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Identifying Bone Marrow Microenvironmental Populations in Myelodysplastic Syndrome and Acute Myeloid Leukemia
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A tale of two sites - Distinct spatial differences between bone marrow and extramedullary AML

Hossein Emami1, Annette I Garbe1, Karin Huber2

  • 1Department of Hematology and Oncology, University Hospital Schleswig-Holstein Kiel, Kiel, Germany; University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany.

Blood Reviews
|July 7, 2026
PubMed

Insights

Extramedullary acute myeloid leukemia (AML) involves leukemic cells outside the bone marrow and is linked to poor survival. Understanding spatial differences and niche interactions is key for better diagnosis and treatment of this AML subtype.

Area of Science:

  • Hematology
  • Oncology
  • Cancer Biology

Background:

  • Acute myeloid leukemia (AML) is a common adult leukemia with poor survival rates.
  • Extramedullary (EM) AML, characterized by leukemic infiltration of peripheral tissues, is clinically relevant and associated with adverse outcomes.
  • Knowledge regarding extramedullary AML, its drivers, and treatment is less developed compared to bone marrow AML.

Purpose of the Study:

  • To review the spatial heterogeneity of AML, distinguishing between bone marrow (BM) and EM disease.
  • To elucidate how niche components influence leukemic behavior, clonal evolution, and treatment resistance in EM AML.
  • To discuss current clinical practices, diagnostic management, and treatment strategies for EM AML.

Main Methods:

  • Review of existing literature on AML, focusing on extramedullary manifestations.
  • Analysis of spatial heterogeneity and niche component interactions in AML.
  • Evaluation of current clinical approaches and diagnostic tools for EM AML.

Main Results:

  • Spatial heterogeneity significantly impacts AML progression, immune evasion, and therapy resistance.
  • Niche components in both BM and EM sites play a crucial role in shaping leukemic cell behavior.
  • Current clinical management and treatment for EM AML are evolving.

Conclusions:

  • Spatial analysis platforms offer transformative potential for mapping cell interactions in EM AML.
  • Improved understanding of niche-leukemic cell interactions can enhance diagnosis and personalize therapeutic strategies for EM AML.
  • Further research into the spatial biology of EM AML is essential for improving patient outcomes.
Keywords:
Diagnosis of extramedullary AMLExtramedullary AMLMyeloid sarcomaSpatial heterogeneityTreatment of extramedullary AML

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