Principles of Hematology 202410 PDF

Principles of Hematology 202410 Michael M. Yakubovskyy, MD, PhD 1 Learning Objectives LO# LO Content 1 List and explain the laboratory tests or studies indicated in a patient with a suspected hematological disorder 2 Identify the components of a complete blood count (CBC) and differential whit...

Principles of Hematology 202410 Michael M. Yakubovskyy, MD, PhD 1 Learning Objectives LO# LO Content 1 List and explain the laboratory tests or studies indicated in a patient with a suspected hematological disorder 2 Identify the components of a complete blood count (CBC) and differential white blood cell (WBC Diff) count and their relevance to blood cell characteristics 3 Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) 4 Classify anemias based on morphology and underlying mechanisms and identify a cause for each type of a (given) anemia 5 Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation 6 SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as their results and relevance to disease 2 LO1. List and explain the laboratory tests or studies indicated in a patient with a suspected hematological disorder Lab Tests/Studies Most Appropriate to Order on a Patient with Suspected Hematologic Disorder • • • • • Complete blood count (CBC) Peripheral blood smear (PBS) Differential WBC count (WBC Diff) Corrected reticulocyte count (CRC) Other lab tests depend upon results of above tests - Hemoglobin electrophoresis - Iron panel - Serum B12 and folate levels • Bone marrow examination, if indicated 3 LO1. List and explain the laboratory tests or studies indicated in a patient with a suspected hematological disorder HemoScreen CBC Analyzer 4 https://commons.wikimedia.org/wiki/File:HemoScreen_C BC_analyzer_-_zfat_01.jpg Jakednb, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons LO1. List and explain the laboratory tests or studies indicated in a patient with a suspected hematological disorder CBC Indices to Count (CDC) RBCs (1012/L) Red cell count Hemoglobin, Hb (g/dL) Hematocrit, HCT or packed cell volume, PCV (%) Mean cell volume, MCV (fL) Mean cell hemoglobin, MCH (pg) MCHC (g/dL) Red cell distribution width, RDW (%) Count WBCs White blood cell count (109/L) Lymphocyte (%) and Lymphocyte number (1000 cells/uL) Monocyte (%) and Monocyte number (1000 cells/uL) Segmented neutrophils (%) and Segmented neutrophils number (1000 cells/uL) Eosinophils (%) and Eosinophils number (1000 cells/uL) Basophils (%) and Basophils number (1000 cells/uL) 5 Count Platelets Platelet count (109/L) Mean platelet volume (fL) Count LO2. Identify the components of a complete blood count (CBC) and differential white blood cell (WBC Diff) count and their relevance to blood cell characteristics CBC: RBC Indices and Their Value RBCs RR Value Red cell count (1012/L) 4.2 - 5.9 x 1012/L Hemoglobin, Hb (g/dL) Males: 14 - 18 g/dL Females: 12 - 16 g/dL • Decreased in anemia • Increased in - Primary polycythemia (polycythemia vera) - Secondary polycythemia - Hemoconcentration (dehydration) • Best indicator of oxygen-carrying capacity of blood • Accurate and preferable to hematocrit for diagnosis of anemia Hematocrit, HCT (%) Males: 40 - 54% Females: 37 - 47% • Accurate and simple screening test for anemia Mean cell volume, MCV (fL or µm3) 80 - 100 µm3 Mean cell hemoglobin, MCH (pg) 25.4 - 34.6 pg MCHC (g/dL) 31 - 36 g/dL Red cell distribution width, 11.5 - 15.4% RDW (%) • Average volume of RBCs • The most important blood index for classifying anemia - MCV < 80 µm3 —> microcytic anemia - MCV 80 - 100 µm3—> normocytic anemia - MCV > 100 µm3—> macrocytic anemia • Average mass of Hb in an individual RBC • Does not provide much additional diagnostic information • Average Hb concentration in a RBC • Used for evaluation of color or chromia of RBCs and classification of anemias - Hypochromic - Normochrmic - Hyperchromic (used to