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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 34-38

Bone marrow trephine biopsies: A single centre experience in Eastern India


Department of Pathology (Hematology Division), IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Web Publication16-Jun-2017

Correspondence Address:
Sarita Pradhan
Division of Hematology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_9_17

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  Abstract 


Introduction: Bone marrow aspiration (BMA) and trephine biopsy are indispensable diagnostic tools for evaluating hematological and nonhematological disorders in the present era. However, trephine biopsy demands greater technical skills and expertise as compared to BMA alone. In this study, we have analyzed the advantages of carrying out trephine biopsy along with BMA in the same sitting. Materials and Methods: This is a prospective observational study carried out from June 2014 to May 2015. The patients attending hematology and medicine outdoors were screened by detailed clinical examination, laboratory investigations including complete blood counts, peripheral smear, and whenever indicated were subjected to BMA and trephine biopsy in the same sitting. Results: Out of total 570 aspirations and trephine biopsies done, 8% showed inadequate aspirates and diagnosis was based only on biopsy findings. Confirmatory diagnosis of aplastic anemia was done on trephine biopsy in 100% cases. Fifty percent cases of granulomas and 33.3% cases of metastasis were missed in aspiration smears. They were diagnosed on trephine biopsy. All cases of myelofibrosis required trephine biopsy for diagnosis, but aspiration alone was adequate for diagnosis in majority of acute leukemias. Conclusion: Trephine biopsy is mandatory for diagnosis of aplastic anemia, myelofibrosis, and for staging of lymphomas. It specially carries diagnostic value in cases of dry tap and bloody aspirates. Aspiration is simple, has high specificity, and is especially useful for nutritional anemia, immune thrombocytopenia, acute leukemia, and multiple myeloma.

Keywords: Bone marrow aspiration, dry tap, trephine biopsy


How to cite this article:
Chauhan S, Pradhan S, Mohanty R, Saini A. Bone marrow trephine biopsies: A single centre experience in Eastern India. Arch Med Health Sci 2017;5:34-8

How to cite this URL:
Chauhan S, Pradhan S, Mohanty R, Saini A. Bone marrow trephine biopsies: A single centre experience in Eastern India. Arch Med Health Sci [serial online] 2017 [cited 2019 Aug 24];5:34-8. Available from: http://www.amhsjournal.org/text.asp?2017/5/1/34/208210




  Introduction Top


Bone marrow aspiration (BMA) and biopsy are invaluable diagnostic tools for both hematological and nonhematological disorders. It is also a routinely used procedure for follow-up of patients undergoing chemotherapy for hematolymphoid malignancies.[1] Aspiration is the best tool for studying morphology, differential count, and M:E ratio assessment, whereas trephine biopsy gives information regarding cellularity, architecture, and focal lesions. Moreover, trephine biopsy is mandatory for staging of lymphomas.[2] Rarely, marrow examination may provide the only clue to occult malignancies.[3]

However, trephine biopsy, unlike aspiration, demands more technical skills, is time consuming, and a painful procedure. Interpretation depends on numerous factors such as quality of tissue section and availability of ancillary techniques such as special staining, immunohistochemistry (IHC), and good coordination between hematopathologists and histopathologists.[4] Few studies have analyzed the advantages of carrying out BMA and trephine biopsy in the same sitting.

This study was carried out with an objective to evaluate the complementary role of both the procedures done simultaneously and analyze the benefits of trephine biopsy.


  Materials and Methods Top


This single-center prospective study was carried out from June 2014 to May 2015 in a single center. Five hundred and ninety-five cases of BMA along with bone marrow trephine biopsies (BMB) were done during this time period, of which 25 biopsies were inadequate for assessment, hence excluded from the study. Adequacy of biopsy was based on the presence of at least 5–6 intertrabecular spaces. Hence, final cohort comprised 570 cases. Sixty-six cases of them were postinduction marrows carried out for the assessment of remission. Hence, new cases comprised 504 cases.

Patient's clinical features and peripheral smear findings were compiled. BMA and biopsy were done using Jamshidi needle. For aspiration, 0.25–0.5 ml aspirate was withdrawn using a 2 ml plastic syringe and smears were drawn immediately. Biopsy was done using the same incision but approximately 0.5–1 cm away from aspiration site to avoid getting a hemorrhagic biopsy. Aspiration smears were stained with Leishman Giemsa. Biopsy was fixed using a solution of formal dehyde, zinc chloride and glacial acetic acid. Decalcified was done with a solution of formal dehyde and formic acid for 24 hours. Hematoxylin and eosin stain, reticulin and PAS stain were routinely done in all cases, and IHC was used as and when required.


