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1 Nungruthai Nimnuch School of Allied Health Sciences Naresuan University Phayao Bone Marrow Examination

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Nungruthai Nimnuch

School of Allied Health Sciences

Naresuan University Phayao

Bone Marrow Examination

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�������� (Bone marrow)

� ������ spongy tissue ������� !�"� ���#$!����%�#&'(�#

� )*���*&+,�-#'./$# #&'(�#/�0!�# 1��.2&� #&'(�# 3�/$3� 4$'�50�,6+�#&!�

� �7!/�0!��� &0!�,1$$8,9:(,$;�(

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���� �����������������������������

� ,);��<�*27!=!9"�#&-����#!&<&�>?&'>7!�3��!�(0!�.$/+<�+��!���,$;�(<3����!�%9� !9!&=/!27!<�*%(0

� @�0?A��.&2<+(,6;B�*!�6�+(, 9�%�0.(�%9��&!* !,/<5 4<�<&�>(0���+D��;��4$0��3��+�+>E3�.&2%9�%(0

� "60<&�>,);���7! staging 4$'?&'#�*#!&&3#F!@�0?A��.&29',&:�*!�6�+(

� "60 7!/&3*?&',9+�@�0?A�����9�.&2��� lymphoreticular system 4$'�3�"/0#!&�+�+>E3�%9�%(0

� "60<+(<!9&3#F!@�0?A��.&2,$;�( 4$'.&2���&'** lymphoreticularsystem

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���������������������� ����������!�������� � 3 $ �%

1. "60,�:9,>!'(�( (Aspirtaion) 2. "60,�:9,>!'<3( (Needle Biopsy) 3. #!&<3(%�#&'(�#�!�Q3$�#&&9 (Surgical Biopsy)

���$��������� ��&������������� #&'(�#/�0!�# (Sternum) ����&'/��!�1��.2&���� 2-3� #&'(�# '.)# (Iliac crest) ,>!'<&�*&+,�- Anterior 4$' posterior iliac crest� ?5A9#&'(�# 3�/$3� (Spinous process) ,>!'<&�*&+,�- Anterior 4$' posterior

superior iliac spine� #&'(�#�+,*�� (Tibia)

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��������������� ������'��%� � ?

� #!&,>!'%�#&'(�#>'"60,�$!,)��� 15 �!��

� 4@$���,#+(>!#,�:9���"60,>!'>'9���!(%9�,#+� 2 mm.

� %�#&'(�#���=�#(�(��#9! (bone marrow aspiration) >'=�#�7!%?<&�>�+,2&!'/8 !�"<0#$0��>5$�&&Q�8

� "�*!�2&3B�4)��8>'�7! ������%�#&'(�#��#9!,$:#�0�� .(�#!&"60,�:9��!("/X� ,&��#��! trephine biopsy

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Bone marrow aspiration

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�������' �� �'�5��������

� ,>!'4$' ,9��&8�3���

� " � EDTA tube 4$'<3B��+B�%�0?&'9!- 30 �!�� ������%�#&'(�#>'$���\B�9!(0!�*�

�7!#!&(�(%�#&'(�#4$'�7!%? ,9��&8

����� �'�5��������

]Push technique` 4$' ]Pull technique`

Push technique : %= ,9��&8.(�#!&"60 spreader

Pull technique (squash preparation) : "60 glass slide 2 4@��?&'#*#3�4$0�(\���#>!##3�

Fixing and straining aspirate smear

� ,9;�� %$(84/0� 2�&<&\� ,9��&8%�#&'(�#�3���(0�� metanol

� Romanowsky stain : basic dye 4$' acid dye �3B�<��#!&,<&��9 �,#!&#&��, pH ��� staining buffer >'<0��=�#<0�� 4$'&'�',�$!"�#!&�0�9>'�!�#��! ,9��&8,$;�(

93#9�,$;�(?�9!(0��

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���BC�D�$E���������5�FEE5�����������(Bone marrow examination)

