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BONE MARROW EXAMINATION Suwanna Semsri Department of Clinical microscopy Faculty of Medical Technology Huachiew chalermprakiet university

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Bone Marrow ปริมาณ 30-50 mL/Kg ส่วนประกอบ (Red : Yellow) - Hemopoietic compartment (Hemopoietic cell) - Non-hemopoietic compartment (Vascular nerves, Reticulum, Fat cell) - Adult (Cell : Fat cell) ~ 1:1

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Bone Marrow Upper Lims 11.44% Lower Lims 38.76% Ribs 7.34% Head 6.93% Spine 14.68% Sternum 1.38% Pelvis 16.28% 100%

Bone Marrow : 

Bone Marrow Architecture of bone marrow Vascular space - Central artery ->carry food O2 to hematopoietic tissue - Central vein -> carry waste product, hematopoietic cell to circulation

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Cellular compartment - Hematopoietic tissue - Reticular cells : reticular fiber for hematopoietic cell attachment - Adipose cell (fat cells) Bone Marrow

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Normal Bone Marrow

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Normal Bone Marrow Fat cell Cell

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Type of Bone Marrow 1. Red marrow : cellularity (hematopoietic cell/fat cell) 1:1 : found in area which active marrow, particularly in children marrow 2. Yellow marrow : cellularity < 1:1 : found in area which decrease (non-active) marrow, particularly in older marrow

Red marrow & Yellow marrow : 

Red marrow & Yellow marrow Red marrow Yellow marrow

Bone Marrow Activity : 

Bone Marrow Activity Bone marrow activity responsible for age

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Objective of Bone Marrow Examination - To evaluate hematopoiesis - To diagnose malignancy of primary and metastatic origin - To determine the cause of infection - To evaluate the progression of some hematologic diseases To response of the marrow to treatment follow up To primary diagnosis of systemic diseases Miscellaneous

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Objective of Bone Marrow Examination To evaluate hematopoiesis 1. Primary diagnosis of hematolympoid malignacies - Acute leukemias - Chronic myeloproliferative disorder - Chronic lynphoproliferative disorder - Myelodysplastic syndromes - Hodgkin and non-Hodgkin lymphomas - Multiple myeloma 2. Staging of lymphoid malignancies and solid tumors

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Objective of Bone Marrow Examination To determine the cause of infection - Mycobacterium and fungal infections - Granulomas - Unknown infection agents using culture and special stairs - Hemophagocytic syndrome To response of the marrow to treatment follow up - Post chemotherapy and radiation - Post bone marrow transplant

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Indication for Bone Marrow Studies 1. Unexplained anemia/erythocytosis 2. Unexplained leukocytosis/leukocytopenia 3. Appearance of immature or abnormal cell in circulation 4. Unexplained thrombocytosis/ thrombocytopenia 5. Leukemia 6. Infiltration disease; Cancer metastasis, TB 7. Fever unknown origin (FUO)

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ข้อห้ามในการเจาะตรวจไขกระดูก 1. ภาวะที่มีกลไกการแข็งตัวของเลือดผิดปกติ 2. ภาวะที่มีเกล็ดเลือดต่ำ - ถ้าจำเป็นต้องเจาะก็สามารถทำได้ด้วยความระมัดระวัง และกดที่บาดแผลหลังการเจาะนานประมาณ 5 นาที หลังจากนั้นก็ให้ผู้ป่วยนอนทับบาดแผลไว้อีกประมาณ 10-15 นาที หรือต้องมีค่า factor activity > 50%

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A-Posterior superior iliac crest B-Sternum C-Anterior superior iliac crest D-Spinal processes (rare) ตำแหน่งที่เจาะ

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ขึ้นอยู่กับความชำนาญของแพทย์ ผู้ใหญ่ Posterior superior iliac crest เด็ก Sternum Anterior superior iliac crest Spinal processes (rare) ตำแหน่งที่เจาะ

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เครื่องมือที่ใช้เจาะ A-Trephine biopsy needle B-Stylet C-Probe D-Sternal aspiration needle ED-Stylet

