SA MEDIESE TYDSKRIF DEEL 64 20 AUGUSTUS 1983 271

Review Article
Trephine biopsy of the bone marrow
A. R. BIRb, P. JACOBS
Summary
We present areview of trephine biopsy of the bone
marrow based on an experience of approximately
10000 examinations. It is our view that, in adults,
examination of material obtained by aspiration
combined with atrephine biopsy allows for the most
thorough morphological assessment of the marrow.
Morbidity is limited to transient discomfort to the
patient, and even bilateral procedures are conve-
niently performed on outpatients. There is no abso-
lute contraindication to combining aspiration and
trephine biopsy, but in severe bleeding disorders
due to acquired or congenital coagulation factor
deficiencies replacement therapy is indicated and
the patient should be observed in hospital for 24
hours following the procedure. Thrombocytopenia
is not associated with significant bleeding from the
biopsy site in our experience. l"he advantages of the
trephine biopsy are that it allows better overall
assessment of ceUularity and morphology and is
indispensable in cases where aspiration has failed
or where infiltration due to the myeloproliferative
syndrome or to haematological and non-haemato-
logical malignancies has occurred. With marrow
hypoplasia and granulomatous disorC:ters involving
the marrow, the trephine biopsy is indispensable for
diagnosis.
S Atr Med J 1963; 64: 271-276.
Examination of the bone marrow is one of the diagnostic corner-
stones of haematological practice. Aspiration techniques are
limited in that they do not provide positive diagnostic informa-
tion in patients with granulomatous disease, myelofibrosis and
infiltrative conditions ofthe marrow, H although some investiga-
tors favour examination of sections prepared from concentrated
particles obtained by aspiration.
7

s
However, up to 10 ml of
aspirated marrow is required to obtain material equivalent to
that of a trephine biopsy.9
We review the various techniques ofobtaining a core biopsy of
the marrow and its processing and preparation for microscopic
study. The indications and the advantages of marrow biopsy are
outlined and the diagnostic pitfalls in the interpretation of mar-
row sections are emphasized.
University of Cape Town Leukaemia Centre and Depart-
ment of Haematology, Groote Schuur Hospital, Cape Town
A. R. BIRD, F.F.PATH. (SA), M.MED.PATH. (HAEM.l, Regisrrar (Present
appointment: Specialist Pathologist, Red Cross War Memorial
Children's Hospital)
P. JACOBS, M.D., PH. D., Professor and Head
Date received: 5 August 1982.
Reprint requests [0; Professor P. Jacobs, DepI of Haematology Research Cemre. University of
Cape Town Medical School, ObservatOry, 7925 RSA.
Techniques of trephine biopsy
Many methods of trephining the bone marrow have been des-
cribed. The Vim-Silverman needle was the first device to be used
regularly. 10 This was followed by the introduction of the
Westerman-Jensen needle, 11 a modification of the Vim-Silverman
needk, which is still used in many centres. The technique is
excellently illustrated by Ellis er al. 11 More recently, the Jam-
shidi needle
l2
was introduced and is now probably the most
widely used device. Other coring techniques using the Bordier
trephine,13 Gidlund's instrument,14 the Radner needle,15 the
Gardner and the Sacker-Nordin needle
l6
have been described.
Larger specimens may be obtained with Burkhardt and Notter-
Labhart needles
2
or by open surgical biopsy. These procedures
are, however, time-consuming and therefore unsuitable if serial
biopsies are required.
Our preference is to use the Jamshidi needle. The'technique of
coring is outlined by Jamshidi and Swaim
l2
and is well known to
most haematologists. We have also had extensive experience
with the Westerman-Jensen needle but now prefer the Jamshidi
needle for the following reasons: (a) there is little disturbance in
the architecture of the core obtained by the Jamshidi needle; (b)
it requires less maintenance than the Westerman-Jensen needle
since sharpening and replacement of cuning blades are avoided;
(c) larger cores are obtained; and (d) it is our experience that
patients tolerate trephining with the Jamshidi needle better than
that with the Westerman-Jensen needle.
