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Automated digital enumeration of plasma cells in bone marrow trephine biopsies of multiple myeloma
  1. Jacques A J Malherbe1,
  2. Kathryn A Fuller1,
  3. Bob Mirzai1,2,
  4. Bradley M Augustson2,3,
  5. Wendy N Erber1,2
  1. 1School of Biomedical Sciences, Faculty of Health & Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
  2. 2PathWest Laboratory Medicine WA, Nedlands, Western Australia, Australia
  3. 3Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  1. Correspondence to Professor Wendy N Erber, School of Biomedical Sciences, Faculty of Health & Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia; wendy.erber{at}


Aims Determination of the number of plasma cells in bone marrow biopsies is required for the diagnosis and ongoing evaluation of plasma cell neoplasms. We developed an automated digital enumeration platform to assess plasma cells identified by antigen expression in whole bone marrow sections in multiple myeloma, and compared it with manual assessments.

Methods Bone marrow trephine biopsy specimens from 91 patients with multiple myeloma at diagnosis, remission and relapse were stained for CD138 and multiple myeloma oncogene 1 (MUM1). Manual assessment and digital quantification were performed for plasma cells in the entire trephine section. Concordance rates between manual and digital methods were evaluated for each antigen by intraclass correlation analyses (ICC) with associated Spearman’s correlations.

Results The digital platform counted 16 484–1 118 868 cells and the per cent CD138 and MUM1-positive plasma cells ranged from 0.05% to 93.5%. Overall concordance between digital and manual methods was 0.63 for CD138 and 0.89 for MUM1. Concordance was highest with diffuse plasma cell infiltrates (MUM1: ICC=0.90) and lowest when in microaggregates (CD138: ICC=0.13). Manual counts exceeded digital quantifications for both antigens (CD138: mean=26.4%; MUM1: mean=9.7%). Diagnostic or relapse threshold counts, as determined by CD138 manual assessments, were not reached with digital counting for 16 cases (18%).

Conclusions Automated digital enumeration of the entire, immunohistochemically stained bone marrow biopsy section can accurately determine plasma cell burden, irrespective of pattern and extent of disease (as low as 0.05%). This increases precision over manual visual assessments which tend to overestimate plasma burden, especially for CD138, and when plasma cells are in clusters.

  • multiple myeloma
  • cell count
  • immunohistochemistry
  • bone marrow
  • lymphocytes

Statistics from


  • Handling editor Mary Frances McMullin.

  • Contributors BMA and WNE selected suitable patient trephine samples for the study. WNE reviewed bone marrow pathology. BM and KAF performed all immunostaining assessments and the digital conversion of immunostained sections. Manual enumeration of immunostained sections was performed by JAJM and WNE. Digital enumeration and statistical analyses were conducted by JAJM. All authors were involved in writing the manuscript and had final approval of the submitted and published versions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study had ethical approval from the Sir Charles Gairdner and Osborne Park Health CareHealthcare Group (RGS0000001894) and The University of Western Australia Human Research Ethics Committees (#RA/4/1/9099).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplemental information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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