Trephine biopsies of the bone marrow should be carried out, when clinically indicated, by trained individuals following a standard operating procedure. A bone marrow aspiration should be performed as part of the same procedure. For patient safety and convenience, biopsies are usually performed on the posterior iliac crest. The biopsy specimen should measure at least 1.6 cm and, if it does not, consideration should be given to repeating the procedure, possibly on the contralateral iliac crest. If bone marrow aspiration is found to be impossible, imprints from the biopsy specimen should be obtained. Otherwise, the specimen is placed immediately into fixative and after fixation is embedded in a resin or, more usually, decalcified and embedded in paraYn wax. Thin sections are cut and are stained, as a minimum, with haematoxylin and eosin and with a reticulin stain. A Giemsa stain is also desirable. A Perls' stain does not often give useful information and is not essential in every patient. The need for other histochemical or immunohistochemical stains is determined by the clinical circumstances and the preliminary findings. Trephine biopsy sections should be examined and reported in a systematic manner, assessment being made of the bones, the vessels and stroma, and the haemopoietic and any lymphoid or other tissue. Assessment should begin with a very low power objective, the entire section being examined. Further examination is then done with an intermediate and high power objective. Ideally, reporting of trephine biopsy sections should be done by an individual who is competent in both histopathology and haematology, and who is able to make an appropriate assessment of both the bone marrow aspirate and the trephine biopsy sections. When this is not possible, there should be close consultation between a haematologist and a histopathologist. The report should both describe the histological findings and give an interpretation of their importance. A signed or computer authorised report should be issued in a timely manner. If the report is a preliminary, this must be clearly stated. (J Clin Pathol 2001;54:737-742)

Bone marrow aspiration biopsies are carried out principally to permit cytological assessment but also for immunophenotypic, cytogenetic, molecular genetic, and other specialised investigations. Often, a trephine biopsy is carried out as part of the same procedure. Bone marrow aspirations should be carried out by trained individuals who are aware of the indications, contraindications, and hazards of the procedure. They should follow a standard operating procedure. The operator should have made an adequate assessment of clinical and haematological features to ensure both that appropriate indications exist and that all relevant tests are performed. For the patient's comfort and safety, the posterior iliac crest is generally the preferred site of aspiration. Films of aspirated marrow and, when appropriate, films of crushed particles should be made and labelled. Once thoroughly dry, films should be fixed and stained. As a minimum, a Romanowsky stain and a Perls' stain are required. A cover slip should be applied. The bone marrow films should be assessed and reported in a systematic manner so that nothing of importance is overlooked, using a low power, then intermediate, then high power objective. A differential count should be performed. An interpretation of the findings, in the light of the clinical and haematological features, should be given. The report should be signed or computer authorised, using a secure password, and issued in a timely manner.

This paper reports clinical and cytogenetic data from 125 cases with t(9;11)(p21-22;q32) which were accepted for a European Union Concerted Action Workshop on 11q23. This chromosome abnormality is known to occur predominantly in acute myeloid leukemia (AML) FAB type M5a and less often in AML M4; in this series it was also found to occur, uncommonly, in other AML FAB types, in childhood acute lymphoblastic leukemia (ALL) (nine cases), in relatively young patients with myelodysplastic syndrome (MDS) (five cases), acute biphenotypic leukemia (two cases), and acute undifferentiated leukemia (one case). All age groups were represented but 50% of the patients were aged less than 15 years. The t(9;11) was the sole abnormality in 57 cases with AML; trisomy 8 was the most common additional abnormality (23 cases, including seven with further abnormalities), and 28 cases had other additional abnormalities. Among the t(9;11)+ve patients with AML, the white cell count (WBC) and age group were significant predictors of event-free survival; central nervous system (CNS) involvement or karyotype class (sole, with trisomy 8, or with other), also contributed to prognosis although our data could not show these to be independent factors. The best outcome was for patients aged 1-9 years, with low WBC, and with absence of CNS disease or presence of trisomy 8. For patients aged less than 15 years, the event-free survival for ALL patients was not significantly worse than that of AML patients.

