SlideShare a Scribd company logo
1 of 60
Common pitfalls in bone marrow
biopsy based diagnostic approach
Dr. N. Varma
Prof. & Head - Hematology
PGIMER, Chandigarh, India
Bone marrow (BM) examination
• Gold standard investigation for diagnosing and
monitoring many hematological diseases
• Useful for investigating various non-hematological
conditions
• Combination of bone marrow aspirate and trephine
biopsy: fine cytological detail, the organization of
BM, and the presence of focal abnormalities
Good-to-have Information
• Accurate clinical information; context and questions being
asked; details of previous investigations
• For neoplastic diseases: ? primary diagnostic investigation/
staging procedure/ re-examination to assess response to
treatment (including transplantation)
• The type and timing of previous BM transplantation are
also important factors; kinetics of engraftment differ
between conditioning regimes and graft types
• Knowledge of the recent therapeutic use of growth factors
such as G-CSF; these may transiently have major modifying
effects on hemopoiesis that can mask or mimic genuine
pathology
Pitfalls in obtaining and interpreting
bone marrow aspirates
• BM aspiration done when not needed
• BM aspiration not done when needed
• BM aspiration done on the wrong site
• The clinical context not adequately assessed and the
correct range of tests is therefore not done on the aspirate
• False negative result as a consequence of a sampling error
• The aspirate is not interpreted together with the trephine
biopsy sections
• The aspirate is misinterpreted
– Problems relating to technical quality
– Correct stains not performed
– Features present not noted
– Misinterpretation of an adequate aspirate
Limiting factors for interpretation of BMB
• Inadequate clinical, hematological (blood and aspirate
findings), genetic and radiological information
• Inadequate specimen
– Too small
– Too crushed/distorted
– Both
– Poorly decalcified/processed
• Inadequate sections (thickness, number of levels)
• Inadequate stains (poor technical quality, range too limited)
• Insufficient experience to avoid common pitfalls
(eg, differential diagnosis of granulomas or fibrosis)
• Insufficient confidence to avoid concluding ‘consistent with’
• ‘Invisible’ pathology
• Forgetting to look at the bone trabeculae and stroma
Common Ancillary Studies complementary to
Bone Marrow Morphologic Examination
• Cytogenetics on BM aspirate or peripheral blood
sample
• FISH studies on BM aspirate or touch preparations
• Molecular studies (PCR or RT-PCR) to detect specific
translocations and/or antigen receptor gene
rearrangements
• Flow cytometric Immunophenotyping of BM aspirate
or peripheral blood cells
• Immunohistochemistry on paraffin sections
• Enzyme cytochemistry on marrow aspirate or
peripheral smear slides
A systematic approach to diagnosis is
required for:
• D/D of hypoplasia/aplasia
• D/D of megaloblastic hemopoiesis
• Assessing key histological features of myelodysplastic
and myeloproliferative haemopoiesis
• D/D of bone marrow fibrosis
• Assessing patterns of lymphoid infiltration associated
with various lymphomas, especially small B-cell
lymphomas
• D/D of granulomatous pathologies
1. D/D hypocellular marrow
Normocellular
• CBC and reticulocyte count
• Blood film examination
• Bone marrow aspirate and trephine biopsy
• HbF% in children
• Peripheral blood lymphocyte cultures for clastogens induced
chromosomal breakage studies
• Ham’s test and / or flowcytometry for GPI anchored proteins
• Urine hemosiderin (if Ham’s test and / or FCM for GPI anchored +)
• Vitamin B12 and folate levels
• Liver function tests
• Renal function tests
• Viral markers (hepatitis A, B, C; EBV; CMV; HIV)
• Antinuclear antibody and anti ds-DNA
• Chest x-ray
• Abdominal ultrasound scan
Investigations recommended for suspected AA
CBS 958
Varma N et al. Multiple constitutional aetiological factors in BMFS patients… Indian J Med Res 2006
Fanconi Anemia associated Aplastic Anemia
(A-1366/11; Tx-1204/11)
2. Subtle increase of immature cells: in hypocellular marrow ?leukemia/lymphoma
IHC: Blasts positive for CD34, anti-MPO (A-1366/11; Tx-1204/11)
Diagnosis: Hypocellular AML
2. Subtle increase of immature cells in hypocellular marrow
3. Problem in differentiating AML-M6 and megaloblastic anemia
Megaloblastic anemia ? Megaloblastic anemia
3. Problem in differentiating AML-M6 and megaloblastic anemia
(A-1305/10; Tx-1056/10) IHC: Blasts positive for anti-MPO, CD34
AML- M6
Hb TLC Platelet
count
Reticulocyte DLC PBF
7 g/dl 7.3 x
109/L
7 x 109/L 5.36% P60L34M4E2 Moderate anisocytosis,
microcytes, macrocytes,
hypochromia & polychromasia
3. D/D of ‘megaloblastic anemia’ picture
Bone marrow aspirate
(BM A-1404/12)
Cellular
M:E= 1:1
Blast1, Pm2, My 40 ,Mm 1, P44, L8, M1, E2
Megakaryocytes: Adequate
Bone marrow
biopsy
(T-1226/12)
Mildly hypercellular with relative erythroid hyperplasia with
megaloblstic changes. Granulocytes and megakaryocytes are adequate.
Granulocytes
Granulocytes
Monocytes
RBCs
Final diagnosis: Classical PNH
RCMD-RS
3. D/D of ‘megaloblastic anemia’ picture: characterization of ‘MDS’ like pathology.
45 M, bicytopenia
Bone marrow infiltration in a case of Hepatosplenic lymphoma
(A-408/10; Tx-323/10)
4. Pattern of bone marrow infiltration by NHL
Bone marrow intravascular infiltration in a case of Hepatosplenic lymphoma.
IHC for CD34 and CD3 (A-408/10; Tx-323/10)
CD34 CD3
4. Pattern of bone marrow infiltration by NHL
Plasma cells in a case of Multiple myeloma (A-1441/08; Tx-1161/08)
5. Differentiation between reactive and malignant plasma cells
IHC: Kappa light chain
Reactive plasmacytosis + LD bodies
(A-1535/11; Tx-1356/11)
5. Differentiation between reactive and malignant plasma cells
Reactive increase in plasma cells in a case of Tubercular Granuloma
(A-1198/12; Tx-1042/12)
5. Differentiation between reactive and malignant plasma cells
BM: GranulomaAFB stain
Renal Osteodystrophy
(A-391/12; Tx-339/12)
6. Identification of etiology in fibrosis
6. Identification of etiology in fibrosis
Acute panmyelosis with myelofibrosis
(A-185/13; Tx-167/13)
ALL with fibrosis
(A-1476/12; Tx-1288/12)
7. Identification of subtle infiltration of leukemia/lymphoma in fibrotic marrow
IHC for CD34
7. Identification of subtle infiltration of leukemia/lymphoma in fibrotic marrow;
IHC is required
IHC for TdT
IHC for CD20