Certain points, however, should be noted. Firstly, the cutting
tip of the Jamshidi needle should be sharpened regularly and the
tip should be kept acutely angled to reduce the incidence of 'lost
cores'. Secondly, we have experien<;:ed difficulty in obtaining
specimens from very osteoporotic patients using large-gauge
Jamshidi needles. In these circumstances, the Westerman-
Jensen needle is often preferable. Thirdly, the anatomy of the
pelvis must obviously be considered when performing a trephine
biopsy. The posterior iliac crest (the most convenient and proba-
bly the safest site for marrow biopsy) is usually easily palpable
with the patient lying prone. The sacro-iliac joint lies perpen-
dicularly below the posterior crest. The wing of the ilium slopes
laterally and it is in this direction that the biopsy needle should
be aimed.
We routinely perform marrow aspiration just prior to biopsy.
We do not aspirate with the same needle but prefer to use the
Klima
l6
or similar needle. As long as the needle is directed away
from the site ofthe proposed biopsy, there is no distortion on the
subsequent trephine sections. .
It is well known that aspiration of marrow can cause sharp
pain. Trephining of the marrow, with few exceptions, seems to
cause less discomfort. Unallayed anxiety, inadequate local anaes-
thesia and poor technique are factors which may make the proce-
dure unacceptable. Physicians inexperienced in the technique of
trephine biopsy usually provide inadequate specimens and
therefore the procedure has to be repeated. In our hospital,
therefore, all patients requiring bone marrow examination are
referred to the Haematology Department. The marrow aspirates
and trephine biopsies are then performed by the residents.
272 SA MEDICAL JOURNAL VOLUME 64 20 AUGUST 1983
Preparation of the specimen for examination
Fixation
Once an adequate core (> 2,0 cm) has been obtained, it is fixed
for a minimum of 4 hours in Zenker's fixative, with constant
agitation. It is washed overnight to remove the dichromate and
the following morning is placed in Formol/Decal solution for 4
hours to decalcify the bone using a roller mixed to ensure even
exposure of the core to solution. After washing for IS minutes, it
is then processed and embedded in Paraplast according to stan-
dard methods.
Poor-quality sections are often the result of one or more of
three problems involving fixation: (i) inadequate time allowed
for proper fixation - we have run a number of trials to assess
optimum fixation time, and 4 hours is the absolute minimum
using Zenker's fixative; (ii) using a Zenker's stock solution older
than 2 weeks; (iii) fixative prepared too far in advance of the
biopsy procedure; it should be prepared just prior to biopsy.
Preparation of sections
The preparation of good sections ensures accurate identifica-
tion of the haematopoietic cells. Ideally, serial sections should be
examined. We recommend that at least three sections taken at
different levels should be studied. If properly decalcified and
fixed, sections can be cut at 4 ).Lm. By using a methacrylate
embedding process, sections as thin as I ).Lm can be prepared. 17
This allows for very accurate identification of haematopoietic
cells. The major disadvantage of this technique is the time re-
quired for preparation of the blocks, usually a minimum of 4
days.
Staining procedures
At least three sections from each core biopsy specimen should
be stained with haematoxylin and eosin, and one section for
reticulin. Romanowsky stains have been recommended
2
but in
our experience add little diagnostic information. Iron stores are
best evaluated on the aspirate smears using Perls's reaction, but
if smears are not obtainable, sections may also be stained for
assessment of iron stores. Loss of iron from the section, however,
may occur during fixation and we do not recommend core biop-
sies for the assessment of iron stores. Special stains for fungi or
tubercle bacilli may be indicated in the presence of granulomas,
although these stains, too, may be affected during the fixation
processes.
Indications for trephine biopsy
In the following section we outline what we consider to be
absolute indications. In these situations, failure to do a trephine
biopsy may result in a missed or delayed diagnosis.
Failure to aspirate marrow
Three failed aspirations from different puncture sites should
be regarded as a 'dry tap'. In these cases, material for cytological
assessment may still be obtained by performing a touch prepara-
tion with the trephine biopsy.
