aggregates in marrow that might not be in the
flow suspension, suspension was dilute]
Coded comment to add to end of flow report when it will precede the complete report
with the above coded comments:
FLOW1: Because these flow cytometric studies do not fully clarify the diagnosis in this case,
immunohistochemical stains will be performed on this specimen and a final report will follow.

Division of Hematopathology
Dictating & Proofing Tissue Reports*
(Suggestions for trainees)
Patient history:
Look at prior cases in CoPath worksheet, outside reports, requisitions, MARS (if patient
is or has been at UPMC), letter (if consult) for historical information and be sure to
include in report since, in part, some or all of this information may be very hard to find at
a later date. This is OUR responsibility. For bone marrow cases, the technologists often
enter a clinical history, but it is up to us to verify the accuracy and completeness.
Be sure pre-op, post-op diagnoses and procedure have been entered.
Diagnosis:
Be sure to use standard format
o Tissue type, tissue site, procedure (and if consult, Outside slide number “OSS….,
institution”)- diagnosis using terminology of WHO (if malignant)
NEVER use “consistent with” in a diagnostic line. This is departmental policy.
If more than one specimen on a consult, the different parts should be in chronological
order.
Abbreviations should be avoided; if used in a report, the full term should be provided the
first time it is used.
Comment:
Be sure that the comment includes the methods used to arrive at the diagnosis.
Phenotypic aberrancies that might be useful to follow up on in any subsequent
specimens are useful to include here. Ask the attending pathologist if there is any
question about what should be included in the comment.
The comment should stress the major diagnosis first and must be consistent with the
diagnoses listed above (i.e.: it should not “back-track” on a definitive diagnosis).
The comment does not necessarily have to follow the same order as the specimens
listed in the diagnosis (i.e., a definitive diagnosis might be dealt with first).
Be sure at least the comment, if not the diagnosis, clearly indicates any studies still
pending at the time of signout. These should not come as a surprise to the physician
receiving the report.
Microscopic description
Microscopic descriptions should “conjure up” and clearly convey an image that is
consistent with the diagnosis. “Buzz words” can be used to help achieve brevity and,
while it is best to avoid using descriptions to make conclusions, there is no need to
describe all the features of obviously reactive follicles or T-zone nodules.
Microscopic descriptions in general should start with a statement concerning the tissue
type, the low magnification architectural features and then the relevant cytologic
features. Special stains should then follow and then the IHC/ISH template (if any such
stains have been performed).
IHC tables should follow the part that has been described in multipart specimens –
easiest way so it’s clear what they refer to.
Cases with flow cytometric studies and immunostains MUST HAVE a FLOW/IHC1 or 2
comment at the end of this section.

On consult cases with prior flow cytometric studies, the outside flow reports should at
least be summarized including a statement as to which laboratory did the studies. Place
after (or before) the IHC/ISH results.
On “UP” consult cases, be sure to dictate a billing code at the end. Cases with flow plus
just H&E sections get BC6. Our other UP cases with 4-7 special stains will be BC3,
more complex cases will be BC4 (8-11 special stains), with the most complex cases with
greater than 12 stains getting BC5.
Synoptic reports
A synoptic should be added to all bone marrow and solid tissue reports when a
hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone
marrows, these are being added on first-time diagnoses only, although they do not need
to be limited to those cases.
There are currently four (4) synoptics used in Hematopathology.
o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic
o Gastrointestinal Lymphoma Resection Synoptic
o Hodgkin Lymphoma Biopsy/Staging Synoptic
o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic
Synoptic reports may be dictated using the templates included this manual. A
hard copy is available in rooms G315 and G323. Alternatively, they can be manually
entered in CoPath after case dictation.
Instructions for the use of synoptics are available online. The CoPath user guide is
posted on the CoPathPlus website http://copath.upmc.com under the link for CoPathPlus
Training Resources. The Synoptic Data Entry and Reporting Chapter is Chapter 24.
Proofreading
Proofread reports carefully and MAKE SURE that what is written not only is what was
intended at sign out but that it makes sense. If proofing prior to giving to a faculty
member and something doesn’t make sense, at least communicate that to them.
Be sure to proof numbers that have been included (including in the flow reports)
Be sure that immunostain designations are what you intended (i.e., sometimes
CD45RO/UCHL1 gets entered instead of CD45/LCA).
Be sure singular/plural forms of words are correct, reports say “and” where you meant
“and” and not “in”, “intra-“and “inter-“are used appropriately.
Be sure the templated tables don’t have capital letters in the middle of a sentence.
Unless directed otherwise, give the faculty member a printed out final version of your
final report – not something with handwriting or a draft.
Be sure to make an arrangement with the faculty member to see what changes were
made in what you considered to be a final report.
[Revised 10/2013]

