An 81-year-old male noted lumps in his neck and 40-pound weight loss in the last few months. Circulating blasts were seen in his peripheral blood smear. A bone marrow biopsy was obtained. Blasts in the peripheral blood and the bone marrow aspirate were large, with a moderate amount of pale to dark blue cytoplasm. No granules were seen within the cytoplasm. The nuclei had lacy chromatin with prominent nucleoli. The bone marrow biopsy (lower left) showed clusters of large, immature cells, consistent with the patient's blasts.