describe RBCs, not to classify anemias) • Reflects variation in RBC size (anisocytosis) - Normal in thalassemias and anemia of chronic disease - High in recent hemorrhages and in iron-deficiency and megaloblastic (B12- and folate6 deficiency) anemias LO2. Identify the components of a complete blood count (CBC) and differential white blood cell (WBC Diff) count and their relevance to blood cell characteristics CBC: WBC Count and Differential Count WBCs RR Changes • Increased: leukocytosis, e.g., as component of (acute) inflammatory White blood cell count (109/L) 4 - 10 x109/L Lymphocyte (%) 25 - 33% Monocyte (%) 3 - 7% Segmented neutrophils (%) 54 - 62% Neutrophils bands (%) 3 - 5% Eosinophils (%) 1 - 3% Basophils (%) 0 - 1% • response Decreased: leukopenia, e.g., inhibition of WBC production with whole body irradiation, or administration of chemotherapeutic drugs • Increased: lymphocytosis, e.g., as as component of (chronic) inflammatory response Decreased: lymphopenia, e.g., in an immunocompromized state • • Increased: monocytosis • Increased: neutrophilia as component of (acute) inflammatory response • Decreased: neutropenia e.g., inhibition of WBC/neutrophil production with whole body irradiation, or administration of chemotherapeutic drugs • Increased: increased WBC/neutrophil production in the BM and release in the peripheral blood • Increased: eosinophilia, e.g., as a component of allergic reactions • Increased: basophilia seen in various conditions 7 LO2. Identify the components of a complete blood count (CBC) and differential white blood cell (WBC Diff) count and their relevance to blood cell characteristics CBC: Platelets Platelets Count Changes Platelet count (109/L) • Increased: thrombocytosis, a rare condition • Decreased: thrombocytopenia, causes 150-400 x109/L - Decreased platelet survival - Sequestration (in hypersplenism) - Dilution (blood transfusions) Mean platelet volume (fL) 8 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) PBS and Nikon Microscope https://commons.wikimedia.org/wiki/File:Blood_smear_review.svg Reytan, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Nikon-Inverted_fluorescence_microscope.jpg ArthurLau1997, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons 9 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) PBS: Principles of Evaluation • • • • RBCs: size, shape, hemoglobin concentration, inclusion bodies WBCs: differential count, abnormal cell morphology Platelets: presence/absence, number, size Any abnormal cells/structures - Immature cells: erythroblasts, myeloblasts, lymphoblasts Atypical lymphocytes Megathrombocytes: very large platelets Parasites: malaria, babesia, filaria, etc. 10 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Normal Adult PBS: RBCs, WBCs (2 Neutrophils and 1 Monocyte), and Platelets 11 https://commons.wikimedia.org/wiki/File:Normal_Adult_Blood_Smear.JPG Keith Chambers, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Normal Adult PBS: RBCs, WBCs (4 Segmented Neutrophils), and Platelets https://commons.wikimedia.org/wiki/File:Neutrophils.jpg12 Dr Graham Beards, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Normal Adult PBS: RBCs and Platelets 13 ttps://commons.wikimedia.org/wiki/File:Blood-rbcs_and_thrombocytes2.jpg Echinaceapallida, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Variation in RBC Size (Anisocytosis, Related to MCV) https://commons.wikimedia.org/wiki/File:Irondeficiency_Anemia,_Peripheral_Blood_Smear_(4422704616).jpg Ed Uthman from Houston, TX, USA, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons Normocytic and normochromic (arrows) RBCs “Microcytic” and “hyperchromic” spherocytes in PBS (arrows) Microcytic and hypochromic RBCs Macrocytic RBCs (arrows) • Classification of anemias based on RBC size - Normocytic (MCV 80 - 100 fL), e.g., sickle-cell anemia - Microcytic (MCV < 80 fL), e.g., iron-deficiency anemia