Wording for Provisional Reports on Lymph Node Biopsies
Provisional reports may be when there is a delay in issuing a complete final report. These are
now a type of “special procedure”. These are to be used only on rare occasions.
When dictating the case, the transcriptionist must be instructed to type a provisional report.
Be sure the comment includes the following: This represents a provisional report. It will be
replaced by a final diagnostic report once…
Hematopathology Case Worksheet in CoPath
1. Log into CoPath.
2. From the top menu bar, choose FILE.
3. Choose BROWSE ITEMS.
4. Look in the Browse Items menu list. Scroll down until you get to HEME WORKSHEET.
5. Click and drag to your menu on the left so that this report will be available to you the next
time you log in.
6. Double click on HEME WORKSHEET. The report will take 1 minute to load.
7. Type the specimen number in the box under "Select a Specimen."
8. Click on ADD.
9. Run the report by clicking on OK.
10. Click on PRINT.
Resident/fellows can now review and print out the results of the special procedures that
have been signed out by following the directions given below. The print out will also
include the original diagnosis.
Special Procedure Review by Resident/Fellow in CoPath
1. Log into CoPath.
2. From the top menu bar, choose FILE.
3. Choose BROWSE ITEMS.
4. Look in the Browse Items menu list. Scroll down until you get to PROCEDURE REVIEW BY
RESIDENT/FELLOW.
5. Click and drag to your menu on the left so that this report will be available to you the next
time you log in.
6. Double click on PROCEDURE BY RESIDENT/FELLOW.
7. Choose the data field criteria desired to run the report:
Typically for the data field:
Choose the time range or date for Sign Out Date.
For Specimen Class choose ALL VALUES
For Procedure choose ALL VALUES
For Person, click in the circle next to Individual Items, highlight the name of the
resident/fellow, then click on ADD. (You can add multiple names.)
8. Run the report by clicking OK.
9. The next time you log in to CoPath, you can just choose the PROCEDURE BY
RESIDENT/FELLOW report from your menu on the left and eliminate steps 2 to 5 above.

SYNOPTICS

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
A1
A2
A3
A4
A5
A6
A7
B1
B2
B3
B4
B5
C1
C2
C3
C4
- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -
SPECIMEN TYPE/PROCEDURE**
(check all that apply)
Aspirate
Biopsy
Particle Preparation
Blood film
Cell block (Clot section)
Touch imprint
Not specified
BIOPSY/ASPIRATE SITE**
Not applicable
Right posterior iliac crest
Left posterior iliac crest
Other (specify):
Not specified
ADEQUACY OF SPECIMEN**
Satisfactory
Limited
Unsatisfactory
See report
D1
D2
D3
D4
D5
D6
D7
D8
D9
D10
D11
D12
D13
D14
- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -
W HO CLASSIFICATION** (check all that apply)
Note: This is NOT the final diagnosis. Use final diagno
/comment for therapeutic decisions.
Myeloproliferative Neoplasms
Chronic myelogenous leukemia, BCR-ABL+
Chronic myelogenous leukemia, accelerated phase
Chronic myelogenous leukemia, myeloid blast crisis
Chronic myelogenous leukemia, lymphoid blast crisis
Chronic myelogenous leukemia, blast crisis, NOS
Chronic neutrophilic leukemia
Chronic eosinophilic leukemia, NOS
Mastocytosis
Cutaneous mastocytosis
Systemic mastocytosis
Systemic mastocytosis with associated clonal,
hematologic non-mast-cell lineage disease
Aggressive systemic mastocytosis
Mast cell leukemia
Mast cell sarcoma
Extracutaneous mastocytoma
---W HO Classifications Continued on Next Page----
This is a worksheet. It is NOT the final diagnosis.
6.5