  Results Top


Age distribution was very wide and ranged from 3 months to 75 years. It was divided into three age groups, with the highest number of cases in >14 years age group [Figure 1]. Out of total 570 cases, 312 were newly diagnosed hematolymphoid malignancies and 66 marrows were carried out to assess remission after induction chemotherapy, so 66 cases were excluded from total 570 while calculating the percentage of individual disease entity. Indications for marrow aspiration was pancytopenia/bicytopenia in 162 cases, leukoerythroblastic blood picture in 9 cases, and evaluation of pyrexia of unknown origin in 21 cases. The cases were divided into diagnostic groups after assessing the peripheral smears, BMA, and trephine biopsy [Figure 2].
Figure 1: Pie chart showing age distribution

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Figure 2: Distribution of 570 cases of hematological disorders diagnosed by trephine biopsies

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Five hundred and twenty-four out of 570 (92%) cases showed the presence of marrow fragments and 46 (8%) were inadequate aspirates. Thirty-five out of 46 inadequate aspirates were diluted with peripheral blood and 11 cases were dry tap. Out of these inadequate specimens, 18 cases were of acute leukemia, 12 cases were of Non–Hodgkin's lymphoma (NHL) with marrow infiltration, 4 cases of myelofibrosis, 9 cases of chronic myeloid leukemia (CML), and 1 case each of metastasis, multiple myeloma, and bone marrow necrosis.

Acute leukemia

This was the largest group comprising 128 cases. BMA was in agreement with trephine biopsy in 110 cases but was inadequate in 18 cases which had tightly packed marrow with blasts on biopsy.

Aplastic anemia

This was the next single largest group with 45 cases [Figure 3] and [Figure 4]. One case diagnosed as hypoplastic marrow on aspiration showed focal increase in immature precursors and diagnosis was revised to hypoplastic myelodysplastic syndrome (MDS) on biopsy.
Figure 3: Bone marrow aspiration showing hypocellular marrow (H and E, ×100)

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Figure 4: Bone marrow trephine biopsies confirming aplastic anemia (H and E, ×400)

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Myeloproliferative neoplasm

Out of 52 cases of myeloproliferative neoplasm (MPN), 42 cases were of CML, 2 cases of essential thrombocythemia, 1 case of polycythemia vera, 3 cases of chronic eosinophilic leukemia/hypereosinophilic syndrome, and 4 cases were of myelofibrosis. Nine cases of CML yielded poor aspirates, of which seven cases showed increased reticulin fibrosis on biopsy. All four cases of myelofibrosis showed dry tap on, but trephine biopsy showed marked fibrosis and atypical bizarre megakaryocytes [Figure 5] and [Figure 6].
Figure 5: Bone marrow trephine biopsies showing hypocellularity and fibrosis (H and E, ×40)

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Figure 6: Bone marrow trephine biopsies showing dense increase in reticulin fibers reticulin stain (×400)

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Lymphoma

A total of 57 cases of lymphoma were analyzed, of which 8 were Hodgkin's lymphoma and 49 cases were of NHL. Out of 49 cases of NHL, 24 cases showed marrow infiltration; 22/24 cases showed marrow infiltration in both aspiration and biopsy. The largest group among these was chronic lymphocytic leukemia/small lymphocytic lymphoma comprising 16 cases, followed by 4 cases of low-grade B-cell lymphoma [Figure 5], 1 case of follicular lymphoma, 1 case of Burkitt lymphoma, and 2 cases showing infiltration in marrow could not be subtyped. None of the Hodgkin's lymphoma showed marrow infiltration in aspiration or biopsy.

Multiple myeloma

Aspiration and biopsy correlated well in 41 out of 42 cases. One case showed hypercellular fragments with poor cell trails in aspiration smears with occasional plasma cells, but biopsy revealed marked plasmacytosis.

Metastasis

Six cases of metastasis were encountered in biopsy, of which two (33.3%) were missed in aspiration. One case was misdiagnosed as plasmablastic myeloma and second case showed no abnormal cells in aspiration.

Granuloma

Two out of 4 (50%) cases showed granulomas in both aspiration and biopsy and two cases showed granulomas in biopsy only.

Myelodysplastic syndrome

Out of 25 cases of MDS, aspiration and biopsy correlated in 24 cases; in one case, diagnosis was done in biopsy only.