and thalassemia - • Spherocytes are sphere-shaped (not biconcave) RBCs with normal MCV, MCH, and MCHC Macrocytic (MCV > 100 fL), e.g., megaloblastic (B12 - and folate-deficiency) anemia 14 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Variation in RBC Color Intensity (“Chromia”, Related to MCH and MCHC) Normochromic and normocytic RBCs (all) Hypochromic and microcytic RBCs (almost all) • Classification of anemias based on RBC color “Hyperchromic”: and “microcytic” spherocytes (arrows) as seen in PBS; CBC analyzer would count those cells as normochromic and normocytic - Normochromic, e.g., sickle-cell anemia - Hypochromic with iron-deficiency and thalassemias as major causes - There is no hyperchromic anemia 15 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Spherocytes • Spherocytes (right image) are sphere-shaped (not biconcave) RBCs with normal MCV, MCH, and MCHC, aka spherocytes are normocytic and normochromic RBCs • Because of the shape, the spherocytes look smaller and hyperchromic • Spherocytes are seen in hereditary spherocytosis (HS) and immune hemolytic anemia (IHA) 16 https://openi.nlm.nih.gov/detailedresult?img=PMC4657338_12866_2015_604_ Fig3_HTML&query=rbc electron scanning&it=xg&lic=by&req=4&npos=7 Mustafa I, Al Marwani A, Mamdouh Nasr K, Abdulla Kano N, Hadwan T. Time Dependent Assessment of Morphological Changes: Leukodepleted Packed Red Blood Cells Stored in SAGM. Biomed Res Int. 2016;2016:4529434. doi: 10.1155/2016/4529434. Epub 2016 Jan 21. PMID: 26904677; PMCID: PMC4745630. LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Nucleated RBCs in Erythropoiesis 17 https://commons.wikimedia.org/wiki/File:Hematopoiesis_(human)_diagram.png A. Rad, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Nucleated RBCs unge Two proerythroblasts Orthochromatic erythroblast (normoblast) cytoplasminemaller Basophilic erythroblast Two orthochromatic erythroblasts (normoblasts) including one with enucleation 18 toplasm CY more red Two polychromatophilic erythroblasts Orthochromatic macrocyte reticulocytes * basophilic stippling: aggregates of ribosomes LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Variation in RBC Color (Polychromasia) and Reticulocytosis • Activation of erythropoiesis —> early release of immature RBCs from the BM • If PBS is stained with Wright-Giemsa, (grayish-blue or bluish-grey) immature RBCs are identified as polychromatophilic or orthochromic macrocytes (polychromasia/polychromatophilia) - The color is determined by presence of RNA in the cytoplasm • If PBS is stained with supra-vital stains, e.g., cresyl violet or new methylene blue, and presence of RNA molecules is identified, the cells are named as reticulocytes • Within 24-72 hours polychromatophilic macrocytes/reticulocytes 19 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Polychromasia vs Reticulocytosis Wright-Giemsa stain https://commons.wikimedia.org/wiki/File:Polychromasia.jpg Prof. Osaro Erhabor, CC0, via Wikimedia Commons Supravital new methylene blue stain 20 https://commons.wikimedia.org/wiki/File:Reticulocytes_Human_Blood_Supravital_Stain.jpg Ed Uthman, MD, pathologist, Houston, Texas, USA, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Reticulocyte Counts (RC) • A marker of erythropoietic activity - Normal reticulocyte count (RC) is <3% (reflects the daily replacement of ≈1.0% of the circulating RBC population) • % RC count is falsely increased in anemia because of destruction of mature RBCs in the spleen, for example; therefore correction in RC is required • Corrected reticulocyte count (CRC) = actual HCT/45 × RC - 45 represents normal HCT - E. g., in a patient with anemia: HCT is 15% and RC is 18%. CRC=15/45x18%=6% • In cases of RBC polychromasia two phenomena are observed - Early release of premature RBCs in the peripheral blood - Early maturation of reticulocytes (RNA expulsion) in the peripheral