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Bone marrow profile in hematological disorders: an experience from a tertiary care centre

Background: Bone marrow aspiration and trephine biopsy are two most important techniques which are complementary for diagnosing both neoplastic and nonneoplastic haematological diseases. The present study was conducted in the department of pathology to compare the role of bone marrow aspirate and trephine biopsy for diagnosing the haematological diseases. Methods: The study was conducted in the department of pathology government medical college Srinagar over a period of 2 years from Feb 2016 to Jan 2018. The study was one-year retrospective and one year prospective. Bone marrow aspiration was done in 626 cases out of which biosy was done in 300 cases. Results: Out of the selected 300 cases were both aspiration and trephine biopsy were available, diagnostic material on bone marrow aspirate was adequate in 288 cases. 12 cases were aparticulate. Biopsy was inadequate in 8 cases. Overall megaloblastic anaemia (26.6%) was most common followed by dual deficiency anemia. Multiple myeloma was the most common neoplastic pathology (13%) followed by followed by acute leukaemia’s (6%) and Chronic lymphoproliferative disorders (CLPDS) (5%). 1 case each of visceral leishmaniasis and malarial parasite were also noted. 4 cases (1.3%) of granulomatous pathology and 2 cases (0.6%) of Hodgkins lymphoma were diagnosed exclusively on bone marrow biopsy. Conclusions: Bone marrow aspiration and biopsy are complimentary to each other in diagnosing hematological disorders with biopsy being gold standard in the assessment of cellularity, pattern, extent of tumor infiltration and focal infiltration. It is more helpful in diagnosing granulomatous pathology and metastatic deposits of tumors eliciting fibrotic response.


INTRODUCTION
Bone marrow aspiration and bone marrow biopsy are useful techniques in the diagnosis of both hematological and non-hematological disorders.
For bone marrow examination clinical findings, complete blood count, peripheral blood picture and other laboratory investigations are required. 1 Bone marrow aspiration (BMA) is usually sufficient individually to diagnose nutritional anemia's, Acute leukemias, myelodysplasia, myeloma and Parasitic infestations.
Bone marrow aspiration is useful in appreciating individual cell morphology. Whereas biopsy is useful in bone marrow architectural pattern and distribution. 2,3 The bone marrow evaluation may either confirm clinically suspected disease or may provide the previously unsuspected diagnosis. 4,5 The aspirate yields semi-liquid bone marrow, which can be examined under a light microscope as well as analyzed by flowcytometry, chromosome analysis, polymerase chain reaction (PCR), Culture.
Frequently, a trephine biopsy is also obtained, which yields a narrow, cylindrically shaped solid piece of bone marrow which is examined microscopically (sometimes with the aid of immunohistochemistry) for cellularity and infiltrative processes. Bone marrow biopsy (BMB) is more sensitive in picking up focal lesions. Marrow reserve is better appreciated on BMB. BMB is also useful in immunohistochemical demonstration of antigens.

METHODS
The study was conducted in the department of pathology government medical college Srinagar. The study was conducted over a period of 2 years from Feb 2016-Jan 2018. Retrospective data was collected from record section of department of pathology. For prospective cases patients were enrolled for the procedure after screening from clinical departments. Written informed consent was taken before the procedure.
The procedure was done under local anesthesia (Inj. 2% xylocaine). PSIS was the most common site used for the procedure followed by ASIS. For aspiration we used Salah 16 G needle and for biopsy we used jamshedi needle. Aspirate slides were checked macroscopically for presence of particles and 2 cm biopsy was considered adequate on gross examination.
Aspirate slides were stained with leishman stain. Perls stain for iron stores was done in all cases. In all leukemia cases we performed myeloperoxidase staining. Trephine biopsy was processed as per standard protocol and stained with Hematoxylin and Eosin stain. Reticulin stain was done in case of myelofibrosis and reactive fibrosis for grading and WHO grading system was used. Complete blood count (CBC), Peripheral smear examination (PBF) was done in all cases.

Inclusion criteria
All cases where both aspiration and biopsy were available were selected.

Exclusion criteria
Cases where only aspiration was available.
Chi square test was used for statistical analysis.

RESULTS
In present study 626 bone marrow aspirations were done over a period of two years.
Authors included 300 cases in present study were both aspiration and biopsy were available. The age ranged from 6 months to 90 years with median age of 34.5 years. Males outnumbered females with M:F of 1.6:1.
Bone marrow aspiration and biopsy diagnosis are given in Table 1 and Table 2.
Anemia was the most common finding in present study (114 cases) followed by plasmacytosis ( Figure 1). Among anemias megaloblastic anemia ( Figure 2) was most common (80 cases) followed by dual deficiency anemia (21 cases) and aplastic anemia ( Figure 3).        2 cases each of visceral leishmaniasis ( Figure 8) and malarial parasite were also seen in present study. Myelodysplastic syndrome (MDS) was diagnosed in cases after clinical correlation in cases previously treated for megaloblastic anemia and not responding to treatment.  All the 4 cases of granulomatous pathology ( Figure 9) were exclusively diagnosed on bone marrow biopsy with aspiration showing reactive marrow Among these 3 cases were of tuberculosis and 1 case turned out to be brucellosis.
Diagnostic accuracy of bone marrow biopsy in present study was 95% with P-value was 0.001 which was statistically significant (P-value <0.05) by chi square test.

