Undesirable occupants of bone marrow creating a menace: A 4.5-year audit from a tertiary care centre in Eastern India

Abstract

Background: Bone marrow (BM) in addition to being the origin of primary hematological malignancies is also commonly involved in metastatic solid tumors. Bone marrow examination includes aspiration and biopsy, and it is a well-known procedure not only to diagnose hematological malignancies but also for staging and prognosis of various solid tumors. The presence of metastasis in the bone marrow is of grave prognostic significance and it is imperative to rule out marrow involvement in any malignancy where curative treatment is considered. The study's objectives were to evaluate the clinical, hematological, and biochemical characteristics of patients with BM metastases of solid tumors diagnosed by bone marrow (BM) aspiration and trephine biopsy and to find out the accuracy rate of diagnosing metastatic infiltration between bone marrow aspiration, trephine imprints, and trephine biopsy procedures.

Methodology: It was a 4.5-year retrospective hospital-based observational study where relevant clinical, biochemical, and hematological parameters including bone marrow aspirate and biopsy were analyzed and compiled from hospital medical records.

Results: The total number of BMA and trephine biopsies that came during the duration of 4.5 years were 3850 and 2980 respectively. Out of the 3850-bone marrow aspiration and 2980 trephine biopsies received in the dept of Hematology, 305 cases were referred to look for metastatic bone marrow infiltration. Out of these 305 cases, 69 cases showed the presence of metastatic deposits (12.6%). 45 patients (65.2%) were males, and 24 patients (34.7%) were females with M:F ratio of 1.8:1. Most common age group was 51-60 years (31.8%). The most common complaints were fever, body aches, weight loss, and weakness. Clinical examination revealed pallor in 38 out of 69 cases (55%) and organomegaly in 14 cases (20.2%). Microcytic hypochromic anemia (26%) was the most common finding on peripheral blood smear examination followed by pancytopenia (18.8%). The biochemical findings most commonly observed were raised LDH (60.8%), serum PSA (36.3%), and alkaline phosphatase (21.7%).

Conclusion: Trephine biopsy is a sensitive method for detecting marrow metastasis and should be done in all cases being investigated for this purpose. BMA alone may miss marrow metastases in almost half of cases. Trephine imprint cytology is more sensitive than BMA and can provide rapid diagnoses while waiting for trephine biopsy results.

Keywords: Bone Marrow Aspiration; Bone Marrow Imprint Smear; Bone Marrow Trephine Biopsy; Metastasis; Solid Tumors.

Fig 1:

pie-chart showing hematological features observed in various metastatic solid tumors.

Fig 2:

pie-chart showing biochemical parameters in various metastatic solid tumors infiltrating bone marrow.

Fig 3:

bar diagram showing the frequency of various primary solid malignancies metastasizing to bone marrow

Fig 4:

Fig 4a-Microphotograph of bone marrow aspiration showing metastatic deposit of neuroblastoma (Leishman stain; x 40X) Fig 4b -Microphotograph of bone marrow aspiration showing presence of metastatic deposit of invasive breast carcinoma (Leishman stain; x 100X) Fig 4c- Microphotograph of bone marrow aspiration showing presence of metastatic deposit of adenocarcinoma colon (Leishman stain; x 40X) Fig 4d- Microphotograph of bone marrow aspiration showing presence of metastatic deposit of adenocarcinoma lung (Leishman stain; x 40X) Fig 4e- Microphotograph of bone marrow aspiration showing metastatic deposit of round cell sarcoma of the urinary bladder of a 20-year-old boy presenting with urinary obstruction (Leishman stain; x 100X) Fig 4f- Microphotograph of bone marrow aspiration showing metastatic deposit of rhabdomyosarcoma of left shoulder Inset shows fibromyxoid matrix. (Leishman stain; x 40X). Fig 4g- Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by invasive breast carcinoma. (H &E stain; x10X) Fig 4h- Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by adenoacarcinoma lung. (H &E stain; x10X) Fig 4i- Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by Neuroblastoma. (H &E stain; x10X) Fig 4j- Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by adenocarcinoma colon. (H &E stain; x40X) Fig 4k- Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by invasive breast carcinoma with associated fibrosis. (H &E stain; x10X) Fig 4l: Microphotograph of bone marrow trephine biopsy showing metastatic infiltration by prostate adenocarcinoma with osteosclerotic changes in bony trabeculae. (H &E stain; x40X) Fig 4m: Microphotograph of bone marrow biopsy trephine imprint smear showing the presence of malignant epithelial cells in clusters having high N/C ratio, scanty cytoplasm, and hyperchromatic nuclei. (Leishman stain; x40X) Fig 4n: Microphotograph of bone marrow biopsy showing the presence of diffuse infiltration of single cells with fibrosis and sclerotic bony trabeculae (H & E; x 100X) Fig 4o: Microphotograph of bone marrow biopsy showing infiltration by signet cells having abundant eosinophilic cytoplasm and eccentrically located hyperchromatic nuclei (H & E; x40X) Fig 4p: Microphotograph of bone marrow biopsy showing signet cells in higher magnification (H&E; x100X) Fig 4q: IHC microphotograph of metastatic prostatic carcinoma showing anti-PSAP positivity (DAB; x 40X) Fig 4r: IHC microphotograph of metastatic prostatic carcinoma showing EMA positivity (DAB; x40X)