BONE MARROW BIOPSY AND INTERPRETATION

JULY 2016

STRCTURE OF BONE MARROW

• A) cellular elements

Haematopoetic stem cells , Progenitors , precursors .

B) Stroma - unique microenvironment of the marrow

BONE MARROW BIOPSY NEEDLES

• Jamshidhi

• Islam

• Westerman jensen

• Drills

• Disposable needles

DRILLER

INDICATIONS

• Evaluation of hematologic abnormalities in peripheral smear

• Evaluation of primary bone marrow disorder

• Staging of bone marrow involvement by metastatic tumors

• Evaluation of metabolic storage disorders

• PUO.

SITES OF BONE MARROW BIOPSY

• Posterior superior iliac spine

• Anterior superior iliac spine

• Iliac crest

• Tibial tuberosity in children .

PROCESSING OF BONE MARROW BIOPSY

1. FIXATION

10% buffered formalin

Zenkers fluid

2. DECALCIFICATION

Formic acid 6-8 hours

Nitric acid 2-3 hours

EDTA

PROCESSING OF BONE MARROW BIOPSY

3.EMBEDDING

Paraffin

Resin

4. STAINING

H & E , Reticulin , Perls

Masson trichrome .

BM BIOPSY EVAULATION

BASED ON

1. Clinical history

2. Physical examination findings

3. Complete hemogram

4. Peripheral blood smear

5. Aspiration

BM BIOPSY EVAULATION • ADEQUACY OF BIOPSY

. Length 1.6 cm ( 1.5 –2.5cm )

.25% shrinkage during processing

.5-6 trabecular spaces

. Good quality staining

Evaluation

• Cellularity

• Topography of hemopoetic cells

• Proliferation of cell lines

• Fibrosis

• Infections

• Infilterative diseases

CELLULARITY

• Exact cellularity of marrow is assessed Decreases with increase in age

• Infants 80- 100%

• Adults 50 – 60 %

• Old age 20 – 30 %

• Adults - sub cortical marrow is hypoplastic

TOPOGRAPHY OF HEMOPOETIC CELLS

• MYELOID CELLS

- Paratrabecular

- mature cells towards centre

ERYTHROID CELLS

- centre in colonies

• MEGAKARYOCYTES

- Centre around sinusoids

. STROMA

fat cells , fibroblast , reticulin fibres , macrophages.

PROLIFERATIVE CELL LINES

• Erythroid cell line hyperplasia –megaloblastic anemia

• Myeloid hyperplasia – in CML

• Megakaryocytic proliferation in – essential thrombocythaemia

• All the three in cellular phase of primary myelofibrosis .

THROMBOCYTHEMIA

OTHER CELLS

• Macrophages , plasmacells , mast cells , eosinophils and lymphocytes .

• Multiple lymphoid nodules – IHC to rule out neoplastic lymphoproliferative disorder

STROMAL CHANGES

• 1.Bone marrow fibrosis – indicates increase in reticulin or collagen

CAUSES• idiopathic / primary myelofibrosis• CML , MDS with fibrosis , Hodgkin deposit in

marrow , Hairy cell leukemia , metastatic deposit in marrow .

• HIV infection , hyperparathyroidism , systemic diseases like scleroderma , SLE

FIBROSIS GRADING – MODIFIED BAUERMEISTER

GRADE 0 No reticulin fibres demonstrable

GRADE 1 Occasional fine individual fibres or foci of fine fibre network

GRADE 2 Fine fibre network throughout most of the marrow section , no coarse fibres

GRADE 3 Diffuse fibre network with scattered thick coarse fibres but no more collagen

GRADE 4 Diffuse , often coarse fibre network with areas of collagenisation

2. GELATINOUS TRANSFORMATION OF BONE MARROW

• Also known as STARVATION MARROW / SEROUS ATROPHY .

