doi: 10.37545/haematoljbd201822

Amin Lutful Kabir¹, Sayed Salahuddin Ahmed², Munim Ahmed³, Md. Abdul Aziz⁴, ASM Anwarul Kabir⁵, Syed Mukarram Ali⁶, Mahbuba Sharmin³

1. Associate Professor of Haematology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka; *for correspondence

2. Senior Consultant of Histopathology, Delta Hospital Limited, Mirpur, Dhaka

3. Medical Officer, Department of Haematology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka

4. Professor of Haematology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka

5. Registrar, Holy Family Red Crescent Hospital, Dhaka

6. Chief Consultant, Department of Pathology, Delta Hospital Limited, Mirpur, Dhaka

Abstract

Background: Trephine biopsy is a core biopsy of bone marrow using a special needle to evaluate the marrow architecture. Taking bone marrow biopsy alongside aspirate is still the most preferred practice for precise diagnosis and evaluation of various haematological and non- haematological disorders. Aims and objective: This study was carried out to evaluate the importance of this procedure in the diagnosis of various haematological and non-haematological disorders especially when bone marrow aspirates alone are non-diagnostic and to assess the prognostic significance of haematological malignancy. Materials and Methods: This was a retrospective study using the trephine biopsy and aspiration reports extracted from hospital records of Delta Medical College Hospital, Dhaka, over an 8years period from May 2009 to December 2016.The patient's profiles along with corresponding diagnoses and the necessary investigation reports were analysed. Result: Eighteen (26.47%) patients had bone marrow involvement for non-Hodgkin's lymphoma, three (4.41%) patients for Hodgkin's lymphoma, and acute lymphoblastic leukaemia was diagnosed in 18 (13.43%) patients, metastatic deposits in 6 (4.5%) patients, acute promyelocytic leukaemia in 3 (2.2%) cases, aplastic anaemia in 7 (5.2%) cases, chronic lymphocytic leukaemia in 1 (0.75%) case, multiple myeloma in 3 (2.2%) cases, myelofibrosis in 6 (4.5%) cases and chronic myeloid leukaemia and immune thrombocytopenic purpura were found in less than 1% cases. Total 37 patients (54.41 %) were reported as normocellular marrow with normal maturation among all the cases of lymphomas (N=68). One trephine biopsy was carried out to assess remission after induction chemotherapy in ALL. Conclusion: Trephine biopsy is an invaluable diagnostic tool in case of diagnostic dilemma and for follow up of patients undergoing chemotherapy and bone marrow transplantation. An expert haematopathological evaluation of the bone marrow trephine can impart light on actual diagnosis and have tremendous impact regarding patient management.

Keyword: Trephine biopsy, haematological malignancy.

Introduction

Trephine biopsy for bone marrow is a well-established essential minimal invasive surgical procedure which is used for the inspection of bone marrow architecture. It is usually done along with bone marrow aspiration. For evaluation of haematological and non-haematological disorders, it is one of the most important diagnostic procedures specially where there is diagnostic dilemma.¹ Trephine biopsy is mandatory in staging of lymphoma.² In cases of metastasis of solid organ tumours, trephine biopsy has been proved superior to aspiration.³ For assessing the pattern of infiltration (focal or diffuse) and cellularity, trephine biopsy has important role. It is also helpful when there is a dry tap or blood tap on aspiration due to fibrosis or infiltration.⁴^,⁵ For immunohistochemical and molecular studies trephine biopsies are also used. Trephine biopsy has added a new dimension for diagnostic evaluation of various haematological disorders like leukaemia, myelodysplastic syndromes and different types of lymphomas that involving the bone marrow.⁶ Usually, trephine biopsy is taken from posterior iliac crest. Bilateral sampling from both iliac crests usually improve tumour detection as compared to sample taken from a single site.⁷ For trephine biopsy, Jamshidi and Islam needles are the most popular but although different biopsy needles are also used all over the world.⁸^,⁹ Trephine biopsy, unlike aspiration, need more technical skill than aspiration only. It is time consuming, and a bit more painful procedure and its interpretation depends on some other factors such as quality of tissue section and availability of special staining, immunohistochemistry (IHC), good coordination between histopathologists and haematopathologists.² This Study was done with an objective to evaluate the role of this trephine biopsy procedure to diagnose haematological disorders as well as non-haematological disorders.

