The document discusses bone marrow biopsy techniques and evaluation. It describes the structure of bone marrow, including cellular elements and stroma. Needle types and biopsy sites are covered. Processing involves fixation, decalcification, embedding and staining. Evaluation is based on clinical history, hemogram, smear and aspiration. Adequacy, cellularity, cell topography, proliferation, fibrosis, infections, and infiltrative diseases are assessed. Stromal changes like fibrosis and necrosis are also evaluated. Common conditions affecting bone marrow including CML, MDS, Hodgkin's, NHL, CLL and metastasis are discussed. Adequate history, processing, cellularity, topography, stromal changes, infections and gran

1. BONE MARROW BIOPSY AND
INTERPRETATION
JULY 2016

2. STRCTURE OF BONE MARROW
• A) cellular elements
Haematopoetic stem cells , Progenitors ,
precursors .
B) Stroma - unique microenvironment of the
marrow

3. BONE MARROW BIOPSY NEEDLES
• Jamshidhi
• Islam
• Westerman jensen
• Drills
• Disposable needles

4. DRILLER

5. 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.

6. SITES OF BONE MARROW BIOPSY
• Posterior superior iliac spine
• Anterior superior iliac spine
• Iliac crest
• Tibial tuberosity in children .

9. 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

10. PROCESSING OF BONE MARROW
BIOPSY
3.EMBEDDING
Paraffin
Resin
4. STAINING
H & E , Reticulin , Perls
Masson trichrome .

11. BM BIOPSY EVAULATION
BASED ON
1. Clinical history
2. Physical examination
findings
3. Complete hemogram
4. Peripheral blood smear
5. Aspiration

12. 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

13. Evaluation
• Cellularity
• Topography of hemopoetic cells
• Proliferation of cell lines
• Fibrosis
• Infections
• Infilterative diseases

14. 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

18. 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.

20. 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 .

21. THROMBOCYTHEMIA

22. OTHER CELLS
• Macrophages , plasmacells , mast cells ,
eosinophils and lymphocytes .
• Multiple lymphoid nodules – IHC to rule out
neoplastic lymphoproliferative disorder

23. 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

24. 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

27. 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

30. 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

31. 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

33. APLASTIC ANEMIA
• Progressive pancytopenia , reticulocytopenia
• Bone marrow biopsy < 25 % of normal
cellularity of that age.

35. CML
BONE MARROW
• Hyper cellular
• M : E 15 : 1 to 30 : 1
• Proliferation of granulocytic precursors
MEGAKARYOCYTES
hyperplasia with focal clustering ,
Smaller and hypolobated forms
Seen in sinusoids , paratrabecular zones

38. MYELODYSPLASTIC SYNDROMES
• Cellularity
• Topography - ALIP
Paratrabecular megakaryocytes
• Dys poeitic features
• Blast count
• associated fibrosis

39. HYPOCELLULAR MDS

40. MDS associated with Fibrosis

41. HODGKINS LYMHOMA
BONEMARROW BIOPSY
• Staging
• Incidence of bonemarrow involvement
2to 30 %
• Mixed cellularity and lymphocyte depleted
• Manifested as focal or diffuse type

42. 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 .

43. 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

44. • Pattern of involvement
• nodular , diffuse , paratrabecular , interstitial ,
mixed
• IHC
• tumor cell burden

46. CLL
• Interstitial / nodular – better prognosis
• Increased fibrosis – bad prognosis
• increased plasma cells – bad prognosis

47. 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

49. GRANULOMA
• Bacterial - TB , leprosy , syphillis , brucellosis ,
typhoid .
• Viral - EBV , HIV
• Rickettsia - Q fever
• Fungal – cryptococcosis , histoplasmosis
• Sarcoidosis

52. 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

54. 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

55. REFERENCES
• WINTROBES CLINICAL HAEMATOLOGY
13 EDITION
• DAICIE PRACTICAL HAEMATOLOGY
• HOFFBRAND
• INTERNET

56. THANK YOU