A STUDY OF BONE MARROW ASPIRATION IN HAEMATOLOGICAL AND NON-HAEMATOLOGICAL DISORDERS, IN AN URBAN, TERTIARY CARE HOSPITAL IN MUMBAI

Transcription

1 Online ISSN: xxxx-xxxx Print ISSN: xxxx-xxxx Available online at Volume1, Issue1, September-October 2018; Page No A STUDY OF BONE MARROW ASPIRATION IN HAEMATOLOGICAL AND NON-HAEMATOLOGICAL DISORDERS, IN AN URBAN, TERTIARY CARE HOSPITAL IN MUMBAI Dr. Rupali Parikh, 1* Dr. Lakshmi Vaswani 2 1 Associate Pathologist, 2* Assistant Pathologist, Department of Pathology, Bhatia Hospital, Tardeo, Mumbai Maharashtra. Address for Correspondence Dr Rupali Parikh, 2 nd Floor, Department of Pathology, Bhatia Hospital, Tardeo, Mumbai, Maharashtra, India. ruprajshri@gmail.com Conflict of Interest: Nil ABSTRACT Background: The bone marrow is frequently involved in variety of cases presenting with hematological and nonhematological disorders. The hematological disorders include acute leukemia, myeloproliferative neoplasm (MPN), hemato-lymphoid neoplasm, nutritional deficiency diseases. On the other hand non-hematological disorders include infectious diseases infiltrating the bone marrow such as tuberculosis, parasitic infections and metastatic deposits. These disorders have diverse modes of presentation and require bone marrow examination for both diagnosis and management. Objective: We conducted this study which was aimed to assess the diagnostic value of the BMA and its role to reach final diagnosis. Material and Methods: Though BMA cytology and trephine biopsy histopathology complement each other, the superiority of one method over the other depends on the underlying disorder. Application of patient s history, clinical examination, complete blood counts, peripheral blood smear examination, biochemical findings, when combined with ancillary techniques such as flow cytometry, cytogenetic studies, gives a complete picture for further management. Conclusion: A total number of all150 cases were included in this study and we concluded that BMA is a very effective tool in arriving at a diagnosis in hematological disorders and it was found to be a simple, reliable, and rapid and cost effective method of marrow evaluation. Keywords: acute leukemia, flow cytometry, hemato-lymphoid neoplasm, myeloproliferative neoplasm (MPN), nutritional deficiency diseases. 10

