Is A Template Bx A Clean Or Contaminated Procedure

Indications need for a trephine biopsy notes on other useful investigations investigation of unexplained microcytic anemia

: misdiagnosis of anaemia of chronic affliction equally iron deficiency is mutual and information technology is not infrequent for such patients to exist subjected to an extensive search for a source of claret loss without a firmly based diagnosis of fe deficiency. If results of biochemical assays are equivocal it is important to perform a bone marrow aspirate to ensure an authentic diagnosis before embarking on other investigations. just if myelodysplastic syndrome

is suspected
investigation of unexplained megaloblastic anemia

: it is acceptable to omit bone marrow examination if the peripheral blood features are totally typical and if assays of vitamin B₁₂ and folic acid are suggestive of a deficiency land. Otherwise, os marrow aspiration is still indicated. If the diagnosis does non appear straightforward, or if the patient requires urgent treatment and haematinic assays are not available, os marrow aspiration is indicated. only if myelodysplastic syndrome

is suspected deoxyuridine suppression test may be useful but is mainly a research technique investigation of unexplained anaemia

usually cytogenetic analysis if MDS is suspected; ultrastructural examination if congenital dyserythropoietic anaemia is suspected investigation of unexplained thrombocytopenia

only if myelodysplastic syndrome

is suspected
investigation of pancytopenia

(including suspected aplastic anaemia) yes cytogenetic analysis if MDS is suspected; appropriate culture if mycobacterial infection or leishmaniasis is suspected; os marrow is a useful source of DNA if investigation for Pearson'south syndrome is required; cytogenetic analysis if a haemophagocytic syndrome is suspected (because EBV-related haemophagocytic syndrome may be associated with a clonal proliferation of neoplastic T cells) investigation of a leucoerythroblastic claret pic and suspected bone marrow infiltration yes cytogenetic analysis if a haematological neoplasm is suspected; if an abnormal infiltrate is plant, immunophenotyping and cytogenetic analysis may be useful; cytogenetic assay is indicated if a pocket-sized cell tumour of childhood is suspected because the sit-in of certain specific cytogenetic abnormalities tin confirm the diagnosis investigation of suspected acute leukaemia : although information technology is often possible to found a diagnosis of acute leukaemia from peripheral claret examination, bone marrow aspiration should nevertheless be carried out. This is both because the likelihood of successful cytogenetic analysis is higher if bone marrow cells are used and because a baseline is needed for comparison with bone marrow aspirates performed during handling. In addition, bone marrow aspiration permits the assessment of trilineage dysplasia, which may be of prognostic relevance. no (unless there is difficulty obtaining a skilful aspirate) cytogenetic and perchance molecular genetic assay; immunophenotypic assay unless cells are clearly myeloid assessment of remission status after treatment of acute leukaemia no (unless there is difficulty obtaining a good aspirate) follow up cytogenetic analysis is only occasionally useful; molecular genetic analysis may be indicated for assessment of minimal rest disease investigation of suspected myelodysplastic syndromes

/ myeloproliferative disorders

yes cytogenetic assay; investigation of colony forming units if juvenile myelomonocytic leukaemia is suspected investigation of suspected chronic myeloid leukaemia

: usually offers little diagnostically useful data beyond that which tin be gleaned from a conscientious examination of the peripheral blood. However, equally for the acute leukaemias, cytogenetic assay is more often successful when performed on the bone marrow and aspiration is therefore indicated for this purpose no (unless there is difficulty obtaining a skillful aspirate or if the accelerated phase of the disease or blast transformation is suspected) cytogenetic analysis; molecular genetic analysis is not indicated because information technology can be performed, when necessary, on peripheral blood cells follow up of chronic myeloid leukaemia

no cytogenetic analysis investigation of suspected myeloproliferative disorders

(polycythaemia rubra vera, essential thrombocythaemia, idiopathic myelofibrosis, or systemic mastocytosis) yes cytogenetic analysis; investigation of colony forming units (erythropoietin independent burst forming units) may be useful merely in most centres is non a routine diagnostic examination investigation of chronic lymphocytic leukaemia

: the diagnosis of chronic lymphocytic leukaemia tin usually exist fabricated without difficulty from the peripheral blood features and the immunophenotype. A bone marrow aspirate is therefore not essential in patients with early stage disease, especially in elderly patients in whom handling may never become necessary. Bone marrow assessment is indicated before treatment is undertaken yes because the os marrow aspirate gives very little information across that already available from test of the blood, while BMTB permits an authentic cess of the extent of infiltration and gives information of prognostic importance. During follow up of intensive handling of CLL in that location is little point in performing a os marrow aspirate alone because at that place may exist balance disease detectable only by trephine biopsy. immunophenotyping is non indicated because information technology can exist performed easily on the peripheral blood investigation of suspected not-Hodgkin's lymphoma