Miscellaneous

In immune thrombocytopenic purpura (ITP), there was 100% concordance between aspiration and biopsy. Out of 5 cases of pure red cell aplasia (PRCA), trephine biopsy of one case showed the presence of paratrabecular collection of lymphoid cells pointing toward the possibility of lymphoma as a probable cause of PRCA (secondary PRCA). However, the patient was lost to follow-up. One nondiagnostic/diluted aspiration showed extensive necrosis in bone marrow trephine biopsy.


  Discussion Top


BMA and biopsy complement each other and therefore should be used together for diagnosis. Out of 570 aspirates included in our study, 46 (8%) were inadequate aspirates.

According to Bird and Jacobs,[5] marked increase in reticulin in both acute lymphoblastic and acute myeloblastic leukemia may lead to dry tap. In the present study, 3 out of 18 cases of acute leukemia presenting with dry tap showed an increase in fibrosis in trephine sections. Hence, a dry tap or inadequate aspiration should not be dismissed as a result of faulty technique but should always be accompanied by trephine biopsy to arrive at a conclusive diagnosis.

In some cases of acute leukemia, adequate bone marrow aspirate cannot be obtained due to extreme cellularity and compactness of the marrow.[5] These are the cases where bone marrow trephine biopsy has primary diagnostic value. An important limitation of using marrow aspiration alone is admixing of marrow with sinusoidal blood which does not allow accurate estimation of cellularity.

In lymphomas, BM biopsy also provides information regarding pattern and extent of infiltration, cellularity, and fibrosis, which cannot be assessed on aspiration.[6] Hence, obtaining an adequate length of biopsy specimen is of utmost importance. Both cytomorphology and IHC were used for diagnosis and subtyping of lymphomas. Twenty-four out of 57 (42.1%) cases of NHL showed evidence of marrow involvement in biopsy. None of the Hodgkin's lymphomas showed marrow infiltration.

Various other studies have reported marrow infiltration in lymphoma ranging from 27.1% to 55.1%.[7],[8]

Biopsy is also useful in postchemotherapy patients to assess residual disease and response to chemotherapy. Pattern of marrow involvement by leukemic cells could only be analyzed by trephine biopsy. Furthermore, trephine biopsy permits an accurate assessment of extent of infiltration and gives information of prognostic importance.

In 100% cases of aplastic anemia, diagnosis was confirmed on trephine biopsy. It is the only tool for accurate assessment of cellularity of the marrow, as aspiration is often diluted with sinusoidal blood. Hence, biopsy is of utmost importance for diagnosing aplastic anemia.[9] In chronic myeloproliferative disorders other than myelofibrosis, peripheral smear and aspirates were adequate for diagnosis, but trephine biopsy added information on fibrosis, cellularity, and morphology of megakaryocytes. Aspiration has no role in diagnosis of myelofibrosis. In our study, all the four cases of myelofibrosis showed dry tap on aspiration, and diagnosis was made on biopsy alone.

In some cases, the methods are complementary and thus both are needed, as described by Sabharwal et al.[10] Forty-one out of 42 (97.6%) cases of multiple myeloma were diagnosed in bone marrow aspirates alone. One case where the plasma cells were scantily scattered in a diluted marrow showed compact masses of plasma cells in biopsy. Our study correlated with the study done by Charles et al. where they detected myeloma in trephine biopsies and all simultaneous bone marrow aspirates.[11] As per Pileri et al., plasma cell myeloma, particularly in cases with low degree of infiltration, were more reliably diagnosed in the biopsy.[12] Granulomas showed higher detection rate in trephine biopsy than aspiration in the present study, like other studies.[13] Toi et al. have mentioned that 80% cases of granulomatous lesions were diagnosed by BMB alone.[1] No added benefits of biopsy were obtained in cases of erythroid hyperplasia, immune thrombocytopenia, and reactive marrows in our study, which also correlated well with other studies.[6]

The new part of our study is that - in the Eastern part of India, the incidence of malignant and nonmalignant conditions involving bone marrow has never been estimated till date. We have done this for the first time in a referral teaching hospital in Eastern India. The largest entity at our place is acute leukemia, accounting for 25.39% of total 504 cases, followed by lymphoma (11.30%), MPN (10.31%), aplastic anemia (8.9%), multiple myeloma (8.33%), ITP (6.34%) MDS (4.96%), metastasis (1.19%), granuloma (0.79%), and others (PRCA, necrosis, hypersplenism, and hemophagocytic lymphohistiocytosis) (3.57%). Rest all are reactive, erythroid hyperplasia, and normal marrows. Majority of the patients were adults and male gender.