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
W HO CLASSIFICATION (check all that apply) CONT'
D15
Polycythemia vera
Myelodysplastic Syndromes
D16
Primary myelofibrosis
F1
Refractory anemia
D17
Essential thrombocythemia
F2
Refractory neutropenia
D18
Myeloproliferative neoplasm, unclassifiable
F3
Refractory thrombocytopenia
D19
Possible myeloproliferative neoplasm, see report
F4
Refractory anemia with ringed sideroblasts
D20
Favor myeloproliferative neoplasm but must rule out
F5
Refractory cytopenia with multilineage dysplasia
other possibilities, see report
F6
Refractory cytopenia with multilineage dysplasia and
ringed sideroblasts
Myeloid and Lymphoid Neoplasms with Eosinophilia and
Abnormalities of PDGFRA, PDGFRB OR FGFR1
Refractory anemia with excess blasts (RAEB)
D21
Myeloid and lymphoid neoplasms with PDGFRA
F7
RAEB-1
rearrangement
F8
RAEB-2
D22
Myeloid neoplasms with PDGFRB rearrangement
D23
Myeloid and lymphoid neoplasms with FGFR1
F9
Myelodysplastic syndrome, unclassifiable
rearrangement
F10
Myelodysplastic syndrome associated with isolated
del(5q)
Myelodysplastic/ Myeloproliferative Neoplasms
F11
Childhood myelodysplastic syndrome
E1
Chronic myelomonocytic leukemia
F12
Refractory cytopenia of childhood
E2
Atypical chronic myeloid leukemia, BCR-ABL-
F13
Possible myelodysplastic syndrome, see report
E3
Juvenile myelomonocytic leukemia
F14
Favor myelodysplastic syndrome but must rule out
E4
Myelodysplastic/myeloproliferative neoplasm,
other possibilities, see report
unclassifiable
F15
Myelodysplastic syndrome, classification pends
E5
Refractory anemia with ring sideroblasts associated
cytogenetics
with marked thrombocytosis
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
G1
W HO CLASSIFICATION (check all that apply) CONT'
Acute Myeloid Leukemias (AML)
Acute myeloid leukemia, not otherwise classified
G12
G13
AML with myelodysplasia - Without antecedent
myelodysplastic syndrome
AML with myelodysplasia - With unknown prior
history
G2
G3
G4
G5
G6
G7
G8
G9
G10
G11
Acute myeloid leukemia with recurrent genetic
abnormalities
AML witH t(8;21)(q22;q22); RUNX1-RUNX1T1
AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);
CBFB-MYH11
Acute promyelocytic leukemia with t(15;17)(q22;q12);
PML-RARA
AML with t(9;11)(p22;q23); MLLT3-MLL
AML with t(6:9)(p23;q34); DEK-NUP214
AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2);
RPN1-EVI1
AML (megakaryoblastic) with t(1:22)(p13;q13);
RBM15-MKL1
AML with mutated NPM1
AML with mutated CEBPA
Acute myeloid leukemia with myelodysplasia-related
changes
AML with myelodysplasia - Following a
myelodysplastic syndrome or myelodysplastic
syndrome/myeloproliferative disorder
Therapy-related myeloid neoplasms
G14 Therapy-related myeloid neoplasms c/w AML
G15 Therapy-related myeloid neoplasms c/w MDS
G16 Therapy-related myeloid neoplasms c/w MDS/MPN
G17 Therapy-related myeloid neoplasm, NOS
G18
G19
G20
G21
G22
G23
G24
G25
G26
G27
G28
Acute myeloid leukemia not otherwise categorized
AML with minimal differentiation
AML without maturation
AML with maturation
Acute myelomonocytic leukemia
Acute monoblastic and monocytic leukemia
Acute erythroid leukemia
Acute megakaryoblastic leukemia
Acute basophilic leukemia
Acute panmyelosis with myelofibrosis
Acute myeloid leukemia, final classification pends
cytogenetic studies
Myeloid sarcoma
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
W HO CLASSIFICATION (check all that apply) CONT'
Myeloid proliferations related to Down syndrome
H2
B lymphoblastic leukemia/lymphoma with recurrent
genetic abnormalities
G29
Transient abnormal myelopoiesis
H3
B lymphoblastic leukemia/lymphoma with
G30
Myeloid leukemia associated with Down syndrome
t(9;22)(q34;q11.2); BCR-ABL1
H4
B lymphoblastic leukemia/lymphoma with t(v;11q23);
G31
Blastic plasmacytoid dendritic cell neoplasm
MLL rearranged
H5
B lymphoblastic leukemia/lymphoma with
Acute leukemias of ambiguous lineage
t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)
G32
Undifferentiated acute leukemia
H6
B lymphoblastic leukemia/lymphoblastic lymphoma
G33
Mixed phenotype acute leukemia with
with hyperdiploidy
t(9;22)(q34;q11.2); BCR-ABL1
H7
B lymphoblastic leukemia/lymphoma with hypodiploidy
G34
Mixed phenotype acute leukemia with t(v;11q23);
(hypodiploid ALL)
MLL rearranged
H8
B lymphoblastic leukemia/lymphoma with
G35
Mixed phenotype acute leukemia, B/myeloid, NOS
t(5;14)(q31;q32) IL 3-IGH
G36
Mixed phenotype acute leukemia, T/myeloid, NOS
H9
B lymphoblastic leukemia/lymphoma with
G37
Natural killer (NK) cell lymphoblastic
t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
leukemia/lymphoma
H10
B lymphoblastic leukemia/lymphoma, final
classification pends cytogenetic studies
Mixed phenotype acute leukemia, NOS
H11
T lymphoblastic leukemia/lymphoma
G38
Bilineal acute leukemia
G39
Biphenotypic acute leukemia
Mature B-Cell Neoplasms
G40
Acute leukemia, uncertain lineage
J1
B-cell lymphoid neoplasm, not further classified
J2
Small B-cell lymphoid neoplasm, not further classified
Precursor lymphoid neoplasms
J3
Chronic lymphocytic leukemia/small lymphocytic
H1
B lymphoblastic leukemia/lymphoma
B lymphoblastic leukemia/lymphoma, NOS
lymphoma
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
J4
J5
J6
J7
J8
J9
J10
J11
J12
J13
J14
J15
J16
J17
J18
J19
J20
J21
J22
J23
W HO CLASSIFICATION (check all that apply) CONT'
