Introduction
Bone marrow is the major site of hematopoesis giving rise to the three cellular elements namely red blood cells (erythrocytes), white blood cells (leucocytes) and platelets (thrombocytes). Various hematological disorders may arise from abnormality in one of the three lineages. It thus becomes necessary to examine the bone marrow to determine the actual cause. The history of in vivo bone marrow examination dates back to as early as 1876 when Mosler used a regular wood drill to aspirate bone marrow particles from a patient with leukaemia.1 It is important in cases where diagnosis can’t be reached after a routine CBC and other biochemical studies. Bone marrow aspirate is often done along with trephine biopsy to aid in the diagnosis. Its various indications include hematological and non hematological disorders like cytopenias, leucocytosis, staging of lymphomas and remission of hematological malignancies or a suspicion of metastasis.
Materials and Methods
This is a retrospective study carried out at Department of Pathology, Sterling hospital, Vadodara over a period of two years from January 2016 to December 2017. The relevant information was derived from the laboratory records to include the age, sex, indication of marrow and final diagnosis. All the 160 cases were included in the study. The peripheral blood smear and the aspirate were stained with Giemsa stain and the trephine biopsy with H&E and reticulin stain for marrow fibrosis.
Results
In our study the age group was from 2 years to 80 years (Table 1). The youngest being a 3 year male and the oldest 80 year male.
The M: F ratio is 1.25:1. Males undergoing BM examination were highest in the age of 51-60 years and females were in the range of 61-70 years (Table 2).
Table 2
Age and sex wise distribution of the cases
Most of the marrows received were hyper cellular -70 cases, followed by normo cellular and hypo cellular for age. There were also a few cases of dry tap (Figure 1).
The most common indication for marrow examination was leucocytosis, followed by bicytopenia and pancytopenia. Also the marrows were done for indications of hematological remissions, lymphoma staging, and suspicion of metastasis, myelomas, thrombocytopenia and anemia (Table 3).
Table 3
Indication of bone marrow
Of all the cases of leucocytosis the most common diagnosis was that of chronic myeloid leukemia, followed by Acute Leukemia, CLL /SLL and three marrows were normal.
The most common diagnosis on B one Marrow was that of Acute leukemia (Figure 2) accounting to 13.12%, followed by Idiopathic thrombocytopenic purpura (ITP) - 11.25% (Figure 3)
Of the 16 cases received for lymphoma staging, 2 cases showed marrow involvement by lymphoma (1.25%). Cases of myeloproliferative neoplasm(8.12%), myeloma (8.12%), metastatic diseases (2.5%) and myleodysplastic syndrome (1.25%) were also diagnosed. Other rare diagnosis included a single cases of hemophagocytic syndrome, Amegakaryocytic thrombocytopenia, hypersplenism, monocytosis and two cases of aplastic anemia (Table 4)
Table 4
Bone marrow examination findings
Discussion
Hematological disorders, both benign and malignant comprise a major health problem. They have a high mortality and morbidity. Both men and women get affected at any age. Early diagnosis and prompt treatment can save the patient if managed timely. Bone marrow examination consists of bone marrow aspirate cytology and bone marrow trephine biopsy. While the aspirate helps in evaluating individual cell population, the trephine biopsy is important to know the overall cellularity, architecture, fibrosis and metastatic deposits. Hence, Bone marrow examination remains a crucial test in diagnosis of both hematological and non hematological malignancies, when the routine peripheral blood and other laboratory tests are not conclusive of a diagnosis. A wide spectrum of diagnosis ranging from anemia to leukemia can be made on the bone marrow and help in management of the patient.
In our study, the patients undergoing bone marrow examination ranged from 2 years to 80 years of age. The M: F ratio was 1.25: 1 which is comparable to most of the studies which show a slight male predominance which is compared in Table 5.
Table 5
Comparison of age and sex with various studies
In our study the most frequent indication of bone marrow examination was of leucocytosis (18.75%), followed by bicytopenia (18.12%) and pancytopenia (15%). Other indications included bone marrow for hematological remission (13.12%), thrombocytopenia, staging for lymphoma, myeloma and anemia. Similar studies like Kumar et al2 reported anemia (34.4%) to be the most common indication, Aljadeyeh et al6 reported anemia (22.4%) and hematological remssion (23.2%) as the most common indication of marrow examination.
In our study the most common diagnosis was that of acute leukemia (13.12%), it was comparable with studies by Al-Gwaiz (27.3%), Ridha (28.16%), Bashwari (17.76%).
This was in contrast with studies from authors of Indian subcontinent like Katiyar, Khatik and Atla BL who reported megaloblastic anemia to be the most common diagnosis with 28.1%, 21.33% and 49.5 % respectively (Table 6). This contrast in our study when compared to the Indian studies may be due to the fact that ours being a tertiary care center, more patients of leukemia and lymphomas are referred while the ones with anemia are treated at primary and secondary centers.
Table 6
Comparison of most frequent diagnosis
We also encountered some rare interesting cases of hemophagocytic syndrome (Figure 4), aplastic anemia and hyperspleenism.
Most of the cases who underwent BM examination for leucocytosis had CML as diagnosis, followed by acute leukemia and chronic lymphocytic leukemia.
In case of dry tap which were followed with a trephine biopsy, diagnosis of acute myeloid leukemia and metastasis were made. This shows how important trephine biopsy is in case of a dry tap and it should not be ignored as a faulty aspiration technique.
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