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  • Letter to the Editor
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Hematolymphoid neoplasms: World Health Organization versus rest of the world

Leukemia volume 23, page 978 (2009)Cite this article

A classification system must have relevance and importance in the clinical management, should be easily applicable and enable uniformity in reporting. Various lymphoma classifications have been formulated on the basis of morphology (Rappaport),1 clinical features (Working formulation)1 and on cell lineage and differentiation (Keil, Lukes and Collins).1 During 1970s and 1980s, popular lymphoma classifications were Lukes and Collins and Working formulation in USA, whereas Keil classification was popular in Europe.1 Pathologists and oncologists from the rest of the world followed either one depending on their training and on the availability of ancillary techniques including immunohistochemistry. It was followed by the Revised European and American Lymphoma classification from the International Lymphoma Study Group,2, 3, 4 an informal group of 19 hematopathologists mainly from Europe and USA. World Health Organization (WHO) classification is an updated version of the Revised European and American Lymphoma classification and include myeloid, histiocytic and mast cell neoplasm.5 WHO classification project included pathologists, hematologists and oncologists. Most of these were from USA and Europe, including two from Asia (one each from Hong Kong and Japan).3, 4, 5 There was no participation from the rest of the Asia and Africa.

For acute leukemia, French-American-British system of classification6 is still in vogue in many centers with limited resources for flow cytometry and molecular diagnostics. Lack of availability of molecular techniques has resulted in paucity of published data on the basis of WHO classification from two-third of the world. Though the present WHO classification system is evidence-based and needs to be followed for best clinical practice, it is impractical in many countries. Such classifications, which are practiced mainly in Europe and USA should preferably be labeled as French-American-British/Revised European and American Lymphoma classification as they defeat the basic mandate of WHO classification, which has a purpose to promote the appropriate selection of classifications in the health field across the world. Also many new cases of acute leukemia first get treated by local physicians and even by quacks by steroids and blood transfusion in the developing countries. It may lead to change in the phenotype and the genotype of the disease. There is no mention of partially treated acute leukemia subtype in the present WHO classification. Such cases form a significant percentage of acute leukemia cases in developing countries as seen in our practice. There is a vast difference in the pattern of diseases,7 and also the infrastructure available in different parts of the world to diagnose hematolymphoid malignancies. Advisory committee of WHO classifications must have representation from developed as well as developing world so to devise a system, which must be easy to follow and as inclusive as possible. Perhaps WHO can advocate two systems, one ideal (which can be implemented in the laboratories of the developed countries) and the other that advocates a minimum data that is required in the report for effective clinical management (to be followed in low and medium resource countries). The laboratories in the developing countries can aspire and shall be encouraged to use the ideal system as much as possible. Immunohistochemistry and flow cytometry are available in most of the hematopathology laboratories; however, molecular genetics is still available in extremely few laboratories.

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References

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  1. Department of Pathology, Tata Memorial Hospital, Mumbai, India

    S Gujral

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Gujral, S. Hematolymphoid neoplasms: World Health Organization versus rest of the world. Leukemia 23, 978 (2009). https://doi.org/10.1038/leu.2008.327

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