B-cell prolymphocytic leukemia
Waldenstrom macroglogulinemia
Heavy chain diseases
Alpha heavy chain disease
Gamma heavy chain disease
Mu heavy chain disease
Splenic marginal zone lymphoma
Hairy cell leukemia
Splenic B-cell lymphoma/leukemia, unclassifiable
Splenic diffuse red pulp small B-cell lymphoma
Hairy cell leukemia-Variant
Lymphoplasmacytic lymphoma
Plasma cell myeloma
Monoclonal gammopathy of undetermined significance
(MGUS)
Solitary plasmacytoma of bone
Extraosseus plasmacytoma
Plasma cell neoplasm, not further categorized
Primary amyloidosis
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue (MALT-lymphoma)
Nodal marginal zone lymphoma
Pediatric nodal marginal zone lymphoma
Follicular lymphoma
J24 Follicular lymphoma, Grade not defined
J25 Follicular lymphoma - Grade 1-2
J26 Follicular lymphoma - Grade 3
J27 Follicular lymphoma - Grade 3A
J28 Follicular lymphoma - Grade 3B
J29 Pediatric follicular lymphoma
J30 Mantle cell lymphoma
J31 Diffuse large B-cell lymphoma (DLBCL), NOS
J32 T-cell/histiocyte rich large B-cell lymphoma
J33 Primary DLBCL of the CNS
J34 Primary Cutaneous DLBCL, leg type
J35 EBV positive DLBCL of the elderly
J36 DLBCL associated with chronic inflammation
J37 Lymphomatoid granulomatosis
J38 Primary mediastinal (thymic) large B-cell lymphoma
J39 Intravascular large B-cell lymphoma
J40 ALK positive large B-cell lymphoma
J41 Plasmablastic lymphoma
J42 Large B-cell lymphoma arising in HHV8-associated
multicentric Castleman disease
J43 Primary effusion lymphoma
J44 Burkitt lymphoma
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
W HO CLASSIFICATION (check all that apply) CONT'
K16
Lymphomatoid papulosis
J45
B-cell lymphoma, unclassifiable, with features
K17
Primary Cutaneous gamma-delta T-cell lymphoma
intermediate between diffuse large B-cell lymphoma
K18
Primary cutaneous CD8 positive aggressive
and Burkitt lymphoma
epidermotropic cytotoxic T-cell lymphoma
J46
B-cell lymphoma, unclassifiable, with features
K19
Primary cutaneous CD4 positive small/medium T-cell
intermediate between diffuse large B-cell lymphoma
lymphoma
and classical Hodgkin lymphoma
K20
Peripheral T-cell lymphoma, NOS
K21
Angioimmunoblastic T-cell lymphoma
Mature T-Cell and NK-Cell Neoplasms
K22
Anaplastic large cell lymphoma, ALK positive
K1
T-cell prolymphocytic leukemia
K23
Anaplastic large cell lymphoma, ALK negative
K2
T-cell large granular lymphocytic leukemia
K3
Chronic lymphoproliferative disorder of NK-cells
Hodgkin Lymphoma
K4
Aggressive NK-cell leukemia
L1
Nodular lymphocyte predominant Hodgkin lymphoma
K5
Systemic EBV positive T-cell lymphoproliferative
Classical Hodgkin lymphoma
disease of childhood
L2
Nodular sclerosis classical Hodgkin lymphoma
K6
Hydroa vacciniforme-like lymphoma
L3
Lymphocyte-rich classical Hodgkin lymphoma
K7
Adult T-cell leukemia/lymphoma
L4
Mixed cellularity classical Hodgkin lymphoma
K8
Extranodal NK/T-cell lymphoma, nasal-type
L5
Lymphocyte-depleted classical Hodgkin lymphoma
K9
Enteropathy associated T-cell lymphoma
L6
Classical Hodgkin lymphoma, not further categorized
K10
Hepatosplenic T-cell lymphoma
L7
Hodgkin vs non-Hodgkin lymphoma
K11
Subcutaneous panniculitis-like T-cell lymphoma
K12
Mycosis fungoides
Histiocytic & Dendritic-Cell Neoplasms
K13
Sézary syndrome
M1
Histiocytic sarcoma
K14
Primary cutaneous CD30 positive T-cell
M2
Langerhans cell histiocytosis
K15
lymphoproliferative disorders
Primary cutaneous anaplastic large cell lymphoma
M3
Langerhans cell sarcoma
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
M4
M5
M6
M7
M8
M9
N1
P1
P2
P3
P4
P5
Q1
Q2
Q3
W HO CLASSIFICATION (check all that apply) CONT'
Interdigitating dendritic cell sarcoma
Follicular dendritic cell sarcoma
Fibroblastic reticular cell tumor
Indeterminate dendritic cell tumor
Disseminated juvenile xanthogranuloma
Dendritic cell sarcoma, not otherwise specified
Other
Malignant neoplasm, type cannot be determined
Post-transplant lymphoproliferative disorders
Plasmacytic hyperplasia
Infectious mononucleosis-like PTLD
Polymorphic PTLD
Monomorphic PTLD (specify type):
Classical Hodgkin-lymphoma type PTLD
ANCILLARY STUDIES**
Flow Cytometry-Phenotyping**
Flow cytometry immunophenotype performed, see
separate report
Flow cytometry immunophenotype pending, report to
follow
Flow cytometry immunophenotype not performed
R1
R2
R3
S1
S2
S3
T1
T2
T3
U1
U2
U3
U4
U5
Immunohistochemistry/In Situ Hybridization**
Immunohistochemistry/ in situ hybridization performed,
see microscopic description
Immunohistochemistry/ in situ hybridization pending,
see addendum
Immunohistochemistry/ in situ hybridization not
performed
Classical Cytogenetic Studies**
Classical cytogenetic studies performed, see separate
report
Classical cytogenetic studies pending, report to follow
Classical cytogenetic studies not performed
Cytogenetic FISH Studies**
Cytogenetic FISH studies performed, see separate
report
Cytogenetic FISH studies pending, report to follow
Cytogenetic FISH studies not performed
Genotypic (Molecular) Studies**
Genotypic (Molecular) studies performed, see separate
report
Genotypic (Molecular) studies pending, report to follow
Genotypic (Molecular) studies not performed
DNA stored,Genotypic (Molecular) studies not
performed
RNA stored,Genotypic (Molecular) studies not
performed
This is a worksheet. It is NOT the final diagnosis.
6.5

