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Role of Flow Cytometry in the Diagnosis of Bone Marrow Involvement by B-Cell Non-Hodgkin Lymphoma: Concordance with Bone Marrow Biopsy and Prognostic Impact

Lymphatics 2026, 4(1), 14; https://doi.org/10.3390/lymphatics4010014

by Luis Viveros¹

, Cristín Olivares², Patricia Huerta³

, Claudia Cabezas⁴, Silvana Vásquez⁵ and Mauricio Chandía^2,4,*

Reviewer 1:

Fernando Martín-Moro

Reviewer 2:

Ilona Holcomb

Reviewer 3: Anonymous

Lymphatics 2026, 4(1), 14; https://doi.org/10.3390/lymphatics4010014

Submission received: 17 December 2025 / Revised: 16 February 2026 / Accepted: 19 February 2026 / Published: 27 February 2026

(This article belongs to the Collection Lymphomas)

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Viveros L et al. have presented an interesting manuscript regarding bone marrow involvement in different B-cell non-Hodgkin lymphomas, focusing on assessment by histology and flow cytometry. Although the manuscript addresses an interesting topic and is well written, several considerations should be addressed before acceptance:

- Abstract: a brief introductory sentence would be appreciated.

- Line 46: the abbreviation “PET-CT” is used without a prior definition.

- The introduction could be more comprehensive. I suggest checking the following reference: Martin-Moro F, Lopez-Jimenez J, Garcia-Marco JA, Garcia-Vela JA. Comparative Review of the Current and Future Strategies to Evaluate Bone Marrow Infiltration at Diffuse Large B-Cell Lymphoma Diagnosis. Diagnostics (Basel). 2024 Mar 21;14(6):658. doi: 10.3390/diagnostics14060658.

- Placing the Materials and Methods section between Introduction and Results should be considered.

- The study includes 202 samples from 172 patients; however, it should be clarified how many assessments were performed at diagnosis and how many during follow-up.

- Although the IPI may be applied to “any” B-cell lymphoma, specific prognostic scores have been designed and validated for FL, MCL and MZL. But I believe this is not a major issue.

- Line 72: check the P value. The Chi-square P value for this comparison is 0.016 rather than < 0.0001.

- Line 74: a median BM infiltration of 22.3% is described in the BMB+/FC+ group, but it is not specified by which technique.

- Line 103: use “0.038” rather than “0,038”.

- The IPI score classifies patients into four prognostic groups. Are the low-intermediate and high-intermediate groups clustered together in this study?

- Table 3: all P values should be reported. For the BMB+/FC+ group, all analyses according to intermediate- and high-risk IPI are statistically significant, as the 95% CI do not include 1.

- Line 199: use “endpoint” rather than “endpoints”.

- Line 228: use “BMB” abbreviation rather than “bone marrow biopsy”.

- Lines 232-233: While I agree that FC is faster than BMB, the timings provided by the authors represent general information and are not derived from the results of this manuscript. Therefore, these timings should be removed. The same applies to the statement that FC is less expensive than BMB; although this conclusion has been reported in other studies, it cannot be inferred from the data presented here.

Author Response

For research article

“Role of flow cytometry in the diagnosis of bone marrow involvement by B-cell non-Hodgkin lymphoma: concordance with bone marrow biopsy and prognostic impact”.

Response to Reviewer 1 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Yes/Can be improved/Must be improved/Not applicable

No comments

Are all the cited references relevant to the research?

Yes/Can be improved/Must be improved/Not applicable

Is the research design appropriate?

Yes/Can be improved/Must be improved/Not applicable

Are the methods adequately described?

Yes/Can be improved/Must be improved/Not applicable

Are the results clearly presented?

Yes/Can be improved/Must be improved/Not applicable

Are the conclusions supported by the results?

Yes/Can be improved/Must be improved/Not applicable

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Abstract: a brief introductory sentence would be appreciated.

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, we have added the following sentence to the abstract in line 14: “Bone marrow involvement in B-cell non-Hodgkin lymphoma is an adverse prognostic factor; therefore, its detection is necessary at the time of diagnosis and during follow-up.”

Comments 2: Line 46: the abbreviation “PET-CT” is used without a prior definition.

