Comparative utility of bone marrow aspiration and trephine biopsy in evaluation of hematological disorders

Lekshmi Vijayamohanan; Sarita Asotra; Kavita Kumari; Pooja Murgai; Digvijay Dattal

doi:10.4103/amhs.amhs_23_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 8 | Issue : 1 | Page : 15-19

Comparative utility of bone marrow aspiration and trephine biopsy in evaluation of hematological disorders

Lekshmi Vijayamohanan¹, Sarita Asotra¹, Kavita Kumari², Pooja Murgai¹, Digvijay Dattal¹
¹ Department of Pathology, IGMC, Shimla, Himachal Pradesh, India
² Department of Pathology, Dr. RPGMC, Dharamshala, Himachal Pradesh, India

Date of Submission	01-Mar-2020
Date of Decision	12-Apr-2020
Date of Acceptance	15-Apr-2020
Date of Web Publication	20-Jun-2020

Correspondence Address:
Dr. Sarita Asotra
Flat No. 5, Block No. 5, Phase 3, New Shimla - 171 009, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/amhs.amhs_23_20

Abstract

Background: Bone marrow examination is a useful investigative tool to diagnose several hematological and nonhematological disorders. While the aspiration provides excellent cytological detail, the biopsy provides information regarding the spatial relationships of cells, marrow architecture, and valuable information when aspirate is nondiagnostic. We conducted this study to compare the diagnostic usefulness and comparison between aspirate and trephine biopsies in the evaluation of hematological disorders. Aim: The aim was to assess the relative efficacy of bone marrow aspiration and trephine biopsy and the overall diagnostic utility of this procedure in the diagnosis of hematological and nonhematological disorders. Materials and Methods: This is a retrospective study of 6-month duration at a tertiary care hospital in Himachal Pradesh. Patients were aged from 1 to 85 years. A total of 169 cases were studied, in whom bone marrow aspiration and trephine biopsy were performed, with special stains used where required. Results: A specific pathology was found in 89 cases(52.66%), rest being a normal or unsatisfactory study. Trephine biopsy was fundamental in the diagnosis in 69 cases(48.93%). Nearly 21.05% of the aspirates indicating a normal study further revealed a specific pathology on trephine biopsy and 38.88% of the unsatisfactory aspirates revealed definite pathology on biopsy. We noted that 8.87% of cases were diagnosed by trephine biopsy alone, with 89.94% concordance between trephine biopsy and aspiration. Conclusion: Bone marrow aspirate cytology and trephine biopsy are useful adjuncts to each other and should be used to supplement each other in arriving at a definite diagnosis, and they remain as a key diagnostic tool in hematological disorders.

Keywords: Anemia, aplastic, biopsy, bone marrow, bone marrow examination, hematologic diseases

How to cite this article:
Vijayamohanan L, Asotra S, Kumari K, Murgai P, Dattal D. Comparative utility of bone marrow aspiration and trephine biopsy in evaluation of hematological disorders. Arch Med Health Sci 2020;8:15-9

How to cite this URL:
Vijayamohanan L, Asotra S, Kumari K, Murgai P, Dattal D. Comparative utility of bone marrow aspiration and trephine biopsy in evaluation of hematological disorders. Arch Med Health Sci [serial online] 2020 [cited 2023 Mar 30];8:15-9. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/15/287354

Introduction

Biopsy of the bone marrow is an indispensable adjunct to the study of diseases of the blood and may be the only way in which a correct diagnosis can be made. Marrow can be obtained by needle aspiration, percutaneous trephine biopsy, or surgical biopsy. When performed correctly, bone marrow aspiration and trephine biopsy are simple and safe procedures that can be repeated many times and can be performed on outpatients.^[1]

Bone marrow aspiration and trephine biopsy have their own advantages and limitations. The two processes are regarded as complementary. Aspirates are unequalled for the demonstration of fine cytological detail, permitting a wider range of cytochemical stains and immunological markers and may well be performed alone in selected diseases. Trephine biopsy is essential when a “blood tap” or “dry tap” occurs, which allows complete assessment of marrow architecture as well as distribution pattern of an abnormal infiltrate.^[2]

Bone marrow examination is useful in the diagnosis of both hematological and nonhematological disorders. Indications have included the diagnosis, staging, and therapeutic monitoring for lymphoproliferative disorders, such as chronic lymphocytic leukemia, Hodgkin's and Non-Hodgkin's lymphoma, hairy cell leukemia, and plasma cell myeloma. Furthermore, evaluation of cytopenia, thrombocytosis, leukocytosis, anemia, and iron status can also be done.

