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Vala and Shrinivasan: Retrospective analysis of the bone marrow received at a tertiary care hospital- A study of 160 cases


Bone marrow is the major site of hematopoesis giving rise to the three cellular elements namely red blood cells (erythrocytes), white blood cells (leucocytes) and platelets (thrombocytes). Various hematological disorders may arise from abnormality in one of the three lineages. It thus becomes necessary to examine the bone marrow to determine the actual cause. The history of in vivo bone marrow examination dates back to as early as 1876 when Mosler used a regular wood drill to aspirate bone marrow particles from a patient with leukaemia.1 It is important in cases where diagnosis can’t be reached after a routine CBC and other biochemical studies. Bone marrow aspirate is often done along with trephine biopsy to aid in the diagnosis. Its various indications include hematological and non hematological disorders like cytopenias, leucocytosis, staging of lymphomas and remission of hematological malignancies or a suspicion of metastasis.

Materials and Methods

This is a retrospective study carried out at Department of Pathology, Sterling hospital, Vadodara over a period of two years from January 2016 to December 2017. The relevant information was derived from the laboratory records to include the age, sex, indication of marrow and final diagnosis. All the 160 cases were included in the study. The peripheral blood smear and the aspirate were stained with Giemsa stain and the trephine biopsy with H&E and reticulin stain for marrow fibrosis.


In our study the age group was from 2 years to 80 years (Table 1). The youngest being a 3 year male and the oldest 80 year male.

Table 1
Male Female
Youngest 3 years 2 years
Oldest 79 years 80 years

Youngest and oldest patient

The M: F ratio is 1.25:1. Males undergoing BM examination were highest in the age of 51-60 years and females were in the range of 61-70 years (Table 2).

Table 2
Age Male % Female %
<10 4 4.49 2 2.81
11-20 13 14.60 8 11.26
21-30 5 5.61 10 14.08
31-40 10 11.23 5 7.04
41-50 11 12.35 9 12.67
51-60 20 22.47 11 15.49
61-70 17 19.10 17 23.94
>70 9 10.11 9 12.67
Total 89 71

Age and sex wise distribution of the cases

Most of the marrows received were hyper cellular -70 cases, followed by normo cellular and hypo cellular for age. There were also a few cases of dry tap (Figure 1).

Figure 1


The most common indication for marrow examination was leucocytosis, followed by bicytopenia and pancytopenia. Also the marrows were done for indications of hematological remissions, lymphoma staging, and suspicion of metastasis, myelomas, thrombocytopenia and anemia (Table 3).

Table 3
Indication No of cases % of cases
Leucocytosis 30 18.75
Bicytopenia 29 18.12
Pancytopenia 24 15
?Metastasis 6 3.75
Hematological remission 21 13.12
Myeloma 11 6.87
Lymphoma staging 15 9.37
Thrombocytopenia 15 9.37
Anemia 6 3.75
Others 3 1.87
Total 160 100

Indication of bone marrow

Of all the cases of leucocytosis the most common diagnosis was that of chronic myeloid leukemia, followed by Acute Leukemia, CLL /SLL and three marrows were normal.

The most common diagnosis on B one Marrow was that of Acute leukemia (Figure 2) accounting to 13.12%, followed by Idiopathic thrombocytopenic purpura (ITP) - 11.25% (Figure 3)

Of the 16 cases received for lymphoma staging, 2 cases showed marrow involvement by lymphoma (1.25%). Cases of myeloproliferative neoplasm(8.12%), myeloma (8.12%), metastatic diseases (2.5%) and myleodysplastic syndrome (1.25%) were also diagnosed. Other rare diagnosis included a single cases of hemophagocytic syndrome, Amegakaryocytic thrombocytopenia, hypersplenism, monocytosis and two cases of aplastic anemia (Table 4)

Table 4
Diagnosis No of cases % of cases
Acute leukemia (AML/ALL) 21 13.12
Lymphoproliferative / CLL 09 5.62
Metastasis 04 2.5
Myeloma / Plasma cell dyscrasia 13 8.12
ITP 18 11.25
Hematological remission Complete remission 15 9.37
Non remission 5 3.12
Normal marrow 17 10.62
Lymphoma staging Un -involved 14 8.75
Involved 2 1.25
Myeloproliferative diseases 13 8.12
MDS 2 1.25
Megaloblastic anemia 12 7.50
Inconclusive 8 5.00
Others 5 3.12
Aplastic anemia 2 1.25
Total 160 100