Response 2: We agree, accordingly we have added the full term “Positron Emission Tomography/Computed Tomography scan” in lines 48-49, followed by the abbreviation PET-CT in parentheses.

Comments 3: The introduction could be more comprehensive. I suggest checking the following reference: Martin-Moro F, Lopez-Jimenez J, Garcia-Marco JA, Garcia-Vela JA. Comparative Review of the Current and Future Strategies to Evaluate Bone Marrow Infiltration at Diffuse Large B-Cell Lymphoma Diagnosis. Diagnostics (Basel). 2024 Mar 21;14(6):658. doi: 10.3390/diagnostics14060658

Response 3:

We agree with this comment and have added the suggested reference. We would like to clarify that the aim of the Introduction is to emphasize the clinical relevance of detecting bone marrow involvement by lymphoma and to highlight the potential value of flow cytometry in our setting. In the public healthcare system to which we belong, access to PET-CT at diagnosis or during follow-up is limited for most patients, whereas flow cytometry represents a more accessible and cost-effective technique in routine clinical practice.

Accordingly, we have partially revised the Introduction and added the following text between lines 45 and 53:

“Its detection may influence therapeutic strategies in certain cases [7–9]. Traditionally, the diagnosis is based on bone marrow biopsy (BMB), an invasive procedure associated with patient discomfort and potential complications. Therefore, imaging techniques such as PET-CT are increasingly used in clinical practice [10]; however, their use is limited in the public healthcare setting. In this context, bone marrow aspiration with flow cytometry (FC) represents a less invasive and complementary method for detecting bone marrow infiltration, which can be performed on aspirated bone marrow obtained simultaneously with BMB, providing faster results at a potentially lower cost [11].”

Comments 4: Placing the Materials and Methods section between Introduction and Results should be considered.

Response 4: At this point, we do not agree, as we have followed the template provided by the journal.

Comments 5: - The study includes 202 samples from 172 patients; however, it should be clarified how many assessments were performed at diagnosis and how many during follow-up.

Response 5: Thank you for pointing this out. We agree with this comment. Of the total number of samples (202), 133 were collected at diagnosis and 69 during follow-up, as clarified in lines 63,64.

Comments 6: - Although the IPI may be applied to “any” B-cell lymphoma, specific prognostic scores have been designed and validated for FL, MCL and MZL. But I believe this is not a major issue.

Response 6: Thank you for pointing this out. We agree with this comment. We have considered the IPI as a tool to describe and assess lymphoma in the overall patient population, as the subgroups are too small to apply specific indices for each histological subtype.

Comments 7: - Line 72: check the P value. The Chi-square P value for this comparison is 0.016 rather than < 0.0001

Response 7: We agree with this comment. The P value has been corrected to 0.016.

Comments 8: - line 74: a median BM infiltration of 22.3% is described in the BMB+/FC+ group, but it is not specified by which technique.

Response 8: Thank you for the comment. We would like to clarify this point. This percentage (23%) refers to the degree of infiltration observed in cases that were positive by both techniques.

Comments 9: - Line 103: use “0.038” rather than “0,038”.

Response 9: We agree with this comment. The value has been corrected to 0.038

Comments 10: - The IPI score classifies patients into four prognostic groups. Are the low-intermediate and high-intermediate groups clustered together in this study?

Response 10: Thank you for the comment. For the purpose of the analysis, we merged the low-intermediate and high-intermediate categories into a single group, and this has been clarified in line 132 by adding the phrase “including both low and high categories” in parentheses.

Comments 11: - Table 3: all P values should be reported. For the BMB+/FC+ group, all analyses according to intermediate- and high-risk IPI are statistically significant, as the 95% CI do not include 1.

Response 11: Thank you for the comment. All p values have been incorporated into Table 3.

Comments 12: - Line 199: use “endpoint” rather than “endpoints”.

Response 12: Thank you for the comment. We have corrected it.

Comments 13: - Line 228: use “BMB” abbreviation rather than “bone marrow biopsy”.

Response 13: Thank you for the comment. We have corrected it.