DISCUSSION
Bone marrow aspiration and trephine biopsy are the two procedures done for the diagnosis of hematological and non-hematological disorders and are complimentary to each other. Frequently it is a combination of clues gathered from examination of several different preparations that leads to a correct diagnosis. 6 We selected 300 cases in present study were both aspiration and biopsy were available. Aspiration was adequate for diagnosis in 288 cases (96%) and biopsy was adequate in 292 cases (97.3%) of cases. Males outnumbered females with M:F of 1.6:1. Commonest presentation in present study was pancytopenia (38.3% of cases) followed by bicytopenia (22% of cases). Similar to present study pancytopenia was the commonest presentation in a study done by Ahmed et al. 7 A study by Bhatnagar et al. from India reported incidence of pancytopenia seen in 54.5% cases and bicytopenia seen in 45.5% cases which is also similar to present study. 8 Most of the cases in present study had hypercellular bone marrow (61.3%) followed by normocellular marrow (33.7%) and hypocellular marrow (5%). Anemia was most common finding in present study (114 cases) followed by plasmacytosis (Figure 1). Among anemias megaloblastic anemia (Figure 2) was most common (80 cases) followed by dual deficiency anemia (21 cases) and aplastic anemia. The commonest cause of pancytopenia reported in various studies throughout the world is aplastic anemia. [9][10][11] However, authors observed megaloblastic anemia as the commonest cause of pancytopenia followed by leukemia and hypoplastic marrow in the study. Some studies conducted in India have also reported megaloblastic anemia to be the major cause of pancytopenia. Among neoplastic diseases multiple myeloma was most common in present study (39 cases) out of which only 2 cases were diagnosed biopsy alone with focal marrow involvement. Acute leukemia was seen in 22 cases with 18 cases of acute myeloid leukemia and 4 cases of acute lymphoblastic leukemia. Among myeloid leukemias commonest was AML-M1 (6 cases) followed APML (4 cases) and AML-M2 (3 cases). In present study, 1 out of 22 cases of acute leukemia presenting with dry tap on aspirate showed increase in fibrosis on trephine sections. Similarly, all 11 cases of metastatic lesions were diagnosed on biopsy sections with their respective aspirate smears showing metastatic deposits in 6 cases only. So, a dry tap or inadequate aspiration should always be accompanied by trephine biopsy to arrive at a final diagnosis. Primary was unknown in 2cases of metastatic deposits were IHC was used on biopsy for identifying the primary site. According to Bird and Jacobs, marked increase in reticulin in both acute lymphoblastic and acute myeloblastic leukemia may lead to dry tap We received 30 cases of bone marrow for staging of nonhodgkins lymphoma with 15 cases showing evidence of marrow involvement in biopsy. In corresponding aspiration smears 11 cases showed infiltration and in 4 cases we missed infiltration. 12 This could be explained by focal pattern of infiltration and fibrosis seen on biopsy. Kumar A showed involvement by lymphoma on biopsy in 27 cases (55.10%). 13 Unilateral positivity was found in four cases (14.81% cases). The overall incidence of marrow involvement by NHL was 55.1%. The diagnosis of aplastic anemia diagnosis was confirmed only after trephine biopsy, as the trephine biopsy is the accurate tool to assess marrow cellularity hence is of utmost importance in diagnosing Aplastic anemia. 11 In chronic myeloproliferative neoplasms (MPNS), trephine biopsy added information about fibrosis, cellularity and morphology of megakaryocytes. All cases 4 of granulomatous pathology and 2 cases of Hodgkins lymphoma infiltration were diagnosed on biopsy alone with their corresponding aspirate smears showing reactive marrow only. Myelodysplastic syndrome (MDS) was diagnosed in cases who were previously treated for megaloblastic anemia not responding to the treatment. One case of Hypoplastic myelodysplastic syndrome was missed on aspirate because of diluted nature of marrow smears. 2 cases each of visceral leishmaniasis and malarial parasite were also seen in present study diagnosed on both aspirate and biopsy. Gupta et al in their study have reported that bone marrow aspiration and trephine biopsy are complementary to each other to arrive at a definitive diagnosis. This was also observed in present study that as cases of metastatic lesions with marrow fibrosis and aparticulate aspirate were picked on biopsy alone similarly few cases of focal NHL infiltration with normal aspirate had infiltration on biopsy sections. In present study all cases of Granulomatous pathology and Hodgkins lymphoma infiltration were diagnosed by biopsy alone.

CONCLUSION
Bone marrow aspiration (BMA) and bone marrow biopsy (BMB) are complimentary to each other. For diagnostic purpose both the procedures can be done simultaneously as BMA gives better morphology of the cells and biopsy is gold standard in the assessment of cellularity, pattern, extent of tumor infiltration and focal infiltration. BMB is especially useful in cases of Granulomatous diseases, myelodysplastic syndromes, and myeloproliferative disorders, non-Hodgkin's lymphomas, aplastic anemia and metastatic tumors eliciting fibrotic response.