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
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