1. Bone marrow smear preparation

2. Bone marrow cellularity

3. ?&+9!- Megakaryocyte

4. M:E ratio

5. Maturation ��� !� myelocytic series 4$' erythrocytic series

6. Megaloblastoid change

7. Histiocyte

8. Plasma cells

9. Eosinophil

10. Blast cells 4$' Metastatic cells

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1.1 ���������������I�'����E���JE���B�5��� low power field

2�&>')* fat cell 4$' megakaryocyte

��������� �'�5��������������E���'�'���� (Low magnification)

1.2 Bone marrow smear preparation� #!& clot� #!&�0�9 ,9��&8%�#&'(�# : �

Fat cellMegakaryocte

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1.3 Bone marrow cellularity#!&#&'>!�<3���� nucleated cell "� ,9��&8%�#&'(�# !�"<0 low power field (10X) $3#F-'#!&#&'>!�<3����,1$$89�(3���BNormal cellularity

nucleated cell 9�#!&#&'>!�<3�?&'9!- 2 "� 4 ������);B���� ,9��&8%�#&'(�#���<&�>�+,2&!'/8 !�"<0 low power field

http://bonemarrowbiopsy.wordpress.com/normal-results/

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Hypocellularity

nucleated cell 9�#!&#&'>!�<3��0��#��! 1 "� 4 ������);B���� ,9��&8%�#&'(�#���<&�>�+,2&!'/8 !�"<0 low power field 1\��$3#F-'��� hypocellularity <&�>)*%(0"�.&2 aplastic anemia, myelofibrosis

www.medscape.com/viewarticle/430138_3

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Hypercellularity

nucleated cell 9�#!&#&'>!�<3�9!##��! 3 "� 4 ������);B���� ,9��&8%�#&'(�#���<&�>�+,2&!'/8 !�"<0 low power field $3#F-'#!&#&'>!�<3����,1$$84** hypercellularity %(04#� acute leukemia

http://img.medscape.com/fullsize/migrated/501/096/lab501096.fig4.jpg

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Diluted specimen

!9!&=<&�>)*%(0"�#&-�����3B�<��"�#!&,>!'(�(%�#&'(�#>!#@�0?A��9�#!&?�,?rs�����,$;�(,�0!9!"�<3����!�

+�����<&�>)* !�"<0#$0��>5$�&&Q�8#7!$3���!�<�7! low power field 2;� )* red blood cell ,)+�9�\B�&��9#3*#!&)* fat cell 4$' megakaryocyte ���$($�

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1.4 ��� �U Megakaryocyte

megakaryocyte ,?t�,1$$8���9���!("/X���� 5(���<&�>)*%(0"�%�#&'(�#

?#<+)* 1-15 cells/LPFMegakaryocyte

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�����$������5�F��5���FEE5� !��E%��������V���� �'�5��������������W����X�

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��������� �'�5��������������E���'�'��� (High magnification)1.1 M:E ratio

�3<&! ������ nucleated cell !� myeloid : nucleated cell !� erythroid

2�!?#<+��� normal bone marrow M:E ratio = 3:1

2�&<&�>�3*���!��0�� 10 fields

Myeloid hyperplasia : 9�#!&,)+�9�\B����,1$$8"� !� myeloid

*��*�#��!9�#!&<+(,6;B� (infection)

Erythroid hyperplasia : 9�#!&,)+�9�\B����,1$$8"� !� erythroid

*��*�#��!@�0?A����!>'9� !�'1�( (anemia)

M:E ratio ��

M:E ratio <�7!

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1.2 Maturation ����' myelocytic series

Normal

,1$$8"� !� myeloid ���)*%(0"� normal bone marrow 2;� ,1$$8"�&'�' metamyelocyte, band form 4$' segmented cell

Shift to the left)*,1$$8<3�����"�&'�' promyelocyte ,)+�99!#�\B�

promyelocyte

metamyelocyte band form segmented cell

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1.3 Maturation ����' erythroid series

Normal

,1$$8"� !� erythroid ���)*%(0"� normal bone marrow 2;� ,1$$8"�&'�' polychromatic normoblast 4$' orthochromatic normoblast

