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Bone Marrow Aspiration and Trephine Biopsy Part 1

Bone Marrow Aspiration and Trephine Biopsy Part 1
September 14, 2021HematologyLab Tests

Indications:

  1. Bone Marrow examination is done to diagnose Leukemia or myeloma.
  2. Bone marrow is done to diagnose anemias e.g Megaloblastic anemia, aplastic anemia or sideroblastic anemia.
  3. To find a deficient iron store by special stains (Prussian blue).
  4. To rule out any infiltration of the tumors.
  5. To rule out the presence of fibrosis.
  6. Bone marrow did as a staging part of lymphoma.
  7. In Fever due to unknown cause (PUO).
  8. This can be indicated for infections.
  9. In the case of thrombocytopenia.

Procedure for Bone Marrow:

  1. This procedure can be done as an outdoor procedure.
    1. Children and patients in tension need mild sedatives prior to the procedure.
    2. If there are hairs then shave the area.
    3. Wash with the soap then clean with the antiseptic.
    4. Drap the area with a sterile cloth.
  2. Bone marrow aspiration is done on the patient under the local analgesia.
    1. 1 to 2% Xylocaine is injected locally.
    2. Go deep to infiltrate the periosteum of the bone.
    3. A small 3 mm incision may be made to pierce the skin and subcutaneous tissue easily.
    4. An adult size Jamshidi needle is needed.
      1. It is the 11-gauge x 4-inch length
    5. Penetrate the bone and when entering the marrow cavity then take out the stylet.
    6. Now attach the syringe (20 to 50 ml size), and suck the marrow, the patient will feel sharp pain which indicates that you are in the marrow cavity.
    7. Get 1 to 1.5 mL of the marrow particles.
      1. The marrow tissue is seen as grey particles floating in the blood and fat droplets.
      2. More samples may be aspirated for flow cytometry, chromosomes studies, culture, and other tests.
    8. immediately make the smears before the blood clots.
      1. You make a slide by putting one drop on one slide and spread it by another slide.
        Bone marrow smear preparation

        Bone marrow smear preparation

  1. The clotted sample is put into fixative (10% buffered formalin) and this is used for the sections.
    Jamshidi needle

    Jamshidi needle

  1. The most common site is the Posterior Iliac crest (pelvis).
    • Other sites are sternum and anterior iliac crest.
      Bone marrow aspiration sites

      Bone marrow aspiration sites

  1. One-half to 2 ml of bone marrow is aspirated.
    1. Bone marrow aspiration is done first.
    2. Bone marrow aspiration is followed by the bone biopsy,
  2. During the aspiration of marrow.
    1. liquid bone marrow is aspirated or sucked in the syringe.
    2. Then spread the sample on the slides.
    3. The patient may feel a sharp pain on suction which indicates the marrow aspiration.
  3. Before the bone marrow aspiration makes the peripheral blood smear and performs the Differential count.
  4. For infants, general anesthesia may be needed.

Complications:

  1. The needle may break.
  2. There may be a hemorrhage.
  3. There may be infections.
  4. Rarely there may be chronic pain at the site of bone marrow aspirate or biopsy.

Contraindications:

  1. In patients who are not cooperative.
  2. The patients with a bleeding tendency or coagulation disorders.

Complications of bone marrow:

  1. There are chances of bleeding if the patient has an increased tendency for bleeding.
  2. There are chances for the infection in the case of leukopenia.
  3. The sternum is not a safe site and chances for the complication are increased.
  4. There may be a sternal fracture in case of a sternal puncture.
  5. Sometimes patient complains of pain and tenderness at the site of the puncture.

Pathophysiology

  1. Bone marrow is found in the central fatty portion of the ribs, sternum, pelvis, long bones like the femur, tibia, and humerus.
  2. Bone marrow consists of differentiated and undifferentiated hematopoietic cells, Reticuloendothelial cells, and fatty tissue.
    1. These are the stem cells that differentiate into the different types of cells in the blood.
    2. These cells after maturation gain entrance to the peripheral blood.
      Bone marrow maturation of the cells

      Bone marrow maturation of the cells

      Bone marrow precursor cells and their maturation

      Bone marrow precursor cells and their maturation

      Bone marrow maturation of myeloid, erythroid and lymphoid cells

      Bone marrow maturation of myeloid, erythroid, and lymphoid cells (CFU = colony-forming unit).

Stages of Red cell maturation.

    1. Pronormoblast
      Pronormoblastic cell

      Pronormoblastic cell

    2. Basophilic normoblast.
    3. Polychromatic normoblast.
      Normoblastic cells

      Normoblastic cells

    4. Reticulocytes.
      Reticulocytes

      Reticulocytes

    5. Erythrocytes (Normal red blood cells).
      Normal Red blood cells

      Normal Red blood cells

Stages of Neutrophils maturation.   

