Bm details

1. BONE MARROW BIOPSY IN
HEMATOLOGICAL MALIGNANCIES
DR SHIVAM SUBUDHI
MODERATOR-DR RANJAN KUMAR MALLICK

2. INTRODUCTION
 Bone marrow examination helps in diagnosis and management of
haematological diseases.
 Complete marrow assessment entails two separate investigation
 Bone marrow aspiration-
• Cell morphology
• Differential count
 Bone marrow biopsy-
• Cellularity
• Fibrosis
• Infiltrative disease

3. Indications of biopsy
 To accurately assess marrow cellularity
 Suspected focal lesions
 To diagnose aplastic anemia, hypoplastic MDS, hypoplastic
acute leukemia
 Investigation and prognostication of MPN
 Diagnosis and staging of Hodgkins, non hodgkins
lymphoma,mets
 Unexplained leucoerythroblastic blood picture
 PUO

4.  Multiple myeloma
 Primary amyloidosis
 For IHC studies
 Stromal changes
• Fibrosis
• Necrosis
• Gelatinous marrow transformation

6. Criteria for adequacy
 Length- 1.5 -2 cm
 5- 6 trabecular spaces
 Section thickness 4 micron

7. Cellularity
 90-100% in infants
 50-60% in adults
 20-30% in old age

8. Normal topography
 Myeloid- paratrabecular, mature cells towards centre
 Erythroid –centre in colonies
 Megakaryocytes- centre around sinusoids
 Lymphoid precursers- periarteriolar region
 Stroma- fat cell, fibroblast, reticulin fibres

9. ACUTE LEUKEMIA

11. AML M0
 Blasts resemble L2 lymphoblasts
 blasts are MPO negative

12. AML M1
 Blasts >90%
 Mature cells <10%
 >3% blasts are MPO positive

13. AML M2
 Most frequent cytogenetic abnormality- t(8;21)
 Blasts 20- 89% of non erythroid MNCs
 Maturing component >10%

14. AML M3
 Blast may be <20%
 Molecular – PML RARA /t(15;17)
 2 types – hypergranular variant, microgranular variant

15. AML M4
 Blast >20%
 Monocytic component> 20% of non erythroid MNCs
 Monocytes in blood>5x103 μl

16. BMA BMB
AML M4 Eo
 inv (16)
 Eosinophilic precursers >5%

17. AML M5
 Extramedullary infiltration into skin, gum, meninges, lungs
 AML M5a- monoblast >80% of monocytic component
 AML M5b- monoblast <80%
 Acute monocytic leukemia- NPM1 mutation

18. BMB AML M5a BMB- CD64 in AML M5a and M5b

19. AML M6
 3-4 % of AML
 Associated with profound anemia
 3 sub types
BMA PAS BMB

20. AML M7
 Dry tap / diluted marrow aspirate
 Megakaryoblastic hyperplasia with extensive fibrosis
 Megakaryocytic cells seen in all stages
 Associated with t (1;22), down syndrome

21. BMB BMB-RETICULIN

22. APMF
 Trilineage hyperplasia with blasts >20%
 Marrow fibrosis
 Pancytopenia
 Doesn't meet the criteria for AML with MDS

23. ALL
 Sub types of ALL(FAB)-
 L1- small homogenous blasts
 L2- large heterogenous blasts
 L3 – large homogenous blasts
BMA ALL L1 BMA ALL L2

24. ALL
BMA ALL L3 BMB

25. ALL
BMB CD 19 AND PAX 5

26. MYELODYSPLASTIC SYNDROME

28. MDS
 ERYTHROID DYSPLASIA

29.  ERYTHROID DYSPLASIA

30.  GRANULOPOIESIS IN MDS

31.  GRANULOPOIESIS IN MDS
ALIP

32.  THROMBOPOIESIS IN MDS

33.  THROMBOPOIESIS IN MDS

34. MDS SLD
BMA
PS
BMB

35. MDS MLD
BMB
BMA

36. MDS RS SLD MDS RS MLD
PS
BMA PERLS’ STAIN
BMA BMA

37. MDS EB1
PS BMA

38. MDS EB2
MPO BMB

39. HYPOPLASTIC MDS
BMB
MDS WITH FIBROSIS

40. MYELOPROLIFERATIVE NEOPLASM

41. MPN WHO2016
1. CML, BCR-ABL1 positive
2. CNL
3. PV
4. PMF
5. ET
6. Chronic eosinophilic leukemia, NOS
7. MPN , unclassifiable
8. Mastocytosis

42. CML
 chronic phase
 PBS- TLC (30-500x103/μl), myelocytic bulge,absolute
basophilia, thrombocytosis
 NAP score (0-20)
 BM-hypercellular, M:E ratio elevated, blast<5%,
megakaryocyte hyperplasia with dwarf forms seen
BMA

43. Dwarf megakaryocytes Pseudogaucher cell

44. CML
 Accelerated phase
 Blasts 10-19%
 Persistent thrombocytosis or thrombocytopenia
 Basophilia >20%
 Blast crisis
 Blast>20%
 Anemia and thrombocytopenia
 25% cases- lymphoblastic
Accelerated phase
Blast crisis

45. Polycythemia vera

46. Polycythemia Vera
PS
BMA
BMB

47.  POST PV MYELOFIBROSIS

48. ESSENTIAL THROMBOCYTHEMIA

49. ESSENTIAL THROMBOCYTHEMIA

50. BMB

51. MYELOFIBROSIS
PRE FIBROTIC PHASE
FIBROTIC PHASE

52. FIBROTIC PHASE- special stains
OSTEOMYELOSCLEROSIS

53. LYMPHPROLIFERATIVE DISORDERS

54. Non Hodgkin’s lymphoma
 Patterns of marrow involvement
 Packed / diffuse
 Nodular
 Paratrabecular
 Interstitial
 Mixed
 Intra sinusoidal

55. CLL
INFILTRATIVE NODULAR
MIXED DIFFUSE

56. Mantle cell lymphoma
 Difffuse marrow invovment
 Paratrabecular arrangement
 Variants- blastoid, lymphocytic, pleomorphic

57. Hairy cell leukemia
 PBS- pancytopenia ,hair like projections on lymphoid cells
 TRAP positive
 Splenomegaly
 BRAFV600E mutation
 BM- dry tap, focal/ interstitial / diffuse replacement of
marrow by hairy cells

58. Burkitt lymphoma DLBCL

59. ALCL

60. Hodgkin’s lymphoma
 Bm involvement – stage IV
 Rarely involves BM
 BM- hyper cellular due to myeloid hyperplasia
 RS cells

61. PLASMA CELL NEOPLASM

63. SUMMARY
 Bone marrow biopsy helps in diagnosis, staging
and predicting prognosis of different
hematological malignancies
 It should be ideally reported along with bone
marrow aspiration and peripheral smear
 Clinical history, laboratory investigations ,
imaging information, all should be taken into
consideration before any diagnosis

64. THANK YOU