A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination

Bone Marrow Biopsies: Is CT, Fluoroscopy, or no Imaging Guidance the Most Cost-Effective Strategy?

RATIONALE AND OBJECTIVES

To determine the most cost-effective strategy for pelvic bone marrow biopsies.

MATERIALS AND METHODS

A decision analytic model from the health care system perspective for patients with high clinical concern for multiple myeloma (MM) was used to evaluate the incremental cost-effectiveness of three bone marrow core biopsy techniques: computed tomography (CT) guided, and fluoroscopy guided, no-imaging (landmark-based). Model input data on utilities, costs, and probabilities were obtained from comprehensive literature review and expert opinion. Costs were estimated in 2023 U.S. dollars. Primary effectiveness outcome was quality adjusted life years (QALY). Willingness to pay threshold was $100,000 per QALY gained.

RESULTS

No-imaging based biopsy was the most cost-effective strategy as it had the highest net monetary benefit ($4218) and lowest overall cost ($92.17). Fluoroscopy guided was excluded secondary to extended dominance. CT guided biopsies were less preferred as it had an incremental cost-effectiveness ratio ($334,043) greater than the willingness to pay threshold. Probabilistic sensitivity analysis found non-imaging based biopsy to be the most cost-effective in 100% of simulations and at all willingness to pay thresholds up to $200,000.

CONCLUSION

No-imaging based biopsy appears to be the most cost-effective strategy for bone marrow core biopsy in patients suspected of MM.

CLINICAL RELEVANCE

No imaging guidance is the preferred strategy, although image-guidance may be required for challenging anatomy. CT image interpretation may be helpful for planning biopsies. Establishing a non-imaging guided biopsy service with greater patient anxiety and pain support may be warranted.

An Extensive Analysis and Comparison of Bone Marrow Aspiration and Bone Marrow Trephine Biopsy at a Tertiary Care Hospital in Jharkhand for Various Hematological and Non-hematological Illnesses

Background Bone marrow examination (BME) is an indispensable diagnostic tool to evaluate various hematological and non-hematological disorders. Bone marrow aspirate cytology and bone marrow trephine biopsy, even though performed simultaneously, are assessed at different points in time due to different processing methods. Aims and objective This study aims to assess and compare the role of bone marrow aspiration and trephine biopsy to formulate an effective and rapid method for diagnosing a wide spectrum of various hematological and non-hematological disorders. Materials and methods The approach of our study was a hospital-based prospective study conducted on 200 patients over a period of 1 year. The role of bone marrow aspiration and a trephine biopsy is to formulate an effective and rapid method for diagnosing a wide spectrum of hematological and non-hematological disorders. Results In our study, a total of 200 cases were studied, of whom 119 patients were male and 81 were female. The most common finding was erythroid hyperplasia, comprising 40 (20%) cases, followed by hypoplastic marrow, comprising 28 (14%) cases. Subsequently, there were 19 (9.5%) cases of acute leukemia, while 15 (7.5%) cases of chronic myeloid leukemia (CML) in the chronic phase were found. In our study, bone marrow aspirate and bone marrow trephine biopsy were found to positively correlate in 137 (68.5%) of the cases. Conclusion Bone marrow aspiration alone is sufficient for the diagnosis of megaloblastic anemia and most of the hematological malignancies. Bone marrow trephine biopsy is more appropriate for the detection of disorders of focal marrow involvement such as lymphoproliferative disorders and staging of lymphomas, metastatic cancers, granulomatous lesions, and hypoplastic marrow. However, it is strongly recommended that both procedures should be done simultaneously to ensure maximum diagnostic accuracy.

Factors Affecting Diagnostic Yield of Lesional Bone Biopsy in Hematologic Malignancy Patients

PURPOSE

To evaluate factors affecting the diagnostic yield (percent of biopsy samples leading to a pathologic diagnosis) of lesional bone biopsies in patients with hematologic malignancies.

MATERIALS AND METHODS

This retrospective study included 206 lesional bone biopsies in 182 patients with a hematologic malignancy between January 2017 and December 2022. The parameters that were reviewed to evaluate diagnostic yield included biopsy device type (manual vs. electric-powered drill), number of biopsy cores acquired, core biopsy needle gauge, preliminary intra-procedural sample adequacy (touch preparation cytology determining if samples are adequate for final pathologic examination), lesion morphology on Computed Tomography (CT), and presence of crush artifact.

RESULTS

Review of 206 lesional biopsies showed overall diagnostic yield to be 89.8% (185/206). The two statistically significant factors affecting diagnostic yield were biopsy device type and in-room adequacy. 41/42 samples obtained with the electric-powered drill and 144/164 samples obtained using a variety of manual needles were diagnostic (97.6% vs 87.8%, p = 0.03). Of the 192 samples that were assessed for sample adequacy intra-procedurally, 97/102 of the samples that were deemed adequate were diagnostic, and 77/90 of the samples where intra-procedural adequacy was not confirmed were diagnostic (95.1% vs 85.6%, p = 0.018). The remaining factors did not affect diagnostic yield.

CONCLUSION

The use of an electric-powered drill bone biopsy device and intra-procedural confirmation of sample adequacy are associated with a higher diagnostic yield of lesional bone biopsies in patients with hematologic malignancies. The presence or absence of crush artifact did not significantly affect the diagnostic yield in these patients.

LEVEL OF EVIDENCE IV

The Effect of Video Streaming With Virtual Reality on Anxiety and Pain During Bone Marrow Aspiration and Biopsy Procedure

BACKGROUND

Pain and anxiety are among the most common symptoms in patients undergoing invasive procedures. Increased pain levels tend to worsen anxiety, and anxiety often leads to more frequent or severe pain.

AIMS

The study was conducted to determine the efficacy of virtual reality goggles (VRG) on pain and anxiety during bone marrow aspiration and biopsy (BMAB) procedure.

DESIGN

A randomized controlled experimental study.

SETTINGS

The outpatient unit of an adult hematology clinic of a tertiary care university hospital.

PARTICIPANTS/SUBJECTS

The study was conducted in patients aged 18 years and older who underwent a BMAB procedure. Thirty-five patients in the experimental (VRG) group and 40 patients in the control group.

METHODS

Patient identification form, visual analogue scale (VAS), state and trait anxiety inventory (STAI), and VRG were used to collect the data.

