Lecture 12 - Bone Marrow Disorders Flashcards
What conditions indicate that there is something going on in the bone marrow?
- Persistent, unexplained cytopenia or cytosis:
* Neutropenia
* Thrombocytopenia
* Pancytopenia
* Non-regenerative anemia - Unexplained rubricytosis (nucleated RBCs)
- Suspected neoplasia or monoclonal gammopathy
- Better classification of leukemia
- Fever of unknown origin; Looking for underlying inflammation, neoplasia
- Rule out osteomyelitis
- Staging lymphoma, mast cell tumor or others
- Monitoring chemotherapy response
Where would you collect bone marrow samples in dogs and cats?
Dogs, cats: Trochanteric fossa, humerus, ilium
Where would you collect bone marrow samples in horses, cattle, and camelids?
Horses, cattle, and camelids: the ilium, ribs, or sternum
What materials are required to collect bone marrow?
- Local or general __________
- Materials:
* Bone marrow ______ needle: ___-____ gauge
* ___cc syringe
* ______ tube or preferable make _______ asap
* air dry, _____ stain
- Local or general anesthesia
- Materials:
* Bone marrow biopsy needle: 16-22 gauge
* 12cc syringe
* EDTA tube or preferable make slides asap
* air dry, Wright’s stain
Illinois sternal aspiration biopsy needle, and a Jamshidi core biopsy needle along with its associated shepherd hook for specimen
removal.
Jamshidi Important to remember here: where should I obtain samples from. You will
go over these techniques later during clinical years
videos are FYI on how the procedure is done.
https://eclinpath.com/cytology/procedure-videos/
https://vod.video.cornell.edu/media/Canine+-+Bone+Marrow+Aspiration-
Forelimb/1_2iytqzo1/45064261
What is the point of obtaining a bone marrow sample?
What do you have to be careful of when collecting the sample?
What do you do in the event that you are unable to obtain a sample?
- Aspirate for cytology –avoid diluting sample with blood–. If can’t obtain - core biopsy for histopathology placed in formalin
- Core biopsy for histopathology
- Do NOT transport/ship these samples together
What is this image showing?
Fig a. Sampling at the craniolateral part of
the greater tubercle of the humerus.
Fig a. Placement of the marrow biopsy needle is shown into the craniolateral part of
the greater tubercle of the humerus. This site is preferred for obese and muscular
adult dogs and cats.
What is this image showing?
Fig b. Sampling at ?
Fig b This location may be most useful for ______ animals. Penetration is made just ______ to the greater trochanter and _______ to the shaft of the samples, avoiding the ______ nerve located more lateral and posterior.
Fig b. Sampling at proximal femur
Fig b The proximal femur may be most useful for small animals. Penetration is made just medial to the greater trochanter and parallel to the shaft of the samples,
avoiding the sciatic nerve located more lateral and posterior.
What is this image showing?
Fig a. Sampling at the ?
Fig.a. This location is popular in ____ or _____-_____ dogs, because it is readily accessible.
Fig a. Sampling at the dorsal iliac crest
Fig.a. The dorsal iliac crest is a popular location in thin or non obese dogs, because it is readily accessible
What is this image showing?
Fig. b. Transilial procedure
Fig. b. One or more samples may be taken via a transilial procedure. This site may be
helpful in young dogs and cats that have a dorsal ilial crest, too narrow to attempt
parallel placement of the biopsy needle.
How do you prepare film for a bone marrow sample?
- Squash or Pull Prep Technique: Bone marrow is collected
- 1- place a drop is placed toward the end of the slide.
- 2-The suspension is spread by placing a second microscope slide over
the sample perpendicular to the slide with the sample and pulling the
two slides apart. The weight of the top slide should be the only
pressure exerted on the sample.
What are the contraindications pf bone marrow sample collection?
- Bleeding disorders
- When you can achieve diagnosis with less invasive tests
- IMHA by CBC and blood smear
What do you have to interpret when analyzing a bone marrow sample?
- Cellularity and morphology
- Presence of megakaryocytes
- Presence of iron stores
- Myeloid:Erythroid ratio
- Orderliness and completeness of maturation
- Presence of other cells, example: Plasma cells
- Presence of abnormal cells
- Presence of microorganisms –rare-
You collect a bone marrow sample, stain it, and are now looking at it under the microscope. What is wrong with this sample?
