Bone marrow biopsy in children: a study of 111 patients

Study of Hemato-morphological Features in Neuroblastoma Infiltrating Marrow

Objective Neuroblastoma typically affects children within the first 5 years of life and accounts for 10% of all pediatric malignancies. Neuroblastoma at onset may manifest as a localized or metastatic illness. The aim of this study was to identify hematomorphological features in neuroblastoma infiltrating marrow as well as to ascertain the prevalence of bone marrow infiltration in neuroblastoma.

Materials and Methods This retrospective study included newly diagnosed 79 cases of neuroblastoma, which were referred for bone marrow examination for the staging of the disease. Medical records were retrieved to acquire hematomorphological findings of peripheral blood and bone marrow smears. Statistical Package for Social Sciences, IBM Inc., USA, version 21.0 was used to analyze the data.

Results The interquartile age range of neuroblastoma cases was 24.0 to 72.0 months (median = 48 months) with a male to female ratio of 2.7:1. Also, 55.6% (44/79) of cases in the study population showed evidence of marrow infiltration. The bone marrow infiltration was significantly linked to thrombocytopenia (p = 0.043) and nucleated red blood cells (p = 0.003) in peripheral blood. The bone marrow smears of cases with infiltration showed a significant shift to the left in the myeloid series (p = 0.001) and an increased number of erythroid cells (p = 0.001).

Conclusion For neuroblastoma patients, a diligent, exhaustive search for infiltrating cells in bone marrow is advised if thrombocytopenia or nucleated red blood cells are identified on a peripheral blood smear and bone marrow smears showed myeloid left shift with an increased number of erythroid cells.

Bone Marrow Involvement in Neuroblastoma: A Study of Hemato-morphological Features

Bone marrow involvement in neuroblastoma indicates advanced stage of disease. The recent use of autologous bone marrow "rescue", has provided an additional important reason for accurate assessment of bone marrow status in newly diagnosed patients. In this study, we analyzed 44 cases of neuroblastoma for bone marrow infiltration status and their hematological parameters. Eighty-eight bone marrow aspirate and trephine touch imprint smears and 44 trephine biopsy sections were examined in these 44 patients. Of these, 24 cases (54.5 %) showed marrow infiltration. Leucopenia and bicytopenia were significantly (p < 0.05) associated with marrow infiltration. Both bone marrow aspirate and biopsy were positive for infiltration in 16 out of 24 positive cases. Only aspirate smears were positive in 4 and only trephine biopsy in another 4 cases. The pattern of infiltration consisted of rosette formation in 40.7 % cases on aspirate smears and 22.2 % cases in trephine biopsies. Remaining cases showed diffuse and interstitial presence of tumor cells and cases positive only on trephine biopsy, showed marked stromal reaction. Bilateral trephine biopsies combined with aspirate smears picked up all positive cases compared to when they were assessed alone.

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

The bone marrow aspirate and biopsy is an important medical procedure for the diagnosis of hematologic malignancies and other diseases, and for the follow-up evaluation of patients undergoing chemotherapy, bone marrow transplantation, and other forms of medical therapy. During the procedure, liquid bone marrow is aspirated from the posterior iliac crest or sternum with a special needle, smeared on glass microscope slides by one of several techniques, and stained by the Wright-Giemsa or other techniques for micro-scopic examination. The bone marrow core biopsy is obtained from the posterior iliac crest with a Jamshidi or similar needle and processed in the same manner as other surgical specimens. Flow cytometric examination, cytochemical stains, cytogenetic and molecular analysis, and other diagnostic procedures can be performed on bone marrow aspirate material, while sections prepared from the bone marrow biopsy can be stained by the immunoperoxidase or other techniques. The bone marrow procedure can be performed with a minimum of discomfort to the patient if adequate local anesthesia is utilized. Pain, bleeding, and infection are rare complications of the bone marrow procedure performed at the posterior iliac crest, while death from cardiac tamponade has rarely occurred from the sternal bone marrow aspiration. The recent development of bone marrow biopsy needles with specially sharpened cutting edges and core-securing devices has reduced the discomfort of the procedure and improved the quality of the specimens obtained.

Bone marrow changes in neuroblastoma

Bone marrow examination at the time of diagnosis of neuroblastoma was performed in 48 new cases prior to instituting therapy. Bone marrow involvement by neuroblastoma was present in 20 patients (approximately 42%). In this study the trephine biopsy was a more reliable technique than marrow aspiration in establishing the presence of metastatic disease, but in a single case the trephine biopsy was negative with metastatic cells present in the aspirate. Myelofibrosis secondary to metastatic neuroblastoma was a frequent finding, being the predominant feature in 6 cases. Bone marrow involvement by neuroblastoma was usually associated with the presence of a primary adrenal tumor and occurred only infrequently with extra-adrenal primary origin. Bone marrow involvement was usually present at the time of presentation in case where the primary tumor was located in the adrenal gland.

Neuroblastoma

Neuroblastoma originates in the adrenal medulla or anywhere in the body that sympathetic tissue normally is present. It may present with a variety of symptoms due to primary tumor, metastatic disease, or unusual signs and symptoms such as opsoclonus-myoclonus or severe diarrhea. Despite the fact that this neoplasm responds to a variety of therapeutic modalities, it remains one of the most frustrating and difficult childhood tumors to treat and cure.

Detection of bone marrow invasion by neuroblastoma is improved by sampling at two sites with both aspirates and trephine biopsies

Two hundred and eight serial bone marrow samples from 49 consecutively diagnosed children with neuroblastoma were studied retrospectively for evidence of tumour invasion. Bone marrow involvement was found in 24 patients at diagnosis and in four more at a later stage in their disease. Trephine biopsies were more effective than aspirates for tumour detection in 20% of the 154 paired aspirate/trephine procedures, whilst the reverse was the case in 7%. Imprints of trephines gave no additional information. Bilateral sampling (aspirates and trephines) improved the tumour detection rate by 10% over that attained by sampling a single site. There was some correlation between specific appearances in aspirate and in trephine samples, for example the hypocellular smear and the trephine biopsy showing much stromal reaction to tumour infiltration. Bilateral iliac crest bone marrow aspirates and trephine biopsies are indicated in children with neuroblastoma, both for initial staging and for monitoring of progress.

The diagnosis and staging of neuroblastoma

Forty-five cases of neuroblastoma were reviewed to assess the value of current diagnostic methods. Urinary catecholamine and 3-methoxy-4-hydroxymandelic acid levels were elevated in only 48% and 60% of cases, respectively. All abdominal or pelvic tumour masses were detected by intravenous urography, ultrasound or computed tomography (CT): CT was the best single investigation but the two less expensive techniques detected most of the tumours. Trephine biopsy was more successful than aspiration in detecting bone marrow metastases. Liver scintigraphy was positive in six of seven cases with hepatic secondaries.

Myelofibrosis in neuroblastoma

Myelofibrosis, a rare childhood disorder, has been reported as an associated complication of certain hematologic malignancies or as an isolated idiopathic process. In this report, we describe a patient with metastatic neuroblastoma whose initial presentation included the findings of myelofibrosis and leukoerythroblastosis. The myelofibrosis regressed with chemotherapy and did not recur when the patient's tumor reappeared.