Myeloproliferative syndrome (Fig. 1)
This is probably the commonest condition leading to failed
aspiration. The appearance of the marrow is pathognomonic, 18
although in the early cellular phase of polycythaemia vera the
diagnosis may not be obvious. Astain for reticulin is mandatory,
Fig. 1. Silver stain showing dense parallel strands of reticulin in a
patient who presented with pancytopenia and splenic enlarge-
ment. Myelofibrosis was diagnosed.
however, as even in polycythaemia vera the typical pattern of
increased marrow reticulin is seen.
Metastatic neoplasia (Fig. 2)
'Dry taps' in patients with cancer metastatic to the marrow are
not infrequent. A review of 74 marrow aspirates and trephine
specimens obtained over a 2-year period (January 1973 -
December 1974) from patients with non-haematological
malignant disease showed the presence of metastatic tumour in
18 (24%). In 7 of these tumour was found in both the aspirate and
the trephine specimen, while 5were 'dry taps'. In only I, a child
with metastatic retinoblastoma, was the aspirate positive in the
face of a negative trephine specimen (A. R. Bird and P. ]acobs
-unpublished observations).
Fig. 2. Metastatic carcinoma with intense desmoplastic reaction
and blood vessel invasion in a patient with fever and weight loss
who was eventually found to have a 0,5 cm primary carcinoma of
the proximal colon.
In a study by Savage et al. 6 u t i l i z i n g ~ a Jamshidi needle for
biopsy and aspiration, a correlation between biopsy and aspira-
tion results was shown in 75% of cases positive for metastatic
cancer. In only I" instance was the aspirate positive and the
trephine biopsy negative. The remaining discrepancies were all
due to biopsy-positive, aspirate-negative specimens. Other stu-
dies also attest to the efficacy of the trephine biopsy in increasing
the yield of positive specimens.
1
,ll,19 Performing bilateral tre
phine biopsies further increases the yield of positive specimens. 20
Garrett et al.,21 however, reviewed 291 patients with non-
haematological malignancies and found 39 positive for metasta-
tic rumour. The biopsy was positive in 3 patients witha negative
aspirate, and in 3 others the aspirate was positive with a negative
biopsy. They attributed their high rate of tumour detection in
the aspirate to a thorough initial screening by technologists; this
process, however, sometimes occupied several hours in scanning
many smears.
The yield of positive marrow specimens may be increased if
biopsies are performed at sites of local tenderness or in a
suspicious area as depicted on the radiograph or bone scan.
However, needle biopsies can be performed safely only from the
anterior or posterior iliac crests, or occasionally from the verte-
bral spines. Negative radiographic studies or bone scans do not
militate against the performance of a marrow biopsy, as positive
marrow specimens may be obtained in the case of a negative
skeletal surveyor scan.
22
Concurrent aspiration and trephine biopsy from the posterior
iliac crest, bilaterally if possible and aided by radiographic stu-
dies and a bone scan, should therefore ensure the best possible
yield of positive specimens from the marrow in the diagnosis of
metastatic rumours.
Acute leukaemia
Although aspirate smears are indicated for the cytological
diagnosis of acute leukaemia, the marked increase in reticulin
sometimes seen in both acute lymphoblastic and acute myelo-
blastic variants may lead to a 'dry tap'. A recent srudy has shown
that the presence of this reticulin does not appear to be related to
the prognosis,23 although there has been a report to the con-
trary.24 Induction of remission in patients with increased mar-
row reticulin results in a distinct reduction in the reticulin.
Recurrence of increased reticulin may herald the onset of a
relapse of the leukaemia.
23
,24
In the follow-up of patients with acute leukaemia, and particu-
larly in the post-induction period of hypoplasia, marrow biopsy
allows for a more comprehensive assessment of marrow reserve
than the scanty particles obtained on aspiration alone.
Leukaemic reticulo-endotheliosis
This rare but well-described condition mainly affects adults,
and patients with pancytopenia and splenomegaly. The diag-
nosis is usually made from the peripheral blood smear where the
diagnostic 'hairy' cells are seen. 25 These cells show a characteris-
tic positive acid phosphatase reaction which is resistant to tart-
rate pretreatment.