2 Dr. Rupali P. et al. Asian Journal of Medical, Dental, Preventive Research (AJMDPR) INTRODUCTION Bone marrow examination may be performed by two methods; Aspiration and trephine biopsy. Bone marrow aspiration (BMA) is simple, reliable, and rapid method of marrow evaluation. It provides information about the numerical and cytological features of marrow cells. These cells are also well suited to further examination by cytogenetic, molecular and flowcytometric methods. However, BMA has low sensitivity in detecting solid tumor metastasis and lymphoma involvement. 8,9 Bone marrow trephine biopsies (BMB) provide excellent appreciation of spatial relationships between cells and of overall bone marrow structure. It is required in conditions such as inadequate or failed aspirate, assessment of cellularity and bone marrow architecture, suspected focal lesion (for example, suspected granulomatous disease, or lymphoma) and bone marrow fibrosis. 6 Aspirate and trephine biopsy specimens are considered complementary and when both are obtained, they provide a comprehensive study of bone marrow. However, biopsy is a painful procedure and its processing takes at least h. Hence, to perform trephine biopsies in all patients may not be cost effective in terms of clinician and laboratory personnel time, efforts, and patient discomfort. 10 With advent of new technologies such as flow cytometry and molecular techniques when combined with BMA s is useful in achieving more accurate and informative diagnostic data in some diagnostically challenging cases. MATERIAL AND METHODS This was a retrospective study done in the Department of Pathology, Bhatia hospital, Mumbai, for a period of 3 years (May January 2018). A total number of all150cases were included in this study. Bone marrow aspiration reports were retrieved from the record file in the department. Peripheral blood smear along with necessary hematological and clinical parameters were also noted from the record file. The bone marrow aspiration smears were stained with Leishman s Stain and Prussian blue stain for iron assessment was performed if indicated. The data was collected manually and then analyzed. The bone marrow diagnosis in this study is only based on aspiration findings. RESULTS A total number of 150 patients were included in this study (Table 1, figure 1). In this study, there were 75 (50%) males and 75 (50%) females. Male to female ratio was 1:1. The age of the 150 patients included in this study ranged between 5 months to 90 years. The average age was 50 years. (Table 2, Figure2) The maximum number of patients, that is 28(18.7%) who had undergone the bone marrow aspiration examination were in the age group of 71 to 80 years, followed by 26 patients (17.3 % ) in the age group of years, 22 patients (14.7%) in the age group of years. The least numbers of patients 7(4.7%) were seen in both the age group of years and years. In our study, 65 patients (43.3%) presented with weakness and fatigue, 19 patients (12.7%) with fever, 12 patients (8%) with back pain, 17 patients (11.3%) with bleeding manifestations (5 patients with hematuria (29.4%) 3 patients (17.6%) had nose bleed, 4 patients (23.5%) had petechial rashes, 2 patients (11.7%) had melena, and 1 patients (5.8%) each gum bleed, heavy menstrual bleeding and Ecchymotic patches). 11 patients (7.3%) with splenomegaly, 9 patients (6%) with lymphadenopathy, 5 patients (3.3%) of known cases of acute myeloid leukemia underwent bone marrow examination as a part of follow up when on treatment. 3 patients (2%) with splenomegaly and bone pain, 2 patients (1.3%) with Hepatosplenomegaly, 1 patient (0.7%) each with ascites, failure to thrive, cough, diarrhea. The others were known cases of testicular lymphoma (for staging) follicular lymphoma (for staging), CLL (for 11