Comments 14: - Lines 232-233: While I agree that FC is faster than BMB, the timings provided by the authors represent general information and are not derived from the results of this manuscript. Therefore, these timings should be removed. The same applies to the statement that FC is less expensive than BMB; although this conclusion has been reported in other studies, it cannot be inferred from the data presented here.

Response 14: Thank you for the comment. To clarify this point, we have replaced the sentence “Unlike BMB, which requires tissue processing and may take 10–12 days to yield results, FC provides diagnostic information within approximately 24–48 hours, at a lower cost and with a less invasive sampling procedure” with the following: “Unlike BMB, FC provides diagnostic information in a shorter time.” In lines 241,242.

4. Response to Comments on the Quality of English Language

Point 1:

No comments

5. Additional clarifications

The changes described have been incorporated into the revised source text file that is being submitted.

Reviewer 2 Report

Comments and Suggestions for Authors

Summary: Most of these recommended changes are simple. By addressing these, I think this will be a simple but nice publication with some worthwhile findings.

Comments:

Flow cytometry (FC) is a tool. The comparison is not between BMB and FC. It is between bone marrow cells collected by biopsy and assessed by hematopathology and cells collected by aspirate and assessed by FC. Throughout the document this is referenced in this strange way as if FC was the method of obtaining the cells (False) and diagnosing the condition (true) and BMB is reference as the method of obtaining the cells (true) and diagnosing the condition (False). For example, Line 47 – flow cytometry is not less invasive. An aspirate is less invasive.
Line 25 – Does IPI need to be spelled out in the abstract like it is in line 62?
Line 50 – What is “FCM”? First introduction of acronyms needs to be spelled out.
Line 58 – There should be some explanation why the percent of the cohort is less than 50% male when NHL is usually more common in men than women. And the way this sentence is written, it sounds like the average age provided is just for the males, not the total population.
Lines 81 – On my screen, the “Kappa” symbol looks different for “FL” that for the other subtypes but I think it is the correct one as shown in line 89.
Line 103 and supplementary figures – both commas and periods are used for decimal place markers. Periods are more standard, but either way, just one marker type must be consistently used throughout.
Line 157 – Is it sure that the negative BMB pathology findings, when FC is positive, represent false positives. The specificity and sensitivity of both methods used should be indicated so this claim can be properly evaluated.

Author Response

For research article

“Role of flow cytometry in the diagnosis of bone marrow involvement by B-cell non-Hodgkin lymphoma: concordance with bone marrow biopsy and prognostic impact”.

Response to Reviewer 2 Comments

1. Summary

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Yes/Can be improved/Must be improved/Not applicable

No comments

Are all the cited references relevant to the research?

Yes/Can be improved/Must be improved/Not applicable

Is the research design appropriate?

Yes/Can be improved/Must be improved/Not applicable

Are the methods adequately described?

Yes/Can be improved/Must be improved/Not applicable

Are the results clearly presented?

Yes/Can be improved/Must be improved/Not applicable

Are the conclusions supported by the results?

Yes/Can be improved/Must be improved/Not applicable

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Flow cytometry (FC) is a tool. The comparison is not between BMB and FC. It is between bone marrow cells collected by biopsy and assessed by hematopathology and cells collected by aspirate and assessed by FC. Throughout the document this is referenced in this strange way as if FC was the method of obtaining the cells (False) and diagnosing the condition (true) and BMB is reference as the method of obtaining the cells (true) and diagnosing the condition (False). For example, Line 47 – flow cytometry is not less invasive. An aspirate is less invasive.

Response 1: Thank you for the comment. We agree with this point. Accordingly, in line 50 we have modified the sentence “Flow cytometry (FC) represents a less invasive and complementary method for detecting BM infiltration, which can be performed on aspirated BM obtained simultaneously with BMB, providing faster results and at lower cost [11]” to “In this context, bone marrow aspiration with flow cytometry (FC) represents a less invasive and complementary method for detecting bone marrow infiltration, which can be performed on aspirated bone marrow obtained simultaneously with BMB, providing faster results at a potentially lower cost [11].”

In addition in line 241, in the Conclusions section, we have replaced the sentence “Unlike BMB, which requires tissue processing and may take 10–12 days to yield results, FC provides diagnostic information within approximately 24–48 hours, at a lower cost and with a less invasive sampling procedure” with “Unlike BMB, FC provides diagnostic information in a shorter time.”.