RESULTS

Postprocedural state anxiety mean scores were found to be statistically significantly higher in the control group than in the VRG group (p = .022). A statistically significant difference was found between groups in terms of procedure-related pain (p = .002). The postprocedural mean pain scores were found to be statistically significantly higher in the control group than in the VRG group (p < .001). A statistically significant but moderate positive correlation was found between the postprocedural pain and preprocedural state anxiety variable (r = 0.477). A statistically significant and strong positive correlation was found between the postprocedural pain and the postprocedural state anxiety variable (r = 0.657). A statistically significant but moderate positive relationship was found between preprocedural and postprocedural state anxiety variables (r = 0.519).

CONCLUSIONS

We determined that video streaming with VRG reduces pain and anxiety felt by adult patients during the BMAB procedure. VRG can be recommended to use in controlling pain and anxiety in patients undergoing a BMAB procedure.

Bone biopsy devices - a patent review

INTRODUCTION

Bone biopsies have great value for the diagnosis of, amongst others, hematologic diseases. Although the bone biopsy procedure is mostly performed minimally invasive with the use of a slender cannula, the patient may still experience discomfort, especially when the procedure has to be repeated due to an unsuccessful biopsy.

AREAS COVERED

This review presents a comprehensive overview of bone biopsy devices presented in the patent literature. The patents were obtained using a classification search combined with keywords in the Espacenet patent database and were subsequently verified using pre-set eligibility criteria. This resulted in 62 unique patents included in this review.

EXPERT OPINION

The included patents were categorized based on the used strategies for the three steps that can be identified during a bone biopsy (1) biopsy sampling, (2) biopsy severing and (3) biopsy harvesting. Most patents described strategies for multiple steps. Insight into the used strategies and the comprehensive overview may serve as a source of inspiration for the design of novel bone biopsy devices.

AMLnet, A deep-learning pipeline for the differential diagnosis of acute myeloid leukemia from bone marrow smears

Acute myeloid leukemia (AML) is a deadly hematological malignancy. Cellular morphology detection of bone marrow smears based on the French-American-British (FAB) classification system remains an essential criterion in the diagnosis of hematological malignancies. However, the diagnosis and discrimination of distinct FAB subtypes of AML obtained from bone marrow smear images are tedious and time-consuming. In addition, there is considerable variation within and among pathologists, particularly in rural areas, where pathologists may not have relevant expertise. Here, we established a comprehensive database encompassing 8245 bone marrow smear images from 651 patients based on a retrospective dual-center study between 2010 and 2021 for the purpose of training and testing. Furthermore, we developed AMLnet, a deep-learning pipeline based on bone marrow smear images, that can discriminate not only between AML patients and healthy individuals but also accurately identify various AML subtypes. AMLnet achieved an AUC of 0.885 at the image level and 0.921 at the patient level in distinguishing nine AML subtypes on the test dataset. Furthermore, AMLnet outperformed junior human experts and was comparable to senior experts on the test dataset at the patient level. Finally, we provided an interactive demo website to visualize the saliency maps and the results of AMLnet for aiding pathologists' diagnosis. Collectively, AMLnet has the potential to serve as a fast prescreening and decision support tool for cytomorphological pathologists, especially in areas where pathologists are overburdened by medical demands as well as in rural areas where medical resources are scarce.

Skin and Bone Regeneration of Solid Bone Marrow Aspirate Concentrate Versus Platelet-Rich Fibrin

Solid bone marrow aspirate concentrate (sBMAC) is harvested from bone marrow aspirate without anticoagulants by a centrifugation protocol similar to that for platelet-rich fibrin (PRF) prepared from peripheral blood. It was hypothesized that sBMAC could accelerate not only wound healing but also bone regeneration because of the abundant growth factor (GF) releases from enriched bone marrow cells. The purpose of the present study was to investigate skin wound healing and bone regenerative potential of sBMAC compared with arterial blood-derived PRF (Ar-PRF) and venous blood-derived PRF (Ve-PRF) in a skin defect and calvarial bone defect model in rabbits. GF release assays revealed significantly higher release of transforming growth factor-β (TGF-β), alkaline phosphatase (ALP), and osteocalcin (OCN) from sBMAC compared with PRFs for 24 h. In the skin defect animal model, sBMAC and PRFs promoted wound bed angiogenesis and re-epithelization in skin defect sites with higher collagen 1 synthesis, cytokeratin AE1/AE3, vascular endothelial growth factor (VEGF) expressions on week 1. Furthermore, a calvarial defect assay revealed that sBMAC promoted new bone formation with a sufficient bone marrow structure similar to that of intact bone in the bone defects. Ar-PRF achieved the second highest bone closure and new bone volume but yielded new bone that was thinner than the intact bone. In conclusion, sBMAC treatment might be a good option instead of PRF as an adjuvant therapy for both skin and bone tissue regeneration therapies in certain clinical situations. Impact statement Solid bone marrow aspirate concentrate (sBMAC) is new type of clot material prepared from bone marrow aspirate. The present study for the first time showed that sBMAC significantly accelerated both skin wound healing and bone formation in the defects, compared with conventional platelet-rich fibrin in rabbit experiment models.

Etiological Profiles of Patients With Thrombocytopenia in Central India: A Tertiary Centre Study

Introduction Platelet-related disease may result from an abnormal platelet count, namely thrombocytopenia or thrombocythemia, or altered platelet function, and thus is associated with bleeding or with thrombotic manifestation. Thrombocytopenia is defined as a subnormal number of platelets i.e. less than 1,50,000/µL in the peripheral blood. It can lead to inadequate clot formation and increased risk of bleeding and is a common indication for bone marrow aspiration and biopsy. Methodology The study was a hospital-based prospective observational study from January 2019 to June 2020. All cases of thrombocytopenia which were diagnosed first on haematology analyser (platelet counts <150,000/µL) and confirmed subsequently by peripheral smear with/without bleeding manifestations due to thrombocytopenia were taken up for the study. The aims and objectives of this study were to find out the epidemiological spectrum and prevalence of thrombocytopenia according to age and sex along with the correlation of haematological and bone marrow findings of such patients. Result This study comprised 100 cases of thrombocytopenia, with acute leukaemia accounting for the majority (28/100), followed by dimorphic anaemia (15/100), megaloblastic anaemia (11/100), hypocellular marrow, infection, and other conditions. All cases (100%) displayed the clinical symptom of widespread weakness and pallor, which was followed by fatiguability (72%) and dyspnoea (48%). Many thrombocytopenic individuals also had lymphadenopathy and hepatomegaly, the last two least common appearances. Lymphadenopathy and hepatomegaly which were the last two least common presentations were present in a significant number of thrombocytopenic patients. Conclusion The study of bone marrow is helpful in the diagnosis of thrombocytopenia cases. Bone marrow examination is a simple, safe outpatient procedure and yields an impressive amount of diagnostically valuable data in a wide variety of disorders of thrombocytopenia. An evaluation of the patient's bone marrow unquestionably aids in the early diagnosis and treatment of their ailment.

