69 yrs old lady with treated B CLL/SLL presented with bone marrow posttherapic (FCR) hypoplasia in 2016 October (not included there), RARS in 2018 June (not included there) and the last therpine (PRESENTED THERE) in 2019 March.  
NO ONE threpine detext minimal residual CLL left (only previous flow based diagnosis).  
THERAPY FURTHER: allo Tx under discussion.  
 
HISTO: Bone marrow panhyperplasia with architectural distortion, reticulin fibrosis MF1, megaloblastic erythropoiesis, massive hyperplasia and dysplasia of megakaryopoiesis: high risk MDS with ringed sideroblasts)(MDS-MD-RS) with acceleration/progression (complex karyotype).  
Blast quantification/monitoring is highly needed due to transformation risk to AML (MDS-MD-RS-EB2)?.  
 
BLOOD (2019)(NORMALs not included, only changes):  
WBC (*10^9/l) 1,97 (4,0-9,8)  
BAS (%) 9,6 (0-1)  
RBC (*10^12/l) 2,96 (female 4,1-5,1)  
HgB (g/l) 88 (female 117-145  
Plt (x10^9/l) 10 (140-450)  
 
 
FLOW/ASPIRATE(2019):  
- Siderocytes and sideroblasts 69% (43 ringed);  
- Stem cells (CD34+) ~ 6,6 %.  
Myeloids blasts ~4 %: CD45+ dim, CD34+het, CD38-/+het, CD117+, HLA-DR+, CD13-/+het , CD33-/+dim, CD123-, cMPO-/+dim, CD2-, CD4-, CD5-, CD7-, CD11b-, CD19-, CD56-/+ partial, CD36-/+dal, CD64-, TdT-.  
abberations (blasts): CD33 ir CD13 partial hypoexpression, CD56 ir CD36 partial coexpression.  
Early B precursors (CD45+dim, CD34+, CD38++, CD10+, CD19+) ~11 %.  
Erithrokaryocytes ~12%.  
 
MOLECS: complex karyotype in 2018 (dels 5q, 6p, 17p, 20p).  
 
DIAGNOSTIC QUESTION:  
1. Quantification of CD34+ <<< HLA DR+/Bcl2+ and ESPECIALLY CD56+ blasts in last threpine (exceding flow and CD34+ counts, large caliber on CD56, clustering).  
2. Blast excess (EB1-2) qualification with clustering withou CD34+ and flow: AML early?  
3. A possibility of some megaloblastic elements CD56+?