Lastly, between lines 244–246, we have replaced the sentence “Collectively, its lower invasiveness, faster turnaround time, and analytical capacity position FC as a complementary or alternative approach to traditional histopathological assessment” with “Collectively, the lower invasiveness of the bone marrow aspirate, faster turnaround time, and analytical capacity position FC as a complementary or alternative approach to traditional histopathological assessment.”

Comments 2: Line 25 – Does IPI need to be spelled out in the abstract like it is in line 62?

Response 2: Thank you for the comment. We believe it is necessary to spell it out in full in this line, as this is the first time the index is mentioned and the origin of the abbreviation should be described to facilitate understanding for readers who may not have prior knowledge of the topic.

Comments 3: Line 50 – What is “FCM”? First introduction of acronyms needs to be spelled out.

Response 3:

Thank you for the comment. The abbreviation “FCM” refers to flow cytometry; therefore, we have changed it to “FC” in line 55.

Comments 4: Line 58 – There should be some explanation why the percent of the cohort is less than 50% male when NHL is usually more common in men than women. And the way this sentence is written, it sounds like the average age provided is just for the males, not the total population.

Response 4: Thank you for the comment. This finding also caught our attention; however, we do not have a reasonable explanation for it. Regarding the comment on age, we have replaced the sentence “A total of 202 samples from 172 patients were included, of whom 84 (49%) were male, with a mean age of 61 years (range 18–91)” with “A total of 202 samples from 172 patients were included, of whom 84 (49%) were male, and the mean age of the overall population was 61 years (range, 18–91).” In lines 62,63

Comments 5: - Lines 81 – On my screen, the “Kappa” symbol looks different for “FL” that for the other subtypes but I think it is the correct one as shown in line 89.

Response 5: Thank you for the comment. The Latin alphabet letter “K” used to indicate the kappa index in that paragraph has been replaced with the Greek letter kappa.

Comments 6: - Line 103 and supplementary figures – both commas and periods are used for decimal place markers. Periods are more standard, but either way, just one marker type must be consistently used throughout.

Response 6: Thank you for the comment. Commas have been removed, and periods will be used as decimal separators throughout the document.

Comments 7: - Line 157 – Is it sure that the negative BMB pathology findings, when FC is positive, represent false positives. The specificity and sensitivity of both methods used should be indicated so this claim can be properly evaluated.

Response 7: Thank you for the comment. We agree that the wording should be corrected; therefore, we have replaced the sentence “Ramanlingam et al. reported a discordance of 12% using 10 color FC and also found no statistically significant difference between the tumor burden of BMB+/FC+ and BMB−/FC+ cases, suggesting that false negative BMB results are not solely attributable to tumor load” with “Ramanlingam et al. reported a discordance of 12% using 10-color FC and also found no statistically significant difference between the tumor burden of BMB+/FC+ and BMB−/FC+ cases, suggesting that negative BMB results are not solely attributable to tumor load.” In lines 159-162

4. Response to Comments on the Quality of English Language

Point 1:

No comments

5. Additional clarifications

The changes described have been incorporated into the revised source text file that is being submitted.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors of this manuscript compared the usefulness of bone marrow biopsy and flow cytometry in the diagnosis of B-cell Non-Hodgkin Lymphomas. The concordance of the two methods was good in most of the lymphomas.

Questions and comments:

When was a sample taken as positive by flow cytometry or by morphology? Please define the criteria!
It is not clear whether immunohistochemistry was performed in all cases. Comparing only hematoxylin and eosin staining with flow cytometry is inappropriate. The two methods do not show the same.
The results of this study differ from those of others. What can cause this difference?
In Table 3, please use a point instead of a comma in the values! Also on page 3, line 103 "p=0,038".

Author Response

For research article

“Role of flow cytometry in the diagnosis of bone marrow involvement by B-cell non-Hodgkin lymphoma: concordance with bone marrow biopsy and prognostic impact”.

Response to Reviewer 3 Comments

1. Summary

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Yes/Can be improved/Must be improved/Not applicable

No comments

Are all the cited references relevant to the research?