Inadequate cellularity
Looking at: Overall % hematopoietic cellularity compared to % of adipose tissue
In addition to evaluating the cellularity, what else are you looking at when you analyzing your bone marrow aspirate?
The number of granulocytes to nucleated erythrocytes.
Normal range is 1:1 up to 3:1
What can be seen in the image below?
Normal bone marrow from a dog. Chunks of dark brown-black iron (arrows) released from ruptured macrophages (Wright’s stain, 50x objective).
Iron content can be semi-quantified in a cellular sample (with spicules) using a
Prussian blue stain.
Arrowhead pointing to a megakaryocyte
What can be seen in the image below?
Normal bone marrow from a dog. Chunks of dark brown-black iron (arrows) released
from ruptured macrophages (Wright’s stain, 50x objective).
Iron content can be semi-quantified in a cellular sample (with spicules) using a
Prussian blue stain
Iron within the bone marrow is stored within _______.
Iron stores are depleted in marrow before the development of _____ or ______ ____ red blood cells, this is the only technique for detecting early iron
deficiency.
macrophages, anemia, microcytic, hypochromic
How do you quantify iron storage levels in bone marrow?
No established guidelines for quantifying it. However, iron content can be semi-quantified in a cellular sample (with spicules) using a
Prussian blue stain.
What is the best way to collect bone marrow samples in order to determine the iron levels?
Best from bone marrow spicules (where macrophages are usually
located)
Is evaluating the iron levels required in establishing iron deficiency?
Not required technique in an established iron deficiency for Dx of
Iron def. anemia
* Remember the hematologic characteristics?
What can be seen below? Label the cells accordingly.
Erythroid maturation
1- Proerythroblast, 2 basophilic erythroblast, 3 polychromatophilic erythroblast 4
normoblast 5 reticulocyte 6 erythrocyte
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What can be seen below? Label the cells accordingly.
When interpreting bone marrow aspirate results, what other diagnostics are necessary?
- It is necessary to have recent CBC
- The day of collection or within 24h from collection
- Blood film evaluation simultaneously
What is the difference between a cytology and a core biopsy histopathology?
What does it mean when you are analyzing your bone marrow aspirate and find that there is DECREASED cellularity? What does decreased cellularity result in?
A decrease in cellularity means that there is a severe decrease in ALL hematopoietic cells in the bone marrow. The aspirate will consist of fat with stromal cells (macrophages, dendritic cells, fibroblasts, mast cells, lymphocytes and plasma cells)
Decreased cellularity results in:
* Bone marrow aplasia or bone marrow anemia
- <5% of erythroid or myeloid precursors or no megakaryocytes
* Results in pancytopenia
What are the causes of pancytopenia?
- drugs,
- hormones (e.g. estrogen),
- infectious agents (e.g. Ehrlichia canis),
- radiation,
- immune-mediated
- idiopathic causes
What does it mean when you are analyzing your bone marrow aspirate and find that there is an INCREASE in M:E ratio?
When there is an increase in the Myeloid:Erythroid ratio, it could mean any of the following:
* Erythroid hypoplasia or Aplasia
* Granulocytic hyperplasia
* Granulocytic leukemia
What does it mean when you are analyzing your bone marrow aspirate and find that there is a DECREASE in M:E ratio?
When there is a decrease in the Myeloid:Erythroid ratio it could mean any of the following:
* Regenerative anemia
* Erythroid leukemia
* Lack of production of neutrophils
What does it mean when you are analyzing your bone marrow aspirate and find that there are PLASMA CELLS in your sample?
If there is more than >15% to 20%, this suggests plasma cell myeloma/multiple myeloma if infectious dz testing is Neg.
BUT up to 5% plasma cells dispersed as single cells is normal
What % range of Lymphocytes in a bone marrow aspirate sample is considered to be normal?
1.7-4.9% is normal
What % range of Macrophages in a bone marrow aspirate sample is considered to be normal?
Up to 0.4% is normal
What % range of Mast cells in a bone marrow aspirate sample is considered to be normal?
Seeing mast cells in your bone marrow aspirate sample is RARE.
What does it mean when you are analyzing your bone marrow aspirate and find that there are OSTEOBLASTS AND OSTEOCLASTS in your sample?
