Essay on Bone Marrow Biopsy | Haematology

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Essay on Bone Marrow Biopsy

Essay Contents:

1. Essay on the Introduction to Bone Marrow Biopsy
2. Essay on the Examination of the Bone Marrow Material
3. Essay on the Clinical Value of Bone Marrow Examination
4. Essay on the Red Cell Series in Bone Marrow Biopsy
5. Essay on the Typical Mononuclear Cells in Bone Marrow Biopsy

Essay # 1. Introduction to Bone Marrow Biopsy:

It is an important and integral part of haematological examination. In some cases like iron deficiency anaemia or chronic myeloid leukaemia it may not be necessary, but in all other haematological cases bone marrow biopsy is essential. Aspiration biopsy is the method that is used commonly nowadays and trephine biopsy, i.e. removal of portion of marrow is hardly ever used these days except in cases of myelosclerosis when the latter is indicated.

Site for aspiration bone marrow biopsy is either sternum or iliac crest. In adults, sternum is the site of choice, while in children iliac crest is preferable. Vertebral-puncture can also be carried out in children.

Sternal Puncture:

Under proper aseptic condition the manubrium, a little to the right, is injected with local anaesthesia. The sternal puncture needle with the stellate on (there are many varieties of sternal puncture needle) is pushed on vertically with a rotatory movement till the marrow cavity is reached.

The guard is often fixed prior to introduction of the needle. When the marrow cavity is reached, then the stellate is withdrawn and a well fitting 2ml or 5ml all-glass sterile syringe is attached and the marrow fluid is aspirated by gentle suction. The needle is immediately withdrawn and puncture site is pressed hard by the assistant for few minutes and then sealed either with collodion or tribenzene.

The author’s procedure is to place the marrow fluid thus withdrawn at the end of 6 to 8 slides and then drain away the fluid blood by tapping the end of the slide against the table. What is left on the slide is mostly marrow material. Another slide is held at an angle of 30° over the marrow material and smears are drawn very quickly.

Iliac crest puncture site is the thickened area of the crest just posterior to the anterior superior iliac spine. The needle after local anaesthesia, is pushed through the crest on a plane at right angles to the upper surfaced Correct depth is indicated by lessening of resistance. The marrow fluid in this technique will be much less; material in the needle should be utilised for making smears.

Vertebral Spine Puncture:

Rarely it is resorted to and that also only in children, whose spines can be seen and felt. The vertebral column is made prominent by the patient sitting up and bending forward or using the same position as in the withdrawal of C.S.F. fluid. The needle is inserted at right angle to the surface. Only few drops of material can be obtained.

Contraindications of Aspiration Biopsy:

Haemophilia and other coagulation disorders are absolute contraindications.

Complications:

In few cases especially in children, while carrying out sternal marrow biopsy, heart or great vessels have been punctured where death occurs suddenly due to cardiac tamponade.

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Essay # 2. Examination of the Bone Marrow Material:

The smears are stained either by Leishman or Giemsa-Leishman stain and examined by the oil immersion lens.

Following points are studied:

(1) Cellularity,

(2) Predominant cell type in red cell and white cell series,

(3) Plasma cells,

(4) Platelet series,

(5) Any abnormal cells,

(6) Parasites.

This is qualitative assessment and is good enough to come to any conclusion. Rarely one may have to resort to differential cell count.

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Essay # 3. Clinical Value of Bone Marrow Examination:

This examination confirms or gives positive result in cases of pernicious anaemias, megaloblastic anaemias, aleukaemic-leukaemias, differentiation of acute types of leukaemias, lipoidosis like Nieman- Pick’s disease, Gaucher’s disease, myelomatosis, myeloid reticulosis, myelosclerosis, erythroleukaemia, kala-azar (L.D.bodies). It also helps in confirming the diagnosis of idiopathic thrombocytopenic purpura.

i. Assessment of Prognosis:

In a case of lymphatic leukaemia, types of cell often help in the assessment of prognosis. The more premature the cells are, the poorer is the prognosis though the peripheral blood may contain mature lymphocytes. In agranulocytosis, marrow having adequate number of myeloid series of cells indicates certain recovery.

ii. Peripheral Blood:

The values of peripheral blood vary according to age and sex. In a new-born, the red cell count is approximately 5-6 x 10^12/1. whilst in a child of one year it is 4. 5 ± 0.8×10^12/1. In an adult man it is 4-6.6 x 10^12/1 whilst in women it is about 3.5-4.5 x 10^12/1. Haemoglobin in infants is about 16-18g/dl whilst in man, it is 13-16g/dl and in women 12-14.5g/dl.

The total white cell count in the peripheral blood in infants is about 15.0-16.0 x 10^9/1 whilst in adults, it varies from 5-10 x10^9/1. The polymorph neutrophils constitute 40-70 per cent, lymphocytes 20-45 per cent, monocytes 2-9 per cent, eosinophils 1-5 per cent and basophils 0-1 per cent.

iii. Absolute Values of Red Cells:

These are calculated from packed cell volume (PCV), haemoglobin (Hb) and red cell count.

(1) M.C.H.C:

Mean Corpuscular Haemoglobin Concentration and represents concentration of haemoglobin in each red cell.

It is calculated as follows:

(2) M.C H:

Mean Corpuscular Haemoglobin. It represents average weight of haemoglobin in the cell and is calculated as follows:

It varies from 27 to 32 pg (picogramme).