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Preparation Marrow film 1. Two cover slips 2. Smearing 3. Squashing

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Sample ที่ได้ 1. Aspirated sample : the best for cytologic morphology cytochemical staining

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Sample ที่ได้ 1. Biopsy sample : the best for evaluation of marrow celluarity (hematopoietic cell : fat cell ratio evaluation marrow involvement by the proliferative cells evaluation marrow structure

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Bone Marrow Specimens 1. Aspirate - Cytogenetic - Immunologic marker - Microbiology - Microscopic marrow examination - Iron storages - Cytochemical stain

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Bone Marrow Specimens 2. Trephine biopsy - Imprint (toch prep) - microscopic marrow examination - Histochemical & Immunologic stain

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Bone Marrow Staining - Wright’s stain - Wright’ s Geimsa stain - May Grunwald stain - Prussian blue stain

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Bone Marrow Examination 1. Cellularity 2. Differential cell count 3. Myeloid:Erythroid ratio (M:E ratio) 4. Iron accumulation

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Bone Marrow Examination 1. Cellularity Cellularity is a hematopoietic cell/fat cell ratio Normal cellularity = 1 Cellularity > 1 refer as “Marrow Hyperplasia” Cellularity < 1 refer as “Marrow Hypoplasia” The mostly evaluated from biopsy specimen

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Bone Marrow Examination Marrow Hyperplasia Marrow Hypoplasia

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Bone Marrow Examination Marrow hyperplasia

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Bone Marrow Examination 2. Differential cell count - 500-1000 cells had been counted

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Myeloblast Promyelocyte Myelocyte Band form Metamelocyte Segmented form Granulocytic series

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Lymphocytic series Lymphoblast Prolymphocyte Lymphocyte

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Monocytic series Monoblast Promonocyte Monocyte

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Erythrocytic series Pronormoblast Basophilic normoblast Polychromatic normablast Othochromatic normoblast Reticulocyte Red cells

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Megakaryocytic series Megakaryoblast Promegakaryocyte Mgegakaryocyte Platelet

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Plasmocytic series Plasmoblast Proplasmocyte Plasmocyte (plasma cell)

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Normal bone marrow

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Normal Bone Marrow - Granulocytic series (65%) (M) - Erythrocytic series (20%) (E) Myeloid : Erythroid = 2:1-4:1 - Lymphocyte (10%) - Others (5%)

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Normal Bone Marrow Others - Megakaryocyte - R.E. Cell (Histiocyte) - Monocyte, Plasma cell - Mitotic cell Ostioblast, Ostiocyte Tissue eosinophil, Mast cell Recticulin fiber, Fat cells

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Bone marrow cells Tissue eosinophil Tissue basophil Osteoclast Osteoblast Rhopheocytosis Histiocyte R.E.cell Mitotic cell

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Bone Marrow Examination

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Bone Marrow Examination 3. Myeloid/Erythroid ratio (M/E ratio) - Normal M/E ratio responsible by age - At birth = 3-4.5 - Up to 1 month 3-4.5 - Children = 1.5-4 - Adult = 2-4

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Bone Marrow Examination 4. Iron Stores - Storage iron is “hemosiderin” - It contained by nucleated erythroid cell - Unstained -golden-yellow granules - Wright’s stain- brownish-blue granules - Prussian blue is the mostly stain for marrow iron storage - Iron stores is benefit for evaluation of anemia

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Anemia - Iron deficiency anemia - Sideroblastic anemia - Megaloblastic anemia - Aplastic anemia Leukemia Multiple Myeloma Hodgkin's disease Lymphoma Abnormal results

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Metastatic Bone Cancer Macroglobulinemia Agammaglobulinemia Myelofibrosis Collagen disease Infection Abnormal results

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Aplastic anemia

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Siderloblastic anemia

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Multiple Myeloma

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Metastatic bone cancer

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Tuberculosis infection

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Marrow and blood interpretation based on cellularity and M:E ratio

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The end

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