This is also an important tool in the diagnosis of nonhematological disorders such as storage diseases, granulomatous lesions, metastatic carcinoma, pyrexia of unknown origin, and disseminated infection in immunocompromised hosts.^[3]

The present study was conducted at our hospital to evaluate and compare the diagnostic efficacy of bone marrow aspiration and biopsy procedures in the rapid, effective evaluation of hematological diseases.

Materials and Methods

A retrospective study was done at the Department of Pathology, Indira Gandhi Medical College, a nodal center and government medical institution in the State of Himachal Pradesh over a period of 6 months in 2019. A total of 169 patients had bone marrow examination performed, and in children <16 years, only bone marrow aspiration was done. Patient characteristics were recorded in each case, including presenting symptoms, physical examination findings, peripheral blood counts with morphology, and diagnostic evaluation.

After obtaining informed consent, patients were made to lie in left or right lateral position with knees drawn up. The area around the posterior iliac spine was cleaned with betadine and 70% ethanol, following which skin, subcutaneous tissue, and periosteum were infiltrated with 5 ml of 2% lignocaine. With a boring movement, Salah bone marrow aspiration needle was passed perpendicularly into the ileal cavity. After the bone was penetrated, the stylet was removed, 20 ml syringe was attached, and 0.3–0.5 ml of marrow contents was sucked up to make films and needle withdrawn. Jamshidi™ trephine biopsy needle was inserted into the bone from the same site but in a different direction, using a to-and-fro movement to obtain a core of tissue. Touch smears were made by rolling the core between two glass slides.

The biopsy tissue was immediately fixed in neutral buffered saline, with tincture benzoin seal applied on the puncture site. Giemsa staining was done for aspiration, and hematoxylin and eosin (H and E) stain was done on biopsy. Perls Prussian blue for iron, reticulin, Ziehl–Neelsen, nonspecific esterase (NSE), Sudan black, and periodic acid–Schiff stains were done where necessary.

All the smears and slides were studied, and comparisons were also made between the aspiration and biopsy findings. Aspirate smears were examined for adequacy of cellularity, megakaryocytes, tumor cells, and granulomas, and myelogram was performed where possible. Biopsies were evaluated for specimen size, integrity, cellularity, distribution and maturation of granulocytes, megakaryocytes, trabecular bone structure, abnormal infiltrates, and stromal changes.

Results

A total of 169 cases were studied. The ages of the patients varied from 1 year to 85 years, of which 43% were female.

Eighteen cases revealed unsatisfactory aspirate owing to dry tap or hemodiluted aparticulate smears, while biopsy was not performed in 28 cases and was poorly preserved in 12 cases.

While a normal study was the most common finding in both aspirate and biopsy (33.72% and 35.50%, respectively), the most common diagnosis on aspiration was acute and chronic leukemias (15.38%), plasma cell myeloma and monoclonal gammopathy of undetermined significance (7.10% and 7.10%, respectively), micronormoblastic anemia (11.24%), megaloblastic anemia (4.73%), dimorphic anemia (3.55%), and lymphoid infiltration (1.77%).

Trephine biopsies revealed leukemias (9.92%) and multiple myeloma (8.51%), followed by lymphoid infiltration by non-Hodgkin's lymphoma (6.38%), micronormoblastic anemia (5.91%), myelofibrosis (4.25%), and megaloblastic anemia (3.55%) [Figure 1] and [Figure 2].

