Role of Bone Marrow
Aspiration and Biopsy in
Diagnosis of Hematological
Disorders: A Prospective Study
INTRODUCTION
Bone marrow is widely distributed throughout the human body. It is the principal site of blood formation, beginning at the time of birth. Bone marrow is composed of cells derived from a variety of lineages includ-ing stromal cells, adipocytes, lymphocytes and hematopoietic precursors1. Overall, bone marrow cellularity is approximately 100% at birth and declines with age2. Bone marrow examination is useful in the diagnosis of hematological and non-hematological disorders. Examination of bone marrow is one of the diagnostic cornerstones of haematological practice3. It may also play an important role in the assessment of patients with fever of undetermined origin as well as in the diagnosis of various storage and infiltrative disorders4.
Bone marrow examination usually involves two separate but interrelated specimens i.e. bone marrow aspiration and needle biopsy of bone and asso-ciated marrow5. Bone marrow aspirate smears are generally important for evaluating individual cell detail. Since the process of aspiration disrupts cell cohesion, the relationship of various cell types and the marrow cellularity cannot be reliably assessed. An adequate bone marrow core biopsy adds this important information. Bone marrow biopsy is essential in case of ‘dry tap’ or ‘blood tap’6–8.
Bone marrow biopsy is performed by specialized biopsy needle devised by Jamshidi and Swaim (1971) which is slightly longer than aspiration needle, generally produce little disruption of bone marrow architecture and can be used for both aspiration and biopsy from iliac crest9,10.
ORIGINAL ARTICLE
Manju1,
Vanita Kumar1,
Neelu Gupta1,
Akhil Kapoor2*,
Harvindra Singh Kumar2
1 Department of Pathology, Sardar Patel Medical College & Associated Group of Hospitals, Bikaner, Rajasthan, India 2 Department of Oncology, Acharya Tulsi
Regional Cancer Treatment & Research Institute, Sardar Patel Medical College & Associated Group of Hospitals, Bikaner, Rajasthan, India
Address reprint requests to
*Dr. Akhil Kapoor, Room No. 73, PG Boys Hostel, PBM Hospital Campus, Bikaner, Rajasthan, India 334003
E-mail: kapoorakhil1987@gmail.com Article citation: Manju, Kumar V, Gupta N,
Kapoor A, Kumar HS. Role of bone marrow aspiration and biopsy in diagnosis of hematological disorders: a prospective study. J Pharm Biomed Sci2016; 06(03):150–154.
Available at www.jpbms.info Statement of originality of work: The manuscript has been read and approved by all the authors, the requirements for authorship have been met, and that each author believes that the manuscript represents honest and original work.
Sources of funding: None.
Competing interest / Conflict of interest: The author(s) have no competing interests for financial support, publication of this research, patents, and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.
Disclaimer: Any views expressed in this paper are those of the authors and do not reflect the official policy or position of the Department of Defense.
NLM Title J Pharm Biomed Sci
CODEN JPBSCT
2230-7885 ISSN No
ABSTRACT
Background The use of bone marrow biopsy as a diagnostic procedure is being increasingly used in recent years.In the present study, an attempt has been made to find out the diagnostic utility of bone marrow aspiration and biopsy with their com-parative study. The objective of this study is to correlate the bone marrow aspiration and biopsy findings.
Materials and Methods This study was hospital-based prospective study in which 35 consecutive patients with haematological disorders were evaluated by both bone marrow aspiration and biopsy. The results were compared with that of previously published literature.
Results Out of 35 cases, maximum number of cases were of acute leukemias 12 (34.28%) followed by lymphoprotiferatide disorders 7 (25%), and one case (2.86%) of myelodysplastic syndrome. Bone marrow aspiration resulted in dry tap in 4 (11.42%) cases, which was observed in aplastic anaemia, myelodysplastic syndrome, primary myelofibrosis and NHL, one case in each.
Conclusions Bone marrow biopsy is more reliable in assessing cellularity, bone marrow architectural pattern, distribution and fibrosis. Bone marrow biopsy is diagnostic investi-gation in ‘dry tap’ aspiration cases, which occur when the marrow is fibrotic or densely cellular. Overall both the procedures are complementary to each other and must be per-formed together for better evaluation of bone marrow.