ALL with fibrosis
(A-1476/12;
Tx-1288/12)
Amyloid deposition in vessel wall
(A-1554/12; Tx-1356/12)
Congo Red stain
8. Problem in cases with subtle Amyloid deposition- need to be confirmed by special
staining by Congo Red
9. Problem in assigning myelodysplasia as reactive or primary
RCMD- predominantly dysplastic megakaryocytes (A-803/12; Tx-690/12)
9. Problem in assigning myelodysplasia as reactive or primary
Case with sepsis- dysplastic megakaryocytes
(A-55/12; Tx-51/12)
Metastatic carcinoma of GIT (A-105/13; Tx-93/13)
10. Problem in assessment of focal lesions- like metastasis may be missed if
sample is inadequate, and also in identification of primary site. These non-
hematologic malignancies may mimic hematological malignancies also.
Metastatic carcinoma- Prostate
(A-983/09; Tx-763/09)
10. Problem in assessment of focal lesions- like metastasis may be missed if
sample is inadequate, and also in identification of primary site. These non-
hematologic malignancies may mimic hematological malignancies also.
Granuloma- TB (A-1198/12; Tx-1042/12)
11. Problem in assessment of focal lesions- like granuloma may be missed if
inadequate sample and also in differentiation of granuloma etiology
Granuloma- Hodgkin’s Lymphoma
(A-1252/12; Tx-1091/12)
11. Problem in assessment of focal lesions- like granuloma may be missed if
inadequate sample and also in differentiation of granuloma etiology
12. Problem in cases with only necrosis- where etiology can not be assessed
BM Necrosis- (A-330/11; Tx-286/11)
13. Problem in identification of lymphocytosis, esp in NK/ T-cell infiltration as
reactive increase or malignant
NK leukemia/lymphoma
(A-444/12; Tx-314/12)
Bone Marrow Trephine Biopsy 314/12
Splenectomy section (S-12985/12) of this case.
IHC for CD56 highlighting NK cell increase in spleen;
case with increased lymphocytes on bone marrow.
13. Problem in identification of lymphocytosis, esp in NK/ T-cell infiltration as
reactive increase or malignant
14. Problem in differentiation of syntitial variant of Hodgkin’s lymphoma and ALCL
Reported as Anaplastic large cell lymphoma
(A-1255/08; Tx-1020/08)
IHC for CD30
IHC for CD15
14. Problem in differentiation of syntitial variant of Hodgkin’s lymphoma and ALCL-
IHC required for differentiation
Reported as Anaplastic large cell lymphoma
(A-1255/08; Tx-1020/08)
15. Problem in identification T-cell rich B-cell lymphoma
IHC for CD3 IHC for CD20
16. There can be technical artefacts leading to inconclusive findings
Washed off marrow spaces
Washed off marrow spaces, hemorrhage and cartilage
16. Procedural artefacts leading to inconclusive findings
16. Technical artefacts leading to inconclusive findings
Crushed marrow spaces
17. 15yrs/M,
TLC 32x109/L, Blasts 95%
Scanty aspirate smears
Tx BxPB smear
MPO +
Positive Markers: CD13, CD33, Anti
MPO, CD19, CD10, CD34, CD45, CD123, H
LADR
Negative Markers: T lineage
FCM-IP Diagnosis: Mixed Phenotype Acute Leukemia (B/ Myeloid)
1444 bp
943 bp
754 bp
585 bp
458 bp
341 bp
258 bp
NC P1 P2 P3 P4 P5 P6 M
bcr-abl transcripts in 1 MPAL (P1) and 5 different CML (P2-6) patients
b3a2 – 385 bp
b2a2 – 310 bp
Bhatia P, Binota J, Varma N, Bansal D, Trehan A, Marwaha RK, Malhotra P, Varma S. A Study on the
Expression of BCR-ABL Transcript in Mixed Phenotype Acute Leukemia (MPAL) Cases Using the
Reverse Transcriptase Polymerase Reaction Assay (RT-PCR) and its Correlation with Hematological
Remission Status Post Initial Induction Therapy. Mediterr J Hematol Infect Dis. 2012;4(1):e2012024.
18. 22M, DOA: 19.11.06; DOD: 26.11.06
C/O fever (↑↑-↑↑↑) 4 weeks
PUO: ? Disseminated TB / lymphoreticular malignancy
CBC: Hb 8.7 g/dl, Retics 1.6-2.6%, TLC 1800-700/ l, platelets 27000-12000/ l; PTI 86%
Bilirubin 4.2/2.8, 4.9/3.6; Serum ferritin 7557.8 mg/dl; Fibrinogen 2.85 g/l; TG 410
BM no. A-1083/06
EBV Zebra LMP 1 EBNA
HPS / HLH
•Screen for underlying genetic, autoimmune,
infectious and malignant diseases
•Uncontrolled hypercytokinemia & many triggers
•Early diagnosis and Rx
PM no. 21703
19. 5 ys. FCh; AML with increased mast cells/ basophils
MPO cytochemistry
P 30 / 07: CD 117 (APAAP)
Varma N, Varma S, Wilkins B.
Br J Haematol 2000;111:991.
Mast cell tryptase
AML with mastocytosis [Systemic mastocytosis with associated
clonal hematological non-mast cell disease (SM-AHNMD)]
Few representative examples
• Assessment of focal lesions
• Differentiation between reactive lymphoid infiltrate and NHL
• Differentiation between reactive and malignant plasma cells
• Identification of malignancies with associated fibrosis
• Effect of growth factors
• Differentiation between hematogones and blasts
• Differentiation between megaloblastic anemia and acute leukemia
• Differentiation between aplastic bone marrow and hypoplastic
myelodysplastic syndrome or hypoplastic acute leukemia
• Identification of lymphomas having a tendency for intravascular
infiltration in the BM
• Subtle amyloid deposition
• Differentiation of macrophage infiltrates and other pathologies that
resemble granulomatous infiltration
• Procedure related artefacts
Take home message
• Integration of clinical, laboratory and imaging information
• Not to assess histology in isolation; uni- / bilateral bx; dry aspirate
• Components of an integrated approach to interpretation are:
– Adequate size of trephine core, with minimal disruption by trauma caused
during collection.
– Access to detailed clinical information and results of additional tests
(specially, peripheral blood cell counts, blood and BM aspirate
cytomorphology, flow cytometry, cytogenetic analysis and radiological
imaging).
– Systematic assessment of all BM components, including trabecular bone and
interstitial stroma.
– Awareness of pathologies that may be ‘invisible’ in trephine specimens
without immunostaining.
– Use of preselected antibody panels for immunostaining and familiarity with
the expected results, including controls.
– Experience in interpreting additional molecular studies, such as clonality PCR
and fluorescence in-situ hybridization.
– Familiarity with the major patterns of bone marrow involvement by reactive
and neoplastic conditions and their differential diagnosis.
– A collaborative approach to working with diverse clinical and laboratory
colleagues.
– Ideally, hematopathologists should report BM Bx along with BM aspirate.
Thank You
Common pifalls in BMB interpretation can be avoided