Yes/Can be improved/Must be improved/Not applicable

Is the research design appropriate?

Yes/Can be improved/Must be improved/Not applicable

Are the methods adequately described?

Yes/Can be improved/Must be improved/Not applicable

Are the results clearly presented?

Yes/Can be improved/Must be improved/Not applicable

Are the conclusions supported by the results?

Yes/Can be improved/Must be improved/Not applicable

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: When was a sample taken as positive by flow cytometry or by morphology? Please define the criteria!.

Response 1: Thank you for the comment, and we agree with it. For this reason, we have added the following sentence to the flow cytometry section of the Materials and Methods: “The sample was considered positive for lymphoma infiltration if the presence of clonal mature B cells with light chain restriction was demonstrated.” between lines 215-217.

Regarding the biopsy, we incorporated the following sentence: “The sample was considered positive if cells with morphology and immunophenotype, as assessed by immunohistochemistry, compatible with lymphoma were identified.” between lines 221-223

Comments 2: It is not clear whether immunohistochemistry was performed in all cases. Comparing only hematoxylin and eosin staining with flow cytometry is inappropriate. The two methods do not show the same.

Response 2:

Thank you for the comment, and we agree with it. For this reason, in the biopsy section of the Materials and Methods, we have replaced the sentence “Immunohistochemistry was performed as needed for each case” with “Immunohistochemistry was performed in all cases.” In lines 220,221. This better reflects the routine practice at our institution.

Comments 3: The results of this study differ from those of others. What can cause this difference?

Response 3:

Thank you for the comment. The main reason why our results show better concordance with biopsy lies in the sensitivity of flow cytometry. As described in the second paragraph of the Discussion, in our institution a higher number of events are acquired than those reported by other authors, which increases sensitivity compared with the gold standard.

Comments 4: In Table 3, please use a point instead of a comma in the values! Also on page 3, line 103 "p=0,038".

Response 4: Thank you for the comment. Commas have been removed, and periods will be used as decimal separators throughout the document.

4. Response to Comments on the Quality of English Language

Point 1:

No comments

5. Additional clarifications

The changes described have been incorporated into the revised source text file that is being submitted.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the review. The manuscript is acceptable for publication.

Author Response

Comments 1: Thank you for the review. The manuscript is acceptable for publication.

Response 1: Dear Reviewer,

Thank you for the time and effort you invested in reviewing our manuscript. We appreciate your comments and suggestions.

4. Response to Comments on the Quality of English Language

Point 1:

No comments

5. Additional clarifications

The main text of the article has not been modified since the last submitted version.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the answers.

It is still unclear what the cutoff was for the positivity in the flow cytometry measurements.

What was the limit of detection and quantitation? How did the authors discriminate normal B-cells from lymphoma cells in the case of MZL if normal B cells were presented in the sample? What was the gating strategy?

If the lack of sensitivity caused the discordance of the other studies, it means that the amount of the lymphoma cells detected by flow cytometry should be under 1%, which caused the difference. The results of this study revealed that BM-/FC+ cases, in which the "lymphoma cell" ratio was very low (median: 0.44%), were similar to BM-/FC- cases. So the sensitivity can not be an issue. At the time of the diagnosis, a low number of monoclonal B cells (<1%) can be named as lymphoma cells? Monoclonal B cells (MBL) can also be found in the bone marrow in very low numbers.