The necessity of bilateral staging bone marrow examinations for paediatric solid tumours

Background: Bone marrow aspirates and trephine biopsies (BMATs) form an important part of staging to detect bone marrow metastases of both haematological and nonhaematological neoplasms.Aim: The study’s primary aim was to determine whether it is necessary to perform bilateral BMATs on paediatric cancer patients as opposed to unilateral BMATs for the staging of solid tumours.Setting: The Paediatric Oncology Unit at Universitas Academic Hospital (UAH) in Bloemfontein, Free State, South Africa.Methods: A retrospective descriptive study was performed using laboratory reports from 01 January 2015 to 31 December 2019. Data were collected and reported on regarding the total number of staging BMATs performed, the average length of the trephine biopsies, the number of BMATs used for primary diagnosis, the number of bone marrow specimens where metastases were detected (left, right or both), the type of primary cancer and demographic information.Results: One hundred and eighteen patients were included for interpretation. Bone marrow metastases were detected in 28 patients, of which five patients had discrepant left and right results. These five cases included nephroblastoma (n = 2), Hodgkin lymphoma (n = 2) and a germ cell tumour (n = 1).Conclusion: Discrepant results were found in five cases (n = 28; 17.8%). Ultimately, the clinical implication of incorrectly staging solid tumours outweighs the small risks and discomfort of a bilateral bone marrow biopsy.

Of drills and bones: Giovanni Ghedini and the origin of bone marrow biopsy

Bone marrow (BM) studies are pivotal for the diagnosis of haematological disorders. Their introduction into clinical haematology dates back to the work of Giovanni Ghedini (1877-1959), an Italian physician who first conceived BM sampling in 1908. Ghedini's proposal stemmed from his clinical experience and from the scientific developments that characterised his epoch. By presenting selected passages of Ghedini's publications, this report considers the theoretical and historical bases of his work and analyses its practical implications for modern haematology.

Bone Marrow Collection: Comparison of Unassisted vs Assisted Bedside Collections by a Laboratory Technologist

OBJECTIVES

Bone marrow collections are often difficult, and creating quality smears and touch preparations at the bedside can prove challenging. The objective of this study is to compare the quality of bone marrow specimens between unassisted and assisted bone marrow collections by a bone marrow technologist.

METHODS

Data for this study were collected from 422 hematopathology reports over 14 months. We recorded the bone marrow quality of the different parts (aspirate smears, touch imprints, core biopsy, and clot/particle sections) as adequate, suboptimal, or inadequate. Student t test statistical analysis was performed between the corresponding parts in the two groups.

RESULTS

Our results demonstrate that the quality of assisted bone marrow specimens is significantly better compared with unassisted specimens, particularly for the aspirate smears (P < .0001) and touch imprints (P < .0001). Notably, the quality of aspirate smears was improved, which is important for cytologic evaluation.

CONCLUSIONS

We conclude that assistance by a bone marrow technologist resulted in a significant improvement in the quality of bone marrow collection.

Regenerative Potential of Solid Bone Marrow Aspirate Concentrate Compared to Platelet-Rich Fibrin

Platelet-rich fibrin (PRF) prepared from venous blood is used in the clinic to improve soft tissue wound healing. Nevertheless, arterial blood or bone marrow aspirate might also be a candidate for the source of PRF-like concentrates. The purpose of the present study was to investigate blood/bone marrow aspirate concentrates obtained from arterial blood, venous blood, and bone marrow aspirate to determine its respective regenerative potential in vitro. Arterial blood-derived PRF (Ar-PRF), venous blood-derived PRF (Ve-PRF), and solid bone marrow aspirate concentrate (sBMAC) were prepared from New Zealand white rabbits. Each clot was evaluated for its cytocompatibility and regenerative potential on primary rabbit gingival fibroblasts and osteoblasts. Both gingival fibroblasts and osteoblasts treated with each concentrate showed excellent viability. Interestingly, the sBMAC-treated cells demonstrated significantly greater migratory potential than the other treatment groups. Furthermore, higher mRNA levels of transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF) and collagen I (COL1) in gingival fibroblasts were observed in sBMAC group compared with Ar-PRF and Ve-PRF groups. Greater osteoblast differentiation potential, including higher osteocalcin (OCN) expression and mineralization potential, was found in osteoblasts treated with sBMAC. However, minor differences between the behaviors of cells treated with Ar-PRF and Ve-PRF were observed. In conclusion, sBMAC might be a new candidate for promoting wound healing and bone regeneration. Further preclinical and clinical experiments are necessary to prove the regenerative potential of sBMAC in the body.

Diagnostic importance of bone marrow aspiration evaluation: A single-center study

Background & Objective

Early diagnosis can be made based on the morphological examination of bone marrow aspiration (BMA) until the bone marrow biopsy (BMB) result is reported. This allows for treatment to be started immediately, especially in hematological malignancies for which urgent treatment is indicated. This study aimed to determine the sensitivity and importance of bone marrow aspiration in the diagnosis of hematological malignancies.

Methods

In this study, the data of patients who underwent bone marrow aspiration and bone marrow biopsy in Van Yuzuncu Yil University hospital between 2017 and 2019 were retrospectively analyzed. A total of 500 patients who simultaneously underwent BMA and BMB were included in the study. Data were obtained from electronic medical records.

Results

Indication for bone marrow evaluation was abnormalities in complete blood count in 270 (54%) of patients. The diagnosis was made based on the evaluation of BMA in 475 (95%). In 456 (96%) of the 475 patients diagnosed with BMA, the diagnosis was consistent with that of BMB. Agreement of BMB with BMA was 100% in acute and chronic leukemias, while BMA was not sufficient for the diagnosis of lymphoma and solid organ metastasis.

Conclusion

Our study showed that the evaluation of BMA was highly sensitive in the diagnosis of hematological malignancies, such as acute leukemias, chronic leukemias, and multiple myeloma.