KEYWORDS bone marrow aspiration, bone marrow biopsy, haematological disorders
J Pharm Biomed Sci JPBSCT
2230-7885
http://dx.doi.org/10.20936/jpbms/160214
The use of bone marrow biopsy as a diagnostic pro-cedure is being increasingly used in recent years11.In the present study, an attempt has been made to find out the diagnostic utility of bone marrow aspiration and biopsy with their comparative study. The objective of this study is to document the bone marrow aspiration and biopsy findings in various disorders and to cor-relate the bone marrow aspiration and biopsy findings.
MATERIALS AND METHODS
The study was carried out in the Department of Pathology, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner from June 2011 to December 2013. This study was a hospital-based prospective study and included the cases admitted to PBM Hospital, Bikaner. Complete clinical data was recorded including patient history, physical examination, complete hematological study along with other relevant investigations and the proforma filled.
The biopsy specimen is fixed in 10% formalin over-night and decalcified with 6% EDTA for 72 hrs.
Tissue processing
Specimen after fixation and decalcification are sub sequently processed as per the standard technique. Paraffin sections were then cut and stained by Haematoxylin & Eosin.
Results: Nuclei - Blue-black Cytoplasm - Pink to red. BM aspirate smears
After thorough drying, films of bone marrow are fixed and stained with Leishman’s stain. Special stains - myeloperoxidase, PAS, Sudan black, Reticulin stain etc. were used, whenever needed.
OBSERVATION AND RESULTS
The study included a total of 35 cases in which bone marrow examination was done by using both the meth-ods i.e. bone marrow aspiration and bone marrow biopsy. All the smears and sections were reviewed for morphological details and findings on aspirate and biopsy were compared to each other. Table 1 shows the distribution of various disorders.
Out of 35 cases, maximum number of cases were of acute leukemias 12 (34.28%) followed by lymphoproti-feratide disorders 7 (25%), with only 1 case (2.86%) of myelodysplastic syndrome (Table 2).
Positive correlation between the BM aspirate cytology and trephine biopsy was found to be 81.81%. Sensitivity of BM aspirate cytology was found to be 79.31%.
The highest number of cases were recorded in the 2nd decade (9; 25.71%) followed by 7 cases (20%) in the 5th decade and only one case (2.86%) was in the 8th decade (Table 3).
Out of total 35 cases, males were 28 (80%) and 7 (20%) females. Male to female ratio was 4:1 (Table 4).
Table 1 Distribution of various disorders (n = 35).
Diagnosis Number of cases %
Anaemias 03 8.57
Acute leukemias 12 34.28
Lymphoproliferative disorders 07 20.00
Chronic myeloproliferative
disorders 03 8.57
Multiple myeloma 03 8.57
Myelodysplastic syndrome 01 2.86
Normal study 04 11.42
Inadequate 02 5.71
Total 35 100
Table 2 Cases diagnosed on bone marrow aspirate
and trephine biopsy.
Diagnosis casesTotal BM aspirate cytology BM trephine biopsy
Megaloblastic
anaemia 2 2 2
Aplastic anaemia 1 0 1
AML 4 4 4
ALL 8 8 8
CML 2 2 2
CLL 3 3 3
Multiple myeloma 3 2 3
MDS 1 0 1
Primary
myelofibrosis 1 0 1
NHL 4 2 4
Normal study 4 4 4
Inadequate 2 -
-Hundred percent cases presenting as pancytopenia were recorded in megaloblastic anaemia, aplastic anae-mia, myelodysplastic syndrome and primary myelofi-brosis and least occurrence in cases of ALL with only 6.25% (Table 5).
Out of total 35 cases, in highest number of cases 26 (74.28%) bone marrow was hypercellular, in only 4 (11.42%) cases hypocellular. Bone marrow aspiration was dry tap in 4 (11.42%) cases, which was observed in aplastic anaemia, myelodysplastic syndrome, primary myelofibrosis and NHL, one case in each (Table 6).
DISCUSSION
Table 3 Distribution of various disorders according to age groups.
Disorder Age in years
<10 11–20 21–30 31–40 41–50 51–60 61–70 >70 Total
Megaloblastic anaemia 0 0 0 01 01 0 0 0 02
Aplastic anaemia 0 0 0 0 01 0 0 0 01
AML 0 01 01 01 01 0 0 0 04
ALL 3 4 1 0 0 0 0 0 08
CML 0 0 1 1 0 0 0 0 02
CLL 0 0 0 0 0 1 1 1 03
Multiple myeloma 0 0 0 0 0 1 2 0 03
MDS 0 0 0 0 0 0 1 0 01
Primary myelofibrosis 0 0 0 0 0 1 0 0 01
NHL 0 1 0 1 2 0 0 0 04
Normal study 0 1 0 0 2 1 0 0 04
Inadequate 0 2 0 0 0 0 0 0 02
Total 3 9 3 4 7 4 4 1 35
Percentage (%) 8.57 25.71 8.57 11.43 20 11.43 11.43 2.86 100
Table 4 Distribution of various disorders according
to gender.
