Hematopathology Report (Bone Marrow Aspirate/Biopsy)

Patient Name: [Patient name] MRN: [Medical record number] DOB: [Date of birth] Sex: [Sex] Location: [Patient location]

Ordering Clinician: [Ordering clinician] Accession Number: [Pathology accession number] Related Accessions: [Related accession numbers for flow, cytogenetics, FISH, molecular, prior marrows / None]

Collection Date/Time: [Collection date and time] Received Date: [Date received] Report Date: [Date reported]

Specimen(s) Submitted: [Bone marrow aspirate / Core biopsy / Clot / Touch imprints] from [Anatomic site], [Left / Right / Midline]

Pathologist: [Reporting pathologist]

Final Integrated Diagnosis

[Primary integrated diagnosis using current disease nomenclature] (Include key qualifiers such as therapy-related status, evolution from antecedent neoplasm, and entity-defining genetic features when applicable. If no neoplasm is identified, state a non-neoplastic conclusion. If diagnosis is uncertain, use explicit uncertainty language and provide a short prioritized differential with what is needed to resolve it. Do not infer lineage-defining genetics, clonality, or blast thresholds from incomplete data; document limitations when they affect interpretation.)

[Additional pertinent findings] (Include significant secondary processes or concurrent conditions only if supported by findings; otherwise omit this line.)

Key Data Elements

Specimen Adequacy – Aspirate: [Particulate / Hemodilute]; spicules [present / absent]; [Dry tap: Yes / No] (If limited, state impact on interpretation.)

Specimen Adequacy – Core Biopsy: [Length in cm]; [Intact / Fragmented / Crush artifact]; [Interpretive limitations or "Adequate"]

Cellularity: [Estimated percentage] ([Appropriate for age / Hypocellular / Hypercellular]) (If not assessable, state reason.)

Blasts: [Blast percentage] by [aspirate differential / touch imprints / CD34 IHC estimate]; [Cell count for differential] cells counted (If blasts cannot be reliably enumerated, state limitation and method used.)

Trilineage Summary – Erythroid: [Maturation pattern; left shift; megaloblastoid change; specific abnormalities]

Trilineage Summary – Myeloid: [Maturation; left shift; toxic change; abnormal granulation]

Trilineage Summary – Megakaryocytes: [Decreased / Normal / Increased]; [Morphology]; clustering [present / absent]

Dysplasia – Erythroid: [Present / Absent] (If present, state severity and whether quantitative thresholds are met; note limitations if hemodilute or inadequate precursors.)

Dysplasia – Granulocytic: [Present / Absent] (If present, detail features and whether thresholds are met; note limitations.)

Dysplasia – Megakaryocytic: [Present / Absent] (If present, detail features and whether thresholds are met; note limitations.)

Fibrosis (Reticulin): [MF-0 / MF-1 / MF-2 / MF-3], [diffuse / patchy] distribution; collagen on trichrome: [present / absent / not performed] (If reticulin not performed, state "Not performed.")

Iron Studies (Aspirate smear): Storage iron: [Absent / Decreased / Normal / Increased / Not performed]; ring sideroblasts: [Percentage / Not performed] (Iron assessment on decalcified core is unreliable and should not be used.)

Plasma Cells: [Percentage] by [aspirate differential / CD138 IHC]; clonality: [Kappa-restricted / Lambda-restricted / Polyclonal / Not performed]

Lymphoid Aggregates: [Present / Absent] (If present: [Benign-appearing / Atypical] with flow/IHC correlation and result.)

Other Findings: [Necrosis / Granulomas / Hemophagocytosis / Metastatic tumor / Organisms / Mast cell increase / Osteosclerosis / Bone remodeling / None identified] (Include only findings that are present.)

Clinical History and Indication

[Indication for bone marrow examination and relevant clinical context] (Include known prior hematologic malignancy with type and date, treatment history, transplant status, recent growth factors or chemotherapy, relevant infections, and reference prior marrow accession numbers when applicable. If no clinical history provided, state "Clinical history: Not provided.")

Specimen Description

Gross

Core Biopsy: [Number of cores]; [Aggregate length]; [Individual core lengths]; [Fragmentation/crush assessment]; decalcification: [Method]; material reserved: [Description / None]

Clot: [Size and description / Not submitted]

Microscopic

Peripheral Blood: [Key findings / Not reviewed]

Aspirate Smears: [Particulate / Hemodilute]; spicules [present / absent]. Differential: [Total cells counted]; M:E ratio [Ratio]. [Narrative of erythroid, myeloid, megakaryocytic maturation]. Blasts: [Morphology description]; Auer rods [present / absent]. [Dysplasia details with examples]. Plasma cells: [Percentage]; lymphocytes: [Percentage].

Core Biopsy: Cellularity [Percentage], [diffuse / patchy] distribution. [Topography description: paratrabecular/interstitial/nodular/diffuse infiltrates]. Megakaryocytes: [Description of distribution and morphology]. Lymphoid aggregates: [Description / None]. Fibrosis: [Grade and distribution]. Bone: [Changes or "Unremarkable"].

Touch Imprints/Clot: [Findings, especially if used for blast estimation due to dry tap or hemodilute aspirate / Not contributory / Not performed]

Ancillary Studies

Flow Cytometry: [Performed / Pending / Not performed / Not applicable]; Accession: [Number]; Source: [Specimen source]. [Abnormal population present/absent; immunophenotype highlights; MRD context if applicable]

Cytogenetics (Karyotype): [Performed / Pending / Not performed / Not applicable]. [ISCN notation]. [Interpretive summary]

FISH: [Performed / Pending / Not performed / Not applicable]. [Probes tested and results]

Molecular/NGS: [Performed / Pending / Not performed / Not applicable]. [Genes/panels tested; variants with VAF and tier; interpretive relevance] (Do not assert germline status from tumor-only testing.)

Pending Studies: [List pending ancillary studies; an addendum will be issued when results are available / None]

Correlation and Interpretation

[Narrative correlation integrating morphology with ancillary findings] (Use explicit correlation statements such as "Morphology and flow cytometry are concordant for...", "Cytogenetics supports...", "Molecular findings refine classification to..." Address any discordance and identify which modality is most reliable and why. Include recommendations for additional work-up only when appropriate. Do not recommend specific therapy.)

Addendum

(Include this section only when updating a previously signed report; otherwise omit entirely.)

Date/Time: [Addendum date and time] Author: [Name and credentials]

[New information and its impact on diagnosis] (State "This result supports/reclassifies the diagnosis as..." or "No change in diagnosis.")