    1. Myeloblast.
      Myeloblastic cell

      Myeloblastic cell

    2. Promyelocytes.
      Promyelocytic cell

      Promyelocytic cell

    3. Myelocytes.
      Myelocytic cell

      Myelocytic cell

    4. Metamyelocytes.
      Metamyelocytic cell

      Metamyelocyte

    5. Band neutrophils.
      Band form poly

      Band form poly

    6. Mature neutrophils or Polys.
      Mature neutrophil

      Mature neutrophil

Bone marrow evaluation shows:

  1. Maturation of red blood series.
  2. Maturation of white blood series.
  3. Presence of megakaryocytes.
  4. Myeloid/erythroid ratio.
  5. Iron stores.
  6. Presence or absence of granulomas.
  7. Any tumor cell infiltrate.
  8. Overall bone marrow activity.

B.M examination reveals the following abnormal pattern:

  1. Bone marrow examination shows:
    1. RBCs shape, number, and size.
    2. White blood cells shapes, size, and number.
    3. Megakaryocytes and platelets formation.
    4. Evaluate cellularity, fibrosis, and infiltrate.
    5. Estimation of iron contents.
  2. The presence or absence and ratio of cells are characteristic of the suspected disease.
  3. Multiple myeloma, Plasma cell myeloma, and macroglobulinemia.
  4. Chronic or acute leukemia.
  5. Anemia,e.g. Megaloblastic, macrocytic and normocytic anemia.
  6. Toxic states produce bone marrow depression or destruction.
  7. Neoplastic conditions where the bone marrow is involved with metastatic carcinoma, lymphoproliferative diseases.
  8. Platelets dysfunctions.
  9. Some types of infections like Tuberculosis and Histoplasmosis.
  10. Lipid or glycogen storage disease.
  11. Deficiency of Iron stores like microcytic anemia.
    1. Prussian blue stain on bone marrow slides shows iron contents.

Normal Bone Marrow Components:

Type of cells   Percentage % of cells in Bone Marrow Percentage % of cells in peripheral blood 
Myeloid cells
Myeloblast 3 to 5 % (mean 2.0%) 0
Promyelocytes  1 to 8 % (mean 5.0%) 0
Myelocytes neutrophils 5 to 19 % (mean 12%) 0
Myelocytes eosinophils 0.5 to 3 % (mean1.5%) 0
Myelocytes basophils 0 to 0.5 %(mean 0.3%) 0
Metamyelocytes 17 to 33 % (mean 0.4%) 0
Neutrophils 11 to 33 % (mean 20%) 40 to 70%
Monocytes 0 to 3 % (mean2.0%) 2 to 10%
Lymphocytes 8 to 20 % (mean 10%) 20 to 40%
Megakaryocytes 0 to 3 % (mean0.4%) 0
Plasma cells 0 to 2.0 % (mean 0.9%) 0
Erythroid series cells
Pronormoblast 0.2 to 4.0 % (mean 0.5%)
Polychromatic normoblast 3.5% to 20.5% (mean 10.4%)
Myeloid/Erythroid ratio (WBC: Nucleated RBC) 2: 1  to 4: 1 Slightly higher in infants
  • M: E ratio in infection may be 6:1 and in leukemia 25:1.
  • Hypercellular or hyperplasia of marrow refers to an increase in one or more cell components. This may be due to compensation or a leukemic process.
  • Hypocellular or hypoplasia of marrow is due to loss of cellularity or incomplete development in one or more lines of the cells.

Abnormal bone marrow findings are seen in:

  1. Infections:
    1. Viral.
    2. bacterial.
    3. Fungal.
  2. Chronic inflammatory diseases.
  3. Myelofibrosis.
  4. Agranulocytosis.
  5. Malignancy:
    1. Multiple myelomas.
    2. Hodgkin’s lymphoma.
    3. Lymphoma.
    4. Polycythemia vera.
    5. Leukemias.
  6. Anemias.
  7. AIDS.
  8. Rheumatic fever.

Difference between bone marrow aspiration and trephine biopsy:

Feature Bone marrow aspiration Bone marrow trephine biopsy
Site Posterior iliac crest, sternum. Posterior iliac crest.
Indication Anemia, pancytopenia, neutropenia, thrombocytopenia, a possible cause of leukemia and myeloma. Polycythemia vera, myelofibrosis, myeloproliferative disorder, aplastic anemia, lymphomas, metastatic infiltrate, splenomegaly,  PUO, and in case of a dry tap.
Information and purpose

1. Assess cytomorphology.

2. Perform a differential count.

3. Find M: E ratio.

4. It can perform cytochemical stains.

1. To assess cellularity.

2. To appreciate different cellular elements.

3. To assess the fibrosis.

4. To assess the infiltration by the tumors.

5. To evaluate bony trabeculae.

6. If in saline then can do flow cytometry.

7. If in formalin then perform immunohistochemical stains.

8. Can do T – cell and B – cell rearrangements by PCR.
Possible studies Cytogenetics, culture, biochemical analysis, cytochemical marker, immunological studies, genetic abnormality studies by DNA, and RNA analysis. Immunological studies and stains
Staining procedure

Romanosky, Giemsa.

Prussian blue stain for iron.

Hematoxylin and eosin stain.

Reticulin stain.
Possible References Used
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