Bone marrow: Difference between revisions

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[[File:Trilineage hematopoiesis, annotated.jpg|thumb|Bone marrow aspirate showing normal "trilineage hematopoiesis":<br>- '''Myelomonocytic''' cells: an eosinophil myelocyte marked<br>- '''Erythroid''' cells: an orthochromatic erythroblast marked<br>- '''Megakaryocytic''' cells.]]

==Autopsy==

Using pliers or similar tool, squeeze some bone marrow from a rib.

===Microscopic evaluation===

*Confirm trilineage hematopoiesis (see image).

Line 14:

Line 16:

| '''Bone marrow''' from rib (or other location if applicable): Trilineage hematopoiesis. There is no evidence of malignancy.

|}

~~==Bone marrow aspirate==~~

Perform a '''differential count''' by counting 500 cells<ref name="pmid29757362">{{cite journal| author=Abdulrahman AA, Patel KH, Yang T, Koch DD, Sivers SM, Smith GH | display-authors=etal| title=Is a 500-Cell Count Necessary for Bone Marrow Differentials?: A Proposed Analytical Method for Validating a Lower Cutoff. | journal=Am J Clin Pathol | year= 2018 | volume= 150 | issue= 1 | pages= 84-91 | pmid=29757362 | doi=10.1093/ajcp/aqy034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29757362 }} </ref> and dividing the numbers by 5 to get their percentages. Don't count cells that don't have a cytoplasm or nucleus.

==Bone marrow biopsy==

Line 23:

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*'''Measure''' length and diameter of each fragment.

*If the biopsy is received in a zinc-containing fixative, '''rinse''' it for about 2 minutes, such as placing the cassette in a container under running water (and block any sink enough so that the cassette won't float away).

*Put in '''decalcifying''' solution, ~~generally~~ about 15 minutes, and palpate the specimen to check whether it is still firm. If it is, decalcify another 5-10 minutes and check again. Rather have it a little bit too soft than a little bit too firm.

[[File:Histopathology of bone marrow with insufficient decalcification.jpg|thumb|200px|Histopathology of bone marrow with '''insufficient decalcification''', wherein the bony trabeculae may get pushed by the microtome blade and plow away the cells of interest as displayed. To compensate, thicker sections may be taken, also making evaluation harder.]]

*Put in '''decalcifying''' solution, preferably using a type that is optimal for performing subsequent immunohistochemistry. Generally decalcify the specimen for about 15 minutes initially, and palpate the specimen to check whether it is still firm. If it is, decalcify another 5-10 minutes and check again. Rather have it a little bit too soft than a little bit too firm. Be careful to follow grossing guidelines for bone marrows, since even a small aberration in the processing is likely to be noticed as creating artifacts.

;Gross report example:

{|class=wikitable

The specimen is received in AZF solution and consists of __ core needle bone marrow biopsy fragment(s) measuring __ cm in length and 0.2 cm in diameter. The specimen is entirely submitted for microscopic examination in one cassette following decalcification.

| The specimen is received in AZF solution and consists of __ core needle bone marrow biopsy fragment(s) measuring __ cm in length and 0.2 cm in diameter. The specimen is entirely submitted for microscopic examination in one cassette following decalcification.

|}

===Microscopic evaluation===

Evaluate the following:

;Bone marrow aspirate

Find a location where bone marrow cells can be seen individually, preferably with minimal peripheral blood among them. Sometimes it is between trabeculae and sometimes it is in the surrounding area. Perform a '''differential count''' by counting 500 cells<ref name="pmid29757362">{{cite journal| author=Abdulrahman AA, Patel KH, Yang T, Koch DD, Sivers SM, Smith GH | display-authors=etal| title=Is a 500-Cell Count Necessary for Bone Marrow Differentials?: A Proposed Analytical Method for Validating a Lower Cutoff. | journal=Am J Clin Pathol | year= 2018 | volume= 150 | issue= 1 | pages= 84-91 | pmid=29757362 | doi=10.1093/ajcp/aqy034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29757362 }} </ref> and dividing the numbers by 5 to get their percentages. Don't count cells that don't have a cytoplasm or nucleus. If you receive several slides, count about the same number of cells from each slide, but don't count cells from slides where the cell types are more indistinct.