Materials and Methods

It was a single-centre retrospective cross-sectional study done in Delta Medical College Hospital from January 2009 to December 2016 over a period of 8 years. After ethical permission by the institutional ethical review board and after informed written consent from each patient, 134 cases of bone marrow trephine biopsies (BMB) were done during this time period and they were included in this study. Before that, detailed history, physical and necessary laboratory investigations were done for each patient. Adequacy of biopsy was based on Average length of biopsy section was 1.48 cm; 89.6% the presence of at least 5-6 intertrabecular spaces. Biopsies which were inadequate for assessment were excluded from this study.

Trephine Biopsy Procedure: Bone marrow aspiration and biopsy were done using modern Jamshidi needle. For aspiration purpose a 2 ml plastic syringe were used and 0.25-0.5 ml aspirates were withdrawn and smears were drawn immediately and stained with Leishman stain. Biopsy procedure consists of a step by step combination of extraction of core bone through trephine biopsy needle, overnight fixing in acetic acid-zinc formalin fixative for decalcification, embedded in paraffin wax and finally 3-4 μm thick sections were cut from paraffin wax box and stained with H&E stain. The patient profile along with corresponding diagnosis was obtained and analysed accordingly. Correlation between age, sex, histopathological diagnosis and the pattern of bone marrow involvement was done.

Results

Over this eight-years period, 134 trephine biopsies have been recorded. Male female ratio was 2.9:1 (100/34). Age of the patients ranged from 4 to 85 years with a median of 45 years (47.5 years in males, 44.5 in females).

Average length of biopsy section was 1.48 cm; 89.6% of them were single piece. Highest rate of biopsies of 24.63% were done in the year 2013 and lowest 1.49% in 2011 (Figure 1). About 2.2% sample was found inadequate for reporting.

Fig 1: Annual distribution of trephine biopsy (2009- 2016) n= 134

There are two common age groups that were biopsied, 40-49 years (17.16%) and 50-59 years (19.40%). (Figure 2)

Fig 2: Number of trephine biopsy in relation to age group and gender n=134

A total of 68 cases lymphoid neoplasm diagnosed by lymph node biopsywere evaluated but revealed marrow involvement in 30.88% (21/68) cases that include 26.47% (18/68) cases as non-Hodgkin`s lymphoma and 4.41% (3/68) as Hodgkin`s lymphoma (Table I).

Table I: Lymphomatous infiltration and non-infiltration findings of bone marrow in all cases of lymphoproliferative disorders. (n= 68)
Histological Diagnosis	Frequency	%
Normal marrow in lymphoid neoplasms	47	35.10
Bone marrow infiltration in all cases of lymphomas	21	30.88
Acute lymphoblastic leukaemia	18	13.43
Aplastic anaemia	7	5.20
Myelofibrosis	6	4.50
Secondary malignant deposit	6	4.50
Chronic lymphocytic leukaemia	5	3.70
Acute myeloblastic leukaemia	4	2.90
Acute promyelocytic leukaemia	3	2.20
Hypocellular Marrow Multiple myeloma	3	2.20
Erythroid hyperplasia	3	2.20
ALL in remission	2	1.50
Chronic myeloid leukaemia	1	0.75
Essential Thrombocythaemia	1	0.75
Immune thrombocytopenia	1	0.75
Myeloproliferative neoplasm	1	0.75
Tuberculosis	1	0.75
Report cannot be done	3	2.20

Acute lymphoblastic leukaemia was diagnosed in 13.43% (18/134) patients and 4.5% (6/134) patients were found to have metastatic deposits. Acute promyelocytic leukaemia and aplastic anaemia were found in 2.2% (3/134) and 5.2% (7/134) cases respectively. Chronic lymphocytic leukaemia, and multiple myeloma were found 0.75% (1/134) and 2.2% (3/134) cases respectively.

Myelofibrosis was diagnosed in 4.5% (6/134) cases. Less than 1% was found in chronic myeloid leukaemia and immune thrombocytopenic purpura. One trephine was carried out to assess remission status after induction chemotherapy in ALL (Table II).

Table II: Histological pattern of lymphoma in trephine biopsies (n=68)
Histological Finding	No. of Patients	No. in Percentage
Infiltration Present	21	30.89
Non-Hodgkin Lymphoma	18	26.47
Hodgkin's Lymphoma	3	4.41
No Infiltration	47	69.11
Normocellular marrow	37	54.41
Hypocellular marrow with normal architecture	8	11.76
Erythroid Hyperplasia	2	2.94

Table III shows the largest entity found at our place are B cell neoplasms, accounting for 21.64% (including NHL, HL, MM, and CLL) followed by acute leukaemia (19.40%), MPN (2.23%), aplastic anaemia (5.2%), ITP (0.75%), metastasis (4.5%) and granuloma (0.75%). But rest of all were reactive, erythroid hyperplasia and normal marrows. In this study majority of the patients were male gender and adult.

