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Questions and Answers
What is bone marrow examination?
What is bone marrow examination?
Pathologic analysis of samples of bone marrow obtained by bone marrow aspiration and bone marrow biopsy (often called a trephine biopsy).
What does the aspirate yield?
What does the aspirate yield?
Semi-liquid bone marrow.
What are some of the ways the aspirate can be examined?
What are some of the ways the aspirate can be examined?
What is a trephine biopsy?
What is a trephine biopsy?
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Bone marrow aspiration procedures can be ordered for a variety of medical reasons.
Bone marrow aspiration procedures can be ordered for a variety of medical reasons.
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Bone marrow aspiration is an invasive procedure that requires skill and medical supervision.
Bone marrow aspiration is an invasive procedure that requires skill and medical supervision.
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What part of the body is often used for bone marrow aspiration?
What part of the body is often used for bone marrow aspiration?
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Bone marrow aspiration can only ever be performed on the back of the hipbone.
Bone marrow aspiration can only ever be performed on the back of the hipbone.
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What is the main absolute reason to avoid bone marrow aspiration?
What is the main absolute reason to avoid bone marrow aspiration?
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Serious complications following bone marrow aspiration are very common.
Serious complications following bone marrow aspiration are very common.
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What are some of the indications for bone marrow examination?
What are some of the indications for bone marrow examination?
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How many methods of bone marrow specimen collection are there?
How many methods of bone marrow specimen collection are there?
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What are two common types of needles used for bone marrow aspiration?
What are two common types of needles used for bone marrow aspiration?
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What are two common types of needles used for trephine biopsy?
What are two common types of needles used for trephine biopsy?
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Why is bone marrow aspiration usually considered simple and safe?
Why is bone marrow aspiration usually considered simple and safe?
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Bone marrow biopsy involves collecting a sample of bone marrow fluid.
Bone marrow biopsy involves collecting a sample of bone marrow fluid.
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Trephine biopsy can be used to examine the bone marrow for overall cellularity and infiltrative processes.
Trephine biopsy can be used to examine the bone marrow for overall cellularity and infiltrative processes.
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Which of the following can be assessed using bone marrow aspiration?
Which of the following can be assessed using bone marrow aspiration?
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Which of the following can be assessed using bone marrow biopsy?
Which of the following can be assessed using bone marrow biopsy?
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Bone marrow aspiration and bone marrow biopsy are always performed together in order to get a complete picture of the patient.
Bone marrow aspiration and bone marrow biopsy are always performed together in order to get a complete picture of the patient.
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The location of the bone marrow aspiration can rely on the age of the patient.
The location of the bone marrow aspiration can rely on the age of the patient.
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Why is the iliac crest considered a good site for bone marrow aspiration?
Why is the iliac crest considered a good site for bone marrow aspiration?
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What is a potential disadvantage of using the iliac crest for bone marrow aspiration?
What is a potential disadvantage of using the iliac crest for bone marrow aspiration?
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The sternum is generally deemed a safe location for bone marrow aspiration in adults.
The sternum is generally deemed a safe location for bone marrow aspiration in adults.
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The iliac crest has an advantage over other aspiration sites if a trephine biopsy is needed.
The iliac crest has an advantage over other aspiration sites if a trephine biopsy is needed.
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Why are the needle types used for bone marrow aspiration and trephine biopsy different?
Why are the needle types used for bone marrow aspiration and trephine biopsy different?
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Why are the sites used for bone marrow aspiration different in infants and children compared to adults?
Why are the sites used for bone marrow aspiration different in infants and children compared to adults?
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It is always easy to collect adequate bone marrow samples in patients with hematologic disorders.
It is always easy to collect adequate bone marrow samples in patients with hematologic disorders.
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In cases where bone marrow aspiration is difficult, trephine biopsy is still crucial for investigation.
In cases where bone marrow aspiration is difficult, trephine biopsy is still crucial for investigation.
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When collecting bone marrow for aspiration, it is preferable to take a large sample.
When collecting bone marrow for aspiration, it is preferable to take a large sample.
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The preparation of bone marrow films for microscopy can significantly impact the accuracy of interpretation.
The preparation of bone marrow films for microscopy can significantly impact the accuracy of interpretation.
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Why are Romanowsky dyes used to stain bone marrow films?
Why are Romanowsky dyes used to stain bone marrow films?
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Perl's method of staining is used to assess iron in the bone marrow.
Perl's method of staining is used to assess iron in the bone marrow.
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What is the purpose of the smear preparation for bone marrow samples?
What is the purpose of the smear preparation for bone marrow samples?
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What is the advantage of crush smears?
What is the advantage of crush smears?
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The systemic scheme for examining bone marrow films starts by looking at the sample at low power.
The systemic scheme for examining bone marrow films starts by looking at the sample at low power.
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Which of the following are examined at higher power when examining bone marrow films?
Which of the following are examined at higher power when examining bone marrow films?
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Cellularity assessment doesn't require knowledge of the patient's age.
Cellularity assessment doesn't require knowledge of the patient's age.