*'''Myeloid/erythroid ratio''', usually defined as the ratio between the number of neutrophil granulocytes and precursors versus the number of erythroblasts. Depending on source, the lower limit of the normal range for this ratio bone marrow aspirate smears in adults is 1 to 2, and the upper limit is 5 to 8.<ref name=Medicalkey>{{cite web|title=Chapter 5: Pathology of the marrow|url=https://basicmedicalkey.com/pathology-of-the-marrow-general-considerations-and-infectionsreactive-conditions/|website=Basicmedical Key|author=BJ. Bain|date=2017-02-19}}</ref> In histologic sections, the normal range is 1.5 – 3.0.<ref name=Medicalkey/> Some hematologists also include eosinophils, basophils and monocytes, as well as their precursors, in the myeloid number, but this has only a minor effect on the M:E ratio in normal individuals.<ref name=Medicalkey/> Still, if you are to calculate the value for a senior, check their preference first.

In a bone marrow count, '''nucleated red blood cells''' count into the total percentage of cells (but does not count into percentage of white blood cells in peripheral blood).

;Bone marrow biopsy, H&E stain

*'''Adequacy''': There should preferably be 5 intertrabecular spaces.

*'''Cellularity''': In patients 20-80 years, the percentage should be about 100 minus age, such as 40% in a 60 year old patient.

*'''Cellularity''': This is a rather rough estimation of the area of hematopoietic cells divided by the area of all intertrabecular matter, which otherwise mainly consists of fat cells and a small interstitial space. Areas of bone, hemorrhage or artifacts are not counted. In patients 20-80 years, the percentage should be about 100 minus age, such as 40% in a 60 year old patient.

*'''Thrombopoiesis''': There are normally about 3 megakaryocytes per 40x field.

*'''Myeloid/erythroid ratio''', usually defined as the ratio between the number of neutrophil granulocytes and precursors versus the number of erythroblasts. Depending on source, the lower limit of the normal range for this ratio bone marrow aspirate smears in adults is 1 to 2, and the upper limit is 5 to 8.<ref name=Medicalkey>{{cite web|title=Chapter 5: Pathology of the marrow|url=https://basicmedicalkey.com/pathology-of-the-marrow-general-considerations-and-infectionsreactive-conditions/|website=Basicmedical Key|author=BJ. Bain|date=2017-02-19}}</ref> In histologic sections, the normal range is 1.5 – 3.0.<ref name=Medicalkey/> Some hematologists also include eosinophils, basophils and monocytes, as well as their precursors, in the myeloid number, but this has only a minor effect on the M:E ratio in normal individuals.<ref name=Medicalkey/> Still, if you are to calculate the value for a senior, check their preference first.

*Look for any '''granuloma''' or '''cancer metastasis'''

~~In a bone~~ marrow ~~count~~, '''~~nucleated red blood~~ cells''' ~~count into~~ the ~~total percentage~~ of cells (~~but does not count into percentage of white blood~~ cells in ~~peripheral blood~~).

;Bone marrow biopsy, other stains

Generally including:

[[File:Ring sideroblast.jpg|thumb|210px|Ring '''sideroblast''', defined by five or more perinuclear iron granules that encompass at least 1/3 of the nuclear circumference.<ref>Salama M, Teruya-Feldstein J, Kremyankaya M. Atlas of Diagnostic Hematology. Philadelphia, PA: Elsevier; 2021.</ref>]]

*'''Iron stain''': Look at approximately 100 cells and semi-quantify the presence of any ring sideroblasts.

*'''Reticulin''' to grade the amount of fibrosis.

*'''CD3''' and '''CD20''' to highlight T and B cells, respectively.