26
Attempted marrow aspiration is invariably
non-productive and a marrow biopsy is required. Sections show
the'characteristic infiltrate with a dense reticulin pattern.
Staging and follow-up of patients with
lymphoma
Hodgkin's disease (HD) (Fig. 3)
Marrow specimens positive for HD show disruption of the
normal marrow architecrure by fibrosis, necrosis, and a cellular
infiltrate of lymphocytes, plasma cells, eosinophils and histio-
cytes, even in the absence of Reed-Sternberg cells. The pattern
of infiltration may be diffuse or focal. 27 Marrow aspiration alone
is of limited value in the detection of marrow involvement by
HD. This is not unexpected, in view of the often focal nature of
the infiltrate and the high incidence of accompanying fibrosis. A
review of 53 trephine biopsies and aspirate smears from patients
with HD during a 2-year period from January 1973 to December
1974 revealed 19 positive specimens. Of these 4 were 'dry taps',
SA MEDIESE TYDSKRIF DEEL 64 20 AUGUSTUS 1983 273
Fig. 3. High-power view of marrow involved by Hodgkin's
disease. Typical Reed-Sternberg cells were not found. Characte-
ristic Hodgkin's mononuclear cells with giant nucleoli are seen.
The diagnosis was subsequently established on examination of a
para-aortic lymph node specimen obtained at laparotomy.
while the remainder were all biopsy-positive and aspirate-
negative (authors' unpublished data).
Positive bone marrow biopsy specimens from untreated
patients have not been reported in patients iJ;litially clinically
classified as stage I and HA. However, up to 25% of patients
thought to have stage III disease may be reclassified as stage IV
as a result of a positive core biopsy.28,29 Occasionally, marrow
infiltration may be the only evidence of stage IV disease. Bilat-
eral biopsies have been shown to increase the yield of positive
specimens.
2o
The diagnosis of HD on the basis of marrow infiltration alone
in patients without peripheral lymphadenopathy presents many
difficulties. Neiman et al. 30 described a group of 13 patients with
lymphocyte-depleted HD. The patients had fever, pancytopenia.
and abnormal liver function, but there was no striking peripheral
lymphadenopathy. The outcome was consistently fatal, usually
within a short period. In 5 patients the marrow sections were
diagnostic, and in 3 of these were the sole criterion for the
diagnosis.
The occurrence of granulomatous lesions in tissues involved
by HD is well recognized.
3
! The significance of isolated non-
caseating granulomas in otherwise uninvolved tissues, however,
is less clear. Kadin eT al. 32 reviewed tissue obtained from 185
patients with HD prior to treatment and noted isolated granulo-
mas in the liver and spleen. Further extensive sectioning ofthese
tissues failed in many instances to reveal a diagnostic infiltrate of
HD. In some, however, the granulomas were intimately associa-
ted with an HD infutrate. It was concluded that the discovery of
isolated epithelioid cell granulomas in HD should not influence
the staging criteria.
Another phenomenon occasionally encountered is the pre-
sence of extensive lymphoid aggregates in otherwise normal
biopsy specimens from patients with HD. The significance of
this remains uncertain.
Non-Hodgkin's lymphoma
Proper histopathological classification and clinicopathological
staging are now regularly employed in the non-Hodgkin's lym-
phomas: (1) to define patterns of disease better; (il) to correlate
these patterns with the clinical course and response to treatment;
and (iil) for selection of the appropriate therapy.
Although aspiration smears or sections of aspirated particles
have been used in the detection of marrow involvement by
lymphoma, several reviews testify to the trephine biopsy as the
274 SA MEDICAL JOURNAL VOLUME 64 20 AUGUST 1983
best method for detection of marrow lymphoma.
3
.
33
-
35
By per-
forming bilateral posterior iliac crest biopsies the yield of posi-
tive specimens is increased by 10 _20%.2 ,36
Marrow biopsy often influences the staging of patients with
non-Hodgkin's lymphoma. It has been shown that 50 - 65% of
patients thought to be in stage I - III m ~ be reclassified as stage
IV as a result of a marrow biopsy.20,2, ,35 A normal full blood
count does not exclude infiltration of the marrow.