Osteoblasts and osteoclasts are the unique cells occurring in bone marrow smears in situations with high bone metabolic turnover (children, trauma, rachitis, Paget disease or tumors).
What are the arrows pointing to in the image below?
Presence of abnormal cells
arrowed red blood cell precursor has a larger nucleus than normal. Mitotic figures can be seen in erythroid and myeloid cells in marrows, but increased erythroid mitoses
were seen (arrowhead) (Wright’s stain, 50x objective).
What types of microorganisms can be found in bone marrow aspiration samples?
- Histoplasma capsulatum
- Toxoplasma gondii
- Leishmania donovani
- Red cell parasites
- Babesia
What can be seen in the image below?
Where in this world can this organism be found?
Once they enter the body, where are they typically found?
Histoplasma capsulatum
It is endemic in North and Central America. Clinical manifestations varies from
pulmonary disease to disseminated multi-organ involvement.
Organisms are seen within macrophages
How do you interpret a bone marrow sample taken from a patient you suspect is infected with a microorganism?
Erlichia canis causes?
Canine monocytic ehrlichiosis
What are the most frequently reported clinical signs of a patient infected with Erlichia canis?
lethargy, anorexia, fever, lymphadenomegaly, splenomegaly, and hemorrhages, mainly petechiae, ecchymoses and epistaxis
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What are the 3 phases of Erlichia canis infection?
–> 3 phases of the dz
* acute phase/subclinical, lasts from months to years
* chronic phase. Not all infected dogs develop this phase
- assumed to be associated with individual susceptibility and breed predisposition
Infection with Erlichia canis produces severe __________ caused by bone marrow ________ in
chronic stage that may not be _________ at the time of Dx
* “______ killer”
- Produces severe pancytopenia caused by bone marrow suppression in
chronic stage that may not be reversible at the time of Dx - “silent killer”
Explain the pathogenesis behind Erlichia canis –> pancytopenia.
Immune-mediated responses play a major role in the pathogenesis of E. canis infection. Anti-platelets antibodies (APA) have been demonstrated less than a week after experimental E. canis infection of dogs. Platelet aggregation abnormalities, anti-nuclear antibodies (ANA), RBC autoagglutination with positive Coombs’ test, and circulating immune-complexes have been shown in infected dogs and are associated with the disease process.
The decrease in platelets during canine ehrlichiosis is probably a result of several mechanisms. These mechanisms include increased consumption with vascular endothelial changes, platelet sequestration and pooling in the spleen, thrombophagocytosis with immunological destruction, a decrease in the half life time of circulating platelets possibly due to opsonization with antibodies, and production impairment due to bone marrow destruction and hypocellularity. In addition to the decrease in circulating platelet number, platelets dysfunction (thrombocytopathy) has also been implicating as an additional factor contributing to lack of platelet functionality in canine monocytic ehrlichiosis.
List which diseases effect the bone marrow.
Effect on the bone marrow correlates with the CBC of the the most important ones:
FeLV
FIV
Myelophthisis
Inflammation
Drugs
Neoplasia (blast cells)
Plasma cells
Primary bone marrow neoplasia arises from the __________ stem cells or ____ stages:
* Accumulate = ?
* Proliferate and die = ?
* Proliferate and overtake = ?
Arise from the hematopoietic stem cells or later stages:
* Accumulate (chronic disease)
* Proliferate and die (myelodysplastic syndrome = immature blood cells in the bone marrow do not mature or become healthy blood cells)
* Proliferate and overtake (acute leukemia)
Hematopoietic neoplasms arise from?
Bone marrow, and also from lymph nodes, spleen or
thymus
* Classification:
* Lymphoid neoplasms
* Myeloid neoplasm
Lymphoma: ______ tumor of neoplastic ________ located _______ of the bone marrow
Lymphoma: solid tumor of neoplastic lymphocytes located outside of the
bone marrow
Leukemia: neoplastic cells (____ type) in the _____ and/or _______ _______.
Leukemia: neoplastic cells (any type) in the blood and/or bone marrow
Define lymphoid leukemia
Lymphoid leukemia: neoplastic lymphocytes in the blood and/or bone
marrow
Define leukemic phase of lymphoma.
