Bone Marrow Aspiration and Trephine Biopsy Part 1
Bone Marrow Aspiration and Trephine Biopsy
- A bone marrow examination is done to diagnose Leukemia or myeloma.
- Bone marrow is done to diagnose anemias e.g Megaloblastic anemia, aplastic anemia or sideroblastic anemia.
- To find a deficient iron store by special stains (Prussian blue).
- To rule out any infiltration of the tumors.
- To rule out the presence of fibrosis.
- Bone marrow did as a staging part of lymphoma.
- In Fever due to unknown cause (PUO).
- This can be indicated for infections.
- In the case of thrombocytopenia.
Procedure for Bone Marrow aspiration and biopsy:
- This procedure can be done as an outdoor procedure.
- Children and patients in tension need mild sedatives before the procedure.
- If there are hairs then shave the area.
- Wash with the soap, then clean with the antiseptic.
- Drap the area with a sterile cloth.
- Bone marrow aspiration is done on the patient under local analgesia.
- 1 to 2% Xylocaine is injected locally.
- Go deep to infiltrate the periosteum of the bone.
- A small 3 mm incision may be made to pierce the skin and subcutaneous tissue easily.
- An adult-size Jamshidi needle is needed.
- It is the 11-gauge x 4-inch length
- Penetrate the bone and take out the stylet when entering the marrow cavity.
- Now attach the syringe (20 to 50 ml size), and suck the marrow; the patient will feel sharp pain, indicating that you are in the marrow cavity.
- Get 1 to 1.5 mL of the marrow particles.
- The marrow tissue is seen as grey particles floating in the blood and fat droplets.
- More samples may be aspirated for flow cytometry, chromosome studies, culture, and other tests.
- Immediately make the smears before the blood clots.
- You make a slide by putting one drop on one slide and spreading it on another slide.
- The clotted sample is put into fixative (10% buffered formalin), which is used for the sections.
- The most common site is the Posterior Iliac crest (pelvis).
- Other sites are sternum and anterior iliac crest.
- One-half to 2 ml of bone marrow is aspirated.
- Bone marrow aspiration is done first.
- Bone marrow aspiration is followed by a bone biopsy,
- During the aspiration of marrow.
- Liquid bone marrow is aspirated or sucked into the syringe.
- Then spread the sample on the slides.
- The patient may feel a sharp pain on suction, indicating the marrow aspiration.
- Before the bone marrow aspiration, makes the peripheral blood smear and perform the Differential count.
- For infants, general anesthesia may be needed.
Complications of Bone Marrow Aspiration and Trephine Biopsy:
- The needle may break.
- There may be a hemorrhage.
- There may be infections.
- Rarely may there be chronic pain at the site of bone marrow aspirate or biopsy.
- There are chances of bleeding if the patient has an increased tendency for bleeding.
- There are chances for infection in the case of leukopenia.
- The sternum is not a safe site, and chances for complications are increased.
- There may be a sternal fracture in case of a sternal puncture.
- Sometimes patient complains of pain and tenderness at the site of the puncture.
Contraindications of bone marrow aspiration and biopsy:
- In patients who are not cooperative.
- The patients with a bleeding tendency or coagulation disorders.
Pathophysiology of Bone marrow:
- Bone marrow is found in the central fatty portion of the ribs, sternum, pelvis, and long bones like the femur, tibia, and humerus.
- Bone marrow consists of differentiated and undifferentiated hematopoietic cells, Reticuloendothelial cells, and fatty tissue.
- These stem cells differentiate into the different types of cells in the blood.
- These cells, after maturation, gain entrance to the peripheral blood.
Stages of Red cell maturation.
- It is the most immature and largest in erythropoiesis.
- The nucleus is round and stains dark violet.
- Densley packed chromatin and indistinct nucleoli blue in color.
- There are cytoplasmic extrusions.
- The cell size is decreased.
- The nucleus is round and contains chromatin with strong contrast.
- The cytoplasm is slightly basophilic.
- The shape of the cells and structure of the nucleus is similar to those of basophilic normoblast.
- The cell size further decreased.
- The cytoplasm is blue-grey-violet due to the presence of hemoglobin.
- It is characterized by the presence of granular or reticular filamentous structures.
- These are present in 0.5% to 1.5% of the mature RBCs.
- These are only seen after staining with methylene blue.
- RBCs are pale greenish-blue, and the filamentous structures are blue-black.
Erythrocytes (Normal red blood cells):
- It is a circular, biconcave, and reddish RBC.
- Size is mostly the same, measuring 7 to 8 µm in diameter.
- There is no visible inner structure.
Stages of Neutrophils maturation.
- This is the least mature white cell.
- Its number is scanty in the bone marrow.
- The size is slightly smaller than the proerythroblast.
- Myeloblast exists in various forms.
- The nucleus is oval and may have a slight indentation on one side.
- Chromatin is in fine, closely meshed, transparent filaments.
- These have a variable nuclear-cytoplasm ratio.
- The granulation is variable.
- Characteristic as an oval-shaped nucleus. These are often flattened or indented on one side (kidney-shaped).
- Chromatin density is moderate.
- The cytoplasm is light-blue with the lighter area near the nucleus.
- There is a decrease in cell size and the nucleus.
- Chromatin is more coarse, and nucleoli are barely visible.
- The cytoplasmic is no longer basophilic; it takes on a pale grey-brown or pink-brown color.
- The nucleus is bean or kidney-shaped.
- Chromatin is coarse and compact in areas.
- The nucleus is C or S shape.
- Chromatin is coarser.
Mature neutrophils or Polys:
- These are mature neutrophilic granulocytes.
- The nucleus is made of 3 to 5 lobes connected by the filament.
Bone marrow evaluation needed for:
- Maturation of red blood series.
- Maturation of white blood series.
- Presence of megakaryocytes.
- Myeloid/erythroid ratio.
- Iron stores.
- Presence or absence of granulomas.
- Any tumor cell infiltrate.
- Overall bone marrow activity.
B.M examination reveals the following information:
- Bone marrow examination shows:
- RBCs shape, number, and size.
- White blood cells’ shapes, size, and number.
- Megakaryocytes and platelets formation.
- Evaluate cellularity, fibrosis, and infiltrate.
- Estimation of iron contents.
- The presence or absence and ratio of cells are characteristic of the suspected disease.
- Multiple myeloma, Plasma cell myeloma, and macroglobulinemia.
- Chronic or acute Leukemia.
- Anemia,e.g. Megaloblastic, macrocytic and normocytic anemia.
- Toxic states produce bone marrow depression or destruction.
- Neoplastic conditions where the bone marrow is involved with metastatic carcinoma and lymphoproliferative diseases.
- Platelets dysfunctions.
- Some types of infections like Tuberculosis and Histoplasmosis.
- Lipid or glycogen storage disease.
- Deficiency of Iron stores like microcytic anemia.
- 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|
|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 % (mean 0.4%)||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:
- Chronic inflammatory diseases.
- Multiple myelomas.
- Hodgkin’s lymphoma.
- Polycythemia vera.
- 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.|
|Information and purpose||