33
,35
One of the major problems in the diagnosis of marrow lym-
phoma is the distinction between benign lymphoid aggregates
and lymphoma. Studies of the prevalence of benign lymphoid
follicles in marrow biopsies and clot sections obtained in virro
show a wide variation. Although most biopsy srudies (including
our unpublished data) report an incidence of 1 - 9%,37 much
higher fi?ures, up to 47%, are reported when clot sections are
used.
37
-
3
These benign lymphoid nodules are commoner in
older patients and in many cases constitute a normal finding
without any known clinical significance. Not infre.quently, how-
ever, we have found it difficult to decide whether the marrow was
involved by a Iymphoproliferative disorder, both in patients with
known lymphoma and in those without evidence of lymphoma
elsewhere. The following features have been described as sugges-
tive of early lymphomatous infiltration: (i) size of aggregate
-any aggregate covering more than 25%of a 40 high-power field
is suspect;36 (ii) cytological atypicality; (iil) multiplicity ofaggre-
gates; (iv) infiltration into surrounding normal marrow; and ('v)
paratrabecular location.
These criteria must be viewed critically, however, as we have
seen several marrow specimens with many of the above fearures
in patients in whom subsequent follow-up revealed no evidence
of lympho.ma. Moreover, nodular lymphoid hyperplasia of the
marrow is a well-described entity. 31 Recent reports of this syn-
drome have emphasized that caution must be exercised before a
definitive diagnosis of lymphoma is made.
37
.40 In a study by
Rywlin er al.J7 10 patients with lymphoid hyperplasia of the
marrow were noted. In 5 of these, follow-up was possible.
During a 2 - 2
1
/
2
-year period, none of these patients developed
signs or symptoms suggestive of a lymphoproliferative disorder.
Careful follow-up of patients in whom the isolated finding of
lymphoid hyperplasia ofrhe marrow is made is therefore prefer-
able to treating them as cases of early lymphoma.
Diagnosis of the hypoplastic anaemias
Marrow trephine biopsy, preferably from more than one site,
is an essential procedure in the diagnosis of hypoplasia. Although
this is important diagnostically, no correlation between estima-
tions of cellularity and prognosis has been shown.
41
,42
Granulomatous disorders (Figs 4 and 5)
Granulomas represent a host inflammatory response which
may be the result of a wide variety of stimuli. In an extensive
study by Pease
43
of 150 patients with granulomatous lesions in
sections of aspirated marrow particles, the commonest underly-
ing disorders were tuberculosis, histoplasmosis, infectious
mononucleosis, sarcoidosis, brucellosis, and Hodgkin's and non-
Hodgkin's lymphoma. Marrow granulomas were also found in a
wide variety of other disorders, some of which are not ordinarily
associated ~ i t h granulomatous change. Okun er al.
44
have des-
cribed the presence of marrow granulomas in a patient with Q
fever. Unless a specific organism can be identified by special
stains or bacteriological culture, there are no diagnostic features
of a granuloma characteristic of a definite etisorder, although
prominent caseous necrosis favours the diagnosis of tuberculosis.
Granulomas may very occasionally be seen in aspirate smears,
but the yield is considerably increased by sectioning particles of
material. Although no adequately controlled studies are avail-
Fig, 4. Granuloma containing Langhans giant cell and epithelioid
hystiocytes in a patient with fever of undetermined origin. Tuber-
culosis was subsequently diagnosed on examination of a sputum
specimen.
Fig. 5. High-power view showing numerous Gaucher cells in a
5-year-old black girl with massive splenomegaly.
able, biopsy will presumably further increase the yield owing to
its ability to reach more deep-seated tissue.