Impact of the Process Variables on the Yield of Mesenchymal Stromal Cells from Bone Marrow Aspirate Concentrate

Human bone marrow (BM) has been highlighted as a promising source of mesenchymal stromal cells (MSCs) containing various growth factors and cytokines that can be potentially utilized in regenerative procedures involving cartilage and bone. However, the proportion of MSCs in the nucleated cell population of BM is only around 0.001% to 0.01% thereby making the harvesting and processing technique crucial for obtaining optimal results upon its use in various regenerative processes. Although several studies in the literature have given encouraging results on the utility of BM aspiration concentrate (BMAC) in various regenerative procedures, there is a lack of consensus concerning the harvesting variables such as choice of anesthetic agent to be used, site of harvest, size of the syringe to be used, anticoagulant of choice, and processing variables such as centrifugation time, and speed. In this review article, we aim to discuss the variables in the harvesting and processing technique of BMAC and their impact on the yield of MSCs in the final concentrate obtained from them.

Bone marrow aspiration and biopsy: techniques and practice implications

Bone marrow aspiration and biopsy (BMAB) is a valuable diagnostic procedure commonly performed for evaluation of a wide spectrum of diseases including hematologic abnormalities, nonhematologic malignancies, metabolic abnormalities, and tumor treatment response such as chemotherapy and bone marrow transplantation, hematologic tumor staging, and suspected infection in patients with fever of unknown origin. This minimally invasive intervention offers excellent safety profile and a high diagnostic yield. Radiologists should be familiar with clinical implications of BMAB for patient care and be able to implement various technical armamentarium available to achieve a safe intervention while maximizing procedure yield.

Image Guided Bone Marrow Biopsy

Bone marrow biopsy and aspiration are common diagnostic procedures used for the diagnosis and monitoring of multiple conditions including hematologic malignancies, non-hematologic malignancies, infection, and metabolic processes. While these procedures can be done on the inpatient floor or in clinic, imaging guidance has been utilized to improve patient safety. This article will review the patient work-up and considerations, as well as technique for performing both computed tomography and fluoroscopic guided bone marrow biopsies.

Cell Therapy: Types, Regulation, and Clinical Benefits

Cell therapy practices date back to the 19th century and continue to expand on investigational and investment grounds. Cell therapy includes stem cell- and non-stem cell-based, unicellular and multicellular therapies, with different immunophenotypic profiles, isolation techniques, mechanisms of action, and regulatory levels. Following the steps of their predecessor cell therapies that have become established or commercialized, investigational and premarket approval-exempt cell therapies continue to provide patients with promising therapeutic benefits in different disease areas. In this review article, we delineate the vast types of cell therapy, including stem cell-based and non-stem cell-based cell therapies, and create the first-in-literature compilation of the different "multicellular" therapies used in clinical settings. Besides providing the nuts and bolts of FDA policies regulating their use, we discuss the benefits of cell therapies reported in 3 therapeutic areas-regenerative medicine, immune diseases, and cancer. Finally, we contemplate the recent attention shift toward combined therapy approaches, highlighting the factors that render multicellular therapies a more attractive option than their unicellular counterparts.

Bone Marrow Aspiration and Biopsy in Critical Pediatric Patients: A Pathologist's Perspective

Bone marrow aspiration (BMA) and bone marrow biopsy (BMB), are medical modalities for the detection of non-malignant diseases as well as hematological malignancies in children. BMA attained momentum in the past few years owing to the possibility of achieving hematopoietic stem cells. Liquid bone marrow is aspirated through posterior/anterior iliac crest, tibia, and vertebral spinous process during BMA procedure in children for assessment of morphology at the microscopic level while BMB allows for cytological evaluation of marrow. It is also used for molecular genetics, immune-phenotypic, cytogenetics, and other specialized examinations. Additionally, BMA is also helpful in the reconstruction of tissue. These procedures should be performed by a specialist who has knowledge about the indication, contradictions, and hazards of these procedures due to their invasive nature. Still, there are no transparent guidelines available especially in the case of BMA for children. The purpose of this overview article is to focus on the specific guidelines to carry out the BMA and BMB in children and the techniques as well as complications associated with the BMA and BMB.

A Synoptic Reporting System to Monitor Bone Marrow Aspirate and Biopsy Quality

Objectives:

Bone marrow evaluation plays a critical role in the diagnosis, staging, and monitoring of many diseases. Although there are standardized guidelines for assessing bone marrow specimen quality, there is a lack of evidence-based tools to perform such assessments. The objective was to monitor bone marrow sample quality in real time by standardizing the basic components of a synoptic report and incorporating it into a bone marrow report template.

Materials and Methods:

A relational database of bone marrow quality parameters was developed and incorporated into our laboratory information system bone marrow report template, with data entry completed during specimen sign out. Data from multiple reports created within a date range were extracted by Structured Query Language query, and summarized in tabular form. Reports generated from these data were utilized in quality improvement efforts.

Results:

The synoptic reporting system was routinely used to record the quality of bone marrow specimens from adult patients. Data from 3189 bone marrow aspirates, 3302 biopsies, and 3183 biopsy touch imprints identified hemodilution as the principal issue affecting bone marrow aspirate quality, whereas aspiration artifact and fragmentation affected bone marrow biopsy quality.

Conclusions:

The bone marrow synoptic reporting process was easy to use, readily adaptable, and has proved a useful component of the overall quality assurance process to optimize bone marrow quality.

Bone marrow trephine biopsies from posterior superior iliac crest in neonates

Cytopenias are common among neonates in neonatal intensive care units (NICU). Although, bone marrow aspirations (BMAs) are often performed as part of diagnostic workup, but trephine bone marrow biopsies (BMBs) have not been reported from living neonates. BMB is indispensable to accurately assess the cellularity and architecture. There is paucity of literature regarding the technique of BMB in neonates. In this report, for the first time, we describe trephine BMB from posterior superior iliac crest (PSIC) using 18-gauge BMA needle in six living neonates admitted to NICU where BMB findings helped in understanding the underlying mechanism and diagnosis of cytopenias.

Complications associated with bone marrow sampling in dogs and cats

OBJECTIVES

To evaluate the prevalence of complications during bone marrow sampling and associated patient and procedural factors in dogs and cats.

MATERIALS AND METHODS

Retrospective cohort study, records were evaluated to identify dogs and cats that had bone marrow sampling between 2012 and 2019. Data including signalment, the presence of specific clinicopathological findings, anatomical site of bone marrow sampling, number of attempts, diagnostic quality of sampling, analgesia protocol and complications postprocedure were recorded.