More Related Content

What's hot

cytology of body fluid
 cytology of body fluid cytology of body fluid
cytology of body fluid
Musa Khan
 

What's hot (20)

Whipple's specimen grossing
Whipple's  specimen grossingWhipple's  specimen grossing
Whipple's specimen grossing
 
Cell block in cytology
Cell block in cytologyCell block in cytology
Cell block in cytology
 
Follicular thyroid differential diagnosis
Follicular thyroid differential diagnosisFollicular thyroid differential diagnosis
Follicular thyroid differential diagnosis
 
Grossing of breast
Grossing of breastGrossing of breast
Grossing of breast
 
Fungi in tissue sections
Fungi in tissue sectionsFungi in tissue sections
Fungi in tissue sections
 
Bone marrow morphology
Bone marrow morphologyBone marrow morphology
Bone marrow morphology
 
The Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary CytologyThe Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary Cytology
 
Fnac of salivary gland tumour
Fnac of salivary gland tumourFnac of salivary gland tumour
Fnac of salivary gland tumour
 
Automation in Hematology part 2
Automation in Hematology part 2Automation in Hematology part 2
Automation in Hematology part 2
 
Pitfalls in diagnosis of soft tissue tumors of childhood
Pitfalls in diagnosis of soft tissue tumors of childhoodPitfalls in diagnosis of soft tissue tumors of childhood
Pitfalls in diagnosis of soft tissue tumors of childhood
 
Small round cell tumors
Small round cell tumorsSmall round cell tumors
Small round cell tumors
 
Utility of cell block in cytology.
Utility of cell block in cytology.Utility of cell block in cytology.
Utility of cell block in cytology.
 
Automation in hematology
Automation in hematologyAutomation in hematology
Automation in hematology
 
Effusion cytology - Diagnosis.
Effusion cytology - Diagnosis.Effusion cytology - Diagnosis.
Effusion cytology - Diagnosis.
 
Fluid cytology in serous cavity effusions
Fluid cytology in serous cavity effusionsFluid cytology in serous cavity effusions
Fluid cytology in serous cavity effusions
 
processing of bone marrow trephine biopsy
processing of bone marrow trephine biopsyprocessing of bone marrow trephine biopsy
processing of bone marrow trephine biopsy
 
cytology of body fluid
 cytology of body fluid cytology of body fluid
cytology of body fluid
 
Cytology of BAL and Brushings
Cytology of BAL and Brushings Cytology of BAL and Brushings
Cytology of BAL and Brushings
 
Liquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusLiquid based cytology | Abdul Quddus
Liquid based cytology | Abdul Quddus
 
Myeloproliferative Neoplasms
Myeloproliferative NeoplasmsMyeloproliferative Neoplasms
Myeloproliferative Neoplasms
 

Viewers also liked

Common pitfalls in bone marrow biopsy based diagnostic approach
Common pitfalls in bone marrow biopsy based diagnostic approachCommon pitfalls in bone marrow biopsy based diagnostic approach
Common pitfalls in bone marrow biopsy based diagnostic approach
spa718
 
Bone marrow class
Bone marrow classBone marrow class
Bone marrow class
globalsoin
 
Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute Pancreatitis
hareesh c
 
Alterações
 Alterações Alterações
Alterações
dapab
 
3..rafi ghori megaloblastic anaemia
3..rafi ghori megaloblastic anaemia3..rafi ghori megaloblastic anaemia
3..rafi ghori megaloblastic anaemia
Afrina Qureshi
 
Dlc by peripheral smear comparison with automated differential
Dlc by peripheral smear comparison with automated differentialDlc by peripheral smear comparison with automated differential
Dlc by peripheral smear comparison with automated differential
Nikhil Bansal
 
