Case 140: Update 3

This lady has been diagnosed with CHAD and we are trying to establish whether it is primary or secondary.

Her viral serology and auto-immune screen are unremarkable. Given her full blood count and splenomegaly, you are concerned about an underlying malignancy.


Her serum protein electrophoresis reveals an IgM paraprotein of 12g/L.
A bone marrow biopsy is performed and you can see the images below:

Aspirate
Trephine
Trephine (close up)

Based on her bone marrow morphology, what do you think is the most likely diagnosis?
Which one diagnostic test do you think would be of benefit to help confirm the diagnosis?

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