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Specimen #:
Patient:
Part:
Initials/Date:
V1
V2
V3
Cytochemical Stains**
Cytochemical stains performed, see microscopic
description
Cytochemical stains pending, see addendum
Cytochemical stains not performed
Y1
ADDITIONAL PATHOLOGIC FINDINGS
Specify:
EXTENT OF BONE MARROW /PERIPHERAL BLOO
INVOLVEMENT
W1 Acute leukemia/MDS (bone marrow) - % blasts W2
Acute leukemia/MDS (peripheral blood) - % blasts W3
Malignant lymphoma - approximately
involved
Multiple myeloma
W4 Plasma cells 30%
% of area
OVERALL MARROW CELLULARITY**
X1

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
A1
A2
A3
A4
A5
- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -
SPECIMEN TYPE**
Lymphadenectomy (specify sites):
Other (specify):
Not specified
Splenectomy
Other extranodal (specify):
D1
D2
- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -
HISTOLOGIC TYPE (W HO CLASSIFICATION)**
Note: This is NOT the final diagnosis. Use final diagno
/comment for therapeutic decisions.
Histologic type cannot be assessed
Non-Hodgkin lymphoma vs Hodgkin lymphoma
B1
B2
B3
B4
B5
B6
C1
C2
C3
C4
C5
PROCEDURE (select all that apply)**
Fine needle aspiration
Needle core biopsy
Biopsy, other
Resection
Other (specify):
Unknown
TUMOR SITE (check all that apply)**
Lymph node(s), site unknown
Lymph node(s) - Specify site(s),
Other tissue(s) - Specify site(s):
Not specified
Only one site biopsied, see above
D3
D4
D5
D6
D7
D8
D9
D10
D11
D12
B-cell Lymphoma
B-cell lymphoma, subtype cannot be determined
B-cell lymphoma with high grade features
B-lymphoblastic leukemia/lymphoma, NOS
B lymphoblastic leukemia/lymphoma with recurrent
genetic abnormalities
B lymphoblastic leukemia/lymphoma with
t(9:22)(q34;q11.2); BCR-ABL1
B lymphoblastic leukemia/lymphoma with t(v;11q23);
MLL rearranged
B lymphoblastic leukemia/lymphoma with
t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)
B lymphoblastic leukemia/lymphoma with hyperdiploidy
B lymphoblastic leukemia/lymphoma with hypodiploidy
(hypodiploid ALL)
B lymphoblastic leukemia/lymphoma with
t(5;14)(q31;q32) IL 3-IGH
---Histologic Types Continued on Next Page----
This is a worksheet. It is NOT the final diagnosis.
6.2