Figure 1: Photomicrograph showing nodule of lymphoid cells in non-Hodgkin's lymphoma involvement in bone marrow biopsy (H and E, ×400)

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Figure 2: Photomicrograph showing paratrabecular arrangement of sheets of myeloma cells in multiple myeloma in bone marrow biopsy (H and E, ×400)

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Diagnoses exclusively made by biopsy included myelofibrosis, granulomatous disease, and hypoplastic anemia, while diagnoses of marrow infiltration by Non–Hodgkin's lymphoma were detected mainly by trephine biopsy, with a normal study on aspirate.

Eighteen cases of unsatisfactory aspirate, on trephine biopsy, revealed ten cases of normal study, one case of hypoplastic anemia, three cases of myelofibrosis, one case of plasma cell myeloma, one case of granulomatous lesion, and in two cases, biopsy was not done.

On evaluation of 80 cases of normal aspirate study, only 47 cases further revealed a normal study on trephine biopsy. Three cases of plasma cell myeloma; six cases of non-Hodgkin's lymphoma; and one case each of leukemia, granulomatous disease, megaloblastic anemia, and myelofibrosis were diagnosed [Figure 3].

Figure 3: Photomicrograph showing granuloma in bone marrow biopsy (H and E, ×400)

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Six cases were not preserved on biopsy, thus could not be commented on, while only aspiration was done for 14 cases [Table 1].

Table 1: Trephine biopsy-diagnosed cases with normal aspirate study and unsatisfactory aspirates (dry tap or hemodiluted samples)

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This highlights the importance of biopsy as a key supplementary procedure in accurate diagnosis, including several cases with a normal aspirate study and particularly in focal marrow infiltration. Twenty-six cases of leukemia were noted in total, where it was possible to type acute lymphoblastic leukemia (32%), acute myeloid leukemia (6.25%), chronic myeloid leukemia (28%), and the rest denoted as myeloproliferative neoplasm (12%) and acute leukemia (20%). While Periodic Acid-Schiff and Myeloperoxidase stain were done in all cases of leukaemia, Non Specific Esterase and Sudan Black stains were done as deemed necessary; the results were supplementary to the diagnosis.

One case each of metastatic prostatic carcinoma and visceral leishmaniasis were noted, with positive findings in both aspiration and trephine biopsy [Figure 4].

Figure 4: Photomicrograph showing intracellular and extracellular Leishman–Donovan bodies in bone marrow biopsy (H and E, ×400)

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Reticulin and Perl's staining revealed varying levels of positivity in all the cases studied.

Discussion

Bone marrow examination is a formidable weapon in the clinician's diagnostic kit, to clinch an unsuspected diagnosis when other test results are noncontributory or inconclusive during the evaluation process.^[4],[5] It is a useful investigative tool to diagnose many hematological and nonhematological disorders.^[6] Biopsy being a painful procedure, may not be cost-effective to be performed in all patients, with relation to patient discomfort and clinician and laboratory personnel time.^[7]

Forty-three percent of our cases were female patients similar to the findings of Gilotra et al. who noted 45.38% of females and 54.61% of males in their study of 100 patients ^[7] and another study of 168 patients, in which 92 (54.76%) were males and 76 (45.23%) were females.^[8]

Nutritional anemia was the most common benign disorder (19%), followed by hypoplastic/aplastic anemia (12%), and the most common malignant disorder was acute leukemia (21%) in the study by Gilotra et al.^[7]

In our study, we found micronormoblastic anemia to be the most common benign disorder (33.72% of aspirate diagnoses and 35.50% of biopsies) followed by megaloblastic anemia; leukemia was the most common malignancy (15.38% of aspirates and 9.92% of biopsies) [Table 2].