Genetics and internal medicine (1& 2& 3)
Genetics and internal medicine  (1& 2& 3) Genetics and internal medicine  (1& 2& 3)
Genetics and internal medicine (1& 2& 3)
Ahmed Elshebiny
 

Viewers also liked (20)

Bone marrow biopsy and interpretation
Bone marrow biopsy and interpretationBone marrow biopsy and interpretation
Bone marrow biopsy and interpretation
 
Bone marrow aspiration
Bone marrow aspirationBone marrow aspiration
Bone marrow aspiration
 
Bone marrow aspiration and biopsy
Bone marrow aspiration and biopsyBone marrow aspiration and biopsy
Bone marrow aspiration and biopsy
 
Common pitfalls in bone marrow biopsy based diagnostic approach
Common pitfalls in bone marrow biopsy based diagnostic approachCommon pitfalls in bone marrow biopsy based diagnostic approach
Common pitfalls in bone marrow biopsy based diagnostic approach
 
Bone marrow class
Bone marrow classBone marrow class
Bone marrow class
 
Bone marrow aspiration
Bone marrow aspirationBone marrow aspiration
Bone marrow aspiration
 
Bone marrow aspirate&biopsy preparation
Bone marrow aspirate&biopsy preparationBone marrow aspirate&biopsy preparation
Bone marrow aspirate&biopsy preparation
 
Bm examination
Bm examinationBm examination
Bm examination
 
Acute leukemia
Acute leukemia Acute leukemia
Acute leukemia
 
Bone marrow
Bone marrowBone marrow
Bone marrow
 
Pavuls presentation bonemarrow aspiration techniques
Pavuls presentation bonemarrow aspiration techniquesPavuls presentation bonemarrow aspiration techniques
Pavuls presentation bonemarrow aspiration techniques
 
Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute Pancreatitis
 
Haemopoisis and Histology of Bone Marrow
Haemopoisis and Histology of Bone MarrowHaemopoisis and Histology of Bone Marrow
Haemopoisis and Histology of Bone Marrow
 
Anemia aplasica adquirida
Anemia aplasica adquiridaAnemia aplasica adquirida
Anemia aplasica adquirida
 
Alterações
 Alterações Alterações
Alterações
 
Anemia
Anemia Anemia
Anemia
 
3..rafi ghori megaloblastic anaemia
3..rafi ghori megaloblastic anaemia3..rafi ghori megaloblastic anaemia
3..rafi ghori megaloblastic anaemia
 
Dlc by peripheral smear comparison with automated differential
Dlc by peripheral smear comparison with automated differentialDlc by peripheral smear comparison with automated differential
Dlc by peripheral smear comparison with automated differential
 
Genetics and internal medicine (1& 2& 3)
Genetics and internal medicine  (1& 2& 3) Genetics and internal medicine  (1& 2& 3)
Genetics and internal medicine (1& 2& 3)
 
appendix gross
appendix grossappendix gross
appendix gross
 

Similar to Common pitfalls in bone marrow biopsy based diagnostic approach

R PPT to Present-1ddddddddddddddddddddd.pptx
R PPT to Present-1ddddddddddddddddddddd.pptxR PPT to Present-1ddddddddddddddddddddd.pptx
R PPT to Present-1ddddddddddddddddddddd.pptx
dmfrmicro
 
ACUTE LEUKEMIA CME FINAL............pptx
ACUTE LEUKEMIA CME FINAL............pptxACUTE LEUKEMIA CME FINAL............pptx
ACUTE LEUKEMIA CME FINAL............pptx
HarishankarSharma27
 
Cytogenetic Analysis in Hematological Malignancies
Cytogenetic Analysis in Hematological MalignanciesCytogenetic Analysis in Hematological Malignancies
Cytogenetic Analysis in Hematological Malignancies
spa718
 

Similar to Common pitfalls in bone marrow biopsy based diagnostic approach (20)

R PPT to Present-1ddddddddddddddddddddd.pptx
R PPT to Present-1ddddddddddddddddddddd.pptxR PPT to Present-1ddddddddddddddddddddd.pptx
R PPT to Present-1ddddddddddddddddddddd.pptx
 
Update on plasma cell myeloma
Update on plasma cell myelomaUpdate on plasma cell myeloma
Update on plasma cell myeloma
 
ACUTE LEUKEMIA CME FINAL............pptx
ACUTE LEUKEMIA CME FINAL............pptxACUTE LEUKEMIA CME FINAL............pptx
ACUTE LEUKEMIA CME FINAL............pptx
 
Cytogenetic Analysis in Hematological Malignancies
Cytogenetic Analysis in Hematological MalignanciesCytogenetic Analysis in Hematological Malignancies
Cytogenetic Analysis in Hematological Malignancies
 
Flowcytometry
FlowcytometryFlowcytometry
Flowcytometry
 
Pancytopenia
PancytopeniaPancytopenia
Pancytopenia
 
pancytopenia-170119201048.pdf
pancytopenia-170119201048.pdfpancytopenia-170119201048.pdf
pancytopenia-170119201048.pdf
 
Multiple Myeloma
Multiple MyelomaMultiple Myeloma
Multiple Myeloma
 
Management of multiple myeloma
Management of multiple myelomaManagement of multiple myeloma
Management of multiple myeloma
 
032 hossein eftekhari,md
032 hossein eftekhari,md032 hossein eftekhari,md
032 hossein eftekhari,md
 
032 hossein eftekhari,md
032 hossein eftekhari,md032 hossein eftekhari,md
032 hossein eftekhari,md
 
Percutaneous coronary intervention by hossein
Percutaneous coronary intervention  by hosseinPercutaneous coronary intervention  by hossein
Percutaneous coronary intervention by hossein
 
Anemia types and role of iron to raisese
Anemia types and role of iron to raiseseAnemia types and role of iron to raisese
Anemia types and role of iron to raisese
 