RESULTS

A total of 131 dogs and 29 cats were included in the study. Complications were recorded in 22 of 160 (14%) of cases. Pain was the most common complication of bone marrow sampling in 20 of 22 (91%) of cases with bruising reported in the remaining patients. A local anaesthetic block was used in 98 of 160 (61%) of patients.

CLINICAL SIGNIFICANCE

Excluding pain, complications associated with bone marrow sampling were rare and no clear association were detected between patient or procedural variables. Haemorrhage and infection are rare complications in dogs and cats when thrombocytopenia and neutropenia are present. Peri-procedure analgesia is strongly recommended to minimise complications.

Bone marrow biopsy diagnostic yield in internal medicine

BACKGROUND

Trephine bone marrow biopsy (BMB) in internal medicine has only been studied in fever of unknown origin and inflammation of unknown origin. The aim was to assess BMB diagnostic yield according to main indications and patient characteristics in internal medicine. Quality of BMB and contribution of bone marrow aspiration (BMA) to BMB were also analyzed.

METHODS

BMB performed in the internal medicine department of Poitiers university hospital between January 2000 and December 2015 were retrospectively analyzed. Patient characteristics, BMB indications, quality parameters, and results were collected from medical records. Contributive BMB was BMB allowing accurate final diagnosis. Diagnostic yield was the proportion of contributive BMB among total BMB performed.

RESULTS

A total of 468 BMBs conducted for primary diagnostic purpose from 468 patients were analyzed. Cytopenia(s) and the indication 'adenopathy and/or splenomegaly and/or hepatomegaly' represented 70% of the indications. Overall BMB diagnostic yield was 32.7%, lymphoma being the main histologic finding (31%). Among indications, cytopenia(s) had the highest diagnostic yield (49.1%). Isolated fever of unknown origin had low diagnostic yield (5.6%). Factors independently associated with contributive BMB were: anemia, neutropenia, circulating immature granulocytes or blasts, monoclonal gammopathy, period of BMB processing, quality of BMB, and immunohistochemestry (IHC) analysis. Concomitant BMA improved diagnostic yield by 5.5%, mostly for myelodysplastic syndromes.

CONCLUSION

Cytopenia(s), blood cythemias and monoclonal gammopathy are indications with the highest diagnostic yield. Concomitant BMA and IHC analysis should be systematically performed to increase BMB diagnostic yield in internal medicine.

Professional accountability in a sternal bone marrow aspiration: a forensic case report

An aortic injury with concomitant pericardial tamponade caused by sternal bone marrow aspiration is rare. We report a case of fatal sternal bone marrow aspiration performed to a 73 year old man for the purpose of confirming the diagnosis of multiple myeloma. This puncture was followed by an injury in the aorta causing a pericardial tamponade and the death of the patient immediately after the aspiration. This paper stresses the precautions to be taken, by the operator, in certain particular situations that make the sternal bone marrow aspiration difficult and risky, and discusses the different types of operator´s liability that can be involved and their foundations.

Developing and Preliminary Validating an Automatic Cell Classification System for Bone Marrow Smears: a Pilot Study

Bone marrow smear examination is an indispensable diagnostic tool in the evaluation of hematological diseases, but the process of manual differential count is labor extensive. In this study, we developed an automatic system with integrated scanning hardware and machine learning-based software to perform differential cell count on bone marrow smears to assist diagnosis. The initial development of the artificial neural network was based on 3000 marrow smear samples retrospectively archived from Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine between June 2016 and December 2018. The preliminary field validating test of the system was based on 124 marrow smears newly collected from the Second Affiliated Hospital of Harbin Medical University between April 2019 and November 2019. The study was performed in parallel of machine automatic recognition with conventional manual differential count by pathologists using the microscope. We selected representative 600,000 marrow cell images as training set of the algorithm, followed by random captured 30,867 cell images for validation. In validation, the overall accuracy of automatic cell classification was 90.1% (95% CI, 89.8-90.5%). In a preliminary field validating test, the reliability coefficient (ICC) of cell series proportion between the two analysis methods were high (ICC ≥ 0.883, P < 0.0001) and the results by the two analysis methods were consistent for granulocytes and erythrocytes. The system was effective in cell classification and differential cell count on marrow smears. It provides a useful digital tool in the screening and evaluation of various hematological disorders.

CT-guided bone marrow aspirations and biopsies: retrospective study and comparison with blind procedures

PURPOSE

To compare the pathology results of CT-guided and blind bone marrow aspirations and biopsies.

METHODS

Ninety-eight consecutive CT-guided biopsies and 98 age- and gender-matched blind (non-CT-guided) posterior iliac crest bone marrow aspirations and biopsies performed in 2017 were reviewed for adequacy of core biopsies and aspirate smears. CT procedure images and CT abdomen/pelvis images were reviewed to evaluate anatomic features of the posterior ilium and soft tissues. Statistical analysis was performed using a T test, Fisher exact test, and Kruskal-Wallis test.

RESULTS

There was no significant difference in the age and gender of the two groups (p > 0.05). However, the CT-guided group had a higher BMI (p = 0.0049) and posterior soft tissue thickness (p = 0.0016). More CT-guided biopsy samples (CT 93 (95%); blind 77 (79%); p = 0.0006) and aspirate smears (CT 90 (92%); blind 78 (80%); p = 0.042) were categorized as adequate. The CT-guided group had longer core lengths (CT 1.4 ± 0.6 (range 0.3-3.5) cm; blind 1.0 ± 0.60 (range 0-2.6) cm; p = 0.0001). Overall, 131/164 (80%) of the cases had at least one of the described features (slanted posterior ilium (angle > 30°), 30%; rounded posterior ilium, 20%; thick posterior ilium cortex, 13%; focal lesion in posterior ilium, 12%; prior procedure in posterior ilium, 5%; posterior soft tissue thickness > 3 cm, 40%).

CONCLUSION

CT-guided bone marrow procedures were more likely to result in both adequate aspirate smears and biopsy samples and longer core lengths when compared with blind procedures.

