Morphology substudy ELN low risk Registry Aims - assess the reproducibility of diagnosis Methods - review of random selected slides from all participating countries - reviewer panel includes both „experts“ as well as physicians in training - description of results and correlation with original findings - calculation of degree of discrepancy using  -test

Methods in detail - Random selection of a total of 100 cases from all countries taking into account the amount of included patients (for example more from France as compared to Germany -> already done by Alex Smith -2 marrow slides (preferably also iron staining) and 1 blood film from each selected case should be sent to Düsseldorf, where the morphology review will take place -> action by country coordinators

Preparation of minimal required data set of selected cases necessary for review, to be sent to Düsseldorf: - ID, (Country, Hospital: only available to Alex Smith) - age at diagnosis - Hb, WBC, Platelets, Defferential count, LDH, Bilirubin, Coombs test - cytogenetic finding at diagnosis: necessary for WHO classification - no original morphology report -> to be done by Alex Smith Methods in detail

Morphology assessment in detail Description of Morphologic characeristics, to be filled in a file during the morphology meeting I)Peripheral blood - % of blasts - % of monocytes - signs of Dysplasia - Anisometry of platelts? - Macroplatelets? - Pseudopelger? - Hypogranulation? - cytoplasma anomalies of erythrocytes?

Morphology assessment in detail Description of Morphologic characeristics, to be filled in a file during the morphology meeting II) Marrow 1)Erythropoiesis -% of erythropoiesis -Clear signs of dysplasia? -Nuclear abnormalities? -Cytoplasma abnormalities? -Ring sideroblasts? (%) 2)Megakaryopoiesis - Assessment of 25 megakaryocytes -Clear signs of dysplasia? (>10%) -Micromegakaryocytes ? -Mononuclear megakaryocytes? -Megas with spreaded nuclei?

Morphology assessment in detail Description of Morphologic characeristics 3)Granulopoiesis - Clear signs of dysplasia? (>10%) -Pseudopelger? -Hypogranulation? -% Medullary blast (if Erythropoiesis >50%, count blasts in the non-erythropoietic cells) 4)Other items - Cellularity (Hypo vs. Normo vs. Hyper) -Plasma cells increased? -Lymphoid cells increased? -Iron load? -Other stainings available?

Morphology assessment in detail Diagnostic categories RCUD (bicytopenia) RC RA RN MDS unclass RCUD with pancytopenia RCUD/RCMD with blasts in blood RCUD without dysplasia but with clonal marker RCMD MDS with del(5q) RARS-T RAEB I RAEB II, RAEB-T, AML, CMML I, CMMLII, ICUS No MDS at all

Methods to analyse the results 1) Within the panel - Discussion of cases during meeting - Report on interobserver variation within experts - Report on possible discrepancies between „experts“ and „non-experts“ - description of staining techniques and quality of slides - comparison of methods to read the slides - correlation of WHO types with hematologic and cytogenetic findings 2) Panel vs. Original reports - Send list of WHO results of the morphology panel to Alex Smith - Comparison of original reports with the results of the panel by k-test (and/or other tests to be done my Alex Smith) to describe amount of discrepancies 3) Final report on - Validation and reliability of the cases included into the ELN low risk R

Methods to analyse the results 3) Final report on - Validation and reliability of the cases included into the ELN low risk Registry to be done within the panel and Alex Smith

Morphology Panel Chairs:Ulrich Germing and Marius MacKenzie Proposed Experts Argiris Symenoidis, Greece Jaroslaw Cermak, Czech Rep. Anna Porwit, Sweden Teresa Valespie?, Spain Proposed „non-experts“ Louise deSwart, Netherlands Judith Neukirchen, Germany By David Bowen, UK Others