====Microscopic report====

Example template:

{|class=wikitable

|

SOURCE:

:Bone marrow aspirate and biopsy

CLINICAL INFORMATION:

:{{Finding-begin}}Lymphocytosis / Pancytopenia / Anemia etc {{Finding-end}}

DIAGNOSIS:<br>PERIPHERAL BLOOD:

:{{Finding-begin}}Lymphocytosis / Pancytopenia / Anemia etc {{Finding-end}}

BONE MARROW, {{Finding-begin}}POSTERIOR ILIAC CREST,{{Finding-end}} ASPIRATE AND BIOPSY:

:{{Finding-begin}}Chronic/Acute lymphocytic/myeloid leukemia.{{Finding-end}}

:See description and comment.

GROSS DESCRIPTION:

:{{Comment-begin}}As per gross report above.{{Comment-end}}

MICROSCOPIC DESCRIPTION:

:

PERIPHERAL SMEAR:

|-

|

:WBC:__ x103/ul

:RBC:__ x106/ul

:HGB:__ g/dl

:HCT:__ %

:MCV:__ fl

:MCHC:__ g/dl

:RDW-CV:__ %

:PLT:__ x103/ul

:RETIC:__ %

|

DIFFERENTIAL(%):

:NEUTR/BANDS:_

:LYMPHS:_

:MONOS:_

:EOS:_

:BASOS:_

:BLASTS:_

:MYELOS:_

:METAS:_

:NRBCS/100WBCS:_

:PLASMA CELLS:_

|}

MORPHOLOGY:

*Red Blood Cells: No significant abnormality.

*White Blood Cells: No significant abnormality.

*Platelets: No significant abnormality.

BONE MARROW ASPIRATE:

:Left / RIGHT / UNDESIGNATED SITE

CELLULARITY ESTIMATE: Adequate. / Hypocellular and hemodilute. / Hypercellular. /

Too few cells for morphologic evaluation.

MARROW DIFFERENTIAL

*Erythroblasts: __%

*Blasts: __%

*Neutrophils/precursors: __%

*Eosinophils: __%

*Basophils: __%

*Lymphocytes: __%

*Monocytes: __%

*Plasma Cells: __%

*M:E ratio: __:__

ERYTHROPOIESIS: Maturing.

GRANULOPOIESIS: Maturing.

MEGAKARYOCYTES: Present.

LYMPHOCYTES: Mature.

PLASMA CELLS: Rare without atypia.

BONE MARROW TOUCH PREPARATION:

_

BONE MARROW BIOPSY:

:Left / RIGHT / UNDESIGNATED SITE

SPECIMEN ADEQUACY:

:Satisfactory. / Limited. / Unsatisfactory.

CELLULARITY:_

:_%: Normocellular / Hypercellular / Hypocellular for age. / Variable ( _ %- _ %, overall _ %) / Cannot assess cellularity due to small biopsy. {{Finding-begin}}With aspirative artifact.{{Finding-end}}

Decalcified bone marrow biopsy demonstrates ____________________

BM Erythropoiesis

_

BM Cellularity

_

BM Megakaryocytes

_

BM Myelopoiesis

_

BONE MARROW IRON STAIN:

Storage iron _/4 on aspirate smear with / without ring sideroblasts.

SPECIAL STAINS:

:Reticulin Stain: ___ reticulin fibrosis (_+/3+)

FLOW CYTOMETRY:

:No immunophenotypic evidence for abnormal myeloid maturation, an increase in blasts, or a lymphoproliferative disorder (see attached report).