Label-free hematology analysis using deep-ultraviolet microscopy

Hematological analysis, via a complete blood count (CBC) and microscopy, is critical for screening, diagnosing, and monitoring blood conditions and diseases but requires complex equipment, multiple chemical reagents, laborious system calibration and procedures, and highly trained personnel for operation. Here we introduce a hematological assay based on label-free molecular imaging with deep-ultraviolet microscopy that can provide fast quantitative information of key hematological parameters to facilitate and improve hematological analysis. We demonstrate that this label-free approach yields 1) a quantitative five-part white blood cell differential, 2) quantitative red blood cell and hemoglobin characterization, 3) clear identification of platelets, and 4) detailed subcellular morphology. Analysis of tens of thousands of live cells is achieved in minutes without any sample preparation. Finally, we introduce a pseudocolorization scheme that accurately recapitulates the appearance of cells under conventional staining protocols for microscopic analysis of blood smears and bone marrow aspirates. Diagnostic efficacy is evaluated by a panel of hematologists performing a blind analysis of blood smears from healthy donors and thrombocytopenic and sickle cell disease patients. This work has significant implications toward simplifying and improving CBC and blood smear analysis, which is currently performed manually via bright-field microscopy, and toward the development of a low-cost, easy-to-use, and fast hematological analyzer as a point-of-care device and for low-resource settings.

A Rationale for the Use of Clotted Vertebral Bone Marrow to Aid Tissue Regeneration Following Spinal Surgery

Vertebral body bone marrow aspirate (V-BMA), easily accessible simultaneously with the preparation of the site for pedicle screw insertion during spinal procedures, is becoming an increasingly used cell therapy approach in spinal surgery. However, the main drawbacks for V-BMA use are the lack of a standardized procedure and of a structural texture with the possibility of diffusion away from the implant site. The aim of this study was to evaluate, characterize and compare the biological characteristics of MSCs from clotted V-BMA and MSCs from whole and concentrate V-BMAs. MSCs from clotted V-BMA showed the highest cell viability and growth factors expression (TGF-β, VEGF-A, FGF2), the greatest colony forming unit (CFU) potency, cellular homogeneity, ability to differentiate towards the osteogenic (COL1AI, TNFRSF11B, BGLAP) and chondrogenic phenotype (SOX9) and the lowest ability to differentiate toward the adipogenic lineage (ADIPOQ) in comparison to all the other culture conditions. Additionally, results revealed that MSCs, differently isolated, expressed different level of HOX and TALE signatures and that PBX1 and MEIS3 were down-regulated in MSCs from clotted V-BMA in comparison to concentrated one. The study demonstrated for the first time that the cellular source inside the clotted V-BMA showed the best biological properties, representing an alternative and advanced cell therapy approach for patients undergoing spinal surgery.

Comparison of bone marrow aspiration cytology with bone marrow trephine biopsy histopathology: An observational study

INTRODUCTION:

Bone marrow examination is a useful investigative tool for the diagnosis of many hematological and nonhematological disorders. Bone marrow aspiration (BMA) provides information about the numerical and cytological features of marrow cells, whereas bone marrow trephine biopsies (BMB) provide excellent appreciation of spatial relationships between cells and of overall bone marrow structure. We conducted this study with the objective of comparing the accuracy of BMA with BMB in the diagnosis of various hematological disorders.

MATERIALS AND METHODS:

Both BMA and BMB were performed on a total of 130 cases and a comparative evaluation was performed in 100 cases to see the complementary role of both the procedures. However, 30 cases were excluded due to inadequate BMA, BMB, or both. Immunohistochemistry (IHC) was employed whenever required.

RESULTS:

In our study of 100 cases, 87% of cases were confirmed on bone marrow biopsy and in remaining 13% of cases final diagnosis was achieved with the help of other ancillary investigations. These cases were excluded for calculation of concordance rate between BMA and BMB. The concordance and disconcordance rate between BMA and BMB was 72.4% and 27.6%, respectively.

CONCLUSION:

BMA cytology and trephine biopsy histopathology complement each other and the superiority of one method over the other depended on the underlying disorder. Furthermore, application of ancillary techniques such as flow cytometery and IHC proved to be an additional advantage in further typing of various diseases.

Forensic Implications of Sternal Bone Marrow Biopsy Fatalities: Autopsy Case Report

Iatrogenic penetrating injuries of the thoracic aorta are rare. When surgical treatment is delayed or unavailable, they are associated with high mortality. Herein we present a case of a 36-year-old woman who had a sternal marrow biopsy performed due to laboratory-confirmed pancytopenia. Autopsy revealed 4 needle punctures extending through the full thickness of the upper right quarter of the sternum. Mediastinal soft tissue and the upper part of the pericardium were diffusely effused with blood. On the aortic arch, between the innominate artery and the left common carotid artery, we found a linear penetrating injury (2 mm in length). Autopsy revealed bilateral hemothoraces, the right hemothorax being generally larger than the left (2000 mL vs 50 mL of blood). In the presented case, the cause of death is considered to be exsanguination due to iatrogenic injury of the aorta during sternal bone marrow aspiration. Death occurring during or after medical procedures requires extremely careful postmortem evaluation.

Clonal diversity revealed by morphoproteomic and copy number profiles of single prostate cancer cells at diagnosis

Tumor heterogeneity is prevalent in both treatment-naïve and end-stage metastatic castration-resistant prostate cancer (PCa), and may contribute to the broad range of clinical presentation, treatment response, and disease progression. To characterize molecular heterogeneity associated with de novo metastatic PCa, multiplatform single cell profiling was performed using high definition single cell analysis (HD-SCA). HD-SCA enabled morphoproteomic and morphogenomic profiling of single cells from touch preparations of tissue cores (prostate and bone marrow biopsies) as well as liquid samples (peripheral blood and bone marrow aspirate). Morphology, nuclear features, copy number alterations, and protein expression were analyzed. Tumor cells isolated from prostate tissue touch preparation (PTTP) and bone marrow touch preparation (BMTP) as well as metastatic tumor cells (MTCs) isolated from bone marrow aspirate were characterized by morphology and cytokeratin expression. Although peripheral blood was examined, circulating tumor cells were not definitively observed. Targeted proteomics of PTTP, BMTP, and MTCs revealed cell lineage and luminal prostate epithelial differentiation associated with PCa, including co-expression of EpCAM, PSA, and PSMA. Androgen receptor expression was highest in MTCs. Hallmark PCa copy number alterations, including PTEN and ETV6 deletions and NCOA2 amplification, were observed in cells within the primary tumor and bone marrow biopsy samples. Genomic landscape of MTCs revealed to be a mix of both primary and bone metastatic tissue. This multiplatform analysis of single cells reveals several clonal origins of metastatic PCa in a newly diagnosed, untreated patient with polymetastatic disease. This case demonstrates that real-time molecular profiling of cells collected through prostate and bone marrow biopsies is feasible and has the potential to elucidate the origin and evolution of metastatic tumor cells. Altogether, biological and genomic data obtained through longitudinal biopsies can be used to reveal the properties of PCa and can impact clinical management.