Table III: Distribution of Mature B cell Neoplasms (n =29)
Histopathological Diagnosis	No. of Patients	No. in Percentage
NHL	18	63%
MM	3	10%
CLL	5	17%
HL	3	10%

Discussion

The bone marrow biopsy and aspiration are complementary to each other. Therefore, should be used together for diagnostic purposes. Among the 134 cases in our study, 2.2% (3/134) cases were inadequate for reporting. In case of bone marrow aspiration only, compactness of the marrow and marked increase cellularity and reticulin in both acute lymphoblastic and myeloblastic leukaemia may lead to dry tap or inadequate aspirate. Another important limitation of using marrow aspiration alone is admixing of marrow with sinusoidal blood. Ultimately it does not allow accurate estimation of marrow cellularity.³ Among the 26 cases of acute leukaemia 14.18% (19/134) cases were acute lymphoblastic leukaemia and 2.9% (4/134) cases were acute myeloblastic leukaemia. In these cases, bone marrow trephine biopsy had primary diagnostic value.

In lymphomas, bone marrow biopsy also provides information regarding cellularity, extent and pattern of marrow infiltration, marrow fibrosis and these cannot be assessed on aspiration only.⁴ So, obtaining an adequate length of biopsy specimen is most important for study of cell morphology and also for immunohistochemistry. In our study 30.89 (21/68) cases of lymphoma had marrow infiltration which coincides with various other studies that reported marrow infiltration ranging from 27.1% to 55.1% in lymphoma.⁵^,⁶ In post chemotherapy patients trephine biopsy is also useful to assess response to chemotherapy and gives information about residual disease. Thus, it has paramount prognostic importance. Pattern of marrow involvement by leukemic cells could be analysed by trephine biopsy only. In this study 5.2% (7/134) cases of aplastic anaemia, diagnoses were confirmed on trephine biopsy as trephine biopsy is the ultimate confirmatory tool for diagnosis of aplastic anaemia.⁷

Only aspiration has no role in diagnosis of myelofibrosis.²^,³^,⁵^,⁷ Though Peripheral smear and aspirates were adequate for diagnosis of chronic myeloproliferative disorders other than myelofibrosis, but trephine biopsy added important clues to assess the degree of marrow fibrosis, cellularity and morphology of megakaryocytes.²^,³^,⁷^-⁹ In this study, 6 cases of myelofibrosis showed dry tap on aspiration and diagnosis were established on biopsy alone. In some cases, as the methods are complementary to each other thus both are essential.¹⁰ In this study three (2.2%) cases of multiple myeloma were diagnosed by bone marrow biopsy and aspiration simultaneously that correlated with the study done by Charles et al where they detected myeloma in trephine biopsies and all simultaneous bone marrow aspirates.⁸ In plasma cell myeloma, particularly in cases with low degree of infiltration were more reliably diagnosed in the biopsy by Pileri et al.¹¹In the present study, Granulomas (0.75%) showed higher detection rate by trephine biopsy like other studies.⁷^,⁸^,¹¹^,¹² Toi et al. have mentioned that 80% cases of granulomatous lesions were diagnosed by bone marrow biopsy alone.⁹ In this study, in cases of erythroid hyperplasia, reactive marrows and in immune thrombocytopenia no added benefits of biopsy were obtained, which also correlated well with other studies.⁴^,⁶^,⁷^-⁹

Conclusion

For evaluation of haematological and non-haematological disorders bone marrow trephine biopsy is one of the most important diagnostic procedures specially where there is diagnostic dilemma. It is more informative for assessment of extent, and pattern of tumour infiltration, cellularity, follow-up and prognosis especially in chronic lymphoproliferative disorders. More advanced techniques such as immunohistochemistry can only be performed on biopsy specimen only. It is an indispensable tool for the diagnosis of aplastic anaemia. In most cases of acute leukaemia and non-neoplastic pathologies except for granulomas, as it provides less additive information, both procedures can be done in the same setting to obtain adequate biopsy material along with aspirate. For all post chemotherapy cases, residual diseases may be missed by aspiration alone during follow-up marrow procedures due to its limitations. But can be evaluated more precisely by bone marrow biopsy. So, in case of all post chemotherapy follow-up patients both aspiration and biopsy simultaneously should be done at the same setting.

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