Bone marrow histology. 3: Value of bone marrow core biopsy in acute leukaemia, myelodysplastic syndromes, and chronic myeloid leukaemia

Accuracy and Relative Value of Bone Marrow Aspiration in the Detection of Lymphoid Infiltration in non-Hodgkin Lymphoma

Aims and background

In hematologic malignancies, bone marrow aspiration is considered complementary to bone marrow biopsy for the detection of tumor infiltration. The present study evaluated the accuracy of bone marrow aspiration and the relative contributions of bone marrow aspiration and bone marrow biopsy in detecting bone marrow involvement by non-Hodgkin lymphomas.

Methods and study design

We compared 51 simultaneous marrow aspirates and core biopsies from non-Hodgkin lymphoma patients for sensitivity, specificity, concordance, quality and clinical relevance.

Results

The agreement level of bone marrow biopsy and bone marrow aspiration was 80%, and the overall sensitivity and specificity for bone marrow aspiration were 69% and 86%, respectively. When considering only the indolent non-Hodgkin lymphoma samples, the sensitivity of bone marrow aspiration was 82% and the specificity was 85%, whereas the sensitivity and specificity were 40% and 86%, respectively, in the aggressive non-Hodgkin lymphoma specimens. Five cases (10%) were reported in which bone marrow biopsy did not detect lymphoid infiltration even though the bone marrow aspiration was positive. In one of these, lymphoid infiltration was documented by a second bone marrow biopsy performed thereafter.

Conclusions

The data from the current study show that bone marrow aspiration is a useful procedure with which to detect bone marrow infiltration by lymphoma. Although it cannot be a substitute for examination of the marrow by core biopsy, the utility of adding an aspirate to bone marrow biopsy is supported by its earlier and easier availability for bone marrow examination, the larger amounts of marrow that can be examined with both procedures, and the percentage, although small, of potentially true-positive bone marrow aspirates with negative biopsies.

Bone marrow flow cytometry in staging of patients with B-cell non-Hodgkin lymphoma

Background

Bone marrow biopsies are routinely performed for staging patients with B-cell non-Hodgkin lymphoma (NHL). In addition to histomorphological studies, ancillary tools may be needed for accurate diagnosis. We investigated the clinical utility of multiparameter flow cytometric examination of bone marrow aspirates.

Methods

A total of 248 bone marrow specimens from 232 patients diagnosed with B-cell NHL were examined. Monoclonal antibodies directed against CD19, CD20, CD10 (or CD5), and κ and λ immunoglobulins were used. Multi-stage sequential gating was performed to select specific cells of interest, and the results were compared with bone marrow histology.

Results

The concordance rate between histomorphology and flow cytometry was 91.5% (n=227). Eight cases (3.2%) were detected by flow cytometry alone and were missed by histomorphology analysis, and 6 of these 8 cases showed minimal bone marrow involvement (0.09-2.2%). The diagnosis in these cases included large cell lymphoma (n=3), mantle cell lymphoma (n=3), and mucosa-associated lymphoid tissue (MALT) lymphoma (n=2). Thirteen cases were histopathologically positive and immunophenotypically negative, and the diagnoses in these cases included diffuse large cell lymphoma (n=7), T-cell/histiocyte-rich large B-cell lymphoma (n=2), anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma (n=1), follicular lymphoma (n=1), MALT lymphoma (n=1), and unclassifiable lymphoma (n=1).

Conclusions

Multi-color flow cytometry can be a useful method for assessing bone marrow in staging NHL and also plays a complementary role, especially in detecting small numbers of lymphoma cells.

Advances in the pathological diagnosis and biology of acute lymphoblastic leukemia

An accurate diagnosis of acute lymphocytic leukemia requires careful examination of the morphology, immunophenotype, genetic features, clinical characteristics, and molecular findings. This multiparametric approach should be used to achieve optimal evaluation of every suspected case of acute lymphocytic leukemia.

Clinical, haematological and histomorphological profile of adult myelodysplastic syndrome. Study of 96 cases in a single institute

Myelodysplastic syndromes (MDS) are clonal haematopoietic stem cell disorders characterised by ineffective and dyspoietic haematopoiesis. The natural history of these disorders is variable and ranges from a chronic to a rapid course towards leukaemic progression. Certain shortcomings have been encountered in the French-American-British (FAB) classification over the years, and therefore there is a need for an alternative method of classification. In 1999, the WHO published a revised classification of MDS. In the present study, we have analysed the clinical, haematological and histomorphological features in 96 cases of primary MDS seen in the department of haematology at the All India Institute of Medical Sciences (AIIMS) over a 6-yr period (1996-2001). Both FAB and WHO classifications have been incorporated and the Bournemouth scoring system applied in each case at presentation. The Bournemouth scoring system, in the absence of a cytogenetic study, offers a good prognostication and long-term survival estimate.

Pathologic diagnosis of acute lymphocytic leukemia

With present knowledge, the optimal management of individual patients with acute leukemia requires that every case be studied by morphology, cytochemistry, cytogenetic, immunologic and molecular techniques. An algorithm for diagnostic evaluation and classification of ALL is provided in Fig. 11. Other techniques, such as DNA or cDNA [figure: see text] microarray, are at present important research tools but have not yet had a major effect on patient care. More detailed studies of individual patients need to be conducted at specialized cancer centers, where preservation of cells, DNA, RNA, or protein is possible. Such investigations will yield important information on the clinical importance of the expression of various markers, the prevalence and relevance of bilineage and biphenotypic leukemias, and above all will reveal the mechanisms of leukemogenesis and of disease evolution. Such insights will further aid clinicians in treating ALL and in preventing refractory disease.

