A prospective survey on trephine biopsy of bone and bone marrow: an experience with 274 Indian patients' biopsies

Trephine bone marrow biopsy is an effective technique for diagnosing hematological malignancies in patients of different ages. During trephine biopsy, bone marrow cores are obtained for detailed morphological evaluation to look for any abnormality and arrive at a diagnosis. The primary goal of this work is to perform a survey on Indian patients of various ages for the trephine bone marrow biopsy process. In the present study, data related to 274 trephine biopsy samples from 300 patients were acquired at the Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India. Pain was found to be the sole major procedure-related complication, and patients reported no/less pain in 41 BMB (14.96%) patients, moderate pain in 82 (29.92%) cases, and unbearable pain in 151 (55.1%) BMB cases. In addition, the patients were evaluated by the authors and hematologist as non-anxious for the procedure in 34 (12.4%), anxious in 92 (33.57%), and very/highly anxious in 148 (56%) cases. The bone texture of the patients significantly affected the needle bending, number of repetitions required, and size of the bone marrow sample. This demonstrates the need for improvement in the biopsy procedure. To this end, a survey was conducted to assess the numerous difficulties and diagnostic outcomes throughout the trephine biopsy process.

Correlation of plasma cell assessment by phenotypic methods and molecular profiles by NGS in patients with plasma cell dyscrasias

Background

Next-generation sequencing (NGS) detects somatic mutations in a high proportion of plasma cell dyscrasias (PCD), but is currently not integrated into diagnostic routine. We correlated NGS data with degree of bone marrow (BM) involvement by cytomorphology (BMC), histopathology (BMH), and multiparameter flow cytometry (MFC) in 90 PCD patients.

Methods

Of the 90 patients the diagnoses comprised multiple myeloma (n = 77), MGUS (n = 7), AL-amyloidosis (n = 4) or solitary plasmocytoma (n = 2). The NGS panel included eight genes CCND1, DIS3, EGR1, FAM46C (TENT5C), FGFR3, PRDM1, TP53, TRAF3, and seven hotspots in BRAF, IDH1, IDH2, IRF4, KRAS, NRAS.

Results

Mutations were detected in 64/90 (71%) of cases. KRAS (29%), NRAS (16%) and DIS3 (16%) were most frequently mutated. At least one mutation/sample corresponded to a higher degree of BM involvement with a mean of 11% pathologic PC by MFC (range, 0.002–62%), and ~ 50% (3–100%) as defined by both BMC and BMH.

Conclusions

The probability of detecting a mutation by NGS in the BM was highest in samples with > 10% clonal PC by MFC, or > 20% PC by BMC/ BMH. We propose further evaluation of these thresholds as a practical cut-off for processing of samples by NGS at initial PCD diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12920-022-01346-1.

Hemophagocytic lymphohistiocytosis diagnosed by bone marrow trephine biopsy in living post-COVID-19 patients: case report and mini-review

Hemophagocytic lymphohistiocytosis (HLH) constitutes a life-threatening inflammatory syndrome. Postmortem histological findings of bone marrow (BM) from COVID-19 patients showed histiocytosis and hemophagocytosis and supported the hypothesis that secondary HLH (sHLH) may be triggered by SARS-CoV-2 infection. However, there are a limited number of sHLH cases in which trephine has been performed in living post-COVID-19 patients. Here we present a recent case and a mini-review of sHLH diagnosed by trephine biopsy in living patients after COVID-19. An 81-year-old man with a past medical history of hypertension, diabetes, ischemic stroke, was referred to the hospital to evaluate leukocytosis, pyuria, and elevation of inflammatory markers four weeks after recovering from COVID-19. Computed tomography of the abdomen did not reveal focal signs of infection or hepatosplenomegaly. The patient received intravenous meropenem and two packed red blood cell units. Leukocytes and C-reactive protein were gradually decreased. A BM biopsy was performed and the patient was discharged on cefixime. BM smear revealed severe anemia, lymphopenia, and dysplastic morphologic findings of erythroblasts, neutrophils, and megakaryocytes. Trephine biopsy revealed hypercellular marrow dyserythropoiesis, plasmacytosis, lymphocytosis, histiocytosis, hemophagocytosis, and the absence of granulomas or carcinoma. Immunohistochemistry documented a mixed population of T lymphocytes (CD3+) and B lymphocytes (CD20+). Strong positivity for CD68 confirmed histiocytosis. CD138 κ, λ staining proved polyclonal plasmacytosis. Perl’s staining showed excess hemosiderin deposits. Based on our findings, we document sHLH in trephine BM biopsy of a living post-COVID-19 patient and persistent leukocytosis, underscoring the diagnostic value of trephine biopsy in preventing life-threatening conditions such as COVID-19.