Myelodysplastic Syndromes (MDS)
Myelodysplastic Syndromes (MDS)Myelodysplastic Syndromes (MDS)
Myelodysplastic Syndromes (MDS)
 
Molecular cytogenetics in hematiological malignancy
Molecular cytogenetics in hematiological malignancyMolecular cytogenetics in hematiological malignancy
Molecular cytogenetics in hematiological malignancy
 
Flowcytometry
FlowcytometryFlowcytometry
Flowcytometry
 
BM failure syndrome.pptx
BM failure syndrome.pptxBM failure syndrome.pptx
BM failure syndrome.pptx
 
Recent advances in leukemia (2019)
Recent advances in leukemia (2019)Recent advances in leukemia (2019)
Recent advances in leukemia (2019)
 
Lab investigations and interpretations in periodontics
Lab investigations and interpretations in periodonticsLab investigations and interpretations in periodontics
Lab investigations and interpretations in periodontics
 
AML management
AML managementAML management
AML management
 

More from spa718

1600 1620 siwanon jirawatnotai
1600 1620 siwanon jirawatnotai1600 1620 siwanon jirawatnotai
1600 1620 siwanon jirawatnotai
spa718
 

More from spa718 (20)

1600 1620 siwanon jirawatnotai
1600 1620 siwanon jirawatnotai1600 1620 siwanon jirawatnotai
1600 1620 siwanon jirawatnotai
 
Controversies in hepato-biliary surgery
Controversies in hepato-biliary surgery Controversies in hepato-biliary surgery
Controversies in hepato-biliary surgery
 
Controversies in Colorectal Cancer
Controversies in Colorectal CancerControversies in Colorectal Cancer
Controversies in Colorectal Cancer
 
Pancreatic Cancer
Pancreatic CancerPancreatic Cancer
Pancreatic Cancer
 
Chemoradiation vs Surgery for rectal cancer
Chemoradiation vs Surgery for rectal cancerChemoradiation vs Surgery for rectal cancer
Chemoradiation vs Surgery for rectal cancer
 
Cholangiocarcinoma
CholangiocarcinomaCholangiocarcinoma
Cholangiocarcinoma
 
Immunotherapy for Colorectal Cancer
Immunotherapy for Colorectal CancerImmunotherapy for Colorectal Cancer
Immunotherapy for Colorectal Cancer
 
Surgical Approach to Non Small Cell Lung Cancer
Surgical Approach to Non Small Cell Lung CancerSurgical Approach to Non Small Cell Lung Cancer
Surgical Approach to Non Small Cell Lung Cancer
 
Role of Radiation Therapy for Lung Cancer
Role of Radiation Therapy for Lung CancerRole of Radiation Therapy for Lung Cancer
Role of Radiation Therapy for Lung Cancer
 
Update on Management of Triple Negative Breast Cancer
Update on Management of Triple Negative Breast CancerUpdate on Management of Triple Negative Breast Cancer
Update on Management of Triple Negative Breast Cancer
 
Technical Advances in radiotherapy for Lung (and liver) Cancer
Technical Advances in radiotherapy for Lung (and liver) CancerTechnical Advances in radiotherapy for Lung (and liver) Cancer
Technical Advances in radiotherapy for Lung (and liver) Cancer
 
Controversies in Surgical Approach to Breast Cancer
Controversies in Surgical Approach to Breast CancerControversies in Surgical Approach to Breast Cancer
Controversies in Surgical Approach to Breast Cancer
 
ImmunoOncology in Lung Cancer
ImmunoOncology in Lung CancerImmunoOncology in Lung Cancer
ImmunoOncology in Lung Cancer
 
Breast Cancer Highlights: ASCO 2015
Breast Cancer Highlights: ASCO 2015Breast Cancer Highlights: ASCO 2015
Breast Cancer Highlights: ASCO 2015
 
Updates in Radiotherapy for Breast Cancer
Updates in Radiotherapy for Breast CancerUpdates in Radiotherapy for Breast Cancer
Updates in Radiotherapy for Breast Cancer
 
Regulatory T Cells and GVHD
Regulatory T Cells and GVHDRegulatory T Cells and GVHD
Regulatory T Cells and GVHD
 
Immunotherapy for Multiple Myeloma
Immunotherapy for Multiple MyelomaImmunotherapy for Multiple Myeloma
Immunotherapy for Multiple Myeloma
 
NHL immunotherapy
NHL immunotherapyNHL immunotherapy
NHL immunotherapy
 
AML and Cell Therapy
AML and Cell TherapyAML and Cell Therapy
AML and Cell Therapy
 
Acute Lymphoblastic Lymphoma: Treatment Update
Acute Lymphoblastic Lymphoma: Treatment UpdateAcute Lymphoblastic Lymphoma: Treatment Update
Acute Lymphoblastic Lymphoma: Treatment Update
 

Recently uploaded

Beyond the EU: DORA and NIS 2 Directive's Global Impact
Beyond the EU: DORA and NIS 2 Directive's Global ImpactBeyond the EU: DORA and NIS 2 Directive's Global Impact
Beyond the EU: DORA and NIS 2 Directive's Global Impact
PECB
 
Seal of Good Local Governance (SGLG) 2024Final.pptx
Seal of Good Local Governance (SGLG) 2024Final.pptxSeal of Good Local Governance (SGLG) 2024Final.pptx
Seal of Good Local Governance (SGLG) 2024Final.pptx
negromaestrong
 
An Overview of Mutual Funds Bcom Project.pdf
An Overview of Mutual Funds Bcom Project.pdfAn Overview of Mutual Funds Bcom Project.pdf
An Overview of Mutual Funds Bcom Project.pdf
SanaAli374401
 

Recently uploaded (20)

Ecological Succession. ( ECOSYSTEM, B. Pharmacy, 1st Year, Sem-II, Environmen...
Ecological Succession. ( ECOSYSTEM, B. Pharmacy, 1st Year, Sem-II, Environmen...Ecological Succession. ( ECOSYSTEM, B. Pharmacy, 1st Year, Sem-II, Environmen...
Ecological Succession. ( ECOSYSTEM, B. Pharmacy, 1st Year, Sem-II, Environmen...
 