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
D13
D14
D15
D16
D17
D18
D19
D20
D21
D22
D23
D24
D25
D26
D27
D28
D29
D30
D31
HISTOLOGIC TYPE (W HO CLASSIFICATION)** (co
B lymphoblastic leukemia/lymphoma with
t(1;19)(q23;p13.3); E2A-PBX1
Chronic lymphocytic leukemia/small lymphocytic
lymphoma
B-cell prolymphocytic leukemia
Splenic marginal zone lymphoma
Hairy cell leukemia
Splenic B-cell lymphoma/leukemia, unclassifiable
Splenic diffuse red pulp small B-cell lymphoma
Hairy cell leukemia-variant
Lymphoplasmacytic lymphoma
Waldenstrom macroglobulinemia
Heavy chain disease
Alpha heavy chain disease
Gamma heavy chain disease
Mu heavy chain disease
Plasma cell myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue (MALT lymphoma)
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue (MALT lymphoma)
with plasmacytic differentiation
D32
D33
D34
D35
D36
D37
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue (MALT lymphoma),
pediatric
Nodal marginal zone lymphoma
Nodal marginal zone lymphoma with plasmacytic
differentiation
Nodal marginal zone lymphoma, pediatric
Marginal zone lymphoma, not further specified
Marginal zone lymphoma with plasmacytic
differentiation, not further specified
Follicular Lymphoma
Grade
D38 Follicular lymphoma, grade 1-2
D39 Follicular lymphoma, grade 3A
D40 Follicular lymphoma, grade 3B
Growth Pattern
D41 Follicular lymphoma, growth pattern - follicular
D42 Follicular lymphoma, growth pattern - follicular &
diffuse
D43 Follicular lymphoma, growth pattern - minimally
follicular
D44 Follicular lymphoma, growth pattern not specified
D45 Follicular lymphoma, not further specified
---Histologic Types Continued on Next Page----
6.2
This is a worksheet. It is NOT the final diagnosis.

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
HISTOLOGIC TYPE (W HO CLASSIFICATION)** (co
D63
ALK positive large B-cell lymphoma
D46
Primary cutaneous follicle center lymphoma
D64
Plasmablastic lymphoma
D47
Primary cutaneous follicle center lymphoma vs
D65
Large B-cell lymphoma arising in HHV8-associated
follicular lymphoma
multicentric Castleman disease
D48
Primary cutaneous follicle center lymphoma vs diffuse
D66
Primary effusion lymphoma
large B-cell lymphoma
D67
Burkitt lymphoma
D49
Primary cutaneous diffuse large B-cell lymphoma, leg
D68
B-cell lymphoma, unclassifiable, with features
type vs diffuse large B-cell lymphoma, not further
intermediate between diffuse large B-cell lymphoma
specified
and Burkitt lymphoma
D50
Follicular lymphoma, diffuse follicle center subtype,
D69
B-cell lymphoma, unclassifiable, with features
grade 1-2
intermediate between diffuse large B-cell lymphoma
D51
Mantle cell lymphoma
and classical Hodgkin lymphoma
D52
Diffuse large B-cell lymphoma (DLBCL), NOS, germinal
D70
B-cell Lymphoma - Other (specify):
center phenotype
D53
Diffuse large B-cell lymphoma (DLBCL), NOS,
T-cell Lymphoma
non-germinal center phenotype
D71
T-cell lymphoma, subtype cannot be determined
D54
Diffuse large B-cell lymphoma (DLBCL), NOS, not
D72
T-lymphoblastic leukemia/lymphoma
further specified
D73
T-cell prolymphocytic leukemia
D55
T-cell/histiocyte rich large B-cell lymphoma
D74
T-cell large granular lymphocytic leukemia
D56
Primary DLBCL of the CNS
D75
Chronic LPD of NK-cells
D57
Primary Cutaneous DLBCL, leg type
D76
Aggressive NK-cell leukemia
D58
EBV positive DLBCL of the elderly
D77
Systemic EBV positive T-cell lymphoproliferative
D59
DLBCL associated with chronic inflammation
disease of childhood
D60
Lymphomatoid granulomatosis
D78
Hydroa vacciniforme-like lymphoma
D61
D62
Primary mediastinal (thymic) large B-cell lymphoma
Intravascular large B-cell lymphoma
D79
Adult T-cell leukemia/lymphoma
---Histologic Types Continued on Next Page----
6.2
This is a worksheet. It is NOT the final diagnosis.