Lymphoma previously diagnosed in other _____ (____ _____) and has spread to ____ and ______ _____ (AKA Stage ___ lymphoma)
Leukemic phase of lymphoma: lymphoma previously diagnosed in other organs (lymph nodes) and has spread to blood and bone marrow (AKA Stage V lymphoma)
What is leukemia characterized by?
CBC leukocyte levels may be?
Neoplastic cells (any type) in the blood and/or bone marrow
* with distorted proliferation and development of leukocytes and their
precursors
- CBC leukocytes count may be low, normal or high
- Will often see very high total WBC count on a CBC, +/- neutrophils and
lymphocytes (depending on cell of origin) - May see concurrent anemia and thrombocytopenia (bicytopenia)
In a case of Acute Leukemia, what type of cells would you see in the bone marrow?
Describe the time line of disease progression.
How old are the affected patients.
See below
In a case of Chronic Leukemia, what type of cells would you see in the bone marrow?
Describe the time line of disease progression.
How old are the affected patients?
See below
In a case of acute lymphocytic leukemia, what will you see on histology?
Undifferentiated/immature lymphocytes (lymphoblasts)
Cats: most were FeLV of FIV positive prior to routine vaccination and
testing
In a case of chronic lymphocytic leukemia, what will you see on histology?
Myeloid neoplams are defined as?
- Proliferation of one or more non-lymphoid marrow cell lines:
- Granulocytes
- Monocytes
- Erythrocytes
- Megakaryocytes
List the different types of myeloid neoplasms.
- Includes
a. Myelodysplastic syndrome (MDS)
b. Acute myeloid leukemia (AML)
c. Chronic myeloid neoplasms (myeloproliferative neoplasms, or MPN)
In a case of myelodysplastic syndrome, you will see:
*__________ bone marrow with
___________ in peripheral blood
* >10% bone marrow cells are
morphologically _________
(__________)
* Bone marrow blast count
<_____%
- Hypercellular bone marrow with
cytopenias in peripheral blood - > 10% bone marrow cells are
morphologically atypical
(DYSPOIESIS) - Bone marrow blast count
<20%
In a case of acute myeloid leukemia, you will see:
* ____________ bone marrow,
often ___________ in peripheral
blood (may be _______, or __________)
* Dx when bone marrow blast
count >____%
* ___ categories in Vet Med. Based
on predominant cell types
- Hypercellular bone marrow,
often leukocytosis in peripheral
blood (may be normal, or
leukopenia) - Dx when bone marrow blast
count >20% - 7 categories in Vet Med. Based
on predominant cell types
How could we differentiate MDS from AML?
It is based on the bone marrow evaluation one has less than 20% blast count while AML has more than 20% blast count.
Chronic myeloid neoplasms are very _____ in veterinary medicine – rule out other possibilities first.
(e.g., ?)
* Characterized by bone marrow __________ + ____ cell counts in
peripheral blood
* Can progress to ____
- Very rare in veterinary medicine – rule out other possibilities first
(e.g., severe systemic inflammation) - Characterized by bone marrow hyperplasia + high cell counts in
peripheral blood - Can progress to AML
Chronic myeloid leukemia (CML)
Very high total ________ count in peripheral blood; morphologically ______
Granulocytic ________ in bone marrow
Very high total leukocyte count in peripheral blood; morphologically normal
Granulocytic hyperplasia in bone marrow
Polycythemia vera
Erythroid __________ + _________ in peripheral blood
hyperplasia, erythrocytosis
Essential thrombocythemia
Megakaryocytic __________ + marked _____________ (often >_________/uL) in peripheral
hyperplasia, thrombocytosis, 1,000,000
Some chronic myeloid neoplasms can be impossible to differentiate from ________ expansions on an aspirate, a core biopsy for _______ _________ pattern may help
reactive, abnormal architecture
Reactive bone marrow processes can affect one or more hematopoietic cell lines, lead to disruption of the normal architecture and specifically affect the bone marrow stroma.
Define non-hematopoietic neoplasms.
Infiltrative neoplasms that do NOT arise in the bone marrow
Define myelophthisis
Replacement of bone marrow cells
Define cytopenias
Alter the bone marrow environment
List the various types of non-hematopoietic neoplasms.
