Bone Marrow Examination

Essentials

• Bone marrow examination is necessary for confirmation or exclusion of haematological malignancies.
• Often it is practical to refer the patient to such hospital outpatient clinic where also other investigations, such as flowcytometric analysis and/or cytomolecular genetic testing, can be performed. Factors to be taken into account when choosing the investigation place include experience of the staff in the respective location, patient's age, suspected disease and distance to the hospital.
• Peripheral blood smear and bone marrow iron stain are routinely examined together with the bone marrow examination. If necessary, bone marrow examination is supplemented with trephine biopsy / biopsy specimen (histological bone marrow specimen).

Indications for examination

• Bone marrow aspiration is used for the exclusion or confirmation/specification of the diagnosis of a blood disease. Bone marrow examination is also needed to determine the prognosis of a blood disease and to monitor the response to treatment (especially in a hospital setting).
• Bone marrow examination provides information that is essential or necessary for the diagnosis of several diseases. These include leukaemias Acute Leukaemias in Adults, myelodysplastic syndromes Myelodysplastic Syndromes (MDS), multiple myeloma Multiple Myeloma (Mm), Waldenström's macroglobulinaemia Waldenström's Macroglobulinaemia (WM), bone marrow metastases (biopsy specimen) and some storage diseases (biopsy specimen).
• Examination of a bone marrow aspiration sample provides preliminary or additional information also in several other diseases, e.g. aplastic anaemia, agranulocytosis, idiopathic thrombocytopenic purpura and hypersplenism.

Indications for bone marrow examination

• Undefined anaemia
• Undefined thrombocytopenia (associated with other changes in the blood picture, rarely as a solitary abnormality)
• Undefined leucocytopenia and neutropenia or agranulocytosis
• Pancytopenia
• Undefined leucocytosis
  • Chronic lymphatic leukemia (CLL) followed up often in primary care
  • Chronic myeloid leukemia (CML) requires hospital investigations
• Investigation of paraproteinemia
• Suspicion of plasma cell disease
• Undefined lymphadenopathy, splenomegaly, hepatomegaly (also biopsy specimen)
• Fever of unknown origin Prolonged Fever in the Adult
• Probable or possible bone marrow involvement of
  • haematological malignancy
  • metastatic malignancy.
• Follow-up of the treatment response of a haematologic malignancy
• Local bone pain if it is suspected that it is caused by a blood disease

Indications for trephine biopsy / biopsy specimen

Performance of bone marrow examination

• The usual sites of aspiration biopsy in adults are the sternum (video Bone Marrow Aspiration from Sternum) and the iliac crest (video Bone Marrow Aspiration from the Posterior Iliac Crest).
• Trephine samples / biopsy specimens are usually taken from the posterior iliac crest.
• In young children, from birth to 1(-2) years, the medial aspect at the border between the middle and upper third of the tibia is a good site. In older children the posterior iliac crest is the site of choice. This site can also be used for children younger than 2 years.

Interpretation

• Good collaboration between the clinician and the examiner (preferably a laboratory haematologist) is a prerequisite of successful bone marrow examination.
• The examiner should be provided with information about
  • clinical background (also medication)
  • size of the spleen and liver, icterus
  • lymph node status
  • current (at maximum a few days old) blood picture: haemoglobin, haematocrit, MCV, leucocyte count and differential, platelet count. In anaemia reticulocyte count is also useful.
• Fruitful collaboration requires that the examiner is active and clear as regards reporting the results and conclusions. An immediate contact is sometimes necessary if the findings demand an urgent response. Hence the examiner must be provided with the name and contact information (phone number, e-mail) of the clinician in charge.