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Normal bone marrow is considered hypercellular.
Normal bone marrow is considered hypercellular.
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The presence of hypercellularity could indicate a condition like polycythemia.
The presence of hypercellularity could indicate a condition like polycythemia.
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Hypocellularity can be a sign of aplastic anemia.
Hypocellularity can be a sign of aplastic anemia.
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What does the M:E ratio represent?
What does the M:E ratio represent?
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In normal bone marrow, the myeloid cells typically outnumber the erythroid cells?
In normal bone marrow, the myeloid cells typically outnumber the erythroid cells?
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A complete differential count of bone marrow is always considered essential for diagnosis.
A complete differential count of bone marrow is always considered essential for diagnosis.
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The differential count is always reliable because the distribution of bone marrow cells is uniform and consistent.
The differential count is always reliable because the distribution of bone marrow cells is uniform and consistent.
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It is recommended to study at least 200 cells when attempting a differential count.
It is recommended to study at least 200 cells when attempting a differential count.
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Briefly describe what cell markers are.
Briefly describe what cell markers are.
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Cell markers can only be detected using flow cytometry.
Cell markers can only be detected using flow cytometry.
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Understanding cell marker expression is essential for diagnosing certain types of leukemia.
Understanding cell marker expression is essential for diagnosing certain types of leukemia.
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Flow cytometry is only used to analyze cell marker expression.
Flow cytometry is only used to analyze cell marker expression.
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Flow cytometry is particularly useful for large cell samples.
Flow cytometry is particularly useful for large cell samples.
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CD molecules are only used in flow cytometry.
CD molecules are only used in flow cytometry.
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TdT is a DNA polymerase that is commonly found in leukemias, including AML.
TdT is a DNA polymerase that is commonly found in leukemias, including AML.
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High levels of TdT are often found in patients with AML.
High levels of TdT are often found in patients with AML.
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Molecular techniques like PCR can help detect chromosomal abnormalities.
Molecular techniques like PCR can help detect chromosomal abnormalities.
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The presence of the Philadelphia chromosome is characteristic of CML.
The presence of the Philadelphia chromosome is characteristic of CML.
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FISH is a molecular technique that can be used to detect chromosomal translocations.
FISH is a molecular technique that can be used to detect chromosomal translocations.
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What does SLE stand for?
What does SLE stand for?
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SLE is usually considered an acute illness with a rapid progression.
SLE is usually considered an acute illness with a rapid progression.
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SLE commonly affects women.
SLE commonly affects women.
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The LE cell is a specific hallmark of SLE.
The LE cell is a specific hallmark of SLE.
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The LE cell is often mistaken for a tart cell.
The LE cell is often mistaken for a tart cell.
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The LE test is always negative in individuals with SLE.
The LE test is always negative in individuals with SLE.
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The LE test is always positive in individuals without SLE.
The LE test is always positive in individuals without SLE.
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A LE cell test involves culturing cells in a specific medium for a few hours.
A LE cell test involves culturing cells in a specific medium for a few hours.
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A LE cell test often involves trauma to leukocytes, which is essential for the formation of LE cells.
A LE cell test often involves trauma to leukocytes, which is essential for the formation of LE cells.
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The LE factor can easily attack healthy living leukocytes.
The LE factor can easily attack healthy living leukocytes.
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The Rotary Method of Zinkham and Conley for LE testing involves rotating a sample of patient blood at a constant speed.
The Rotary Method of Zinkham and Conley for LE testing involves rotating a sample of patient blood at a constant speed.
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During LE testing, it's recommended to analyze the edges and tails of the bone marrow film first.
During LE testing, it's recommended to analyze the edges and tails of the bone marrow film first.
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Study Notes
Bone Marrow Smear Preparation, Staining, and Examination
- Bone marrow examination is a crucial diagnostic tool in hematology
- It involves the analysis of bone marrow samples obtained through bone marrow aspiration and biopsy
- The aspirate yields semi-liquid bone marrow, which can be examined under a light microscope or analyzed by flow cytometry, chromosome analysis, or polymerase chain reaction (PCR)
- Trephine biopsy provides a solid piece of bone marrow, examined microscopically for cellularity and possible infiltrative processes
Bone Marrow Aspiration
- Common sites for aspiration in adults are the posterior iliac crest
- Posterior iliac crest is preferred because there is less risk of injury to blood vessels and easier observation of the procedure
- In cases of children, the sternum is useful and considered a good site when aspiration is needed.
- For infants, the proximal portion of the tibia is often the preferred site due to thinner bone
- A minimum of approximately 0.3 mL of marrow is needed for analysis
Bone Marrow Biopsy
- This involves collecting a solid piece of bone marrow often obtained with a trephine biopsy or needle biopsy
- This is critical for analyzing cellularity and architectural structure, with a view to examine for potential focal lesions which can be associated with Hodgkin's, non-Hodgkin's lymphoma, granuloma, and multiple myeloma
Bone Marrow Film Preparation
- Films are obtained with a smooth-edge spreader and 2 cm in width to create films of the aspirated bone marrow 3 to 5 cm in length.