3 follow up), ALL (for follow up), ALL with (with CNS relapse), chronic renal failure (with anaemia), acute renal failure, Ca esophagus, HIV positive and fracture vertebra. (Table 3, Figure3) A majority of patients, i.e. 48 (32%) in this study presented with pancytopenia, followed by 41 patients ( 27.3 %) with anemia, 19 (12.7%) patients with isolated thrombocytopenia, 18 patients (12%) with anaemia and thrombocytopenia both, 10 patients (6.7%) with normal complete blood counts, 5 patients (3.3%) with Leucocytosis, 4 patients (2.7%) with Leucocytosis and thrombocytosis both. 2 patients (1.3%) patients with autoimmune hemolytic anaemia, 1 patient (0.7% ) each with Leucoerythroblastic blood picture, isolated neutropenia and thrombocytosis. (Table 4, Figure4) Out of 150 bone marrow aspirate samples, 93 (62.7%) were normocellular, 42(28%) were hypercellular, and 14 (9.3%) were hypocellular. The spectrum of the hematological and nonhaematological disorders diagnosed on the bone marrow aspiration alone was very wide. (Table 5, Figure5) The diagnosis of Myelodysplastic syndrome was most common in 22 (14.7%) patients. This correlated well with the most common age group of the patients (71-80 years) who had undergone the bone marrow examination. Out of 22 MDS patients, 10(45.5%) cases were diagnosed as refractory cytopenia with multilineage dysplasia, of which 3 (30%) cases showed increased ring sideroblasts on iron staining, in the range of %; 7(31.8%) cases of Refractory Anaemia with Excess Blasts of which 3(42.9%) were RAEB-II, 1(14.2%) was RAEB-I with Ring sideroblasts and 3(42.9%) cases of RAEB-I). 3(13.6%) cases were diagnosed as hypoplastic MDS, 1(4.5%) case each of Refractory Anemia and Refractory Anemia with Ring Sideroblasts. (Table 6, Figure 6a) The 2 nd common diagnosis was immune thrombocytopenic Purpura in 15(10%) patients, followed by hypoplastic anaemia in 12(8%) patients, acute myeloid leukemia in 12(8%) patients, of which based on morphology it was possible to sub categorize, 3 patients as (25%) as Acute Promyelocytic Leukemia, 1(8.3%) as Acute Myeloid Leukemia M4 Eo and 1(8.3%) as Acute Myeloid Leukemia with Myelodysplasia. Haemophagocytic Lymphohistiocytosis was seen in 11(7.3%) patients. Out of 10(6.7%) bone marrows of patients who were known cases of acute leukemia, 9 (90%) were found to be in remission on follow up marrow examination and 1(10 %) patient was suspected to have Minimal Residual Disease, because of borderline blast percentage. The same was confirmed later by Flowcytometry. 9 (6%) of patients were diagnosed having chronic Myeloproliferative disorders of which 8{88.8%} were the cases of CML in chronic phase and 1{11.1%} case was of essential thrombocythaemia). The diagnosis of multiple myeloma was offered in 9 (6%) patients. Out of 9(6%) cases of suspected or known chronic Lymphoproliferative disorders, diagnosed on peripheral blood smears and lymph node biopsies and who underwent bone marrow examination for investigation and staging, 4(44.4 %) cases showed marrow involvement [1(25%) case of Hairy Cell Leukemia, 2(50%) cases of Large Cell Lymphomas and 1(25%) case of Chronic Lymphocytic Leukemia] (Table 6, Figure 6b) Pure red cell aplasia was diagnosed in 8 (5.3%) patients. Erythroid hyperplasia was the only finding in 6(4%) patients. However it was also associated with other conditions like 4 (20%) cases which were consistent with Hypersplenism, 2 (10%) cases of Megaloblastic anaemia, 2 (10%) cases of iron deficiency anaemia, 2 (10%) cases of refractory cytopenia with multilineage dysplasia, 1 (5%) case each of anaemia of chronic disease, refractory anaemia, refractory anaemia with ring sideroblasts, and refractory anaemia with excess blasts with ring sideroblasts. So Erythroid hyperplasia was another common finding isolated or associated with other conditions, in 20 (13.3%) patients all together. There were 4(2.7%) cases each of acute lymphoblastic lymphoma, reactive marrow, marrow 12

4 metastasis and Hypersplenism. There were 2 (1.3%) cases each of iron deficiency anaemia and Megaloblastic anaemia, followed by 1 (0.7%) case each of anaemia of chronic disease, storage disorder (Gaucher s disease), myeloproliferative and Myelodysplastic overlap syndrome, congenital neutropenia and fungal infection (Histoplasmacapsulatum). Pure Red Cell Aplasia- the bone marrow aspirate showing near total absence of erythroids with normal granulopoiesis and megakaryopoiesis in a 5 month old female, diagnosed as Diamond Blackfan anaemia. (Figure 7) Hypocellular Anaemia- the bone marrow aspirate smear shows markedly hypocellular spicule with little to no residual hematopoietic activity consisting of small lymphocytes, plasma cells and other stromal elements; in a 22 year old male presenting with pancytopenia. (Figure 8) AML M4 EO: The bone marrow aspirate shows proliferation of blast cells with monocytic features and a population of abnormal eosinophils having large, coarse basophilic granules in a case of one year old male presenting with anaemia and thrombocytopenia. (Figure 9) Bone marrow aspirates showing abundant iron stores and ring sideroblasts in 75 year old female presenting with anaemia diagnosed as Sideroblastic anaemia. (Figure 10) Haemophagocytic Lymphohistiocytosis. The bone marrow aspirate showing increased mononuclear phagocytic histiocytes engulfing hematopoietic cells in a case of 26 year old female presenting with fever, lymphadenopathy and pancytopenia. (Figure 11) The hypercellular bone marrow aspirate showed myeloid hyperplasia with prominent dysplasia in granulocytes and megakaryocytes, in a case of 86 year old female presenting with anaemia with thrombocytopenia and Leucocytosis. (Figure 12) DISCUSSION Diseases of bone marrow present with various clinical symptoms and also involve the blood but peripheral blood picture alone does not reflect the nature of disease process. Depending upon diagnosis suspected from the clinical features and peripheral blood examination, the definitive indications for bone marrow examination can be summarized. 1. Investigation and Prognosis of suspected Myeloproliferative Disorders 2. Investigation and Prognosis of Acute leukemia 3. Investigation and staging of suspected Hodgkin s disease and Non-Hodgkin s Lymphoma 4. Diagnosis and follow up of Hairy Cell Leukemia 5. Diagnosis, prognostication and follow up of Chronic Lymphocytic Leukemia 6. Diagnosis of suspected metastatic carcinoma or sarcoma 7. Diagnosis, staging and follow up of small cell tumors of childhood 8. Investigation of unexplained Leucoerythroblastic blood film 9. Investigation of Fever of Unknown origin; especially in immunodeficient cases like HIV for infections like tuberculosis, parasitic and fungal infections. 10. Investigation of suspected Multiple Myeloma and of patients with serum paraproteins without other evidence of myeloma 11. Investigation and evaluation of cytopenia, thrombocytosis, Leucocytosis, anemia, and iron status 12. Diagnosis of storage diseases 13. Diagnosis of Granulomatous diseases 14. Diagnosis of toxic effects of certain offending medications or substances, such as alcohol, or nutritional deficiencies, such as copper/zinc or vitamin B12/foliate. 15. Investigation for pathological fracture 16. Radiological suspicion of occult malignancies (any lytic, porotic or osteoblastic areas or abnormal uptake on bone scan) 17. Laboratory studies suspicious of occult malignancies (elevated calcium, alkaline Phosphatase, PSA etc.) 13

