bone marrow aspiration and biopsy
TRANSCRIPT
![Page 1: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/1.jpg)
Bone Marrow Procedures and
ProcessingDr Richards Kakumanu
![Page 2: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/2.jpg)
ModeratorsDr V Vijay Sreedhar (Prof & HOD)Dr Manimekhala (Assoc. Prof)
Upgraded Department of Pathology
![Page 3: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/3.jpg)
Marrow Specimen
![Page 4: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/4.jpg)
Needle Aspiration
![Page 5: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/5.jpg)
Percutaneous Trephine Biopsy
![Page 6: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/6.jpg)
Surgical Biopsy
![Page 7: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/7.jpg)
Why do we need to do bone marrow studies?
![Page 8: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/8.jpg)
Bone Marrow Aspiration
![Page 9: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/9.jpg)
•Simple and safe
•Repeated many times
•Performed on outpatients
•Safe in almost circumstances
![Page 10: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/10.jpg)
Advantages
•Individual cells are well preserved
•Subtle differences between the cells recognized
![Page 11: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/11.jpg)
Disadvantages
•Arrangement of cells in the marrow
•Relationship between the cells
•Fibrotic marrows: aspiration of blood
![Page 12: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/12.jpg)
![Page 13: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/13.jpg)
![Page 14: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/14.jpg)
General considerations
•Iliac spines: advantages of trephine biopsy
•Obese and immobile patients: technical difficulties
•Sternum should be avoided in children
•Danger of perforating inner cortical layer and damage to the underlying large blood vessels and right atrium
![Page 15: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/15.jpg)
Important considerations
•Always wear surgical gloves
•Avoid needle stick injuries
•Local and oral analgesia
•Use only needles designed for the purpose
![Page 16: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/16.jpg)
Marrow puncture needles
•Needles should be stout
•Hard stainless steel
•About 7-8 cm in length
•Well fitting stilette
•Adjustable guard
![Page 17: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/17.jpg)
•Most common reusable needles: Klima and Salah
•Point of the needle and the edge of the bevel must be kept well sharpened
![Page 18: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/18.jpg)
•Islam's bone marrow aspiration needle: the dome-shaped handle and the T-bar are intended to provide stability and control during the operation
•Disposable bone marrow aspiration needles
![Page 19: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/19.jpg)
•Clean the skin
•70% alcohol
•0.5% chlorhexidine(5% diluted 1 in 10 in ethanol)
![Page 20: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/20.jpg)
•Infiltrate the skin, subcutaneous tissue, and periosteum
•2% lignocaine 2-5ml
![Page 21: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/21.jpg)
WAIT...
![Page 22: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/22.jpg)
•Pass the needle with a boring movement
•Needle - perpendicular into the cavity
•Remove the stilette when bone has been penetrated
•Attach a 1-2ml syringe
•Aspirate marrow contents
•Second sample: Attach a second 5-10 ml syringe for cytogenetic and immunophenotypic analysis
![Page 23: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/23.jpg)
•As a rule material can be sucked into the syringe without difficulty
•If unable to aspirate: Insert the stilette, push the needle and then Aspirate
•Dry tap: failure to Aspirate marrow suggests fibrosis or infiltration
•Dry tap: insert the stilette, push any material in the lumen onto a slide
•Obese patients: CT guided marrow sampling
![Page 24: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/24.jpg)
•Ethylenediaminetetra-acetic acid(EDTA)
•Preservative free heparin: phenotyping and cytogenetic analysis
•Preservative in fixative: histopathology
•Fixation in absolute methanol: romanosky method or perls' stain or cytochemical staining
![Page 25: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/25.jpg)
Puncture of the Ilium
![Page 26: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/26.jpg)
Puncture of the ilium•Usual sites: Posterior and anterior iliac spines
•Center of the oval posterior superior iliac spine
•2cm posterior and 2cm inferior to anterior superior iliac spine
•Posterior iliac spine: 1) overlies a large marrow containing area. 2)relatively large volumes of marrow can be aspirated
•Posture: 1)patient lying sideways or 2)prone
•Anterior superior iliac spine: 1) overlying bone is thinner than iliac crest 2) very obese
![Page 27: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/27.jpg)
Puncture of the sternum
![Page 28: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/28.jpg)
Puncture of the sternum
•Avoid pushing the aspiration needle through the bone
•Usual sites: 1) manubrium, 2) 1st or 2nd parts of the body of sternum
![Page 29: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/29.jpg)
Manubrium•Denser bone than body of
sternum
•More fatty marrow in elderly subjects
•Thickness of cortex: 0.2-5.0mm
•Difficult to ascertain that the needle point has reached the cavity of the bone
•Site: about 1cm above the sternomanubrial angle and slightly to one side of the midline
![Page 30: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/30.jpg)
Body of Sternum•Site: opposite the second
intercostal space
•Slightly to one side of the midline
![Page 31: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/31.jpg)
•Essential: Needle with a guard
•Adjust the guard When needle reaches the periosteum
•Allow it to penetrate about 5mm further