- Films are fixed and stained with Romanowsky dyes
- Additional staining options, like Perl's method, help detect the presence of iron
- Films need adequate staining procedure to yield high-quality results
- Over night staining procedure to achieve optimal results
Bone Marrow Examination Objectives
- Identify conditions warranting bone marrow examination
- Indicate bone marrow aspiration sites based on age groups
- Describe techniques for bone marrow smear preparation and examination
- Evaluate bone marrow cellularity (normal/hypercellular/hypocellular)
- Assess myeloid-to-erythroid ratio
- Interpret differential counts
Indications for Bone Marrow Examination
- Unexplained anemia, unexpected cytopenia, or cytosis
- Multilineage abnormalities of circulating blasts in adults
- Abnormal peripheral blood smear morphology
- Diagnosis, staging, and follow-up of hematological malignancy
- Investigation of suspected bone marrow metastases
- Unexplained focal bony lesions or organomegaly
- Investigations for pyrexia or specific infections (e.g., granulomatous disease, tuberculosis, leishmaniasis, fungal infections)
- Evaluation of iron stores
- Monitoring after chemotherapy, radiation therapy, or stem cell transplantation
Contraindications
- Severe bleeding disorders
Complications
- Mild soreness lasting 12-24 hours is common, but severe complications are rare
Particle/Crush Smears
- Useful to assess cellularity and detect abnormal cells, megakaryocytes numbers, and certain focal diseases
Systemic Scheme for Examining Aspirated BM Films
- Low power (x10): assess cellularity, identify megakaryocytes, and abnormal cell clumps. Identify macrophages
- High power (x40, x100): assess maturation stages of myeloid and erythroid cells, determine myeloid:erythroid ratio(M:E), perform differential counts, assess iron content, check for necrosis.
Assessment of Bone Marrow Cellularity
- Cellularity is assessed by comparing the areas occupied by fat spaces and nucleated cells.
- Normal marrow is considered normocellular or normoplastic
- Cellularity varies based on patient age and site of aspiration
Myeloid to Erythroid Ratio
- The myeloid to erythroid ratio (M:E ratio) expresses the proportion of myeloid (granulocytic) versus erythroid cells in bone marrow
- In normal adult bone marrow, myeloid cells usually outnumber erythroid cells
Differential Count on Aspirated Bone Marrow
- Expression of cell types as percentages is not routinely performed because of long preparation times and limited clinical utility.
- The count may be unreliable due to irregular distribution of cells and possible inclusion of cells from peripheral blood
- A minimum of 200 cells should be assessed
Differential Counts in Adults
- Includes specific percentages of different cell types (myeloblasts, promyelocytes, myelocytes, metamyelocytes, band/segmented neutrophils, eosinophils, basophils, normoblasts, lymphocytes, plasma cells, and monocytes)
Review Questions
- Include questions about the conditions for examination, the sites in different age groups, preparation techniques, cellularity, the myeloid-to-erythroid ratio, and differential counts.
Hematological Cell Markers
- Identifying proteins on cell surfaces that are associated with cell lineage and maturation stage.
- Immunophenotyping is necessary for diagnosing and characterizing Acute Leukaemia, chronic myeloid leukaemia, and chronic lymphoproliferative disorders
Cell Marker Studies by Flow Cytometry
- Using monoclonal or polyclonal antisera and immunofluorescent methods to analyze cell markers and CD (cluster differentiation) markers which are specific to particular cells
- Flow cytometry is suitable for small samples
Terminal Deoxynucleotidyl Transferase (TdT) Test
- TdT is a nuclear enzyme marker. High levels are in lymphoblastic leukemias but not AML. TdT is helpful in differentiating between ALL and AML.
Molecular Methods (e.g., FISH)
- DNA probes and PCR used clinically are used to diagnose leukemia.
- Confirm chromosomal abnormalities and monitor residual disease after therapy
- Helpful in diagnosing certain leukemias and determining presence of mutations/markers associated with certain leukemias.
Systemic Lupus Erythematosus (SLE)
- Chronic rheumatic disease that affects many parts of the body.
- Immunologic disorder characterized by inflammation
- Associated with skin rashes, arthralgia, fever, and renal, cardiac, and vascular lesions
- Common in women of childbearing age.
LE Cell Phenomenon
- Presence of an immunoglobulin in serum that causes depolymerization of nuclear chromatin in polymorphs; phagocytosis occurs.
- The phagocyte (usually a neutrophil) incorporates a denatured nucleus from another cell into the LE cell.
Examination of Films for LE Cells
- Examine films for LE cells, especially the edges and tails.
- At least 500 polymorphs must be examined/counted.
- Differentiate from “tart cells” which are usually monocytes that have ingested nuclei of lymphocytes.
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Description
This quiz focuses on the critical techniques involved in the preparation, staining, and examination of bone marrow samples. Participants will learn about the different methods of obtaining samples, including aspiration and biopsy, and the implications of these procedures in hematology. Test your knowledge on the anatomy of aspiration sites and the analysis methods used in evaluating bone marrow.