blood • Therefore, calculation of reticulocyte production index (RPI) is required: RPI = CRC/2 - E. g., in a patient with anemia: HCT is 15, RC is 18%, and polychromatophilic RBCs are - identified. RPI=6%/2=3% RPI <2: a severe defect in erythroid marrow proliferation or maturation 21 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Variation in RBC Shape (Poikilocytosis) • Spherocytes: round/spheroid in shape - Spheroid shape is difficult to appreciate in PBS - In PBS, spherocytes are smaller than ordinary RBCs and - hyperchromic (loss of central pallor due to accumulation Hb in the central area of RBC cytoplasm) Osmotically fragile Seen in hereditary spherocytosis and immune hemolytic anemia • Sickle cells (drepanocytes) seen in sickle cell anemia • Teardrop cell (dacrocytes) seen in myelofibrosis, marrow infiltration, etc. • Shistocytes (helmet cells) seen in anemias resulting from trauma to RBCs 22 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) Target Cells • Target cells (codocytes): too much cell membrane or too little cell volume —> accumulation of Hb in the central area of RBCs • Cells are osmotically resistant • Seen in hemoglobinopathies (S, C, thalassemias), iron deficiency, postsplenectomy 23 LO3. Recognize and interpret the characteristics evaluated in a peripheral blood smear (PBS) RBC Inclusions • Howell-Jolly bodies: nuclear remnants visualized with Wright-Giemsa stain - Howell-Jolly bodies are normally taken from the reticulocytes during their transit - through the interendothelial slits of the splenic sinuses Major causes od appearance: splenectomy, hyposplenism • Basophilic stippling: ribosomal aggregates that stain deep blue with WrightGiemsa stain - Supravital stains will reveal “reticulum” similar to observed in reticulocytes - Major causes: lead intoxication, thalassemia • Heinz bodies: aggregates of denatured proteins, primarily Hb produced in RBCs as a result of chemical insult - Heinz bodies are eliminated as RBCs traverse the endothelial slits of the splenic sinuses Not seen in Wright/Giemsa-stained blood films Identified with supravital stains only: brilliant cresyl blue or crystal violet Major cause: G6PD-deficiency anemia • Cabot rings: the ringlike or figure-of-eight structures probably originating from mitotic spindle - Major cause: megaloblastic anemia 24 LO4. Classify anemias based on morphology and underlying mechanisms, and identify a cause for each type of a (given) anemia Classification of RBC Disorders Major diagnostic criteria Polycythemia Types of Classification Types of Anemia ↑RBC count ↑Hb concentration ↑HCT Normocytic According to RBC size Microcytic Macrocytic Anemia ↓RBC count ↓Hb concentration ↓HCT According to RBC color Normochromic Hypochromic Post-hemorrhagic (due to blood loss) According to underlying mechanism 25 Hemolytic (due to increased RBC destruction) Impaired RBC production LO4. Classify anemias based on morphology and underlying mechanisms, and identify a cause for each type of a (given) anemia Classification of Anemias Bases on the Underlying Mechanisms Mechanism Classification Subcategory Disease Acute blood loss Posthemorrhagic Chronic blood loss Extravascular hemolysis Hemolytic Sickle cell anemia (SCA) Thalassemias Immune hemolytic anemia (IHA) G6PD-deficiency anemia Intravascular hemolysis Impaired RBC production Trauma, vessel/heart wall rupture Chronic GI or gynecologic diseases Hereditary spherocytosis (HS) G6PD-deficiency anemia Paroxysmal nocturnal hemoglobinuria (PNH) Anemia resulting from trauma to RBCs Anemia in malaria Aplastic anemia and pure red cell aplasia Megaloblastic anemias: B12- and folate-deficiency Anemia of chronic kidney disease Anemia of inflammation (AOI) Iron-deficiency anemia Thalassemias Marrow infiltration and/or replacement (myelophthisic anemia): acute leukemia, 26 myelodysplastic