5 18. Monitoring post therapy response and cytopenia post therapy period Complete hematological evaluation of cases where bone marrow examination was indicated includes BMA smear and bone marrow trephine biopsy as they are complementary to each other. The diagnosis can be further complemented by special studies like immunohistochemistry, Flowcytometry and cytogenetic studies for chromosomal analysis. However, as per the study conducted by Mainali N. et al, the overall diagnostic accuracy of bone marrow aspiration cytology in diagnosing hematological disorders was 84.09%. 3 Similarly, in the studies conducted by Nanda A.et al, Pandya A. et al, Chandra S. et al and Patel K et al, the accuracy of diagnosis on bone marrow aspiration was 88.6%, 70 %, 70% and %, respectively, as compared to bone marrow biopsy 2. In the study conducted by Hota R. et al, out of 158 cases with simultaneous bone marrow aspiration and bone marrow biopsy procedures were performed simultaneously showed 85.4% positive correlation between these two procedures. However, it was found that in cases of myelofibrosis, non-hodgkin s lymphoma, myeloproliferative disorders and granulomas, involvement of marrow was detected better in bone marrow biopsies 4. In our study, all cases of hypoplastic anaemia the quality of aspirate was good with sufficient number of bone marrow particles available for assessment of cellularity. However it is always recommended to confirm the same with bone marrow biopsies to assess overall percentage of cellularity. In all cases of Myelodysplastic syndromes, hypoplastic anaemia, chronic myeloproliferative disorders and MDS- MPN, cytogenetic study was advised and flowcytometry in cases of acute leukemia in addition. Aspirating first through a biopsy needle itself and then advancing the same needle to obtain a bone marrow biopsy sounds attractive as it shortens the procedure time and reduces the number of needles being introduced into the skin wound. This reduces both the cost and possibly post procedure infective risk. However this carries considerable risk of introducing aspiration artifacts like inter trabecular spaces filled with blood in the bone marrow biopsy. The current recommendation is to take bone marrow biopsy first followed by an aspirate with a separate Salah/ Klima needle. Bone marrow biopsy is most helpful in situations where: 1. The bone marrow aspirate has failed, or is inadequate or not obtained or cannot exhibit the specific histological findings like myelofibrosis, related to marrow architecture eg. ALIP (Abnormal Localization of Immature Precursors in MDS) and related to marrow components eg. Marrow necrosis or gelatinous transformation. 2. To accurately assess the marrow cellularity 3. It is also superior to bone marrow aspirations in conditions where fibrosis makes aspiration difficult. 4. Serial sectioning of bone marrow biopsy as compared to aspirate allows examination of greater volume of bone marrow in a circumscribed area, thus making it superior tool for detection of focal findings (small foci of granulomas and small focal deposits of metastasis) but at the cost of cytological details which is better appreciated on smear preparations. 5. Immunohistochemistry and prognostic studies like hormone receptors in case of marrow metastasis when sample from the primary site are not available. However a non-diagnostic biopsy can sometimes be compensated for by a high quality aspirate. (Table 7) CONCLUSION Bone marrow examination is a safe, quick and easy procedure with very less patient discomfort. It is cost-effective and does not require sophisticated equipment. It may be difficult to perform bone marrow biopsy under local anesthesia in noncooperative cases and relatively takes longer time to perform with a bit of patient discomfort. Bone marrow aspiration and biopsy complement each other. It is always a clinician decision to choose whether to perform a Bone marrow aspiration or a 14

