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Updated: Mar 18, 2026
Database-guided Flow-cytometry for Evaluation of Bone Marrow Myeloid Cell Maturation
Published on: November 3, 2018
Considering Bone Marrow Blasts From Nonerythroid Cellularity Improves the Prognostic Evaluation of Myelodysplastic
Leonor Arenillas1, Xavier Calvo2, Elisa Luño2
1Leonor Arenillas, Xavier Calvo, Carme Pedro, Ana Ferrer, and Lourdes Florensa, Hospital del Mar Research Institute; Esther Alonso, Hospital Universitario Bellvitge Hospitalet de Llobregat; Julia Montoro, Hospital Universitario Vall d' Hebron; Salut Brunet, Hospital Santa Creu i Sant Pau; Benet Nomdedeu, Hospital Clínic, Barcelona; Elisa Luño, Hospital Universitario Central Asturias, Oviedo; Leonor Senent and Guillermo F. Sanz, Hospital Universitario La Fe; Mar Tormo, Hospital Clínico Universitario de Valencia; Rafael Andreu, Hospital Universitario Doctor Peset, Valencia; Fernando Ramos, Hospital Universitario de León, León; María Teresa Ardanaz, Hospital Universitario Txagorritxu, Vitoria; Víctor Marco, Hospital Arnau Vilanova, Lleida; María Díez-Campelo, Hospital Universitario de Salamanca, Salamanca; Beatriz Arrizabalaga, Hospital Universitario Cruces, Baracaldo; Blanca Xicoy, ICO-Badalona, Badalona; Santiago Bonanad, Hospital La Ribera, Alzira; and Andrés Jerez, Hospital Morales Meseguer, IMIB-Arrixaca, Murcia, Spain. larenillas@parcdesalutmar.cat.
Purpose:
WHO classification of myeloid malignancies is based mainly on the percentage of bone marrow (BM) blasts. This is considered from total nucleated cells (TNCs), unless there is erythroid-hyperplasia (erythroblasts ≥ 50%), calculated from nonerythroid cells (NECs). In these instances, when BM blasts are ≥ 20%, the disorder is classified as erythroleukemia, and when BM blasts are < 20%, as myelodysplastic syndrome (MDS). In the latter, the percentage of blasts is considered from TNCs.
Patients And Methods:
We assessed the percentage of BM blasts from TNCs and NECs in 3,692 patients with MDS from the Grupo Español de Síndromes Mielodisplásicos, 465 patients with erythroid hyperplasia (MDS-E) and 3,227 patients without erythroid hyperplasia. We evaluated the relevance of both quantifications on classification and prognostication.
Results:
By enumerating blasts systematically from NECs, 22% of patients with MDS-E and 12% with MDS from the whole series diagnosed within WHO categories with < 5% BM blasts, were reclassified into higher-risk categories and showed a poorer overall survival than did those who remained in initial categories (P = .006 and P = .001, respectively). Following WHO recommendations, refractory anemia with excess blasts (RAEB)-2 diagnosis is not possible in MDS-E, as patients with 10% to < 20% BM blasts from TNCs fulfill erythroleukemia criteria; however, by considering blasts from NECs, 72 patients were recoded as RAEB-2 and showed an inferior overall survival than did patients with RAEB-1 without erythroid hyperplasia. Recalculating the International Prognostic Scoring System by enumerating blasts from NECs in MDS-E and in the overall MDS population reclassified approximately 9% of lower-risk patients into higher-risk categories, which indicated the survival expected for higher-risk patients.
Conclusion:
Regardless of the presence of erythroid hyperplasia, calculating the percentage of BM blasts from NECs improves prognostic assessment of MDS. This fact should be considered in future WHO classification reviews.