Comparison of Bone Marrow Biopsy Specimens Obtained Using a Motorized Device and Manual Biopsy Systems

Objective:

Bone marrow biopsy is an essential component in the diagnosis of hematopoietic disorders. Researchers evaluated the quality of bone marrow biopsy tissue acquired with a motorized bone marrow biopsy device versus a standard manual device based on the following criteria: biopsy length, percentage of aspiration artifact/intrastromal hemorrhage, length of nonhematopoietic bone, and overall quality of the sample.

Methods:

Bone marrow biopsies (motorized, n = 30; manual, n = 120) from two academic medical centers were evaluated by two board-certified hematopathologists. For each specimen, the following parameters were recorded: biopsy length (cm), aspiration artifact (assessed in intervals of ≤10%, 11%–25%, 26%–50%, 51%–75%, and >75%), length (cm) of nonhematopoietic biopsy (e.g., cortical bone and skin), and overall quality of sample (inadequate, suboptimal, adequate, and excellent).

Results:

Operators from two centers included physicians and nurse practitioners. The manual system was superior to the powered drill with respect to the amount of crush artifact (0.15 cm ± 0.01 vs. 0.24 cm ± 0.04, P = 0.01 [t-test]). There was a trend toward less aspiration artifact/intrastromal hemorrhage with the use of the manual biopsy; however, the difference was not statistically significant (P = 0.06). There was no statistically significant difference in the overall biopsy size, biopsy length, amount of nonhematopoietic elements, and overall adequacy of the sample.

Conclusions:

There was no significant difference in the biopsy length, amount of nonhematopoietic elements, and overall adequacy of the sample. Results suggest that the manual bone marrow biopsy device has significantly less crush artifact of the specimen and has a trend toward less aspiration artifact/intrastromal hemorrhage as well.

Contribution to diagnosis and treatment of bone marrow aspirate results in critically ill patients undergoing bone marrow aspiration: a retrospective study of 193 consecutive patients

Background

The purpose of the work was to assess the contribution to diagnosis and/or treatment (CDT) of bone marrow aspiration (BMA) in the critically ill patient.

Methods

The retrospective study included 193 patients. On the basis of BMA findings, contribution to diagnosis was defined by one of four previously unestablished diagnoses (maturation arrest of granulocyte precursors, hemophagocytic lymphohistiocytosis, hematological malignancy, marrow infiltration with cancer cells) and to treatment as the initiation or withdrawal of a specific treatment including the decision to forgo life-sustaining treatment (DFLST).

Results

A CDT of BMA was observed in 40/193 patients (20.7%). BMA contributed to diagnosis in 37 cases (granulocyte precursor maturation arrest, N = 10; hemophagocytic lymphohistiocytosis, N = 12; hematological malignancy, N = 15) and to treatment in 14, including three DFLSTs. In multivariate analysis, the factors associated with a CDT were hematological malignancy, cancer or non-malignant hematological abnormality known on admission, indication for BMA excluding isolated thrombocytopenia, higher pre-BMA HScore (calculated prior to BMA), and higher SOFA score with or without platelet-count SOFA subscore. In the 160 patients without hematological malignancy or cancer known on admission, non-malignant hematological abnormality known on admission, indication for BMA excluding isolated thrombocytopenia, higher pre-BMA HScore, and higher SOFA score calculated with or without platelet-count SOFA subscore were independently associated with a CDT of BMA.

Conclusion

BMA can have a significant CDT in ICU patients with or without a known hematological malignancy or cancer on admission. An HScore calculated before BMA can be a valuable tool for predicting a CDT of BMA.

Electronic supplementary material

The online version of this article (10.1186/s40560-017-0263-7) contains supplementary material, which is available to authorized users.

A Novel Approach for Performing Bone Marrow Aspiration at the Time of Radical Prostatectomy

The bone marrow microenvironment represents a “metastatic niche” in which prostate cancer cells may persist and evade cytotoxic therapy. In order to study the biology of prostate cancer dissemination, we have established a safe and efficient method for performing pubic bone marrow aspiration at the time of radical prostatectomy. We herein describe our experience with this technique.

Using Stem Cells to Grow Artificial Tissue for Peripheral Nerve Repair

Peripheral nerve injury continues to pose a clinical hurdle despite its frequency and advances in treatment. Unlike the central nervous system, neurons of the peripheral nervous system have a greater ability to regenerate. However, due to a number of confounding factors, this is often both incomplete and inadequate. The lack of supportive Schwann cells or their inability to maintain a regenerative phenotype is a major factor. Advances in nervous system tissue engineering technology have led to efforts to build Schwann cell scaffolds to overcome this and enhance the regenerative capacity of neurons following injury. Stem cells that can differentiate along a neural lineage represent an essential resource and starting material for this process. In this review, we discuss the different stem cell types that are showing promise for nervous system tissue engineering in the context of peripheral nerve injury. We also discuss some of the biological, practical, ethical, and commercial considerations in using these different stem cells for future clinical application.

Bone Marrow Aspiration: A Randomized Controlled Trial Assessing the Quality of Bone Marrow Specimens Using Slow and Rapid Aspiration Techniques and Evaluating Pain Intensity

BACKGROUND/AIMS

Bone marrow aspiration (BMA) is an essential procedure in the examination of hematological disorders, but there is limited evidence as to whether the aspiration rate affects specimen quality. We aimed to assess the specimen quality and pain intensity using slow (S-technique) or rapid (R-technique) aspiration.

METHODS

This was a single-center, prospective, randomized patient- and assessor-blinded study of 482 patients scheduled for BMA. Specimen quality was evaluated by grading bone marrow (BM) cellularity and counting the number of marrow particles. Pain was assessed using a visual analog scale (VAS).

RESULTS

We found a significant difference between the 2 groups with regard to the quality of specimens. For cellularity, the odds ratio (OR) for having a poor quality aspirate using the S-technique versus the R-technique was 3.05 [confidence interval (CI) 1.79-5.31]. For BM particles, the quality of specimens with the S-technique proved to be poor compared with the R-technique (OR 2.52; CI 1.51-4.28). We found a statistically significant difference of 1 VAS point (p < 0.001) of the median pain intensity in favor of the S-technique.

CONCLUSION

Even though the pain intensity is significantly higher with the R-technique, the median difference is relatively small. We propose that the R-technique is preferable to the S-technique due to better specimen quality.