Beyond the EU: DORA and NIS 2 Directive's Global Impact
Beyond the EU: DORA and NIS 2 Directive's Global ImpactBeyond the EU: DORA and NIS 2 Directive's Global Impact
Beyond the EU: DORA and NIS 2 Directive's Global Impact
 
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
 
ICT Role in 21st Century Education & its Challenges.pptx
ICT Role in 21st Century Education & its Challenges.pptxICT Role in 21st Century Education & its Challenges.pptx
ICT Role in 21st Century Education & its Challenges.pptx
 
microwave assisted reaction. General introduction
microwave assisted reaction. General introductionmicrowave assisted reaction. General introduction
microwave assisted reaction. General introduction
 
Código Creativo y Arte de Software | Unidad 1
Código Creativo y Arte de Software | Unidad 1Código Creativo y Arte de Software | Unidad 1
Código Creativo y Arte de Software | Unidad 1
 
Z Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot GraphZ Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot Graph
 
Web & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdfWeb & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdf
 
Seal of Good Local Governance (SGLG) 2024Final.pptx
Seal of Good Local Governance (SGLG) 2024Final.pptxSeal of Good Local Governance (SGLG) 2024Final.pptx
Seal of Good Local Governance (SGLG) 2024Final.pptx
 
PROCESS RECORDING FORMAT.docx
PROCESS      RECORDING        FORMAT.docxPROCESS      RECORDING        FORMAT.docx
PROCESS RECORDING FORMAT.docx
 
Introduction to Nonprofit Accounting: The Basics
Introduction to Nonprofit Accounting: The BasicsIntroduction to Nonprofit Accounting: The Basics
Introduction to Nonprofit Accounting: The Basics
 
An Overview of Mutual Funds Bcom Project.pdf
An Overview of Mutual Funds Bcom Project.pdfAn Overview of Mutual Funds Bcom Project.pdf
An Overview of Mutual Funds Bcom Project.pdf
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
 
SECOND SEMESTER TOPIC COVERAGE SY 2023-2024 Trends, Networks, and Critical Th...
SECOND SEMESTER TOPIC COVERAGE SY 2023-2024 Trends, Networks, and Critical Th...SECOND SEMESTER TOPIC COVERAGE SY 2023-2024 Trends, Networks, and Critical Th...
SECOND SEMESTER TOPIC COVERAGE SY 2023-2024 Trends, Networks, and Critical Th...
 
Class 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdfClass 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdf
 
psychiatric nursing HISTORY COLLECTION .docx
psychiatric  nursing HISTORY  COLLECTION  .docxpsychiatric  nursing HISTORY  COLLECTION  .docx
psychiatric nursing HISTORY COLLECTION .docx
 
Sports & Fitness Value Added Course FY..
Sports & Fitness Value Added Course FY..Sports & Fitness Value Added Course FY..
Sports & Fitness Value Added Course FY..
 
fourth grading exam for kindergarten in writing
fourth grading exam for kindergarten in writingfourth grading exam for kindergarten in writing
fourth grading exam for kindergarten in writing
 
Grant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy ConsultingGrant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy Consulting
 
Basic Civil Engineering first year Notes- Chapter 4 Building.pptx
Basic Civil Engineering first year Notes- Chapter 4 Building.pptxBasic Civil Engineering first year Notes- Chapter 4 Building.pptx
Basic Civil Engineering first year Notes- Chapter 4 Building.pptx
 