COMMENT:

:{{Finding-begin}}Cytogenetic study and next generation sequencing panel for myeloid neoplasm are pending.{{Finding-end}}

:All stains have functional controls.

|}

==See also==

*[[Flow cytometry]]

</noinclude>

@@ Line 5: / Line 5: @@
 [[File:Trilineage hematopoiesis, annotated.jpg|thumb|Bone marrow aspirate showing normal "trilineage hematopoiesis":<br>- '''Myelomonocytic''' cells: an eosinophil myelocyte marked<br>- '''Erythroid''' cells: an orthochromatic erythroblast marked<br>- '''Megakaryocytic''' cells.]]
 ==Autopsy==
+Using pliers or similar tool, squeeze some bone marrow from a rib.
 ===Microscopic evaluation===
 *Confirm trilineage hematopoiesis (see image).
@@ Line 14: / Line 16: @@
 | '''Bone marrow''' from rib (or other location if applicable): Trilineage hematopoiesis.  There is no evidence of malignancy.
 |}
-==Bone marrow aspirate==
-Perform a '''differential count''' by counting 500 cells<ref name="pmid29757362">{{cite journal| author=Abdulrahman AA, Patel KH, Yang T, Koch DD, Sivers SM, Smith GH | display-authors=etal| title=Is a 500-Cell Count Necessary for Bone Marrow Differentials?: A Proposed Analytical Method for Validating a Lower Cutoff. | journal=Am J Clin Pathol | year= 2018 | volume= 150 | issue= 1 | pages= 84-91 | pmid=29757362 | doi=10.1093/ajcp/aqy034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29757362  }} </ref> and dividing the numbers by 5 to get their percentages. Don't count cells that don't have a cytoplasm or nucleus.
 ==Bone marrow biopsy==
@@ Line 23: / Line 22: @@
 *'''Measure''' length and diameter of each fragment.
 *If the biopsy is received in a zinc-containing fixative, '''rinse''' it for about 2 minutes, such as placing the cassette in a container under running water (and block any sink enough so that the cassette won't float away).
-*Put in '''decalcifying''' solution, generally about 15 minutes, and palpate the specimen to check whether it is still firm. If it is, decalcify another 5-10 minutes and check again. Rather have it a little bit too soft than a little bit too firm.
+[[File:Histopathology of bone marrow with insufficient decalcification.jpg|thumb|200px|Histopathology of bone marrow with '''insufficient decalcification''', wherein the bony trabeculae may get pushed by the microtome blade and plow away the cells of interest as displayed. To compensate, thicker sections may be taken, also making evaluation harder.]]
+*Put in '''decalcifying''' solution, preferably using a type that is optimal for performing subsequent immunohistochemistry. Generally decalcify the specimen for about 15 minutes initially, and palpate the specimen to check whether it is still firm. If it is, decalcify another 5-10 minutes and check again. Rather have it a little bit too soft than a little bit too firm. Be careful to follow grossing guidelines for bone marrows, since even a small aberration in the processing is likely to be noticed as creating artifacts.
 ;Gross report example:
 {|class=wikitable
-The specimen is received in AZF solution and consists of __ core needle bone marrow biopsy fragment(s) measuring __ cm in length and 0.2 cm in diameter. The specimen is entirely submitted for microscopic examination in one cassette following decalcification.
+| The specimen is received in AZF solution and consists of __ core needle bone marrow biopsy fragment(s) measuring __ cm in length and 0.2 cm in diameter. The specimen is entirely submitted for microscopic examination in one cassette following decalcification.
 |}
 ===Microscopic evaluation===
 Evaluate the following:
+;Bone marrow aspirate