Shift to the left)*,1$$8<3�����"�&'�' basophilic normoblast

,)+�99!#�\B�

basophilic normoblast

polychromatic normoblast orthochromatic normoblast

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1.4 Megaloblastoid change

,?t�#!&,?$����4?$����,1$$8"� !� erythroid ,�;���>!##!&�!( �+<!9+� B12 4$' folate �7!"/0�+�,2$�� 9�)3w�!#!&60!#��! ������%1.<)$! 9 1 &'�' 4$',1$$89���!(���"/X�@+(?#<+

http://www.vet.uga.edu/vpp/clerk/Smith/index.php

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1.5 Histiocyte

� Histiocyte 2;� ,1$$8 Reticuloendothelial cell (RE cell) ���#+�,1$$8,9:( ,$;�(4(�/&;�,9:(,$;�(�;��y���/9(�!�5�3�,�0!%?

� )*%(0"�%�#&'(�#%9�=\� 1% ��� nucleated cell

� )*,)+�9�\B�"�@�0?A�����9�#!&<+(,6;B� (infection) .(�>')*&��9#3* plasma cell 4$' eosinophil

_Rhopheocytosisa 2;� ?&!#{#!&-8���,1$$8 histiocyte 9�,1$$8,9:(,$;�(4(�<3�����.(�,E)!',1$$8 polychromatic normoblast >7!���9!#9!$0�9&�*,);��(�(13*,/$:#>!#,1$$8 histiocyte

Reactive histiocyte

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Plasma cell

1.6 Plasma cells� Plasma cell 9�$3#F-'�+�,2$�� ,?t�&�?%��4$'93#>'����6+(��*(0!�"(

(0!�/�\�����,1$$8 (eccentric) %1.<)$! 92$0!�|���B7!(spongy)�)*%(0"�%�#&'(�#%9�=\� 1% ��� nucleated cell�)*,)+�9�\B�"�@�0?A�����9�#!&<+(,6;B� (infection)�#!&)* plasma cell �3B�<3�����4$'<3�4#�,)+�99!#�\B�"�%�#&'(�#

!9!&=*��6�B=\�.&29',&:�6�+( Multiple myeloma (MM)1\��@�0?A��9�#!& &0!� monoclonal immunoglobulin (MoIg) ���\B����!�@+(?#<+

�MoIg ,&��#��! M-protein /&;� paraprotein 1\��>'9�&'(3* ���\B��3B�"�,$;�(4$'"�?} !�'���@�0?A��

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1.7 Eosinophil� "�%�#&'(�#?#<+>')* eosinophil %(0 1-5% ��� nucleated cell �������"�%�#&'(�#

� ?&+9!-��� eosinophil ���,)+�9�\B��\B�#��!?#<+ !9!&=)+>!&-!%(0(3���B

~ Infection 93#>')* eosinophil ,)+�9�\B�"� !�' infection &��9#3*#!&,)+�9�\B���� histiocyte 4$' plasma cell

~ CML "�@�0?A��9',&:�,9:(,$;�(�!�6�+( Chronic Myelocytic Leukemia 93#>')* eosinophil ,)+�9 ���\B�(0��

~ "60"�#!&<+(<!9@$#!&&3#F!/$3�>!#%(0&3*#!&&3#F!(0���!,29�4$0� .(�>'<0���&!*?&'�3<+���@�0?A��#���#!& treatment /!#9�#!&<�* ���<��#!&&3#F!>')* eosinophil ���,)+�9�\B�&��9#3*#!&9�,1$$8<3��������$($�4$',1$$8,&+�99�#!& differentiation ,#+(�\B� !9!&=*��*�#%(0��!@�0?A��9��!#!&(��\B� (Well recovery)

Eosinophil

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1.8 Blast cells

� "�%�#&'(�#?#<+ !9!&=<&�>)* blast cell %(0%9�,#+� 3% ��� nucleated cell

� blast cell > 30% leukemia?Pronormoblast

Myeloblast

Lymphoblast

Monoblast

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1.9 Metastatic cells

2;� ,1$$89',&:����,#+(>!#��3��'�;��4$'9�#!&$5#$!9 (metastasis) >!#��3��'���,?t�9',&:�9!�3�%�#&'(�#

http://www.healthsystem.virginia.edu/internet/hematology/hessidb/Rare-bone-marrow-findings.cfm

Metastatic cells

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