: diagnosis of not-Hodgkin's lymphoma is usually based on a lymph node biopsy. However, in patients with bone marrow interest, diagnosis can be reliably based on cytology, immunophenotyping, and the pattern of bone marrow infiltration. When there are circulating lymphoma cells, immunophenotyping can be performed on the peripheral blood and the bone marrow aspirate is of piffling importance. The trephine biopsy is much more important considering information technology permits an assessment of the pattern and extent of infiltration, which is of both diagnostic and prognostic relevance, and may demonstrate lymphoma when no abnormal cells take been detected in the blood or the bone marrow aspirate. However, if circulating lymphoma cells are not nowadays, the detailed immunophenotyping that is possible on cells in a bone marrow aspirate tin can assist in both diagnosis and classification of NHL yes if an abnormal infiltrate is present, immunophenotyping, molecular analysis and cytogenetic analysis may be needed diagnosis and follow upwardly of hairy cell leukaemia

yes immunophenotyping, unless there are sufficient circulating cells for it to be performed on peripheral claret cells; tartrate resistant acid phosphatase stain if detailed immunophenotyping is not available staging of depression grade non-Hodgkin's lymphoma

(if the results of investigation volition alter management) yes. A bone marrow biopsy performed in patients with depression form lymphoma sometimes shows unexpected loftier grade transformation, which necessitates a different therapeutic arroyo. immunophenotyping, unless in that location are sufficient circulating cells for this to be done on blood cells; cytogenetic and molecular genetic analyses are sometimes useful if the specific type of NHL has not already been adamant staging of high course non-Hodgkin's lymphoma

(in those cases where results of the investigation volition alter management) yes
investigation of

multiple myeloma

(indicated)

monoclonal gammopathy of undetermined significance (MGUS)

(controversial). If such patients are referred to a haematologist then a bone marrow aspirate is often performed. Nonetheless, it should be remembered that at to the lowest degree 1% of patients over the age of 60 years have a paraprotein and over the age of lxx years the figure rises to three%. Furthermore, investigation of serum immunoglobulins is often performed without a clear clinical indication. It seems reasonable not to perform a bone marrow examination if a low concentration paraprotein has been detected almost incidentally in a patient who does non have anaemia, bone pain, hypercalcaemia, or other relevant clinical features.

A beat training of os marrow fragments is useful generally indicated. Considering infiltration is oft focal, it is sometimes essential for a diagnosis. In other patients it provides a baseline for comparison with follow up biopsies cytogenetic analysis may be useful because demonstration of poor prognosis abnormalities may influence management; immunophenotyping is just needed if cytology of the aspirate is not diagnostic and if it is not certain whether or non a monoclonal plasma cell population is present investigations of suspected storage disease

not essential
investigation of fever of unknown origin (FUO)

yes cultures for mycobacteria and besides, if there is a possibility of previous exposure, for Leishmania and Histoplasma in suspected chromosomal disorders in neonates when rapid confirmation is required no cytogenetic assay (may produce results in 1 day cf. several days if cultured peripheral claret lymphocytes are used) confirmation of normal os marrow if bone marrow is being aspirated for allogeneic HSCT

no
autoimmune thrombocytopenic purpura (AITP)

: some controversy surrounds the office of bone marrow aspiration in suspected AITP. In children, the American Society of Haematology (ASH) guidelines propose that os marrow aspiration is not usually needed^ref. The guidelines of the British Paediatric Haematology Group recommend os marrow examination for children whose affliction does not remit inside 2-three weeks or if treatment, especially with corticosteroids, is planned^ref. The consensus has swung confronting BMAB provided the history and the clinical picture is entirely typical of acute onset ITP and the peripheral blood is entirely normal autonomously from profound and isolated thrombocytopenia. Nevertheless, the threshold for marrow examination should be low if there is the slightest clinical doubtfulness^ref.

in adults with acute onset of thrombocytopenia, treatment is usually indicated and in British haematological practice a pretreatment bone marrow aspiration is usually thought to be indicated. If AITP appears very likely, trephine biopsy is not needed

in adults with moderately severe chronic thrombocytopenia, investigation is indicated to establish a diagnosis, even if immediate treatment does not announced to exist indicated. If autoimmune affliction appears very likely, only an aspirate is required but, if a myelodysplastic syndrome

is suspected, a trephine biopsy is besides needed. American practice appears to differ somewhat from that in the Great britain, with the ASH guidelines suggesting os marrow aspiration only in patients higher up the historic period of 60 years^ref.