syndromes, metastases, sarcoidosis, etc. LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Hemolytic Anemias: Definitions • Hemolysis = premature destruction on RBCs • Sequelae - ↓ RBC cell life span < 120 days - Compensatory erythropoiesis: ↑elevated erythropoietin (EPO) and reticulocytosis • Anemia is the result of insufficiency in compensatory erythropoiesis - Retention of the products of degraded red cells (heme = 2+ Fe -protoporphyrin IX) • Protoporphyrin ring —> unconjugated hyperbilirubinemia • Iron —> hemosiderosis • Sites of hemolysis - Extravascular: within the macrophages of the spleen, liver, and lymph nodes - Intravascular: within the bloodstream 28 LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Extravascular Hemolysis: Mechanism Steps in Metabolic Transformation Sites and Mechanisms of Metabolic Transformation 1 Phagocytosis of RBC by macrophages Spleen > liver > lymph nodes macrophages with Anemia following destruction of RBCs and release of heme Splenomegaly 2 Heme —> biliverdin —> Liver and spleen macrophages with following unconjugated bilirubin (UCB) release of UCB into the bloodstream Splenomegaly, Jaundice 3 UCB —> conjugated (to Liver (hepatocytes) glucuronic acid) bilirubin (CB) ↑ serum CB Splenomegaly, Jaundice, Pigmented gallstones (calcium bilirubinate) 4 CB —> urobilinogen CB is secreted with bile to the duodenum, is deDark (brown) stools conjugated and converted to urobilinogen; in the large intestine, urobilinogen converts to stercobilin 5 Urobilinogen excretion Urobilinogen is absorbed from small intestine into the blood and is excreted by the kidneys Urobilinogen —> urobilin In the urine, when contacted with air, urobilinogen Intense-yellow urine oxidizes to urobilin (amber, honey) 29 Clinical features Labs Anemia ↑ serum UCB ↑ urinary urobilinogen LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Intravascular Hemolysis: Mechanism Steps of Metabolic Transformation Sites and Mechanisms of Metabolic Clinical Transformation Features Labs 1 Intravascular RBC damage Immune destruction, e.g., by C5b-9 Anemia Mechanical damage, e.g., by prosthetic valve 2 Release of free hemoglobin Free hemoglobin appears in the blood and is Cola-colored urine Hemoglobinemia secreted with urine (—> brown) Hemoglobinuria Low serum haptoglobin Binding of free hemoglobin Consumption of serum haptoglobin by haptoglobin Clearance of hemoglobin-haptoglobin Jaundice, Mildly ↑ serum UCB and CB complexes by tissue macrophages —> UCB Pigmented Normal-to-↑ urinary urobilinogen (as free hemoglobin is partially —> CB (liver) —> bile —> small intestine —> gallstones (calcium excreted with the kidneys, less amount urobilinogen —> blood —> urine bilirubinate) 3 Anemia with shistocytes of hemoglobin in converted to bilirubins and urobilinogen) 5 Synthesis and excretion of hemosiderin 1. Filtration of free hemoglobin through the glomerular basement membrane 2. Absorption of free hemoglobin by the renal tubular epithelium 3. Conversion fo hemoglobin to hemosiderin 4. Death of renal tubular epithelium with release of hemosiderin in the tubular lumen and following excretion30with urine Hemosiderinuria LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Major Steps in Extra- and Intravascular Hemolysis 3 1 A copyrighted Image from Springer LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Extra- vs Intravascular Hemolysis Criteria Extravascular Hemolysis Intravascular Hemolysis Site of hemolysis Clinical features Spleen, liver, and lymph node macrophages Splenomegaly Jaundice Moderately dark urine (yellow-orange, honey-colored) Pigmented gallstones Blood vessel lumen Jaundice Dark urine (coca-cola colored) Pigmented gallstones Labs: PBS ↑Corrected reticulocyte count (CRC, >3%) Spherocytes, spur cells, bite cells Labs: blood Shistocytes ↑Bilirubin (mainly unconjugated) Enzymes: ↑AST, normal ALT, ↑LDH No free hemoglobin Normal haptoglobin Hemoglobinemia ↓Haptoglobin