Table 2: Comparative evaluation of bone marrow aspiration and trephine biopsy (n=169)

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A previous study from the state found the most common hematological disorder to be anemia in 173 cases (37.6%), with megaloblastic anemia being the most common (18.47%).^[9]

Others also found megaloblastic anemia (26.6%) to be the most common diagnosis overall (26.6% and 39.74%), while multiple myeloma was the most common neoplastic pathology (13%) followed by acute leukemias (6%) in one study. Another study revealed acute leukaemia to be the most common haematological malignancy (58.97%), followed by multiple myeloma (12.82%) and chronic myeloid leukemia (10.25%), similar to our study.^[8],[10]

The study by Shastry and Kolte found megaloblastic anaemia to be most common benign disorder while acute myeloid leukaemia was the commonest haematological neoplasm.^[11]

In our study of 169 patients, we found one case of visceral leishmaniasis and two granulomatous lesions. Another study revealed one case of visceral leishmaniasis and four cases (1.3%) of granulomatous disease in 626 cases,^[10] thus we had a higher percentage.

One study showed four (15.38%) cases of visceral leishmaniasis. Visceral leishmaniasis can present as anemia, pancytopenia, and myelofibrosis. Although their incidence is low, hemoparasites can be a cause of hematological disorders, and they should be specifically looked for while examining the bone marrow aspirate.^[8]

Similar studies also detected granulomatous disease on biopsies only;^[6],[7],[12] due to focal marrow involvement, it is very difficult to detect granulomas on aspirate smears; fibrosis around the granuloma often results in a dry tap. Hence the role of biopsy is key to detection of granulomas; with better morphology and adequate material, especially important in nations with a high prevalence of granulomatous diseases such as tuberculosis.^[13]

We found only one case of metastatic deposits of prostatic carcinoma, with infiltrating cells in both aspirate and biopsy, similar to another study,^[11] while no storage disorders were found in our study. Other studies have shown deposits of adenocarcinoma and squamous cell carcinoma.^[14]

Biopsy was necessary for diagnosis in 11.4% and 26.2% of cases in two studies, with the rest being diagnosed by aspiration primarily.^[15],[16]

In our study, we found that 8.87% of cases were diagnosed by trephine biopsy alone, with overall 68.67% concordance in findings between trephine biopsy and aspiration [Table 2].

It is a well-known fact that aspiration is better in making out individual cell morphology, whereas biopsy is useful in the study of bone marrow architectural pattern and distribution.^[9]

In a study of bone marrow procedures in Hodgkin's patients, Subramanian et al. noted that 18% of cases revealed marrow involvement, all of which were diagnosed on biopsy, only one aspirate was suspicious of involvement, and the rest were either diluted (28%) or normal (64%), highlighting the importance of biopsy in the staging of even clinically early-stage Hodgkin's disease.^[17]

We found a higher rate of diagnoses on biopsy for lymphomas; a total of nine cases were diagnosed, of which only three showed infiltration on marrow aspirate, all being non-Hodgkin lymphomas; the remaining six revealed a normal study, in which biopsy revealed infiltration. Further typing was done at private laboratories outside the institution for confirmation and exact characterization.

Khan et al. noted that all cases of lymphoma were diagnosed on trephine biopsy, but lymphoma cells were observed only in 4 out of 18 (22.2%) cases on bone marrow aspirate smear, similar to studies and Chandra and Chandra.^[12]

Biopsy was the only diagnostic method for myelofibrosis in our study, similar to other studies.^{[7],[15],[16],[18]} The cause of increased number of dry taps in myeloproliferative disorders could be due to the increased cellularity or increased fibrosis in the bone marrow.^[9]

Twenty-six cases of leukemia, however, had a higher diagnosis rate on aspiration than biopsy, with several revealing normal marrow histopathology.

We thus found that hematological disorders were more common than nonhematological diseases in our study in the Himalayan region of North India, and several cases of normal study or unsuccessful aspirate ultimately revealed a definitive diagnosis on trephine biopsy, aiding the early initiation of therapy.

Conclusions

Bone marrow examination provided a rapid diagnosis of a variety of disorders, particularly in cases where other tests were futile, however our study shows the utility of trephine biopsy as a complementary and necessary aid to marrow aspiration in arriving at an accurate diagnosis, in spite of its disadvantages; we recommend routine performance of a sequential aspiration followed by biopsy in all cases wherever possible to facilitate a proper diagnostic work up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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