MHM, Christine Likes My Salsa U O
* Lymphoma
* Multiple myeloma (aka systemic plasma cell tumor)
* Histiocytic sarcoma (dog)
* Mast cell tumor
* Chronic lymphocytic leukemia
* Metastatic tumors -carcinomas –
* Urothelial carcinoma, mammary carcinoma
* Sarcomas of bone
* Osteosarcomas
List the advanced diagnostic techniques used for Lymphoma/Leukemia.
- Immunophenotyping
a. Immunocytochemistry (ICC): cytology
b. Immunohistochemistry (IHC): histology
c. Flow cytometry - Clonality assays: PCR for antigen receptor rearrangement (PARR)
Explain how Immunocytochemistry and Immunohistochemistry are useful in diagnosing leukemia.
- Useful when cytology or histology are inconclusive for neoplasia
- For immunophenotyping/classifying lymphoma diagnosed on
cytology or histology - Both ICC or IHC detect antigens on cells by chemical or immunologic
reactions
List some examples of when it would be useful to use Immunocytochemistry and Immunohistochemistry
- CD8+ cells in dog bone marrow: T-lymphocyte leukemia
- CD79a+ cells in dog bone marrow: B-lymphocyte leukemia
- Myloperoxidase (MPO)+ cells in cat bone marrow: Myeloid leukemia
How is immunophenotyping helpful? List examples
- Can identify lymphocyte subsets by the proteins they express on their
surface
Remember which markers are expressed by T cells and which one for B cells.
What is flow-cytometry used for?
- Use for Immunophenotyping
* Previously diagnosed lymphoma on cytology/histology
* Leukemia (especially acute, when morphology is unreliable) - Use for differentiating reactive from neoplastic lymphocytosis
What samples should be collected for Flow-cytometry? What should NOT be used?
For testing use:
* Live cells in a fluid suspension
- Fresh aspirates or cavitary fluids in saline and serum
- Whole blood or bone marrow in EDTA
- NOT cytology slides
Describe the process of flow cytometry.
It is a biophysical based instrument used to study cell size, cell count, etc
The study is based on on principle of fluorescence analysis and can count thousand
of cells in seconds.
immunolabelling for antibody to the cell is used to characterized them, could be
inside or outside the cell. Can look at size, shape, density, DNA, RNA, protein content,
internal or external receptors, membrane surface, apoptosis, necrosis, calcium influx,
intracellular pH, etc.
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How does Flow cytometry work?
- Stains _____ cells with labeled _______ that bind to proteins (antigens) expressed _____ of cells and on cell _______
- Lasers within the instrument _______ the number of cells that express particular antigens and the relative expression levels
- FS: Cell _____
- SS: Internal ______
- Determines cell _______ which correlates with _______.
- Stains live cells with labeled antibodies that bind to proteins (antigens) expressed inside of cells and on cell surfaces
- Lasers within the instrument quantify the number of cells that express particular antigens and the relative expression levels
- FS: Cell size
- SS: Internal complexity
- Determines cell lineage which correlates with prognosis
FS correlates with cell _____ and SS is proportional to the __________ of the cells. In this manner, cell populations can often be distinguished based on these differences alone.
Light beam measures _______ scatter (FS) and several detectors to the side measure ___ scatter (SS)
size, granularity, forward, side
What is the FSC (forward angle scatter)?
It measures the cell size
What is the SSC (side angle scatter)
It measures cell granularity or complexity
The more complex the cell the higher the ____ value (go up on Y axis - Granulocytes for example
SSC
The bigger the cell the higher ____ value (to towards the right of the X axis)
- Lymphocytes, monocytes
FSC
FSC vs SSC plot to exclude debris then the closer to the 0 on then it is debris likely
because they have low granularity or complexity.
Single parameter histograms to identify cells w particular marker expression
Double parameter uses 2 markers for 2 populations (CD3 for T cells) and CD19 for B
cells and will quantify there presence in the sample in %.
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Normal canine blood and LN aspirates predominantly contain ?
more CD3, CD4
(T-lymphocytes) than CD21 or CD19 (B-cells)
Interpret the data below:
- What does each quadrant represent?
- What % of cells is higher? B cells or T cells?
- Upper Left Quadrant = (-) for T cells, (+) for B cells
Upper Right Quadrant = (+) for T cells, (+) for B cells
Lower Left Quadrant = (-) for T cells, (-) for B cells
Lower Right Quadrant = (+) for T cells, (-) for B cells - T cells = 60.3% > B cells = 7%
What are clonality essays: PARR used for?