Utility of bone marrow examination for workup of fever of unknown origin in patients with HIV/AIDS

AIMS

The utility of bone marrow aspiration and biopsy (BMAB) as a diagnostic tool in patients with HIV/AIDS and fever of unknown origin (FUO) is a subject of debate. Because highly active antiretroviral therapy has reduced incidence of opportunistic infections, it is important to reassess the efficacy of BMAB for this diagnostic purpose. To our knowledge, no such studies have been performed in Harris County which has the highest incidence of HIV in the state of Texas.

METHODS

We reviewed all BMABs from patients with HIV/AIDS and FUO or persistent cytopenia(s) from 2007 to 2011.

RESULTS

Of 57 evaluable patients, BMAB was positive in 24 samples by acid fast bacilli (AFB) or Gomori methenamine silver (GMS) stains (17.5%), presence of granuloma and/or lymphohistiocytic aggregates (31.6%), culture (21.0%) or a combination. Cultures demonstrated Mycobacterium avium/intracellulare (4), M tuberculosis (2), M gordonae (1), Histoplasma capsulatum (3) and Cryptococcus neoformans (2). There were three cases in which a pathogen was grown in culture but that had a negative of 'direct examination' on tissue sections (negative AFB and GMS special stains, no morphological evidence of granuloma/lymphohistiocytic infiltrates).

CONCLUSIONS

This study supports the use of diagnostic BMAB as a rapid decision-making tool in patients with HIV and FUO in the proper clinical setting. BMAB demonstrated infection-related evidence prior to positive bone marrow culture in 75% of cases. Special stains and blood cultures had similar diagnostic yield, but BMAB offers faster results. Thus, this procedure assists in clinical decision making and the refinement of treatment in a more timely manner.

Bone marrow cytological evaluation in dogs with chronic kidney disease

Since anemia is indicated as an important compromising factor for the quality of life of dogs with chronic kidney disease (CKD), bone marrow cytological analysis may provide more information on the hematological profile these dogs and, therefore, allow clinicians to not only choose the most adequate treatment but also monitor the response to therapy. The aim of this study was to investigate the feasibility with sternal bone marrow puncture in chronic kidney disease (CKD) using only local anesthesia and check if the cytological analysis is helpful to determine the hematological status. We found that erythroid hypoplasia occurred only in terminal CKD patients, and that the bone marrows of dogs with CKD stages 2 and 3 were quantitatively similar to those of elderly dogs. All dogs tolerated the bone marrow puncture using only local anesthesia with lidocaine and bone marrow cytological evaluation may be a useful tool for hematopoietic evaluation of anemic dogs with CKD.

Diagnostic value of bone marrow aspiration and biopsy in routine hematology practice

BACKGROUND

The bone marrow is frequently involved in variety of cases presenting with hematological and non-hematological disorders, which are diagnosed by two separate but interrelated techniques such as bone marrow aspiration (BMA) and bone marrow biopsy (BMB).

AIM

This study was aimed to assess the diagnostic value of the BMA and BMB and role of both the procedures to reach final diagnosis when done simultaneously.

SETTINGS AND DESIGN

It was a prospective study. The findings of BMA smears were correlated with BMB sections and data obtained was analysed.

MATERIALS AND METHODS

BMA and BMB were performed on 50 patients. Criteria of inclusion included the main indications for performing this procedure, the availability of full medical records and patient consent. The patients had a male to female sex ratio of 1.6:1 and a wide age range from 4 years to 74 years.

RESULTS

In the present study, the main indications for bone marrow examination were categorized. Out of 50 cases studied, in 23 cases, a strong positive correlation between BMA and BMB was noted. However, it was found that in the cases of aplastic anaemia, different phases of myeloproliferative neoplasm (MPN), multiple myeloma, tubercular granulomas and hemato-lymphoid neoplasm, involvement of the marrow was detected better in bone marrow biopsies.

CONCLUSION

The study concludes that preparations of aspirate and trephine biopsy are easy, rapid and complementary to each other in majority of the lesions. The advantage of both the procedures done together enabled us to study the cytomorphology of the cells along with the pattern of distribution of the cells depending on the cases, hence help in making the diagnosis accurately.

Pathologic risk-based adjuvant chemotherapy for unilateral retinoblastoma following enucleation

BACKGROUND

There are no standardized diagnostic or treatment guidelines for patients with advanced unilateral retinoblastoma.

MATERIALS AND METHODS

Patients with advanced unilateral retinoblastoma were prospectively treated after enucleation using a risk-based protocol. Patients were assigned to low risk (LR), intermediate risk (IR), or high risk (HR) based on pathology. LR patients underwent observation. IR patients received 4 courses of chemotherapy with vincristine, doxorubicin, and cyclophosphamide (VDC). In the HR group, patients received 3 courses of VDC alternating with 3 courses of vincristine, carboplatin, and etoposide (VCE) and irradiation when indicated.

RESULTS

Fifty patients with advanced unilateral retinoblastoma were treated (LR, n=36; IR, n=7; HR, n=7). All eyes were Reese-Ellsworth group V. All bone scans (n=81), lumbar punctures (n=16), and bone marrow aspirates (n=16) were negative. Chemotherapy was well tolerated. Grades 3/4 hematologic toxicities were seen in all patients; grades 3/4 nonhematologic toxicities were seen in half the patients. Only one patient in the HR group received radiation therapy. All patients were alive at the time of analysis with no signs of disease recurrence. Median follow-up was 3.4 years (range, 0.8 to 6.4 y).

CONCLUSIONS

Patients with nonmetastatic unilateral retinoblastoma undergoing primary enucleation can be cured with a graduated intensity approach based on pathology.

Second-Generation Tyrosine Kinase Inhibitors (Tki) as Salvage Therapy for Resistant or Intolerant Patients to Prior TKIs

With the advent of target therapies, imatinib became the mainstay for treatment of chronic myeloid leukemia. However, despite the brilliant results obtained with this drug, more than 30% of patients discontinue therapy in long-term due to several reasons, including failure and/or intolerance. Second-generation tyrosine kinase inhibitors (TKIs) are more potent drugs and have expanded inhibition against a broad spectrum of mutations resistant to imatinib. Both nilotinib and dasatinib have demonstrated in vitro and in vivo clinical activity against different types of mutations and various forms of resistance. However, patients with T315I mutation do not obtain an advantage from these drugs and a third generation inhibitor ponatinib, a pan-BCR drug, was tested with significant results. In this review, we report the results of second-and third-generation TKIs tested as second or third line therapy in patients resistant and/or intolerant to previous inhibitors.