Labs: urine No free hemoglobin No free hemosiderin ↑Urobilinogen Hemoglobinuria Hemosiderinuria Normal-to-↑urobilinogen Labs: BM Erythroid hyperplasia with cortical bone thinning Head x-ray: “crew-cut” (“hair-on-end”) and “chipmunk” appearance 3 2 LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Examples of Clinical Presentation of Hemolytic Anemias: Jaundice (G6PD-deficiency) and Splenomegaly (Malaria) https://commons.wikimedia.org/wiki/File:Jaundice.jpg Sab3el3eish, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Hyper-reactive_malarial_splenomegaly_(gross_splenomegaly_marked_on_the_patient_skin)_2015.png Stefania Leoni, Dora Buonfrate, Andrea Angheben, Federico Gobbi, Zeno Bisoffi, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons 33 LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Urinary Samples: Normal(1), Increased Urobilinogen/Urobilin (2), Increased Direct Bilirubin (3), Cola-Colored (4) 1 https://commons.wikimedia.org/wiki/File:Urinbecher.jpg Polarlys, CC BY-SA 3.0 <http://creativecommons.org/licenses/bysa/3.0/>, via Wikimedia Commons 2 3 4 Bilirubinuria - https://commons.wikimedia.org/wiki/File:Choluria.svg Jmarchn, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons 34 LO5. Compare and contrast the anemias with extra- and intravascular hemolysis in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation Hair-on-End or Crew-Cut: Permission Needed 35 LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease Bone Marrow (BM) Examination • Procedures - BM aspiration: to aspirate the tissue fluid - BM (trephine) biopsy: to get a piece (“column) of tissue • Indications - Evaluation of unexplained CBC results - Confirm/rule out the diagnosis of malignancy (cancer) • Primary BM cancers: leukemia and myeloma • Secondary BM cancers: metastatic tumors - Evaluation of iron stores - Evaluation of disseminated infection: tuberculosis, fungal disease - BM donor harvesting (aspiration) 36 LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease Sets for BM Aspiration and Trephine; Aspiration Procedure https://commons.wikimedia.org/wiki/File:Load_out_for_Bone_Marrow_Biopsy.jpg Thirteen Of Clubs from Minneapolis, CC BY-SA 2.0 <https://creativecommons.org/licenses/bysa/2.0>, via Wikimedia Commons https://commons.wikimedia.org/wiki File:Bone_marrow_biopsy.jpg Photographer’s Mate 2nd Class Chad McNeeley, Public domain, via Wikimedia Commons LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease BM Aspiration and Biopsy Technique • Sites: sternum, anterior iliac crest, posterior iliac crest (safest and the site of choice) • Position: prone, or on the contralateral to biopsy site • Surface anatomic landmarks: iliac crest identified by palpation • Biopsy site marked with indelible ink • Preparation: informed, written, and signed consent - Aseptic technique - Local anesthesia 38 LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease BM Aspirate, Wright Stain, Maturating WBCs https://commons.wikimedia.org/wiki/File:Bone_marrow_WBC.JPG Bobjgalindo, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons 39 LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease BM Trephine Biopsy, Wright Stain Normal BM trephine column https://commons.wikimedia.org/wiki/File:Bone_marrow_core_biopsy_microscopy_(trephine)_H&E_ panorama_by_gabriel_caponetti.jpg LO6. SELF-STUDY. Explain the indications for bone marrow aspirate and biopsy, as well as the results and its relevance to disease BM Trephine, Hypercellular BM in (Acute Megakaryoblastic Leukemia and Hypocellular BM, H&E Stain https://commons.wikimedia.org/wiki/File:AML-M7,_bone_marrow_section.jpg The Armed Forces Institute of Pathology (AFIP), Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:13256_2010_Article_1435_Fig1_HTML.webp Krista JM Stibbe, Hajo IJ Wildschut & Pieternella J Lugtenburg, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons The End 42