Common pitfalls in bone marrow biopsy based diagnostic approach

  • 1. Common pitfalls in bone marrow biopsy based diagnostic approach Dr. N. Varma Prof. & Head - Hematology PGIMER, Chandigarh, India
  • 2. Bone marrow (BM) examination • Gold standard investigation for diagnosing and monitoring many hematological diseases • Useful for investigating various non-hematological conditions • Combination of bone marrow aspirate and trephine biopsy: fine cytological detail, the organization of BM, and the presence of focal abnormalities
  • 3. Good-to-have Information • Accurate clinical information; context and questions being asked; details of previous investigations • For neoplastic diseases: ? primary diagnostic investigation/ staging procedure/ re-examination to assess response to treatment (including transplantation) • The type and timing of previous BM transplantation are also important factors; kinetics of engraftment differ between conditioning regimes and graft types • Knowledge of the recent therapeutic use of growth factors such as G-CSF; these may transiently have major modifying effects on hemopoiesis that can mask or mimic genuine pathology
  • 4. Pitfalls in obtaining and interpreting bone marrow aspirates • BM aspiration done when not needed • BM aspiration not done when needed • BM aspiration done on the wrong site • The clinical context not adequately assessed and the correct range of tests is therefore not done on the aspirate • False negative result as a consequence of a sampling error • The aspirate is not interpreted together with the trephine biopsy sections • The aspirate is misinterpreted – Problems relating to technical quality – Correct stains not performed – Features present not noted – Misinterpretation of an adequate aspirate
  • 5. Limiting factors for interpretation of BMB • Inadequate clinical, hematological (blood and aspirate findings), genetic and radiological information • Inadequate specimen – Too small – Too crushed/distorted – Both – Poorly decalcified/processed • Inadequate sections (thickness, number of levels) • Inadequate stains (poor technical quality, range too limited) • Insufficient experience to avoid common pitfalls (eg, differential diagnosis of granulomas or fibrosis) • Insufficient confidence to avoid concluding ‘consistent with’ • ‘Invisible’ pathology • Forgetting to look at the bone trabeculae and stroma
  • 6. Common Ancillary Studies complementary to Bone Marrow Morphologic Examination • Cytogenetics on BM aspirate or peripheral blood sample • FISH studies on BM aspirate or touch preparations • Molecular studies (PCR or RT-PCR) to detect specific translocations and/or antigen receptor gene rearrangements • Flow cytometric Immunophenotyping of BM aspirate or peripheral blood cells • Immunohistochemistry on paraffin sections • Enzyme cytochemistry on marrow aspirate or peripheral smear slides
  • 7. A systematic approach to diagnosis is required for: • D/D of hypoplasia/aplasia • D/D of megaloblastic hemopoiesis • Assessing key histological features of myelodysplastic and myeloproliferative haemopoiesis • D/D of bone marrow fibrosis • Assessing patterns of lymphoid infiltration associated with various lymphomas, especially small B-cell lymphomas • D/D of granulomatous pathologies
  • 8. 1. D/D hypocellular marrow Normocellular
  • 9. • CBC and reticulocyte count • Blood film examination • Bone marrow aspirate and trephine biopsy • HbF% in children • Peripheral blood lymphocyte cultures for clastogens induced chromosomal breakage studies • Ham’s test and / or flowcytometry for GPI anchored proteins • Urine hemosiderin (if Ham’s test and / or FCM for GPI anchored +) • Vitamin B12 and folate levels • Liver function tests • Renal function tests • Viral markers (hepatitis A, B, C; EBV; CMV; HIV) • Antinuclear antibody and anti ds-DNA • Chest x-ray • Abdominal ultrasound scan Investigations recommended for suspected AA
  • 10. CBS 958 Varma N et al. Multiple constitutional aetiological factors in BMFS patients… Indian J Med Res 2006 Fanconi Anemia associated Aplastic Anemia
  • 11. (A-1366/11; Tx-1204/11) 2. Subtle increase of immature cells: in hypocellular marrow ?leukemia/lymphoma
  • 12. IHC: Blasts positive for CD34, anti-MPO (A-1366/11; Tx-1204/11) Diagnosis: Hypocellular AML 2. Subtle increase of immature cells in hypocellular marrow
  • 13. 3. Problem in differentiating AML-M6 and megaloblastic anemia Megaloblastic anemia ? Megaloblastic anemia
  • 14. 3. Problem in differentiating AML-M6 and megaloblastic anemia (A-1305/10; Tx-1056/10) IHC: Blasts positive for anti-MPO, CD34 AML- M6
  • 15. Hb TLC Platelet count Reticulocyte DLC PBF 7 g/dl 7.3 x 109/L 7 x 109/L 5.36% P60L34M4E2 Moderate anisocytosis, microcytes, macrocytes, hypochromia & polychromasia 3. D/D of ‘megaloblastic anemia’ picture
  • 16. Bone marrow aspirate (BM A-1404/12) Cellular M:E= 1:1 Blast1, Pm2, My 40 ,Mm 1, P44, L8, M1, E2 Megakaryocytes: Adequate
  • 17. Bone marrow biopsy (T-1226/12) Mildly hypercellular with relative erythroid hyperplasia with megaloblstic changes. Granulocytes and megakaryocytes are adequate.
  • 18.
  • 23. RCMD-RS 3. D/D of ‘megaloblastic anemia’ picture: characterization of ‘MDS’ like pathology. 45 M, bicytopenia
  • 24. Bone marrow infiltration in a case of Hepatosplenic lymphoma (A-408/10; Tx-323/10) 4. Pattern of bone marrow infiltration by NHL
  • 25. Bone marrow intravascular infiltration in a case of Hepatosplenic lymphoma. IHC for CD34 and CD3 (A-408/10; Tx-323/10) CD34 CD3 4. Pattern of bone marrow infiltration by NHL
  • 26. Plasma cells in a case of Multiple myeloma (A-1441/08; Tx-1161/08) 5. Differentiation between reactive and malignant plasma cells IHC: Kappa light chain
  • 27. Reactive plasmacytosis + LD bodies (A-1535/11; Tx-1356/11) 5. Differentiation between reactive and malignant plasma cells
  • 28. Reactive increase in plasma cells in a case of Tubercular Granuloma (A-1198/12; Tx-1042/12) 5. Differentiation between reactive and malignant plasma cells
  • 30. Renal Osteodystrophy (A-391/12; Tx-339/12) 6. Identification of etiology in fibrosis
  • 31. 6. Identification of etiology in fibrosis Acute panmyelosis with myelofibrosis (A-185/13; Tx-167/13)
  • 32. ALL with fibrosis (A-1476/12; Tx-1288/12) 7. Identification of subtle infiltration of leukemia/lymphoma in fibrotic marrow
  • 33. IHC for CD34 7. Identification of subtle infiltration of leukemia/lymphoma in fibrotic marrow; IHC is required IHC for TdT IHC for CD20 ALL with fibrosis (A-1476/12; Tx-1288/12)