Forty of the 550 patients (7%) entered to the 11q23 Workshop had secondary (s) acute lymphoblastic leukemia (nine cases), s-acute myeloid leukemia (25 cases, predominantly of FAB type M5), s-acute leukemia unspecified (one case) or s-myelodysplastic syndrome (five cases) following treatment for a primary malignancy. Breast cancer (12 cases) and non-Hodgkin's lymphoma (eight cases) were the most frequent primaries. Twentythree patients had been treated with either an epipodophyllotoxin (seven patients) or an anthracycline (10 cases) or both (four cases) frequently combined with alkylating agents (12 cases) and with radiotherapy (six cases). Two further patients had alkylating agents and two had radiotherapy alone. Time between diagnosis of the primary and secondary malignancy was between 10 months and 22 years (median 24 months). The incidence of secondary malignancies in 11q23 subgroups was: t(11;19)(q23;p13.1) (33%), t(9;11) (8%), t(4;11) (5.5%), t(10;11)(5%), t (6;11) (3%), del11q23(2%) and 10 patients had a rare 'other' abnormality. No associations were seen between type of prior malignancy and 11q23 subgroup, or between prior malignancy and leukemia subtype. Remission, when achieved (32 patients), was short (median 5 months). Two patients survived following a bone marrow transplant for s-leukemia and s-myelodysplastic syndrome.

Aims: To identify how many particles should be examined to enable a confident assessment of the presence or absence of iron stores and the quantity of iron in a bone marrow aspirate to be made. Methods: One hundred and ninety consecutive bone marrow aspirate samples were stained with Perls' stain and the iron content of 10 consecutive particles was recorded. The first particle found to be positive and the particle that was most positive were also noted. Results: A minimum of seven particles must be examined to establish the absence of stainable iron. A minimum of nine particles must be reviewed to see the maximum iron stores in 100% of samples and therefore make a valid judgment of whether iron stores are reduced, normal, or increased. By these criteria, 46% of the samples tested here could not be optimally assessed for absence of iron or maximum iron stores. Conclusions: The sensitivity of examination of bone marrow aspirates for iron stores can be optimised by increasing the number of particles reviewed to seven or more. This may require the staining of additional slides.

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Summary. In healthy subjects the ESR is higher in women than in men, and in both sexes a rise with age occurs. It is well established that pathological elevation of the ESR may be due to elevation of the fibrinogen level. The present study has shown that in normal subjects the ESR correlates not only inversely with the haemoglobin level but also directly with the fibrinogen level. These two factors together explain the difference in ESR between men and women, and the major part of the age‐related increase in the ESR. Fibrinogen levels were found to be significantly higher in male smokers than male non‐smokers, and in women were inversely correlated with alcohol consumption; despite this the ESR did not differ in smokers and non‐smokers, nor was it related to alcohol intake. Oral contraceptive intake influenced neither the fibrinogen level nor the ESR. The correlation of ESR and fibrinogen concentration in healthy subjects suggests that physiological variation in the ESR is determined by the fibrinogen concentration as well as the haemoglobin level.

He was treated with cytosine arabinoside, hydroxyurea and busulphan but responded poorly. He had minimal recovery of hearing in his right ear. He died suddenly eight months after diagnosis. Histological findingsPost mortem examination showed hepatosplenomegaly with severe pulmonary oedema. The auditory nerves were grossly normal. Temporal bone histology showed that two thirds of the right scala tympani of the cochlear basal coil had been obliterated by myxoid fibrous tissue which also partly replaced the modiolus and vestibule (Figure). Spiral ganglion cells were absent in the apical and middle coil regions of the modiolus and reduced in the basal coil region. Basilar membrane nerve fibres were greatly reduced. The organ of Corti was atrophic with hydrops in the cochlear duct of each coil. The vestibule had also been replaced by myxoid fibrous tissue with some new bone formation around the periphery. The wall of the lateral semicircular canal was thickened by bone and its lumen occluded by fibrous material. The maculae ofthe saccule and utricle were absent. The vestibular nerves were atrophic with a loss of vestibular ganglion cells in the internal auditory meatus. The superior and posterior semicircular canals were fibrosed. The left temporal bone showed similar though less extensive changes with myxoid fibrous tissue in the scala tympani and semicircular canal fibrosis. Brain histology was normal. DiscussionOur patient with Ph negative CML followed the usual clinical course with refractoriness to chemotherapy and a short survival. His deafness seems related to the leukaemia with a close temporal relationship to the onset of disease and some recovery of hearing on lowering the white cell count. Deafness is rare in chronic phase CML, usually being attributed to hyperviscosity; the presenting white count in our parient was uncharacteristically low, counts in previous reported cases ranging from 210 to 1288 x 109/1.2-5