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
HISTOLOGIC TYPE (W HO CLASSIFICATION)** (co
ANCILLARY STUDIES**
D80
Extranodal NK/T-cell lymphoma, nasal type
D81
Enteropathy-associated T-cell lymphoma
Flow Cytometry-Phenotyping**
D82
Hepatosplenic T-cell lymphoma
E1
Flow cytometry immunophenotype performed, see
D83
Subcutaneous panniculitis-like T-cell lymphoma
separate report
D84
Mycosis fungoides
E2
Flow cytometry immunophenotype pending, report to
D85
Sézary syndrome
follow
D86
Primary cutaneous anaplastic large cell lymphoma
E3
Flow cytometry immunophenotype not performed
D87
Lymphomatoid papulosis
D88
CD30 positive lymphoproliferative disease, NOS
Immunohistochemistry/In Situ Hybridization**
D89
Primary cutaneous gamma-delta T-cell lymphoma
F1
Immunohistochemistry/ in situ hybridization performed,
D90
Primary cutaneous CD8-positive aggressive
see microscopic description
epidermotropic cytotoxic T-cell lymphoma
F2
Immunohistochemistry/ in situ hybridization pending,
D91
Primary cutaneous CD4-positive small/medium T-cell
see addendum
lymphoma
F3
Immunohistochemistry/ in situ hybridization not
D92
Peripheral T-cell lymphoma, NOS
performed
D93
Angioimmunoblastic T-cell lymphoma
D94
Anaplastic large cell lymphoma, ALK positive
Classical Cytogenetic Studies**
D95
Anaplastic large cell lymphoma, ALK negative (provisional)
G1
Classical cytogenetic studies performed, see separate
D96
T-cell Lymphoma - Other (specify):
report
G2
Classical cytogenetic studies pending, report to follow
Other
G3
Classical cytogenetic studies not performed
D97
Blastic plasmacytoid dendritic cell neoplasm
D98
Other (specify):
---ANCILLARY STUDIES Continued on Next Page----
6.2
This is a worksheet. It is NOT the final diagnosis.

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
H1
H2
H3
J1
J2
J3
J4
K1
ANCILLARY STUDIES** (cont'd)
Cytogenetic FISH Studies**
Cytogenetic FISH studies performed, see separate
report
Cytogenetic FISH studies pending, report to follow
Cytogenetic FISH studies not performed
Genotypic (Molecular) Studies**
Genotypic (Molecular) studies performed, see separate
report
Genotypic (Molecular) studies pending, report to follow
Genotypic (Molecular) studies not performed
DNA stored, Genotypic (Molecular) studies not
performed
ADDITIONAL PATHOLOGIC FINDINGS
Specify:
L5
L6
L7
L8
L9
L10
L11
L12
M1
M2
M3
M4
Involvement of multiple lymph node regions on both
sides of diaphragm
Specify sites:
Splenic involvement
Liver involvement
Bone marrow involvement
Other organ involvement
Specify:
Not specified
CLINICAL PROGNOSTIC FACTORS AND INDICES
(Select all that apply)
International Prognostic Index (IPI) (specify):
Follicular Lymphoma International Prognostic Index
(FLIPI) (specify):
B symptoms present
Other (specify):
L1
L2
L3
L4
EXTENT OF PATHOLOGICALLY EXAMINED TUMO
(check all that apply)
Involvement of a single lymph node region
Specify site:
Involvement of multiple lymph node regions on same
side of diaphragm
Specify sites:
Comment:
This is a worksheet. It is NOT the final diagnosis.
6.2

Hodgkin Lymphoma Biopsy/Staging Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
- - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - - -
SPECIMEN TYPE**
A1 Lymphadenectomy (specify sites):
A2 Staging laparotomy
A3 Extranodal (specify):
A4 Other (specify):
A5 Not specified
PROCEDURE**
B1 Fine needle aspiration
B2 Needle core biopsy
B3 Biopsy, other
B4 Resection
B5 Other (specify):
B6 Unknown
TUMOR SITE (check all that apply)**
C1 Lymph node(s), site not specified
C2 Lymph node(s) - specify sites(s):
TUMOR SIZE (largest single mass) - Resections Only
D1 Greatest dimensions: cm.
D2 Additional dimensions: cm.
D3
D4
E1
E2
E3
E4
E5
E6
E7
E8
Specify site:
Cannot be determined (see Comment)
- - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - - -
HISTOLOGIC SUBTYPE**
Note: This is NOT the final diagnosis. Use final diagno
/comment for therapeutic decisions.
Nodular lymphocyte predominant Hodgkin lymphoma
(NLPHL)
Nodular sclerosis classical Hodgkin lymphoma (NSHL)
Mixed cellularity classical Hodgkin lymphoma (MCHL)
Lymphocyte-rich classical Hodgkin lymphoma (LRCHL)
Lymphocyte-depleted classical Hodgkin lymphoma (LDHL)
Classical Hodgkin lymphoma, further subtype cannot be
determined
Hodgkin lymphoma, subtype cannot be determined
Other (specify):
C3
C4
C5
Other tissue(s) or organ(s) - specify
site(s):
Not specified
Only one site biopsied, see above
F1
F2
F3
F4
HISTOLOGIC GRADE (NSHL only) - OPTIONAL
Not applicable
Grade I
Grade ll
Grade uncertain