- Can differentiate ________ lymphocytosis from _______
- When _______ cytology or histopathology
- Examples
- to differentiate _______ lymphomas such as __-zone lymphoma or ____ zone lymphoma from _______ reactions when there is lack of _______ effacement
- to characterize ________ proliferations in the feline or canine skin
- to differentiate feline _______ ______ disease from _______ lymphoma
- Can differentiate reactive lymphocytosis from lymphoma
- When inconclusive cytology or histopathology
- Examples
- to differentiate follicular lymphomas such as T-zone lymphoma or marginal zone lymphoma from hyperplastic reactions when there is lack of architectural effacement
- to characterize lymphohistiocytic proliferations in the feline or canine skin
- to differentiate feline inflammatory bowel disease from intestinal lymphoma
What is PARR?
FYI
- Technique is based on the fact that during maturation, lymphocytes
undergo a series of genetic alterations (VDJ rearrangements) which are
unique from cell to cell, and ultimately culminate in almost unlimited
variety among the antigen receptors on B and T lymphocytes. - By using PCR primers to amplify the area encoding diversity of the Ig heavy
chain (IgH) of B cells and the gamma subunit of the T cell receptor of T cells
(TCRγ), DNA from clinical specimens can be analyzed to determine
whether the lymphocytes in a specimen share identical antigen receptors
(i.e. are “clonal”), or whether they are genetically different (i.e.
“polyclonal”). - As suggested by the clonal theory of cancer, a clonal expansion is very
highly suggestive of neoplasia.
What samples are used for PARR testing?
- _____ blood or bone ______
- ______ fluids and ___
- ______ aspirates in saline
- _____ specimens
- Cytology slides – _____ or _____ slides-
- EDTA blood or bone marrow
- Cavitary fluids and CSF
- Fresh aspirates in saline
- Biopsy specimens
- Cytology slides –stained or unstained slides-
How does PARR work?
_____ extraction and PCR from __ and ___-lymphocyte receptors
* Specifically _______ DNA encoding __________ determining region ___ (CDR3) using __ and ___ primers
DNA extraction and PCR from T and B-lymphocyte receptors
* Specifically amplifies DNA encoding complementarity determining region 3 (CDR3) using V and J primers
Why do you have to be careful when using PARR?
- Dogs infected with Ehrlichia canis
* may induce a ________ of ______ lymphocytes
* May induce ________ T cells (CD__+, CD__+) clonality expansion- This mimics a ______ ______ ______ on PARR
- Dogs infected with Borrelia burgdorferi may have clonality expansion of ___ cells
- Dogs infected with Leishmania may have clonality expansion of __ or ___ cells
The ______ T cell expansion on PARR can mimic a chronic lymphocytic leukemia
- Dogs infected with Ehrlichia canis
* may induce a lymphocytosis of granular lymphocytes
* May induce cytotoxic T cells (CD3+, CD8+) clonality expansion
* This mimics a CLA (chronic lymphocytic leukemia) on PARR - Dogs infected with Borrelia burgdorferi may have clonality expansion of B
cells - Dogs infected with Leishmania may have clonality expansion of T or B cells
The CLONAL T cell expansion on PARR can mimic a chronic lymphocytic leukemia
Should you use the PARR test alone in diagnosing your patients?
- Be careful how to use the PARR test NEVER USE ALONE–it is adjunctive
and should be interpreted with clinical pathology and diagnostic tests - Hemogram, chemistry, bone marrow or other aspirates
clinical pathological testing (hemogram, chemistry, bone marrow or other aspirates)
and diagnostic (e.g. imaging) tests. In particular, assessment of morphologic features
of the cells in blood or aspirate smears by a clinical pathologist is essential for
establishing a diagnosis of hematopoietic neoplasia. It cannot be over-emphasized
that the techniques listed below should never be used alone to make a diagnosis of
hematopoietic neoplasia.
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If you suspect your patient may have leukemia, what samples should be collected? What further Dx should be run?
- Samples:
* blood smear
* CBC
* Bone marrow aspirate AND core biopsy- Aspirate: best for cellular morphology and determination of lineage
* Core biopsy: best for architecture- Myelophthisis
- Aspirate: best for cellular morphology and determination of lineage
- Further advanced Dx test: ICC, IHC, Flow cytometry, PARR