• Characterised by focal or diffuse extracellular deposition of gelatinous material in between fat cells and hypocellular marrow

• CAUSES post chemotherapy , malnutrition , anorexia nervosa , HIV , chronic tuberculosis , chronic liver disease .

acid mucopolysaccharides in the gelatinous material stain with ALCIAN BLUE

BONE MARROW NECROSIS

• Necrosis of hematopoietic cells or necrosis of neoplastic cells that have replaced normal marrow elements .

• may be associated with osteonecrosis -absence of osteoblasts lining the trabeculae & osteocytes in the lacunae

• Necrotic areas – anucleate pink ghost cells

Contd…

• Degree of necrosis variable – focal , moderate or extensive

CAUSES • acute leukemia ( pre / post chemotherapy )• sickle cell anemia • CML , NHL , HODGKINS DISEASE • HIV • Q fever , histoplasmosis• metastatic deposits

APLASTIC ANEMIA

• Progressive pancytopenia , reticulocytopenia

• Bone marrow biopsy < 25 % of normal cellularity of that age.

CML

BONE MARROW • Hyper cellular• M : E 15 : 1 to 30 : 1 • Proliferation of granulocytic precursors

MEGAKARYOCYTEShyperplasia with focal clustering , Smaller and hypolobated forms Seen in sinusoids , paratrabecular zones

MYELODYSPLASTIC SYNDROMES

• Cellularity

• Topography - ALIP

Paratrabecular megakaryocytes

• Dys poeitic features

• Blast count

• associated fibrosis

HYPOCELLULAR MDS

MDS associated with Fibrosis

HODGKINS LYMHOMA BONEMARROW BIOPSY

• Staging

• Incidence of bonemarrow involvement 2to 30 %

• Mixed cellularity and lymphocyte depleted

• Manifested as focal or diffuse type

CRITERIA FOR BM INVOLVEMENT

CERTAIN TYPICAL RS CELLS OR MONONUCLEAR VARIANTS IN CHARACTERISTIC CELLULAR ENVIRONMENT

SUGGESTIVE ATYPICAL HISTIOCYTE OR CHARACTERISTIC CELLULAR BACK GROUND

SUSPICIOUS FIBROSIS / NECROSIS ALONE .

BONE MARROW IN NHL

• Staging

• Marrow involvement is more frequent in low grade NHL – modest effect on patient outcome

• Less common in high grade NHL – poor prognosis .

• Predictor of high risk for CNS involvement

• Pattern of involvement

• nodular , diffuse , paratrabecular , interstitial , mixed

• IHC

• tumor cell burden

CLL

• Interstitial / nodular – better prognosis

• Increased fibrosis – bad prognosis

• increased plasma cells – bad prognosis

HAIRY CELL LEUKEMIA

• Pancytopenia , spleenomegaly

• Bone marrow aspiration - DRY TAP

• Biopsy – diffuse / focal / nodular marrow involvement

• Cell morphology – fried egg appearance / honey comb appearance

• Web like reticulin meshwork

GRANULOMA

• Bacterial - TB , leprosy , syphillis , brucellosis , typhoid .

• Viral - EBV , HIV

• Rickettsia - Q fever

• Fungal – cryptococcosis , histoplasmosis

• Sarcoidosis

METASTASIS

• Carcinoma / lymphoma

• For staging of malignancy

• Evaulate occult malignancy

Adults

ca breast, thyroid , prostate , stomach , kidney , lung .

Children

neuroblastoma , RMS, retinoblastoma , PNET , Ewings sarcoma

SUMMARY

EVAULATION OF BONE MARROW BIOPSY

• Adequate clinical history

• Better tissue processing

• Cellularity and topography of cellular elements , their physiological variation .

• Stromal changes – fibrosis , necrosis .

• Infections - granulomas

REFERENCES

• WINTROBES CLINICAL HAEMATOLOGY 13 EDITION

• DAICIE PRACTICAL HAEMATOLOGY

• HOFFBRAND

• INTERNET

THANK YOU