Bone Marrow Metastasis of Solid Tumors: A Study of 174 Cases Over 2 Decades from a Single Institution in India

To analyze the pathological findings in patients with marrow metastasis from solid tumors and to compare the accuracy of the bone marrow aspirate, trephine imprint and trephine biopsy in detecting metastasis. A total number of 174 cases diagnosed on bone marrow aspiration and/or bone marrow biopsy from January 2000 to December 2018 were included in the study. In addition to clinical and demographic data, we evaluated peripheral blood findings, and pattern as well as morphology of the tumor cells in bone marrow aspirate, imprint cytology and biopsy. The changes in the bony trabeculae were classified according to the classification of carcinomatous osteodysplasia. The most common laboratory findings included cytopenias and leucoerythroblastic blood picture. Trephine biopsy was found to be the most sensitive technique for detection of marrow metastases with a sensitivity of 99.4%. Trephine imprint cytology (89.9%) showed a significantly better detection rate than bone marrow aspiration (58.5%). Metastatic adenocarcinomas and undifferentiated carcinomas were more common than non-epithelial tumors. Metastatic carcinomas with known primary were mostly from breast, prostate and lung. Ewings/PNET and neuroblastoma were the commonest among metastatic non-epithelial tumors. Fibrosis (53.4%) was the most frequent stromal change and abnormalities in bony trabeculae were noted in 61.2% cases. Trephine biopsy has the highest sensitivity in detection of marrow metastasis followed by trephine imprint cytology. Immunohistochemistry on trephine section will help in confirming and or suggesting the primary tumor in unknown cases.

Diagnosis and Classification of Acute Leukemia in Bone Marrow Trephine Biopsies, Utility of a Selected Panel of Minimal Immunohistochemical Markers

BACKGROUND

Acute leukemias are characterized by neoplastic proliferation of hematopoietic stem cells and accumulation of blasts and immature cells in bone marrow. We applied a selective panel of immunohistochemical markers on bone marrow trephine tissue sections and observed their utility in diagnosis and typing of acute leukemia.

MATERIALS AND METHODS

The study was done at PSG Institute of Medical Sciences and Research from 1st January, 2008 to 30th June, 2012. Immunohistochemistry was done to detect the expression of Myeloperoxidase (MPO), Terminal deoxynucleotidyl transferase (TdT), Cluster of Differentiation 3 (CD3) and Cluster of Differentiation 20 (CD20).

RESULTS

On an average, 76 new cases of leukemia are diagnosed each year in our hospital. Of these 28.7% are acute leukemias, which had a bimodal peak age of occurrence with almost equal sex distribution. Only 9 cases could be typed as Acute Myeloid Leukemia (AML) or Acute Lymphoid Leukemia (ALL) purely by morphology. Another 10 cases were typed using cytochemistry. Immunohistochemical panel helped to type 90% of cases. We also identified 1 case of AML of ambiguous lineage. The data were analysed statistically using SPSS version 21 and found out that the immunohistochemistry was found to be extremely significant (p<001) by Chi-Square test.

CONCLUSIONS

Based on our results, we suggest the use of this limited panel of markers for routine evaluation of all acute leukemias. It is easier to type using immunohistochemistry rather than flow cytometry, given the disadvantage of the costs involved with the latter.

Cryptococcososis of bone marrow: a case report with review of literature

Cryptococcus has been increasingly seen as a pathogen with the growing incidence of Acquired Immune Deficiency Syndrome (AIDS). Cryptococcosis commonly presents with pulmonary, CNS or skin involvement. Bone marrow involvement of Cryptococci has been rarely reported. We are reporting a case of bone marrow Cryptococcosis in a 50-year-old Human Immune Deficiency Virus (HIV) positive male, with review of literature.

Miliary tuberculosis with hemophagocytosis in a two months old infant

A two months old male infant, presented with fever, hepatosplenomegaly and pancytopenia. On bone marrow aspirate, hemophagocytosis was noted. Trephine biopsy showed epithelioid granulomas. ZN stain AFB detected, which confirmed the diagnosis of miliary tuberculosis. This case highlights the rare association of hemophagocytic syndrome with tuberculosis in infancy.