•Push the needle with a boring motion, enter the cavity and Aspirate
![Page 32: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/32.jpg)
Puncture of the Spinous process
![Page 33: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/33.jpg)
Puncture of the Spinous process•Done in adults
•Spines of the lumbar vertebrae
•Not difficult as bones lie superficially
•More pressure is required
•Patient sitting up or lying sideways
•Pass the needle at right angles to the skin surface
•Into the spine of the Lumbar vertebra slightly lateral to the midline
![Page 34: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/34.jpg)
Comparison of different sites for marrow puncture •In general, the overall cellularity, the hemopoietic
maturation pathways, and the balance between erythropoiesis and leucopoiesis are similar at all sites
•Considerable variation in the composition of the cellular marrow in certain conditions
•Aspiration from only one site may give misleading information. Eg: aplastic anemia - patchily affected
•Dry tap/bloody tap: advantage in choice of several sites
![Page 35: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/35.jpg)
Aspiration of bone marrow in children•Small babies: medial aspect of
upper end of tibia, just below the level of tibial tubercle
•Caution! Vulnerable to fractures and laceration of adjacent major blood vessels
•Children: iliac puncture(posterior spine)
•Older obese children: anterior ilium
•Tibial cortical bone: too dense, marrow normally less active
•Sternal puncture avoided in children
![Page 36: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/36.jpg)
Processing of Aspirated Bone Marrow
![Page 37: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/37.jpg)
•Preparing films from Bone Marrow Aspirates
•Concentration of Bone marrow by centrifugation
•Preparation of films of post-mortem bone marrow
![Page 38: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/38.jpg)
Processing of marrow Aspirates
![Page 39: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/39.jpg)
General considerations•0.3 ml of marrow fluid from a single site
•>0.3ml: little advantage - peripheral blood dilution
•A second syringe: 5-10 ml of marrow - immunophenotyping, cytogenetics and molecular studies
•Sample of peripheral blood: finger prick or venepuncture
•Good practice: obtain full blood count and storage
•The blood film should be permanently stored with the bone marrow films
![Page 40: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/40.jpg)
Preparing films from Bone Marrow Aspirates•Smears should be made without
delay
•Smear length: 3-5cm
•Glass spreader: smooth edged, not more than 2cm width
•Marrow fragments dragged behind the spreader
•Fragments leave a trail of cells behind them
•Spreading should be towards the label area.
•Avoids particles dragged to the tip of the slide
![Page 41: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/41.jpg)
•Insufficient fragments: can be concentrated
•Deliver single drops of Aspirate onto slides about 1cm from one end
•Most of the blood is quickly sucked off from the edge of the drop using the marrow syringe or a fine plastic pipette
•Irregularly shaped marrow fragments tend to be left behind, can be lifted off with a spreader
•Smears can be made
![Page 42: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/42.jpg)
•Thorough drying, fix the smears, and stain (Romanosky)
•A longer fixation time(at least 20 min in methanol) is essential for high-quality staining
![Page 43: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/43.jpg)
•Perls' method: demonstrates the presence or absence of iron
•Atleast one film should be fixed for perls' stain
•Overnight drying may be necessary to achieve to achieve optimal results
![Page 44: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/44.jpg)
•Satisfactory: only when marrow particles and free marrow cells can be seen in stained films
•Differential counts should be made in cellular trails commencing from the marrow fragment and working back towards the head of the film
•Smaller numbers of cells from the peripheral blood are included in a differential count
![Page 45: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/45.jpg)
•Appropriate amounts of anticoagulant for the volume of marrow to be anticoagulated are used
•Gross excess of anticoagulant: masses of pink-staining amorphous material may be seen
•Clumping of some erythroblasts and reticulocytes may be seen
![Page 46: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/46.jpg)
Concentration of bone marrow by centrifugation
•To concentrate the marrow cells
•To assess the relative proportions of marrow cells, peripheral blood and fat in aspirated material
•Useful in poorly cellular samples
![Page 47: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/47.jpg)
Preparation of films of post-mortem bone marrow •Smears: Seldom satisfactory
•Satisfactory results: procedure must be Carried out as soon after death as possible
•Majority of cells tend to break up when making films
•Better preservation: a small piece of marrow is suspended in 1-2ml of 5% bovine albumin( 1 vol. 30% albumin, 5 vol. 9 g/l NaCl)
•The suspension is then centrifuged
•The deposited marrow cells are resuspended In a vol. of supernatant approx equal to or slightly less than that of the deposit
•Films made from the suspension in the usual way
![Page 48: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/48.jpg)
Trephine Biopsy
![Page 49: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/49.jpg)
•A little less simple than aspiration
•Can be performed on outpatients or at bedside
•Structure of relatively large pieces of marrow
•Imprint smears: morphological features of individual cells
•Superior for diagnosing marrow involvement by lymphoma and non hematological neoplasms
![Page 50: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/50.jpg)
•Invaluable in the diagnosis of conditions that yield a "dry tap".