However, there was one limitation of our study. Lack of use of IHC routinely in cases of lymphomas due to financial constraints might have hampered the accuracy of detection of infiltration in biopsies.


  Conclusion Top


Bone marrow trephine biopsy is an integral part of diagnosis and is more informative in the assessment of cellularity, extent, and pattern of tumor infiltration cell type and follow–up, especially of chronic lymphoproliferative disorders. It is an indispensable tool for diagnosis of aplastic anemia. It, however, provides less additive information in most acute leukemias and nonneoplastic pathologies except for granulomas. However, since both procedures can be done in the same sitting, obtaining adequate biopsy material along with aspirate is suggested. Another point we want to stress that during follow-up marrow procedures for all postchemotherapy cases, we noted that we missed around 4% cases of residual diseases in BMA (due to its limitations), which were diagnosed in bone marrow biopsy. Hence, all postchemotherapy follow-up cases should undergo both aspiration and biopsy simultaneously, at the same sitting for proper and better management, leading to increased years of disease-free survival. Last but not the least, interpretation of biopsy should be carried out not in isolation but keeping in mind the aspiration findings as morphology is best assessed in aspiration smears.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toi PC, Varghese RG, Rai R. Comparative evaluation of simultaneous bone marrow aspiration and bone marrow biopsy: An institutional experience. Indian J Hematol Blood Transfus 2010;26:41-4.  Back to cited text no. 1
    
2.
Fend F, Kremer M. Diagnosis and classification of malignant lymphoma and related entities in the bone marrow trephine biopsy. Pathobiology 2007;74:133-43.  Back to cited text no. 2
    
3.
Ozkalemkas F, Ali R, Ozkocaman V, Ozcelik T, Ozan U, Ozturk H, et al. The bone marrow aspirate and biopsy in the diagnosis of unsuspected nonhematologic malignancy: A clinical study of 19 cases. BMC Cancer 2005;5:144.  Back to cited text no. 3
    
4.
Bain BJ. Bone marrow trephine biopsy. J Clin Pathol 2001;54:737-42.  Back to cited text no. 4
    
5.
Bird AR, Jacobs P. Trephine biopsy of the bone marrow. S Afr Med J 1983;64:271-6.  Back to cited text no. 5
    
6.
Goyal S, Singh UR, Rusia U. Comparative evaluation of bone marrow aspirate with trephine biopsy in hematological disorders and determination of optimum trephine length in lymphoma infiltration. Mediterr J Hematol Infect Dis 2014;6:e2014002.  Back to cited text no. 6
    
7.
Kumar S, Rau AR, Naik R, Kini H, Mathai AM, Pai MR, et al. Bone marrow biopsy in non-Hodgkin lymphoma: A morphological study. Indian J Pathol Microbiol 2009;52:332-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Moid F, DePalma L. Comparison of relative value of bone marrow aspirates and bone marrow trephine biopsies in the diagnosis of solid tumor metastasis and Hodgkin lymphoma: Institutional experience and literature review. Arch Pathol Lab Med 2005;129:497-501.  Back to cited text no. 8
    
9.
Milosevic R, Jankovic G, Antonijevic N, Jovanovic V, Babic D, Colovic M. Histopathologic characteristics of bone marrow in patients with aplastic anemia. Srp Arh Celok Lek 2000;128:200-4.  Back to cited text no. 9
    
10.
Sabharwal BD, Malhotra V, Aruna S, Grewal R. Comparative evaluation of bone marrow aspirate particle smears, imprints and biopsy sections. J Postgrad Med 1990;36:194-8.  Back to cited text no. 10
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11.
Charles KS, Winfield DA, Angel C, Goepel J. Audit of bone marrow aspirates and trephine biopsies in multiple myeloma – A single centre study. Clin Lab Haematol 2004;26:403-6.  Back to cited text no. 11
    
12.
Pileri S, Poggi S, Baglioni P, Montanari M, Sabattini E, Galieni P, et al. Histology and immunohistology of bone marrow biopsy in multiple myeloma. Eur J Haematol Suppl 1989;51:52-9.  Back to cited text no. 12
    
13.
Bhargava V, Farhi DC. Bone marrow granulomas, clinicopathological findings in 72 cases and review of the literature. Hematol Pathol 1988;2:43-50.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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