Diagnosis Male Female
Megaloblastic anaemia 2 0
Aplastic anaemia 1 0
AML 3 1
ALL 6 2
CML 2 0
CLL 2 1
Multiple myeloma 2 1
MDS 1 0
Primary myelofibrosis 1 0
NHL 3 1
Normal study 3 1
Inadequate 2 0
Total 28 7
Percentage (%) 80 20
Table 5 Cases presenting as pancytopemia in
various disorders (n = 8).
Diagnosis (total no. of cases)Number of cases %
Megaloblastic anaemia 2(2) 100
Aplastic anaemia 1(1) 100
AML 1(4) 25
ALL 1(8) 6.25
MDS 1(1) 100
Primary myelofibrosis 1(1) 100
NHL 1(4) 25
Table 6 Cellularity of bone marrow in various
disorders.
Disorders Number of cases
Hypocellular Normocellular Hypercellular
Megaloblastic
anaemia 0 0 2
Aplastic
anaemia 1 0 0
AML 0 0 4
ALL 0 0 8
CML 0 1 1
CLL 0 0 3
Multiple
myeloma 0 0 3
MDS 0 0 1
Primary
myelofibrosis 1 0 0
NHL 0 0 4
Normal
study 0 4 0
Inadequate 2 0 0
Total 4 5 26
% 11.42 14.28 74.28
there was a good correlation between semi-quantitative results obtained by cytology and histology12. Another study found that core needle biopsy of bone marrow is a valuable diagnostic aid for measurement of marrow cellularity, metastatic tumours and fibrosis13. It should not be taken as a substitute for examination of marrow by aspirate smears but is a complementary procedure, which affords several advantages14.
In the present study, in 74.28% cases bone marrow was reported as hypercellular while remaining 25.72% cases it was reported as either hypocellular or normocel-lular. Another study found 54% bone marrow as hyper-cellular on aspiration method15.An important limitation of bone marrow examination obtained by aspirate is the admixing of marrow and sinusoidal blood, which may not allow for reliable estimates of marrow cellu-larity. This evaluation is of particular importance in the hypercellular marrow which yields a ‘dry tap’ or only dilutes sinusoidal blood. Thus the use of biopsy avoids misinterpretation of cellularity by smear in patients in whom the biopsy confirmed a normal, hypocellular or hypercellular marrow.
In our study, the percentage of ‘dry taps’ was 11.42%, all of which were diagnosed on biopsy sections. It is necessary that findings of a dry tap should never be dismissed as being due to faulty technique and always needs a bone marrow biopsy. In the present study, out of 35 cases, 8 (22.85%) cases were evaluated for pancyto-penia, which was in close agreement with another study where 21.27% cases were evaluated for pancytopenia16.
In our study, 2 (5.71%) cases were diagnosed as megaloblastic anaemia. Both were male with mean age 40 years. Both were diagnosed by aspirated smears as well as by biopsy sections. One study stated that aspi-ration is useful in making better individual cell mor-phology, whereas biopsy is useful in bone marrow architectural pattern and distribution17. Bone marrow biopsy proved to be complementary to aspiration for the diagnosis of megaloblastic anaemia in our study.
In the present study, age range of patients of ALL was between 5–30 years, mean age 14.47 years, male to female ratio was 3:1 and patients of AML were in age range 15–48 years, mean age 32 years and male to female ratio 3:1. For all the cases of acute leukemias, both the methods revealed concordant results. The assessment of overall cel-lularity, residual hematopoietic tissue and myelofibrosis which all affect the prognosis and treatment of patient can be known only by examination of trephine sections. The results of another study also found that when acute leukemias were diagnosed on aspiration alone, trephine biopsy provided additional useful information18.
In both the cases of CML, findings of bone marrow aspiration and biopsy were complementary to each other. Male to female ratio was 1:1, mean age of patient was 31.5 years. We observed that a single case of primary myelofibrosis which yielded ‘dry tap’ on bone marrow aspiration, was subsequently diagnosed on trephine biopsy. Patient was 53 years old male and splenomegaly
was the only physical finding at presentation, our find-ings were comparable to findfind-ings of other study19.