Bone marrow examination findings

Figure 2

Hyper cellular marrow showing lymphoblasts in a case of ALL

Figure 3

Hypercellular marrow showing increased megakaryocytes in a case of ITP


Hematological disorders, both benign and malignant comprise a major health problem. They have a high mortality and morbidity. Both men and women get affected at any age. Early diagnosis and prompt treatment can save the patient if managed timely. Bone marrow examination consists of bone marrow aspirate cytology and bone marrow trephine biopsy. While the aspirate helps in evaluating individual cell population, the trephine biopsy is important to know the overall cellularity, architecture, fibrosis and metastatic deposits. Hence, Bone marrow examination remains a crucial test in diagnosis of both hematological and non hematological malignancies, when the routine peripheral blood and other laboratory tests are not conclusive of a diagnosis. A wide spectrum of diagnosis ranging from anemia to leukemia can be made on the bone marrow and help in management of the patient.

In our study, the patients undergoing bone marrow examination ranged from 2 years to 80 years of age. The M: F ratio was 1.25: 1 which is comparable to most of the studies which show a slight male predominance which is compared in Table 5.

Table 5
Study name Age range M: F ratio
Kumar K et al2 9 days to 75 years 1.02 : 1
Pudasaini S et al5 9 months to 75 years 1.1 : 1
Gilotra M et al4 1.5 years to 88 years 1.2 :1
Thiyagarajan P3 8 years to 90 years 1.3 :1
Present study 2 years to 80 years 1.25 : 1

Comparison of age and sex with various studies

In our study the most frequent indication of bone marrow examination was of leucocytosis (18.75%), followed by bicytopenia (18.12%) and pancytopenia (15%). Other indications included bone marrow for hematological remission (13.12%), thrombocytopenia, staging for lymphoma, myeloma and anemia. Similar studies like Kumar et al2 reported anemia (34.4%) to be the most common indication, Aljadeyeh et al6 reported anemia (22.4%) and hematological remssion (23.2%) as the most common indication of marrow examination.

In our study the most common diagnosis was that of acute leukemia (13.12%), it was comparable with studies by Al-Gwaiz (27.3%), Ridha (28.16%), Bashwari (17.76%).

This was in contrast with studies from authors of Indian subcontinent like Katiyar, Khatik and Atla BL who reported megaloblastic anemia to be the most common diagnosis with 28.1%, 21.33% and 49.5 % respectively (Table 6). This contrast in our study when compared to the Indian studies may be due to the fact that ours being a tertiary care center, more patients of leukemia and lymphomas are referred while the ones with anemia are treated at primary and secondary centers.

Table 6
Study name Most frequent diagnosis % of cases % of Acute leukemia
Katiyar et al12 Megaloblastic anemia 28.1 3.59
Khatik et al11 Combined def anemia 21.33 12.67
Atla BL et al10 Anemia 49.5 16.2
Bashawri9 Acute leukemia 17.76 17.76
Parajuli8 Erythroid hyperplasia 13.33 12
Ridha13 Acute leukemia 28.16 28.16
Al-gwaiz7 Acute leukemia 27.3 27.3
Present study Acute leukemia 13.12 13.12

Comparison of most frequent diagnosis

We also encountered some rare interesting cases of hemophagocytic syndrome (Figure 4), aplastic anemia and hyperspleenism.

Figure 4

Macrophage showing hemophagocytosis in a case of Hemophagocytic syndrome.

Most of the cases who underwent BM examination for leucocytosis had CML as diagnosis, followed by acute leukemia and chronic lymphocytic leukemia.

In case of dry tap which were followed with a trephine biopsy, diagnosis of acute myeloid leukemia and metastasis were made. This shows how important trephine biopsy is in case of a dry tap and it should not be ignored as a faulty aspiration technique.


The study concludes that bone marrow aspirate along with trephine biopsy are very crucial in reaching a final diagnosis in cases of various cytopenias, leucocytosis and suspected metastasis. It also aids in the hematological staging and a therapeutic response.

Source of funding


Conflict of interes


Author statement

All authors have read, reviewed, agree and approved the final manuscript.



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