6 biopsy or both. Better result is yielded out when both are perform simultaneously. Bone marrow aspiration provides detail about the pattern of cellular distribution, cellularity, infiltration by tumor cells. This also provides a block if immunohistochemistry is to perform later on.the present study showed the usefulness of bone marrow aspiration in evaluation of the bone marrow in routine hematological provides better study of the cell, whereas biopsy disorders and also for understanding disease progression, for diagnosis and therapeutic evaluation. These are also helpful in planning further investigation and management. REFERENCES 1. Sreedevi P, Rao P.S. Spectrum of Hematological Disorders detected by Bone Marrow aspiration in a span of 3 months period. IOSR Journal of Dental and Medical Sciences, 2016, 15: 4: Patel K. et al, Comparison of bone marrow aspiration cytology, touch imprint cytology and bone marrow biopsy for bone marrow evaluation. International Archives of Integrated Medicine, 2015, 2: Mainali et al, A Comparative Study of Bone Marrow Aspiration and Bone Marrow Biopsy in Hematological Diseases. Journal of Nobel Medical College, 2015, 4:1: Hota R, A Comparative Evaluation of Simultaneous Bone Marrow Aspiration and Bone Marrow Biopsy Interpretations in Routine Hematology Practice with Special Reference to Flow Cytometry and Cytogenetic Analysis. IOSR Journal of Dental and Medical Sciences, 2017: 16; Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. 2001; 54: Riley RS, Hogan TF, Pavot DR, Forysthe R, Massey D, Smith E, et al. A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination. J Clin Lab Anal. 2004; 18: Bates I, Burthem J. Bone marrow biopsy. In: Bain BJ, Bates I, Laffan MA, Lewis SM, editors. Dacie and Lewis Practical Hematology. 11th ed. China: Elsevier, Churchill Livingstone; pp Atla BL, Anem V, Dasari A. Prospective study of bone marrow in haematological disorders. Int J Res Med Sci. 2015; 3: 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:e Bain BJ. Bone marrow aspiration. J Clin Pathol. 2001; 54: TABLES AND FIGURES Figure 1: Chart Depicting Gender wise distribution of Bone marrows aspirates Table 1: Gender wise distribution of the patients Gender Number % Male Female Total

7 Table 2: Age group wise distribution of the patients Figure 2: Chart Depicting Age group wise distribution of bone marrow aspirates Age group No % 0 to to to to to to to to to Total Table 3: Symptoms wise distribution of patients Symptoms No % Weakness And Fatigue Fever Back Pain Splenomegaly Lymphadenopathy 9 6 Hematuria Ascites Failure To Thrive Diarrhea K/C/O Testicular Lymphoma K/C/O CLL For Staging K/C/O ALL Table 4: distribution of patients based on peripheral smear findings Figure 3: Chart Depicting Symptom wise Distribution Figure 4: Chart depicting distribution based on Peripheral Smear Findings Peripheral Blood Smear Findings No % Pancytopenia Anemia Isolated Thrombocytopenia Anemia And Thrombocytopenia Normal Complete Blood Counts Leucocytosis Leucocytosis And Thrombocytosis Thrombocytosis Total