(3) M.C. V:

Mean Corpuscular Volume. It tells us the average volume of red cells and is calculated as follows:

Value range in normal varies from 76-94 fl.

(4) P C.V:

Packed cell volume which is obtained by centrifuging a Wintrobe tube for 30 mins. at a speed of 3500 revolutions per min. One can use a micro-haematocrit tube in the microhaematocrit method which allows the determination of P.C.V. with small quantity of blood and is highly accurate. It is one of the simplest, most accurate and most valuable of all haematological investigations.

Its value in man is 40%-54% and in woman range is 35%-47%.

(5) Peripheral Smear:

One of the most important haematological examinations to assess the disorders of blood in a patient is the peripheral smear examination. The smear must be thin and should have a good tail. It should be properly stained. One examines the smear first by low power and then under oil immersion. All the cellular series in the smear are examined one after another and evaluated.

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Essay # 4. Red and White Cell Series in Bone Marrow Biopsy:

(a) Its size and shape are examined. Small sized cells are called microcvtes. Larger than normal size are called macrocytes. Normocytes are normal sized cells. Variation of size is called anisocytosis. It may be due to increase in small sized cells or macrocytes or both It could also be a round cell instead of a biconcave disc. It is then called spherocyte. It is round, small and densely stained in cases of hereditary spherocytosis.

(b) Its Shape:

If the cell is pear or tear drop shaped, it is called poikilocyte. It could be oval or elliptical in shape as in Ovalocytosis or Elliptocytosis. In sickle-cell anaemia, it is sickle-shaped. It could be ‘Burr’ cell with spinous projections on the surface which is seen in renal failure. Schistocytes are fragmented red cells whilst acanthocytes are spur cells – both are seen in haemolytic anaemia.

(c) Staining Properties:

Normal red cells are stained reddish, brick-coloured with a light staining area in the centre. Perpihery is densely stained. Hypochromasia means less staining which is seen in various types of anaemia. If it is a thin rim of stained material at the periphery and rest of the red cell is absolutely pale, it is called Ieptocytes. It is mostly seen in iron deficiency anaemia of severe degree.

If there is a stained -rim of Hb in the periphery and a central pale area in which a rounded central drop of stained material is seen like a “target”in shooting range, it is called “Target cell” as seen in thalassemia and other haemoglobinopathies. Hyperchromasia is seen in young red cells like reticulocytes. It indicates an active marrow. It is also called Polychromasia and has the same significance as reticulocytosis.

(d) Inclusion Bodies- Punctate Basophilia:

It is seen in chronic lead poisoning and indicates damage to red cells. These are blue staining dots in the red cells. Occasionally, they are seen in severe anaemia and following splenectomy.

Siderocytes:

Siderocytes are red cells containing iron granules. They give Prussian blue reaction with ferrocyanide. It is seen in sideroblastic anaemia, lead poisoning and in some haemolytic anaemias. When stained by Romanowsky stain, it is called Pappenheimar bodies seen following splenectomy and in cases of haemolytic anaemias.

Howell-Jolly Bodies:

Howell-Jolly bodies are nuclear remnants. They are seen as small, round, dark staining particles usually one, occasionally more. Seen after splenectomy and sometime in cases of leukaemia.

Cabot Rings:

Cabot rings are ring-shaped or twisted or convoluted threads blue in colour and are seen in cases of megaloblastic anaemia.

Malarial Parasites:

Malarial parasites are also seen in the red cells either in ring forms, shizonts, merozoites or gametes.

White Cell Series:

White cell series increase or decrease in number could be assessed. Increase in polymorphonuclear leucocytes with a shift to the left indicates infection. Toxic granules are basophilic coarse granules seen in the cytoplasm of neutrophils. Polymorph neutrophils also increase in moderate to severe haemorrhage, in burns, in extensive tissue injuries, damage, coronary thiombosis, and generally after an initial phase of shock.

The polymorph neutrophils may show Pelger-Huet abnormality where the nuclei are dumb-bell- shaped and have coarse chromatin. They do not segment further. It is a non-sex linked, rare, dominant hereditary abnormality. Hyper segmented neutrophils or macropolycytes are abnormally large (15 to 25 µm) with more than 4 nuclear lobes. They are associated with Vit.B₁₂ or folic acid deficiency.

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Essay # 5. Typical Mononuclear Cells in Bone Marrow Biopsy:

i. Turk cells are about 15 µm in diameter and have deeply stained narrow rim of cytoplasm and a large round nucleus seen in patients with infection. Now it is thought that this hyperbasophilic medium sized mononuclear cell (probably lymphoid series) appears in the blood after immunization, infection, hypersensitivity reaction and onset of autoimmune disorder. It is now considered to be derived from lymphoid tissue responding to an antigenic stimulation. Sezaty cell has PAS positive coarse granules and is seen in Sezary syndrome.

ii. Glandular fever cell is an atypical mononuclear cell with pseudopodia flowing around nearby red cells. It has a round nucleus and large pale blue cytoplasm.

iii. Eosinophilia indicates an absolute increase in the number of eosinophils as seen in pulmonary or tropical eosinophilia. It is seen in allergic condition, parasitic infection and in certain skin diseases. It is occasionally seen in Hodgkin’s disease.

iv. Abnormal increase in number and presence of premature white cells help in the diagnosis of leukaemias.

v. Platelet Series -Shape, size, granularity as well as number can be estimated from a peripheral blood film.