Although marrow aspiration and biopsy are complementary to
other investigations, marrow examination and culture may
sometimes succeed in establishing the diagnosis ofa granuloma-
tous disorder when orher tests have failed to do SO.40-47
Chronic lymphocytic leukaemia (CLL)
Bone marrow histological patterns and rheir relationship to
prognosis in chronic lymphocytic leukaemia have been evaluated
by some authors. Gray er al. 48 studied 115 patients and showed
that those wirh diffuse marrow infiltration had a poorer prog-
nosis than those presenting with a nodular or mixed (nodular and
diffuse) pattern. Rozman er al. 49 studied 63 patients with eLL
and described 4 different histological patterns: (i) interstitial
(lymphoid infiltration without displacement of fat cells); (ii)
nodular (abnormal lymphoid nodules without interstitial infil-
tration); (iii) mixed (combination of the first two patterns); and
(iv) diffuse (replacement of both haematopoietic and fat cells by
lymphoid infiltration). Statistical analysis of actuarial curves
showed a significant difference of survival probability according
to the marrow infiltration patterns. In patients with interstitial or
nodular patterns life expectancy is significantly less than in those
with mixed or diffuse patterns. They also noted a significant
degree of correlation between bone marrow infiltration patterns
and the various methods of clinical staging.
--
Miscellaneous
Bone disease. Bone trabeculae can easily be studied in mar-
row trephine sections and thus provide a simple method for the
diagnosis of bone disease, such as may accompany chronic renal
failure, intestinal malabsorption, and other disorders.
50
Lead poi.soning. Bone is a primary site of lead storage and
core biopsies may therefore be used to estimate stored lead levels.
A recent study of skeletal lead concentrations in Americans has
documented the presence of plumbism in polluted environments
and underlines the value of this investigation in such epidemio-
logical studies.
51
Contraindications to marrow trephine
biopsy
These are all associated with a tendency to increased bleeding.
Thrombocytopenic bleeding (Fig. 6) has never been a problem in
our experience, provided adequate compression has been applied
to the biopsy site on completion of the procedure. In the face of
disseminated intravascular coagulation, haemorrhage following
a trephine can be catastrophic, and marrow biopsy is therefore
contraindicated in the presence of this disorder. In patients with
hereditary coagulation factor deficiencies, marrow biopsy should
be performed only with adequate cover by the approximate
component. For patients on anticoagulant therapy, cessation of
therapy is indicated until adequate haemostatic status has been
regained.
Fig. 6. Megakaryocytic hyperplasia in an otherwise normal bone
marrow specimen from a patient who presented with purpuric
bleeding and a platelet count of 5 x 10
9
/1. Auto-immune thrombo-
cytopenic purpura was diagnosed.
Complications
The problem of post-biopsy bleeding has been discussed
above. The only other complication we have experienced is
infection. Our incidence of infection is less than 1%. Infection
has occurred only in immunocompromised patients on cytotoxic
dtugs. We therefore use a strict aseptic technique and wear
surgical masks and gloves when biopsying these patients.
Diagnostic pitfalls
Besides some of the diagnostic problems that have already been
mentioned, we should like to emphasize a few other problems of
interpretation occasionally encountered.
SA MEOIESE TYOSKRIF OEEL 64 20 AUGUSTUS 1983 275
Megaloblastic anaemia
The cellular and apparently blastic appearance of the marrow
tissue on sections stained with haematoxylin and eosin may lead
to an erroneous diagnosis of leukaemia or lymphoma. The mar-
row aspirate should obviously lead to the correct diagnosis, but
the trephine biopsy may still be misinterpreted by the inexpe-
rienced, especially if examined in isolation.
Angio-immunoblastic lymphadenopathy
This unusual hyperimmune disorder ofB-lymphocyte origin
52
may involve the marrow.
53
The characteristic morphological
features ofimmunoblastic and plasma cell infiltrates, amorphous
acidophilic interstitial material and vascular proliferation may
closely resemble HD. The diagnosis is usually made on clinical
grounds in conjunction with a lymph node biopsy.
Eosinophilic fibrohistiocytic lesions
These lesions were described by Rywlin el al. 54 in 1972. They
consist of spindle cells, numerous eosinophils, some plasma cells
and occasional mast cells. In Rywlin el al.'s series, some of the
patients were anaemic and all of them were raking numerous
medications. Withdrawal of the drugs led to an improvement in
the anaemia and disappearance of the eosinophilic lesions. We
have noted a similar lesion in a patient with urticaria pigmentosa.