+Find a location where bone marrow cells can be seen individually, preferably with minimal peripheral blood among them. Sometimes it is between trabeculae and sometimes it is in the surrounding area. Perform a '''differential count''' by counting 500 cells<ref name="pmid29757362">{{cite journal| author=Abdulrahman AA, Patel KH, Yang T, Koch DD, Sivers SM, Smith GH | display-authors=etal| title=Is a 500-Cell Count Necessary for Bone Marrow Differentials?: A Proposed Analytical Method for Validating a Lower Cutoff. | journal=Am J Clin Pathol | year= 2018 | volume= 150 | issue= 1 | pages= 84-91 | pmid=29757362 | doi=10.1093/ajcp/aqy034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29757362  }} </ref> and dividing the numbers by 5 to get their percentages. Don't count cells that don't have a cytoplasm or nucleus. If you receive several slides, count about the same number of cells from each slide, but don't count cells from slides where the cell types are more indistinct.
+*'''Myeloid/erythroid ratio''', usually defined as the ratio between the number of neutrophil granulocytes and precursors versus the number of erythroblasts. Depending on source, the lower limit of the normal range for this ratio bone marrow aspirate smears in adults is 1 to 2, and the upper limit is 5 to 8.<ref name=Medicalkey>{{cite web|title=Chapter 5: Pathology of the marrow|url=https://basicmedicalkey.com/pathology-of-the-marrow-general-considerations-and-infectionsreactive-conditions/|website=Basicmedical Key|author=BJ. Bain|date=2017-02-19}}</ref> In histologic sections, the normal range is 1.5 – 3.0.<ref name=Medicalkey/> Some hematologists also include eosinophils, basophils and monocytes, as well as their precursors, in the myeloid number, but this has only a minor effect on the M:E ratio in normal individuals.<ref name=Medicalkey/> Still, if you are to calculate the value for a senior, check their preference first.
+In a bone marrow count, '''nucleated red blood cells''' count into the total percentage of cells (but does not count into percentage of white blood cells in peripheral blood).
+;Bone marrow biopsy, H&E stain
 *'''Adequacy''': There should preferably be 5 intertrabecular spaces.
-*'''Cellularity''': In patients 20-80 years, the percentage should be about 100 minus age, such as 40% in a 60 year old patient.
+*'''Cellularity''': This is a rather rough estimation of the area of hematopoietic cells divided by the area of all intertrabecular matter, which otherwise mainly consists of fat cells and a small interstitial space. Areas of bone, hemorrhage or artifacts are not counted. In patients 20-80 years, the percentage should be about 100 minus age, such as 40% in a 60 year old patient.
 *'''Thrombopoiesis''': There are normally about 3 megakaryocytes per 40x field.
-*'''Myeloid/erythroid ratio''', usually defined as the ratio between the number of neutrophil granulocytes and precursors versus the number of erythroblasts. Depending on source, the lower limit of the normal range for this ratio bone marrow aspirate smears in adults is 1 to 2, and the upper limit is 5 to 8.<ref name=Medicalkey>{{cite web|title=Chapter 5: Pathology of the marrow|url=https://basicmedicalkey.com/pathology-of-the-marrow-general-considerations-and-infectionsreactive-conditions/|website=Basicmedical Key|author=BJ. Bain|date=2017-02-19}}</ref> In histologic sections, the normal range is 1.5 – 3.0.<ref name=Medicalkey/> Some hematologists also include eosinophils, basophils and monocytes, as well as their precursors, in the myeloid number, but this has only a minor effect on the M:E ratio in normal individuals.<ref name=Medicalkey/> Still, if you are to calculate the value for a senior, check their preference first.