8 Table: 5 Cellularity wise distribution of cases Figure 5: Chart Depicting Distribution based on Cellularity of Bone marrow aspiration Cellularity No % Normocellular Hypercellular Hypocellular Total Table 6: Diagnosis wise distribution of cases S.N O DIAGNOSIS NO % 1 Myelodysplastic Syndromes a. RCMD b. Hypoplastic MDS c. RAEB d. RAEB e. RCMD-RS f. Refractory Anemia g. Refractory Anemia with Ring Sideroblasts Immune Thrombocytopenic Purport Hypoplastic Anemia Acute Myeloid Leukemia Haemophagocytic Lymphohistiocytosis Known Cases Of Leukemia On Follow Up Chronic Myeloproliferative Disorders Multiple Myeloma Investigation And Staging Of Suspected 9 Chronic Lymphoproliferative Disorders Pure Red Cell Aplasia Erythroid Hyperplasia (Not Associated With 6 Any Other Condition) Acute Lymphoblastic Leukemia Consistent With Hypersplenism Reactive Marrow Metastasis To Bone Marrow Sideroblastic Anemia Iron Deficiency Anemia Megaloblastic Anemia Anemia Of Chronic Disease Storage Disorders MDS/MPN Congenital Neutropenia Infective Total

9 Figure 6 a: Distribution based on Diagnosis rendered on bone marrow aspiration Figure 6b: Chart Depicting Distribution of Myelodysplastic Syndromes based on morphology and iron stain Table 8: Age group wise comparison with other studies Table 7: Comparison of Age and Sex distribution in different studies Name of Study Age Distribution M:F ratio Timothy et al 2-75 years 1.2 : 1 Ahmed et al 8 months years 1.1 : 1 Jha et al 1-79 years 1.5 : 1 Egesie et al 3-80 years 1.5 : 1 Shilpa et al 3-70 years 2.4 : 1 Sreedevi P. Et al 6 days to 70 years 1 : 1.4 Our Study 5 months - 90 years 1 : 1 Our Study Sreedevi P.et al AGE GROUP % % 0 TO TO TO TO TO TO TO TO TO Table 9: Comparison of cellularity with other studies Our Study Sreedevi P. et al Cellularity % % Normocellular Hypercellular Hypocellular

10 Table 10: Comparison of Bone marrow examination findings with other studies Kibri Ahme Pudasi Timoth Diagnosis Our study Sreedevi Jha et Khodke Khujuri a sg d sq ni s. y ae. p.et al al et al a et al et al et al Et al Et al Myelodysplastic Syndromes Immune Thrombocytopenic Purpura Hypoplastic Anemia Acute Leukemia Haemophagocytic Lymphohistiocytosis Known Cases Of Leukemia On Follow Up Chronic Myeloproliferative Disorders (Only CML ) Multiple Myeloma Chronic Lymphoproliferative Disorders Pure Red Cell Aplasia Erythroid Hyperplasia Consistent With Hypersplenism Reactive Marrow Metastasis To Bone Marrow Sideroblastic Anemia Iron Deficiency Anemia Megaloblastic Anemia Anemia Of Chronic Disease Storage Disorders (Gaucher s Disease) MDS/MPN Congenital Neutropenia Infective Figure 7: Hypocellular Anaemia Figure 8: Pure Red Cell Aplasia 19

11 Figure 9: AML M4 Eo. Figure 10: Sideroblastic anemia: Bone marrow aspirate Figure 11: Haemophagocytic Lymphohistiocytosis. Figure 12: MDS MPN. Rupali P., Lakshmi V. A study of bone marrow aspiration in haematological and nonhaematological disorders, in an urban, tertiary care hospital in Mumbai. Asian Journal of Medical, Dental, Preventive Research, 2018:1:1: