I.

INTRODUCTION
A. Definition
Hematopoiesis is the proliferation of
progenitor cells, which are maintained by
the stem cells and their differentiation into
all the cellular components of blood.
B. Sites of hematopoiesis depend on the
presence of disease and on the develop-
mental state of the individual.
1. Normal conditions originate in the bone
marrow
Some components (e.g., erythrocytes and
platelets) complete their development at
medullary (i.e., bone marrow) sites, whereas
other components (e.g., T and B cells)
complete their development at extramedullary.
Foetus : 0 2 months yolk sac
0 7 months liver, spleen
5 9 months bone marrow
Infants : Bone marrow (practically all bones)
Adults : vertebrae, ribs, sternum, skull,
sacrum, proximal ends of femur

2. Disease
In the presence of disease, extramedullary
sites can serve as primary sites of blood
cell development.
II. BONE MARROW
A. Stem cells CFU (Colony - Forming Unit)
are found within the BM as the origin of all
blood cells.


~ Blood cells are formed by a process of
differentiation from the least developed stem
cells to highly specialized blood cells. (Table 1)
~ Stem cells :
1. pluripotential stem cells 3 main marrow
cell lines :
a). erythrocytes (red cells)
b). granulocytes monocytes (white cells)
c). thrombocytes (platelets) and probably
lymphocytes (T & B lymp.,plasma cells).




2. Multipotential stem cells myeloid multi-
potential stem cells and lymphoid multipoten-
tial stem cells.
- Myeloid multipotential stem cells :
* CFU-GEMM (CFU-S) CFU granulocytes,
erythrocytes, monocytes and megakaryocy-
tes; the earliest detectable myeloid precursor
* CFU-C (CFU-GM) CFU - granulocytes
and monocytes

* CFU-E and BFU-E
- CFU-E CFU erythropoiesis
- BFU-E Burst - Forming Unit - erythroid
committed to erythropoiesis and
precursor of the CFU-E
- CFU-E and BFU-E are dependent on Epo
* CFU-Meg
- progenitor of megakaryocytes
- derives from CFU-GEMM
- controlled by thrombopoietin
Figure 1. Schematically summarizes the role of the major
progenitor cells of hematopoiesis
Pluripotent
stem cell





CFU
GEMM
Lymphoid
stem cell



BFU
E
CFU
GMEo
CFU
baso


Erythroid CFU
Eo
Progenitors CFU
Meg
CFU
GM

CFUE
Thymus

CFU-M CFU-G




Red Cells Platelets Mono- Neutro- Eosino- Baso- Lymphocytes
FIGURE 1. cytes phils phils phils







B
T
Tabel 1. Some hematopoietic progenitors cells
Term Required stimulus Postulated Role
CFU-LM Multiple GF Pluripotent stem cell
CFU-GEMM
(CFU-S)
GM-CSF, G-CSF,
M-CSF, IL-3
Pluripotent stem cell

CFU-GM
(CFU-C)
GM-CSF, G-CSF,
M-CSF, IL-3
Committed progenitor of
granulopoiesis
BFU-E Erythropoietin, helper T
lymphocytes (IL-1, GM-
CSF, IL-3, IL-4)
Committed progenitor of
erythropoiesis (early)
CFU-E Erythropoietin Committed progenitor of
erythropoiesis (late)
CFU- Meg IL-3, GM-CSF, G-CSF.
thrombopoietin
Committed progenitor of
thrombopoiesis
~ Lymphoid multipotential stem cells leave
the bone marrow and complete diff. in
lymph nodes (B cells) and thymus (T cells)
B. Hematopoietic Growth Factors CSF (Colony-
stimulating factor)
Classification :
a. Non-lineage-specific GF act on pluripo-
tential and multipotential stem cells to
initiate self-renewal and differentiation

~ IL-3 (Multi-CSF) induces the formation
of colonies granulocyte, monocytes,
eosinophils, erythroid cells,megakaryocytes
and mast cells production
~ GM-CSF stimulates granulopoiesis and
macrophage production
b. Lineage-specific GF act on the commit-
ted progenitor cells and are involved in the
diff. and maturation of blood cells in the
later stages of hematopoiesis.
These factors include :
~ Epo stimulates erythropoiesis, mediates
its feed-back control
~ G-CSF inducing formation of granulocyte
and stimulates proliferation of some leuke-
mic cells
~ M-CSF influencing macrophage prod.
~ Thrombopoietin influencing CFU-mega
(Table 2)


Table 2. Myeloid Hematopoietic Growth Factor
Factor Major Biological Activities in Vivo
Erythropoietin
(Epo)
Stimulates erythropoiesis. Mediates its feedback
control
GM-CSF
Stimulates granulopoiesis and macrophage
production
G-CSF
Stimulates granulopoiesis and proliferation of
some leukemic cells
M-CSF
Stimulates macrophage production
IL-3 (Multi-CSF)
Stimulates granulocyte, monocyte, eosinophils,
erythroid cells, megakaryocyte and mast cells
production
Thrombopoietin
Influencing CFU-mega
C. Lymphokines and monokines
- released by lymphocytes and monocytes
(macrophages) have wide-ranging
h.poietic effects through extensive network
of interaction involving immune responses
to infection and tumor invasion.

- IL (Interleukin) : secreted by lymphocytes,
affect the function of other leukocytes (com-
munication links between leukocytes)
- engage in complex interactions with other IL,
HGF and many other protein such a TNF and
lymphotoxins (Table 3)

Table 3. Lymphoid Hematopoietic Growth Factors
Name Source Function
IL - 1
Macrophages, T
and B cells,
fibroblasts
Stimulates growth of T and B cells,
mediates inflammation, inhibits growth of
some cancer cells.
IL - 2 (T
cells GF)
T cells Binds to receptors on cytotoxic T cells,
promote their growth, stimulates growth of
helper T cells.
IL - 4
T cells, NK cells,
mast cells
Stimulates & regulates growth and diff. of T
and B cells, eosinophils and basophils.
IL 5
(EoGF)
T cells Regulates production of eosinophils.
Activates mature eosinophils.
IL - 6
Lymphocytes,
fibroblasts
Promotes macrophage formation.
Stimulates IgG production by B cells.
IL-7
Stromal Cells Supports long-term survival of B and T
cells in vitro.
IL - 8
Fibroblasts,
vasc. endot.
Enhancement of neutrophil function
Common General Features of
Hematopoietic Growth Factors
1. All are glycoproteins
2. Regulators of blood cell development and
maturation and enhancers of mature cell
functions, which are active at very low
concentration
3. Active both in vitro and in vivo
4. Produced by cells of many types

5. Usually have both unique and
overlapping specificities
6. Active on both stem (progenitor) cells
and end cells
7. Biologic affects are mediated after
binding to a small number of specific
high - affinity receptors on the surfaces
of target cells

8. Also bind to receptors on some nonhema
- topoietic cells. The significance of this is
unknown
9. Display synergy or additive effects with
other growth factor
10. Also act on neoplastic counterparts of
normal cell type
III. SPLEEN
The chief organ of RES, which also
includes BM, lymph nodes, liver, circulating
monocytes and fixed tissue macrophages.
Its chief role in hematopoiesis occurs in
utero ; its postnatal participation is limited.
Extramedullary hematopoieis in the spleen
occurs in several circumstances

Functions :
Participates in immunologic and phagocytic
activities
Produces stem cells capable of
differentiating along hematopoietic, histiocytic
and fibroblastic cell lines
Play roles in the autoantibody response and
determining blood volume.




IV. EVALUATION OF THE BONE MARROW
1. Indication for a bone marrow aspirate :
Evaluation of decreased numbers of cells
from a single lineage
Ev. of patients with decreased blood cell
counts (bicytopenia or pancytopenia) and
leukemias (stem cell defects & disorder)
Ev. of iron stores and abnormal iron in
erythroid precursor

Diagnosis of tumor involvement
To demonstrate possible infection by
intracellular organism
To investigate an immunologic disorder
Diagnosis of nonhematopoietic diseases
2. Indications for a BM biopsy
Failure to obtain an adequate marrow
aspirate
Evaluation of pancytopenia or bicytopenia
Leukoerythroblastic findings in the
peripheral blood smear
Evaluation of hematologic malignancies
and tumor staging
To defined endpoint of aplasia


Erythropoiesis is the segment of hemato-
poiesis concerned with the production of
erythrocytes (red cells). In essence, it is a
system for the production and packaging of
Hb molecules.
Maturation stages begin with the pronormo-
blast, which derives from a pool of more
primitive stem cells

ERYTHROPOIESIS
STEM CELLS
PRONORMOBLAST
BASOPHILIC NORMOBLAST
POLYCHROMATOPHILIC NORMOBLAST
ORTHOCHROMATOPHILIC NORMOBLAST
RETICULOCYTE
MATURE RED CELL



MATURATION STAGES
Pool of nucleated erythroid precursor in marrow
~ 2% pronormoblast
~ 18% basophilic normoblast
~ 54% polychromatophilic normoblasts
~ 26% orthochromatophilic normoblasts
Nucleated red cells (normoblasts) appear in the
blood if erythropoiesis is occurring outsides the
marrow (e.medullary e.poiesis) and also with
some marrow diseases.
Erythropoietin (Epo)
- Regulate erythropoietic activity
- Also shorten the total time taken for a pro-
normoblast to mature into marrow reticu-
locytes & for the later to be released
into the circulation
The life span averages aprox. 120 days.
Marrow requires many precursor to synthesize
the new cells & large amount of Hb.
The substances are :
1. Metals : iron, manganese, cobalt
2. Vitamins : vit. B
12
, folate, vit.C, vit.E, vit.B
6,

thiamine, riboflavin & pantothenic acid
3. Amino acid
4. Hormones : SCF, IL-3, GM-CSF, Epo,
androgen and thyroxine

GRANULOPOIESIS
Leucocyte or white cell refer to any of the
nucleated cells normally present in blood, whose
major function is defense against foreign invaders
Types of leucocytes :
- Type of defense function : phagocytes (i.e., granu-
locytes and monocytes) and immunocytes (i.e.,
lymphocytes and plasma cells)
- Shaped of the nucleus polymorpho-
nuclear or mononuclear)
- Site of origin myeloid or lymphoid
- Presence of absence of specific- staining
granules granulocytes or non-granu-
locytes
Maturation stages
MYELOBLAST
PROMYELOCYTE
MYELOCYTE
METAMYELOCYTE
BAND FORM
MATURE PMN GRANULOCYTE

1. NEUTROPHILS
Functions : ~ Chemotaxis
~ Cytotoxic activities : phagocytosis
and granule toxicity
Life span and circulation :
~ Transit time in blood for mature neutrophils :
1 day or less.
~ Probably survive 1-2 days in tissue.
~ N peripheral blood levels : 4.0 10 x 10
3
/ul

2. EOSINOPHILS
Functions :
~ a first line defense against parasites
~ modulate hypersensitivity reactions
~ migrate to inflammatory sites
Life span and circulation :
~ Usually exist in concentr. of 100-400/ul
in PB
~ BM maturation time : 2-6 days ,
circ. half life : 6 - 12 hours
3. Basophils and Mast cells
Functions :
~ involved in immediately hypersensitivity
~ trigger anaphylactic degranulation
~ active arachidonic acid metabolites
(e.g..leukotrienes, prostaglandin)
Life span and circulation :
~ Basophils : about 1-2 days
~ Mast cells : present in blood only in pathologic
conditions. Murine studies : mast cells survive
several weeks to several month in tissue

4. MONOCYTES
Functions : Morphology :
~ Activating stimuli Monoblast
~ Chemotaxis
~ Phagocytosis Promonocytes

Monocytes
Life span :
4.5 10 hours (mean 8.5 h)
LYMPHOCYTOPOIESIS
There are three major functional classes of lymphocy-
tes : B lymphocytes (B cell), T lymphocytes (T cell)
and Natural Killer (NK cell)
Differentiation :
~ B - lymphocyte diff. in BM :
Early pre-B cell
pre B-cell
immature B cell
mature B celll

~ T-lymphocyte diff. in the thymus :
Pre-T cell (thymic lymphoblast)
Early thymocyte (large cortical thymocyte)
Intermediate thymocyte (small c. thymocyte)
Late thymocyte (medullary thymocyte)
Mature T cell

Function :
~ B cell function : humoral immunity (i.e.,anti
body/immunoglobulins production)
~ T cell function : cell-mediated immunity
including delayed hypersensitivity, graft
rejection, contact allergic reaction
Life span : years
THROMBOPOIESIS
Blood platelets play an essential role in
hemostasis, thrombosis and coagulation of
blood
The platelet count ranging from 140,000-
450,000/ul
Life span : 8 to 12 days
Functions : Platelets participate in the formati-
ons of a platelet plug and a stable fibrin clot
(adhesion and aggregation)

Maturation stages
Pluripotential stem cell CFU-Meg Megakaryoblast

Proliferation

CSF-Mega

Megakaryocyte maturation Platelet shading

Thrombopoietin (TP)
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