Hodgkin Lymphoma Biopsy/Staging Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
G1
G2
G3
G4
G5
G6
G7
G8
G9
H1
H2
H3
EXTENT OF PATHOLOGICALLY EXAMINED TUMO
(check all that apply)
Involvement of a single lymph node region.
Specify site:
Involvement of multiple lymph node regions on the
same side of the diaphragm.
Specify sites:
Involvement of multiple lymph node regions on both
sides of the diaphragm.
Specify sites:
Splenic involvement
Liver involvement
Bone marrow involvement
Other organ involvement
Specify:
Not specified
ANCILLARY STUDIES**
Flow Cytometry - Phenotyping**
Flow cytometry immunophenotype performed, see
separate report
Flow cytometry immunophenotype pending, report to
follow
Flow cytometry immunophenotype not performed
J1
J2
J3
K1
K2
K3
L1
L2
L3
M1
M2
M3
M4
Immunohistochemistry/In Situ Hybridization**
Immunohistochemistry/ in situ hybridization performed,
see microscopic description
Immunohistochemistry/ in situ hybridization pending,
see addendum
Immunohistochemistry/ in situ hybridization not
performed
Classical Cytogenetic Studies**
Classical cytogenetic studies performed, see separate
report
Classical cytogenetic studies pending, report to follow
Classical cytogenetic studies not performed
Cytogenetic FISH Studies**
Cytogenetic FISH studies performed, see separate
report
Cytogenetic FISH studies pending, report to follow
Cytogenetic FISH studies not performed
Genotypic (Molecular) Studies**
Genotypic (Molecular) studies performed, see separate
report
Genotypic (Molecular) studiending, report to follow
Genotypic (Molecular) studies not performed
DNA stored,Genotypic (Molecular) studies not performed

Hodgkin Lymphoma Biopsy/Staging Synoptic Template
Specimen #:
Patient:
Part:
Initials/Date:
ADDITIONAL PATHOLOGIC FINDINGS
(check all that apply)
N1 Progressive transformation of germinal centers (PTGC)
N2 Castleman disease
N3 Other (specify): ________________________________
CLINICAL PROGNOSTIC FACTORS AND INDICES
P1 International Prognostic Score (IPS) (specify):
P2
P3
B symptoms present
Other (specify): ____________
Comment:

Web-Based Resources

WEBSITE EDUCATIONAL RESOURCES & CALL SCHEDULES
Division of Hematopathology Intranet website (Hematopathology schedules/paging and general
information)
1. http://path.upmc.edu/divisions/hematopath.html
UPMC Pathology Residents Server (includes on call schedule for AP and CP)
1. http://residents.pathology.pitt.edu/
Hematological Malignancies Program
1. http://www.upmccancercenter.com/portal_hema/overview.cfm
For general pathology (Hematopathology, Dermatopathology and others)
1. http://www-medlib.med.utah.edu/WebPath/webpath.html
2. http://dermatlas.med.jhmi.edu/derm (Users can search by categories, diagnoses, or body site)
3. www.uscap.org (numerous teaching resources)
4. http://www.pathologyoutlines.com
HEMATOPATHOLOGY
Atlas
1. http://www.ashimagebank.org/
2. http://www.bloodmed.com/home/
Virtual Slide Set
1. https://secure.opi.upmc.edu/hematopathology/index.cfm (or link via residents web page
http://residents.pathology.pitt.edu/ -- the link to Hematopathology virtual slide set is on the right hand
side (direct link to virtual slide set Division of Hematopathology UPMC Presbyterian)
2. http://cclcm.ccf.org/vm/VM_cases/lymphoid_main.htm
(Virtual Hematopathology slides (and other fixed images) from Cleveland Clinic)
3. www.uscap.org (Virtual Slide Box at USCAP)
General
1. http://www.sh-eahp.org/
2. http://medmark.org/hem/
3. http://www.cancer.gov/ (treatment of leukemias/lymphoma)
Case Studies
1. http://path.upmc.edu/cases.html
2. http://teachingcases.hematology.org/
USCAP Hematopathology Evening Session Cases
1. http://www.uscap.org/
Societies
1. http://www.hematology.org/
2. http://www.aspho.org/
3. http://www.blacksci.co.uk/uk/society/bsh/default.htm
4. http://www.leukemia.org/

Educational Site
1. http://www.cyto.purdue.edu/index.htm
2. http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm
Cases and Tests
1. http://www.madsci.org/~lynn/VH/APIII/CPflow.html
Societies
1. http://www.cytometry.org/
2. http://www.isac-net.org/
Books
1. http://www.cyto.purdue.edu/cdroms/cyto2/14/pucl/flowcyt/refclin.htm
CYTOGENETICS
1. http://www.pathology.washington.edu/Cytogallery/
2. http://cgap.nci.nih.gov/cgap.html
NOTE: IF THERE ARE ANY SITES YOU FEEL SHOULD BE ADDED TO THIS LIST OR DEFUNCT SITES,
PLEASE LET DR. SWERDLOW OR DR. ROTH KNOW
Online Conference Access for Pathology Faculty and Residents
• Visit Department of Pathology Conference Access for Pathology Faculty and Residents
• http://teleconference.upmc.edu/index.html
Weekly Conference includes:
• Anatomic Pathology Grand Rounds conference
• Departmental Seminar (Archived)
These LIVE and archived conferences are only accessible through the UPMC network.
Note: Additional non-web based resources are in UPMC-
Presbyterian G304, G315 and G323.