In our study, there were 4 (11.42%) cases of NHL, which were diagnosed on bone marrow biopsy, while only 2 (50%) cases were diagnosed on bone marrow aspiration. In remaining two cases, in one case bone marrow aspiration was ‘dry tap’ and in another one case, aspiration showed erythroid hyperplasia. This is in variance with the results of another study where 9.8% cases were positive on only aspiration20.This stresses the point that both aspiration and biopsy should be done in case of suspected NHL. We found that 81.81% of cases showed a positive correlation between bone marrow aspiration and bone marrow biopsy.
CONCLUSION
This study suggested that aspiration is easy to perform and is important for cytological assessment with anal-ysis directed towards morphology and obtaining a dif-ferential count while bone marrow trephine biopsy is slightly more painful and requires more skill to per-form and more reliable in assessing cellularity, bone marrow architectural pattern, distribution and fibrosis. Bone marrow biopsy is diagnostic investigation in ‘dry tap’ aspiration cases, which occur when the marrow is fibrotic or densely cellular. Overall, both the pro-cedures are complementary to each other and must be performed together for better evaluation of bone marrow.
REFERENCES
1. Mauch P, Bothick LE, Hannon EC, Obbagy J, Hellman S. Decline in bone marrow proliferative capacity as a function of age. Blood 1982;60:245–52.
2. Riley RS, Hogan TF, Pavot DR, Forysthe R, Massey D, Smith E, et al. A pathologist’s perspective on bone marrow aspiration and biopsy; performing a bone marrow examination. J Clin Lab Anal. 2000;18:70–90.
3. Pasquale D, Chikkapa G. A comparative evaluation of bone marrow aspirate particle smears, biopsy imprints and biopsy sections. Am J Hematol. 1986;22:381–9.
4. Greer JP, Foester J, Rodgers GM, Paraskevas F, Glador B.
Wintrobe’s Clinical Hematology 12th ed. Lippincott Williams and
Wilkins; 2009.
5. Barekman CL, Fair KP, Cotelingam JD. Comparative utility of diagnostic bone marrow components: a 10 year study. Am J Hematol. 1997;56: 37–41.
6. Jamshidi K, Swaim WR. Bone marrow biopsy with unaltered archi-tecture: a new biopsy device. J Lab Clin Med. 1971;77:335–42. 7. Trewhitt KG. Bone marrow aspiration and biopsy. Collection and
interpretation. Oncol Nurs Forum. 2001;28:1409–15.
8. Bain BJ. Bone marrow aspiration. J Clin Pathol. 2001;54:657–63. 9. Bearden JD, Ratkin GA, Cottman. Comparison of the diagnostic
value of bone marrow biopsy and bone marrow aspiration in neoplastic disease. J Clin Pathol. 1974;27:738–40.
11. Ioannides K, Rywlin AM. A comparative study of histologic sections of bone marrow obtained by aspiration and by needle biopsy. Am J Clin Pathol. 1976;65:267.
12. Cruikshank B, Thomas MJ. Mineral oil (follicular) lipidosis II. Histologic studies of spleen, liver, lymphonodes and bone marrow. Hum Pathol. 1984;15:731–7.
13. Rywlin AM, Ortega R. Lipid granulomas of the bone marrow. Am J Clin Pathol. 1972;57:457–62.
14. Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DA, Gralnick HR. Proposed revised criteria for the classification of acute myeloid leukemia: a report of the French-American-British Co-operative group. Ann Intern Med. 1985;103: 620–5.
15. Cheson BD, Cassileth PA, Head DR, Schiffer CA, Bennet JM, Bloomfield CD. Report of the National cancer institute sponsored
workshop on definition of diagnosis and responses in acute myeloid leukemia. J Clin Oncol. 1990; 8: 813–9.
16. Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Alexander B. The diagnostic utility of bone marrow trephine biopsies. Indian J Pathol Microbiol. 2005;48(2):173–6.
17. De Wolf-Peeters C. Bone marrow trephine interpretation: diag-nostic utility and potential pitfalls. Histopathology. 1991;18:489–93. 18. Rao S, Sen R, Singh S, Ghalut PS, Arora BB. Grading of marrow
fibrosis in chronic myeloid leukemia- a comprehensive approach. Indian J Pathol Microbiol. 2005;48(3):341–4.
19. Clough V, Greary CG, Hashmik, Davson J, Knowlson T. Myelo-fibrosis in chronic granulocytic leukemia. Br J Hematol. 1979; 42:515–26.