Post-induction therapy for leukaemia
Atrephine biopsy is indicated in the follow-up of patients with
acute leukaemia after intensive cytotoxic therapy for the induc-
tion of a remission. This applies particularly to acute myeloblas-
tic leukaemia. The trephine biopsy ensures good assessment of:
(i) the extent of residual disease, if present; and (ii) the extent of
haematopoietic reserve and early signs of regeneration of normal
haematopoietic tissue.
Occasionally, diagnostic problems may be encountered in the
assessment of biopsy specimens when clusters of blasts are pre-
sent - is this a sign of residual disease or of regeneration? It is
our experience that these sections should be interpreted with
caution. Very often these blasts are part of a regenerative process
and do not represent residual leukaemia.
\1( e have also noted some unusual regenerative phenomena in
classic myeloid leukaemias following induction therapy, e.g.
megakaryocytic hyperplasia.
Comment
Needle biopsy of the bone marrow has for some time been the
accepted method for obtaining a specimen of bone marrow for
examination when aspiration has resulted in a 'dry tap'. It is only
in the last decade, however, that it has become clear that biopsy is
superior to aspiration in the detection of Ho.dgkin's and non-
Hodgkin's lymphomas and metastatic malignant tumours. Some
authors have advocated the use of sections of aspirated material
and have demonstrated their superiority to aspirate smears in the
detection of granulomas, metastatic tumours and lymphoma. A
comparative study by Dee el al. 3 indicated a distinct superiority
of the biopsy specimen when this was compared with the aspirate
and sections of aspirated particles in the diagnosis of HD.
In non-Hodgkin's lymphomas, biopsy was also the most
sensitive diagnostic procedure, particularly with follicular lym-
phomas, although there were several positive clot sections in the
presence of negative biopsies. On the basis of a study performed
on 30 cadavers, Rywlin
9
concluded that aspirated marrow par-
276 SA MEDICAL JOURNAL VOLUME 64 20 AUGUST 1983
ticles which were concentrated before sectioning yielded larger
areas of marrow for examination than needle biopsy sections.
This may be misleading, as 10 ml of marrow was aspirated in
each case and this is not always possible in vivo. It is nevertheless
clear that the various techniques are complementary. In practice,
however, we have found it simpler to obtain and process biopsy
specimens as described earlier. Moreover, in contrast to Rywlin,
we are able to obtain equally as good cytological detail in our
trephine sections as in the particle sections. It is rare to obtain
inadequate specimens, whereas with aspiration inadequate sec-
tions for examination may be obtained in as many as 10% of
cases.7
We should like to re-emphasize the importance of proper
fixation and preparation of sections. We have frequently recei-
ved slides which are difficult to interpret owing to poor fixation
and thick sections. To obtain good trephine sections is an art
which requires some practice and it is therefore preferable to
refer patients requiring marrow trephines to centres where biop-
sies are regularly performed and the specimens examined, rather
than submit an inadequate specimen for opinion. This often
leads to the patient having to undergo the procedure a second
time.
Bone marrow sections should be interpreted by a pathologist
or haematologist in conjunction with a thorough examination of
the smear preparations. The practice of examining marrow sec-
tions in isolation is not recommended and may lead to misdiag-
nosis.
In summary, therefore, it is our experience that bone marrow
biopsy sections with concurrent marrow aspiration smears are
complementary, and together allow for a thorough assessment of
the bone marrow. The morbidity is minimal and the procedure
can be performed on outpatients. The few contraindications to
biopsy are those associated with a severe bleeding tendency as a
result of depletion of coagulation factors.
This study was supported by the Universiry of Cape Town Leuk-
aemia Centre and Staff Research Fund, the South African Medical
Research Council and the National Cancer Association. We thank
Donald Alexander, Kathy Hunter and Johan van Wyk for excellent
technical assistance, Jackie Davies for typing, Sheila Katcher for
bibliographic assistance and the Medical Superintendent, Groote
Schuur Hospital, for permission to publish.
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