Author Response

1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Yes	No comments
Are all the cited references relevant to the research?	Can be improved
Is the research design appropriate?	Can be improved
Are the methods adequately described?	Yes
Are the results clearly presented?	Yes
Are the conclusions supported by the results?	Yes
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: Thank you for the answers. It is still unclear what the cutoff was for the positivity in the flow cytometry measurements. What was the limit of detection and quantitation? How did the authors discriminate normal B-cells from lymphoma cells in the case of MZL if normal B cells were presented in the sample? What was the gating strategy? If the lack of sensitivity caused the discordance of the other studies, it means that the amount of the lymphoma cells detected by flow cytometry should be under 1%, which caused the difference. The results of this study revealed that BM-/FC+ cases, in which the "lymphoma cell" ratio was very low (median: 0.44%), were similar to BM-/FC- cases. So the sensitivity can not be an issue. At the time of the diagnosis, a low number of monoclonal B cells (<1%) can be named as lymphoma cells? Monoclonal B cells (MBL) can also be found in the bone marrow in very low numbers.
Response 1: Dear Reviewer, Thank you for the time and effort you invested in reviewing our manuscript. We appreciate your comments and suggestions. Below, we address your questions point by point: What was the limit of detection and quantitation? Thank you for this comment. We will clarify this point in the manuscript. The number of events reported in the Materials and Methods section corresponds to a median of 1,000,000 acquired events per sample (range: 165,568–5,000,000). If 20 clonal events are considered as the lower limit of detection (LOD) and 50 events as the lower limit of quantification (LOQ), this corresponds to an LOD of 0.01% and an LOQ of 0.03% in samples with the lowest number of acquired events, and an LOD of 0.0004% and an LOQ of 0.001% in samples with event numbers at the upper limit of the range. How did the authors discriminate normal B cells from lymphoma cells in the case of MZL if normal B cells were present in the sample? Thank you for this comment. We will clarify this point. It is well known that the immunophenotype of marginal zone lymphoma is not highly distinctive, which may make it challenging in some cases to discriminate lymphoma cells from normal mature B lymphocytes. However, an altered kappa/lambda light chain ratio and differences in parameters such as cell size, CD45 intensity, and CD19 or CD20 expression may help in this discrimination. What was the gating strategy? Thank you for this comment. In all cases, the gating strategy was initiated by identifying B cells based on CD19 and/or CD20 expression, followed by assessment of their distribution in CD45 and evaluation of light chain (kappa/lambda) expression. If clonality was not evident using this initial strategy, we further explored the B-cell population according to the expression patterns of additional markers to identify potential clonal populations. In particular, the main combination used included CD5 and CD10, which allowed targeted selection of specific B-cell subpopulations. If the lack of sensitivity caused the discordance of the other studies, it means that the amount of lymphoma cells detected by flow cytometry should be under 1%, which caused the difference. The results of this study revealed that BM−/FC+ cases, in which the “lymphoma cell” ratio was very low (median: 0.44%), were similar to BM−/FC− cases. So the sensitivity cannot be an issue. Thank you for this comment. Regarding this point, we believe that the difference with other studies was not only related to the number of acquired events but also to the number of colors used in our flow cytometry panels (8 colors in our study versus 6 colors in most previous studies), which may have increased the analytical resolution and the ability to detect small clonal populations. At the time of diagnosis, can a low number of monoclonal B cells (<1%) be named as lymphoma cells? Monoclonal B cells (MBL) can also be found in the bone marrow in very low numbers. Thank you for this comment. We will clarify this point. In monoclonal B-cell lymphocytosis (MBL), patients do not present other findings suggestive of lymphoma, such as lymphadenopathy or splenomegaly. In our series, all patients had a confirmed diagnosis of lymphoma; therefore, the detection of clonal mature B cells in the bone marrow cannot be attributed to MBL.
4. Response to Comments on the Quality of English Language
Point 1:
No comments
5. Additional clarifications
The main text of the article has not been modified since the last submitted version.

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

Please insert into the Materials and Method section the LOD and LOQ and how many events were needed for a case to be considered positive.

Author Response

1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Yes	No comments
Are all the cited references relevant to the research?	Yes
Is the research design appropriate?	Yes
Are the methods adequately described?	Yes
Are the results clearly presented?	Yes
Are the conclusions supported by the results?	Yes
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: Please insert into the Materials and Method section the LOD and LOQ and how many events were needed for a case to be considered positive.
Response 1: Thank you for pointing this out. We agree with the reviewer. The relevant information has now been consolidated into a single sentence between lines 231–235 of the revised manuscript, based on the content addressed in the previous round of revision.
4. Response to Comments on the Quality of English Language
Point 1:
No comments
5. Additional clarifications
The main text of the article has been modified since the last submitted version.

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Role of Flow Cytometry in the Diagnosis of Bone Marrow Involvement by B-Cell Non-Hodgkin Lymphoma: Concordance with Bone Marrow Biopsy and Prognostic Impact

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