 *Look for any '''granuloma''' or '''cancer metastasis'''
-In a bone marrow count, '''nucleated red blood cells''' count into the total percentage of cells (but does not count into percentage of white blood cells in peripheral blood).
+;Bone marrow biopsy, other stains
+Generally including:
+[[File:Ring sideroblast.jpg|thumb|210px|Ring '''sideroblast''', defined by five or more perinuclear iron granules that encompass at least 1/3 of the nuclear circumference.<ref>Salama M, Teruya-Feldstein J, Kremyankaya M. Atlas of Diagnostic Hematology. Philadelphia, PA: Elsevier; 2021.</ref>]]
+*'''Iron stain''': Look at approximately 100 cells and semi-quantify the presence of any ring sideroblasts.
+*'''Reticulin''' to grade the amount of fibrosis.
+*'''CD3''' and '''CD20''' to highlight T and B cells, respectively.
+====Microscopic report====
+Example template:
+{{Comprehensiveness|otherlegend=yes|noheader=yes}}
+{|class=wikitable
+|
+SOURCE:
+:Bone marrow aspirate and biopsy
+CLINICAL INFORMATION:
+:{{Finding-begin}}Lymphocytosis / Pancytopenia / Anemia etc {{Finding-end}}
+DIAGNOSIS:<br>PERIPHERAL BLOOD:
+:{{Finding-begin}}Lymphocytosis / Pancytopenia / Anemia etc {{Finding-end}}
+BONE MARROW, {{Finding-begin}}POSTERIOR ILIAC CREST,{{Finding-end}} ASPIRATE AND BIOPSY:
+:{{Finding-begin}}Chronic/Acute lymphocytic/myeloid leukemia.{{Finding-end}}
+:See description and comment.
+GROSS DESCRIPTION:
+:{{Comment-begin}}As per gross report above.{{Comment-end}}
+MICROSCOPIC DESCRIPTION:
+:
+PERIPHERAL SMEAR:
+{{col-begin|width=95%}}
+|-
+|
+:WBC:__ x103/ul
+:RBC:__ x106/ul
+:HGB:__ g/dl
+:HCT:__ %
+:MCV:__ fl
+:MCHC:__ g/dl
+:RDW-CV:__ %
+:PLT:__ x103/ul
+:RETIC:__ %
+|
+DIFFERENTIAL(%):
+:NEUTR/BANDS:_
+:LYMPHS:_
+:MONOS:_
+:EOS:_
+:BASOS:_
+:BLASTS:_
+:MYELOS:_
+:METAS:_
+:NRBCS/100WBCS:_
+:PLASMA CELLS:_
+|}
+MORPHOLOGY:
+*Red Blood Cells:  No significant abnormality.
+*White Blood Cells:  No significant abnormality.
+*Platelets:  No significant abnormality.
+BONE MARROW ASPIRATE:
+:Left / RIGHT / UNDESIGNATED SITE
+CELLULARITY ESTIMATE: Adequate. / Hypocellular and hemodilute. / Hypercellular. /
+Too few cells for morphologic evaluation.
+MARROW DIFFERENTIAL
+*Erythroblasts: __%
+*Blasts: __%
+*Neutrophils/precursors: __%
+*Eosinophils: __%
+*Basophils: __%
+*Lymphocytes: __%
+*Monocytes: __%
+*Plasma Cells: __%
+*M:E ratio: __:__
+ERYTHROPOIESIS: Maturing.
+GRANULOPOIESIS: Maturing.
+MEGAKARYOCYTES: Present.
+LYMPHOCYTES: Mature.
+PLASMA CELLS: Rare without atypia.
+BONE MARROW TOUCH PREPARATION:
+_
+BONE MARROW BIOPSY:
+:Left / RIGHT / UNDESIGNATED SITE
+SPECIMEN ADEQUACY:
+:Satisfactory. / Limited. / Unsatisfactory.
+CELLULARITY:_
+:_%:  Normocellular / Hypercellular / Hypocellular for age. / Variable ( _ %-  _ %, overall _ %) / Cannot assess cellularity due to small biopsy. {{Finding-begin}}With aspirative artifact.{{Finding-end}}
+Decalcified bone marrow biopsy demonstrates ____________________
+BM Erythropoiesis
+_
+BM Cellularity
+_
+BM Megakaryocytes
+_
+BM Myelopoiesis
+_
+BONE MARROW IRON STAIN:
+Storage iron _/4 on aspirate smear with / without ring sideroblasts.
+SPECIAL STAINS:
+:Reticulin Stain: ___ reticulin fibrosis (_+/3+)
+FLOW CYTOMETRY:
+:No immunophenotypic evidence for abnormal myeloid maturation, an increase in blasts, or a lymphoproliferative disorder (see attached report).
+COMMENT:
+:{{Finding-begin}}Cytogenetic study and next generation sequencing panel for myeloid neoplasm are pending.{{Finding-end}}
+:All stains have functional controls.
+|}
+<noinclude>
 ==See also==
 *[[Flow cytometry]]
 {{Bottom}}
+</noinclude>

Bone marrow: Difference between revisions

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