Clinical course and therapy of chronic myelogenous leukemia with interferon-alpha and chemotherapy

This article begins with a review of the natural history of chronic myelogenous leukemia (CML), with an emphasis on prognostic features. Current standard therapy of CML with interferon-alpha based regimens, and interferon-alpha, in the context of allogenic stem cell transplantation is then discussed. Finally, some potentially effective novel agents including homoharringtonine, decitabine, ATRA, and topotecan are described.

Comparative utility of diagnostic bone-marrow components: a 10-year study

Ten years of cumulative experience represented by 4,902 consecutive diagnostic bone-marrow examinations at a tertiary care and referral center were reviewed to assess the value of specific components. While it has been shown previously that the information obtained from each component is generally complementary, the inclusion of some or all components may vary between institutions. The components studied included aspirate smears, clot sections, biopsy cores, and touch imprints of biopsy and clot sections. Three clinical presentations accounted for the majority of cases: staging for carcinoma or lymphoma, cytopenias, and acute leukemia. We conclude that bilateral aspirates with biopsies are required for diagnosis in staging of neoplasms and that a unilateral aspirate with biopsy is sufficient to assess patients with cytopenia or leukemia. Only rarely were touch imprints of biopsy cores necessary to establish a diagnosis; however, their early availability prior to examining sections of the clot and core did provide immediate information, when positive, in the staging of patients with carcinoma. In a small percentage of staging and leukemia cases the diagnosis rested with the clot section alone. The findings in this study address common assumptions associated with routine diagnostic hematology and oncology procedures, and are important to both clinicians and pathologists concerned with accuracy, quality assurance, turnaround time, and cost containment.

Importance of the day 7 bone marrow biopsy as a prognostic measure of the outcome in children with acute lymphoblastic leukemia

The presence of > or = 25% blasts in a marrow aspirate obtained on day 7 of induction followed by a remission at day 28 has been associated with a poor prognosis in children with acute lymphoblastic leukemia (ALL). We evaluated whether a day 7 marrow biopsy may be used to more accurately assess therapeutic reduction of leukemia tumor burden. Studied were 76 children with ALL enrolled on CCG protocols at B.C's Children's Hospital who received both a day 7 aspirate and biopsy and were in remission by day 28. Evaluation for the correlation of the percentage aspirate blasts on day 7 with the biopsy demonstrated a moderate correlation with the percentage biopsy blasts (R = 61), but not correlation with the biopsy cellularity. We saw a similar prediction of outcome by the percentage blasts on day 7 marrow aspirate in the study as reported previously although it was not significant. Outcome analysis was done using leukemia burden as measured by the day 7 absolute blast index-aspirate (ABI-aspirate) calculated as the product of the biopsy cellularity with the percentage blasts on the aspirate. The ABI-aspirate significantly predicted patient outcome with 83% survival in those with an ABI-aspirate of < .06 compared to 51% in those > or = .06 (P = .01) and was highly significant when analyzed as a continuous predictor (P = .004). This is the first study to demonstrate that information gained from the day 7 marrow biopsy can improve prediction of outcome in children with ALL. Based on this preliminary study, we recommend that large population ALL therapy trials evaluate the role of the day 7 marrow biopsy for outcome prediction in children with ALL.

Bone marrow one step fixation-decalcification in Lowy FMA solution: an immunohistological and in situ hybridization study

The immunoreactivity of paraffin embedded bone marrow biopsies (BMB) was studied following a one step 20-hour-fixation-decalcification in Lowy formalin mercuric chlorid acid solution which permits excellent histological stainings. Antibodies reactive with myeloid, megakaryocytic, erythroid cells, T and B lymphocytes, mastocytes and metastatic cells were compared. Nearly all antibodies working on paraffin sections were demonstrated on Lowy FMA fixed BMB. Special care was taken to define an optimal working dilution. Trypsinization was not necessary. A slide microwave pre-treatment appeared essential before testing CD20 L26, CD8, CD3, CD34, MB1 Kappa and Lambda antibodies. It was suitable for UCHL1, LN2, CD30 antibodies. The same fixative allowed an m RNA Kappa or Lambda in myeloma and EBER 1 EBV RNAs in HIV lymphoma visualization by in situ hybridization. The safety handling of the toxic mercuric chloride component is discussed.

Collagenase digestion of bone marrow trephine biopsy specimens: an important adjunct to haematological diagnosis when marrow aspiration fails

Failure to obtain sufficient material from marrow aspiration (dry tap) posed a diagnostic problem in two patients with pancytopenia. By using collagenase digestion of the trephine biopsy specimen, a precise diagnosis was reached. This technique is very useful because it permits flow cytometric and immunocytochemical analyses of cell suspensions obtained after collagenase digestion of the trephine biopsy specimen core. Acute leukaemia presenting with a dry tap can therefore be accurately immunophenotyped. The technique is easy to perform and merits wider use.