  • 34. Amyloid deposition in vessel wall (A-1554/12; Tx-1356/12) Congo Red stain 8. Problem in cases with subtle Amyloid deposition- need to be confirmed by special staining by Congo Red
  • 35. 9. Problem in assigning myelodysplasia as reactive or primary RCMD- predominantly dysplastic megakaryocytes (A-803/12; Tx-690/12)
  • 36. 9. Problem in assigning myelodysplasia as reactive or primary Case with sepsis- dysplastic megakaryocytes (A-55/12; Tx-51/12)
  • 37. Metastatic carcinoma of GIT (A-105/13; Tx-93/13) 10. Problem in assessment of focal lesions- like metastasis may be missed if sample is inadequate, and also in identification of primary site. These non- hematologic malignancies may mimic hematological malignancies also.
  • 38. Metastatic carcinoma- Prostate (A-983/09; Tx-763/09) 10. Problem in assessment of focal lesions- like metastasis may be missed if sample is inadequate, and also in identification of primary site. These non- hematologic malignancies may mimic hematological malignancies also.
  • 39. Granuloma- TB (A-1198/12; Tx-1042/12) 11. Problem in assessment of focal lesions- like granuloma may be missed if inadequate sample and also in differentiation of granuloma etiology
  • 40. Granuloma- Hodgkin’s Lymphoma (A-1252/12; Tx-1091/12) 11. Problem in assessment of focal lesions- like granuloma may be missed if inadequate sample and also in differentiation of granuloma etiology
  • 41. 12. Problem in cases with only necrosis- where etiology can not be assessed BM Necrosis- (A-330/11; Tx-286/11)
  • 42. 13. Problem in identification of lymphocytosis, esp in NK/ T-cell infiltration as reactive increase or malignant NK leukemia/lymphoma (A-444/12; Tx-314/12)
  • 43. Bone Marrow Trephine Biopsy 314/12 Splenectomy section (S-12985/12) of this case. IHC for CD56 highlighting NK cell increase in spleen; case with increased lymphocytes on bone marrow. 13. Problem in identification of lymphocytosis, esp in NK/ T-cell infiltration as reactive increase or malignant
  • 44. 14. Problem in differentiation of syntitial variant of Hodgkin’s lymphoma and ALCL Reported as Anaplastic large cell lymphoma (A-1255/08; Tx-1020/08)
  • 45. IHC for CD30 IHC for CD15 14. Problem in differentiation of syntitial variant of Hodgkin’s lymphoma and ALCL- IHC required for differentiation Reported as Anaplastic large cell lymphoma (A-1255/08; Tx-1020/08)
  • 46. 15. Problem in identification T-cell rich B-cell lymphoma IHC for CD3 IHC for CD20
  • 47. 16. There can be technical artefacts leading to inconclusive findings Washed off marrow spaces
  • 48. Washed off marrow spaces, hemorrhage and cartilage 16. Procedural artefacts leading to inconclusive findings
  • 49. 16. Technical artefacts leading to inconclusive findings Crushed marrow spaces
  • 50. 17. 15yrs/M, TLC 32x109/L, Blasts 95% Scanty aspirate smears Tx BxPB smear MPO +
  • 51. Positive Markers: CD13, CD33, Anti MPO, CD19, CD10, CD34, CD45, CD123, H LADR Negative Markers: T lineage FCM-IP Diagnosis: Mixed Phenotype Acute Leukemia (B/ Myeloid)
  • 52. 1444 bp 943 bp 754 bp 585 bp 458 bp 341 bp 258 bp NC P1 P2 P3 P4 P5 P6 M bcr-abl transcripts in 1 MPAL (P1) and 5 different CML (P2-6) patients b3a2 – 385 bp b2a2 – 310 bp Bhatia P, Binota J, Varma N, Bansal D, Trehan A, Marwaha RK, Malhotra P, Varma S. A Study on the Expression of BCR-ABL Transcript in Mixed Phenotype Acute Leukemia (MPAL) Cases Using the Reverse Transcriptase Polymerase Reaction Assay (RT-PCR) and its Correlation with Hematological Remission Status Post Initial Induction Therapy. Mediterr J Hematol Infect Dis. 2012;4(1):e2012024.
  • 53. 18. 22M, DOA: 19.11.06; DOD: 26.11.06 C/O fever (↑↑-↑↑↑) 4 weeks PUO: ? Disseminated TB / lymphoreticular malignancy CBC: Hb 8.7 g/dl, Retics 1.6-2.6%, TLC 1800-700/ l, platelets 27000-12000/ l; PTI 86% Bilirubin 4.2/2.8, 4.9/3.6; Serum ferritin 7557.8 mg/dl; Fibrinogen 2.85 g/l; TG 410 BM no. A-1083/06
  • 54. EBV Zebra LMP 1 EBNA HPS / HLH •Screen for underlying genetic, autoimmune, infectious and malignant diseases •Uncontrolled hypercytokinemia & many triggers •Early diagnosis and Rx PM no. 21703
  • 55. 19. 5 ys. FCh; AML with increased mast cells/ basophils
  • 57. P 30 / 07: CD 117 (APAAP) Varma N, Varma S, Wilkins B. Br J Haematol 2000;111:991. Mast cell tryptase AML with mastocytosis [Systemic mastocytosis with associated clonal hematological non-mast cell disease (SM-AHNMD)]
  • 58. Few representative examples • Assessment of focal lesions • Differentiation between reactive lymphoid infiltrate and NHL • Differentiation between reactive and malignant plasma cells • Identification of malignancies with associated fibrosis • Effect of growth factors • Differentiation between hematogones and blasts • Differentiation between megaloblastic anemia and acute leukemia • Differentiation between aplastic bone marrow and hypoplastic myelodysplastic syndrome or hypoplastic acute leukemia • Identification of lymphomas having a tendency for intravascular infiltration in the BM • Subtle amyloid deposition • Differentiation of macrophage infiltrates and other pathologies that resemble granulomatous infiltration • Procedure related artefacts
  • 59. Take home message • Integration of clinical, laboratory and imaging information • Not to assess histology in isolation; uni- / bilateral bx; dry aspirate • Components of an integrated approach to interpretation are: – Adequate size of trephine core, with minimal disruption by trauma caused during collection. – Access to detailed clinical information and results of additional tests (specially, peripheral blood cell counts, blood and BM aspirate cytomorphology, flow cytometry, cytogenetic analysis and radiological imaging). – Systematic assessment of all BM components, including trabecular bone and interstitial stroma. – Awareness of pathologies that may be ‘invisible’ in trephine specimens without immunostaining. – Use of preselected antibody panels for immunostaining and familiarity with the expected results, including controls. – Experience in interpreting additional molecular studies, such as clonality PCR and fluorescence in-situ hybridization. – Familiarity with the major patterns of bone marrow involvement by reactive and neoplastic conditions and their differential diagnosis. – A collaborative approach to working with diverse clinical and laboratory colleagues. – Ideally, hematopathologists should report BM Bx along with BM aspirate.
  • 60. Thank You Common pifalls in BMB interpretation can be avoided

Editor's Notes

  1. Contribute to diagnose and treat AMLs better!