THE USE OF BONE MARROW BIOPSY TO DOCUMENT
THE PROLIFERATIVE EFFECTS OF HEMATOPOIETIC GROWTH
FACTORS ON BONE MARROW CELLS
Hematopoietic growth factors are increasingly used in clinical hematology and oncology. GM-CSF and G-CSF
are used to stimulate the production of neutrophils in patients with AIDS, aplastic anemia, and
myelodysplastic syndromes or to hasten blood count recovery in patients following bone marrow transplant or
myelotoxic chemotherapy. GM-CSF stimulates the formation of neutrophils, macrophages, and eosinophils.
G-CSF has activities similar to those of GM-CSF on mature neutrophils but has no effect on macrophages or
eosinophils.
Bone marrow changes in neutropenic patients treated with GM- and G-CSF include increased marrow cellularity
with an elevated myeloid to erythroid ratio, marked mature granulocytic hyperplasia and the presence of
paratrabecular and perivascular clusters composed of immature myeloid cells, predominantly promyelocytes and
myelocytes. If biopsied around the time of 0.5x109/L WBC most of these patients will show markedly
left-shifted myelopoiesis with sheets and clusters of promyelocytes (Scmidtz et al, 1994). This may raise
question about acute myeloid leukemia.
Immunohistochemistry can be used to fully delineate the various stimulatory effects of these growth factors.
The proliferation associated antigens PCNA (PC10) and Ki-67 (MIB-1), which can be successfully applied to
routinely processed bone marrow biopsies, have been used by us to monitor the proliferative effects on
different hematopoietic cell lineages exerted by the different growth factors. When PCNA or MIB-1 are used
in combination with hemoglobin, myeloperoxidase and vWF immunostainings the type of proliferative response
observed can furtherly be defined.
In our experience double positive myeloperoxidase/PCNA cells are augmented by IL-3, GM-, and G-CFS
treatment. Due to the increased proportion of promyelocytes in marrows treated with IL-3 and GM-CSF, the
proportion of HLA-DR -positive cells is often decreased in post treatment samples. IL-11 and thrombopoietin
stimulate platelet production by stimulating the proliferation and maturation of megakaryocytic progenitor
cells. Their thrombopoietic effect can be documented by staining with proliferation associated markers bone
marrow megakaryocytes (identified by morphology or vWF staining). The early acting growth factors such as
IL-3 and Stem Cell Factor (c-Kit ligand) increase the percentage of CD34 positive progenitors/early
precursor cells in the bone marrow; this effect can be documented by staining bone marrow section with CD34
monoclonal antibody. However the observed effect is modest with a less than doubling of normal number of
CD34 positive cells in the post treatment samples.
This methodologic approach can be used in the following settings:
- Phase I and II or other types of clinical trails which uses hematopoietic cytokines. A similar approach
can be used when monitoring marrow effects due to chemokines (e.g. MIP-1alpha; Broxmeyer et al, 1998) or
lymphokines.
- In patients with acute leukemia in remission following chemotherapy treated with growth factors such as
GM- or G-CSF. If biopsied around the time of 0.5x109/L WBC most of these patients will show markedly
left-shifted myelopoiesis with sheets and clusters of promyelocytes that may raise questions about acute
myeloid leukemia. However, in these patients the frequency of CD34 positive marrow progenitor cells remains
unchanged and virtually identical to normal control marrows. Thus, CD34 immunostaining can be successfully
used to distinguish between growth factor induced hyperplasia and the presence of residual leukemic blasts
in bone marrows of patients affected by CD34 positive leukemia. In CD34 negative disorders and in acute
lymphoid leukemia, immunohistology confirms the promyelocytic nature of the proliferating cell population by
showing a characteristic strong expression of myeloperoxidase and other myeloid markers in the absence of
CD34, HLA-DR, or lymphoid associated markers.
References
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