•Hodgkin's disease, lymphoma: disrupted architecture of the marrow is an important diagnostic feature
•Usual site: posterior iliac spine
•Posterior iliac spine: longer, larger samples. Less comfortable for the patient
•Anterior iliac spine can also be used
![Page 51: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/51.jpg)
•Insert the biopsy needle into the bone
•Obtain a core of tissue using a to-and-fro rotation
•Main problems: specimen may be crushed, distortion of the architecture, difficulty to detach the core of the bone from inside the marrow space
•Trephine biopsy needles: specifically designed to overcome theses problems
![Page 52: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/52.jpg)
Jamshidi trephine•Tapering end to reduce crush
artefact
![Page 53: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/53.jpg)
![Page 54: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/54.jpg)
Islam trephine•Has a core securing device
•The distal cutting edge is shaped to hold the core secure during extraction of the material
![Page 55: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/55.jpg)
•Larger specimens: trephine needles with bores of 4-5mm
•Occasionally used needles: 2-mm bore microtrephine, Vim-Silverman needle
•Smaller yield of marrow specimen that are prone for fracturing
![Page 56: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/56.jpg)
Thrombocytopenia and neutropenia in small preterm neonates•19 G, half-inch Osgood needle
•Introduced 2cm below tibial tuberosity
•The trocar is removed
•The hollow needle is advanced by twisting 2-3mm into the marrow space
•Suction applied with a syringe until marrow appears
•Then needle and syringe are withdrawn
![Page 57: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/57.jpg)
•The marrow clot is gently dislodged with the tip of a needle and placed into fixative
•The specimen is processed
•Decalcification is not required
![Page 58: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/58.jpg)
Complications of bone marrow biopsy
![Page 59: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/59.jpg)
•Generally a safe procedure
•Serious adverse events <0.05% of procedures
•Most common complication: bleeding
•Gluteal compartment syndrome
•Very rarely death
•Bleeding is related to impairment of platelet function than to thrombocytopenia or a coagulation factor defect
![Page 60: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/60.jpg)
Imprints from bone marrow trephine biopsy
![Page 61: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/61.jpg)
•Can be taken before the specimen is transferred into fixative
•Particularly useful if the bone marrow Aspirate is inadequate
•Bony core is gently dabbed or rolled across the slide
•Fixed and stained
•Allows immediate examination of cells that fall out of the specimen onto the slide
•May provide a diagnosis several days before trephine biopsy has been processed
![Page 62: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/62.jpg)
Processing of bone marrow trephine biopsy specimens
![Page 63: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/63.jpg)
•Fixed in 10% formal saline
•Buffered to ph 7, for 12-48 hrs
•Decalcifying, dehydrating and embedding in paraffin wax
•Cell shrinkage and distortion from the decalcification process may distort cellular detail
•Methyl methacrylate(plastic) embedding
![Page 64: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/64.jpg)
Staining of Sections of Bone Marrow Trephine Biopsy Specimens
![Page 65: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/65.jpg)
•Routinely stained for H& E
•Silver impregnation method for reticulin
•Romanosky dyes: MGG - hemopoietic cells may be more easily identified
•Perls' reaction for iron
![Page 66: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/66.jpg)
•H&E staining: excellent for demonstrating the cellularity and pattern of the marrow
•Pathological changes: fibrosis, granulomata, carcinoma cells
•IHC: paraffin/plastic embedded specimens
![Page 67: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/67.jpg)
•Silver impregnation: stains the glycoprotein matrix
•Reticulin: an early form of collagen
•Increase in marrow reticulin: increase in the number and thickness of fibers
•Eg: myeloproliferative disorders - proliferation of megakaryocytes, lymphoproliferative disorders, secondary carcinoma with marrow infiltration. Osseous disorders such as hyperparathyroidism and paget's disease and inflammatory reactions.
![Page 68: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/68.jpg)
•In myelofibrosis or myelosclerosis, a more "mature" form of collagen is present
•Visible on H&E staining
![Page 69: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/69.jpg)
References
•Dacie and Lewis practical hematology
•Bone Marrow Pathology - Barbara Bain - 4th edition
•Wintrobe's clinical hematology
•Google images
![Page 70: Bone marrow aspiration and biopsy](https://reader036.vdocument.in/reader036/viewer/2022062412/5874d2071a28abd05f8b4a45/html5/thumbnails/70.jpg)
Thank you