Disclosures of: Maciej Machaczka
Dr. Maciej Machaczka has indicated he has the following affiliations:
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Research
Support
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Genzyme
✔
Actelion
✔
Shire HGT
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The author declares that he has no conflicts of interest
concerning his presentation entitled:
Fine Needle Aspiration vs. Trephine Biopsy of Bone Marrow –
Comparison of Utility in Diagnostics of Sporadic Cases of Gaucher
Disease Type 1 – A Cytohistological Study
FINE NEEDLE ASPIRATION VS.
TREPHINE BIOPSY OF BONE MARROW –
COMPARISON OF UTILITY IN DIAGNOSTICS OF SPORADIC CASES OF GAUCHER DISEASE TYPE 1
A CYTOHISTOLOGICAL STUDY
Maciej Machaczka MD, PhD
Senior Consultant and Research Scientist
Department of Medicine and Hematology Center Karolinska,
Karolinska Institutet and Karolinska University Hospital Huddinge,
Stockholm, Sweden
Bone marrow (BM) examination is generally no longer recommended for
the sole purpose of Gaucher disease (GD) diagnosis
Kilma Rossegar Bone Marrow Biopsy Needle
• Common initial symptoms of GD type 1 such as thrombocytopenia or
splenomegaly, often result in a referral of the patient to hematologist for
diagnostics
• In patients of Ashkenazi ancestry, the frequency of Gaucher disease is 1
in 800 while hematologic malignancies are much less frequent at 1 in
2,500
• In the non-Ashkenazi populations Gaucher disease is markedly less
frequent (1 in 40,000) compared with hematologic malignancies
• Among non-Jewish patients, initial
symptoms of sporadic GD type 1 such as
splenomegaly or thrombocytopenia, often
lead to hematological diagnostics
• Routine diagnostic measures include fine
needle aspiration for the cytological
assessment of bone marrow smears (BM-S)
and trephine biopsy of bone marrow for the
histological evaluation of bone marrow
biopsies (BM-TB)
• The results of the above mentioned
examinations are often the first ones given
the suspicion of GD in non-Jewish patients
with a sporadic GD type, which should
always be confirmed by enzymatic and
genetic analysis
• However, the choice of the bone marrow examination method in the
sporadic cases of GD type 1 is often accidental, influenced by many
different factors related both:
- to the patient (e.g., concomitant symptoms, co-morbidities, local
conditions at the examination site, etc) and
- to the physician (e.g., local routines, personal experience, etc)
Bone Marrow Aspiration Needle
Bone Marrow Biopsy Needle
• Trephine biopsy of BM was introduced in many countries into routine
hematological diagnostics relatively recently (approx. for the last 20
years) and definitely at the time when BM examination (i.e., fine
needle biopsy) was generally no longer recommended in GD
• Thus, little is known about the comparison of accuracy of both
methods in assessment of bone marrow involvement in GD, and
further, about their utility in the diagnostics of sporadic cases of GD1
FINE NEEDLE ASPIRATION VERSUS
TREPHINE BIOPSY OF BONE MARROW –
COMPARISON OF UTILITY IN DIAGNOSTICS OF SPORADIC CASES
OF GAUCHER DISEASE TYPE 1 – A CYTOHISTOLOGICAL STUDY
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Maciej Machaczka
Sofie Regenthal
Agnes Bulanda
Krystyna Gałązka
Grazina Kleinotienė
Björn E. Wahlin
Hans Hägglund
Monika Klimkowska
• The aim of the study was to compare the accuracy of
cytological versus histological assessment of BM in patients
with GD1
Material and Methods
• BM-S (May-Grünwald Giemsa stain) and BM-TB (hematoxylin-eosin
stain), previously obtained from 6 non-Jewish, sporadic GD1 patients
(2 female and 4 male) for diagnostic purposes, were retrospectively
analyzed
• median age 65 years (range 21–84 years)
• 3/6 pts were splenectomized
• 5/6 pts carried at least one allele with a N370S (c.1226A>G) mutation
in the GBA1 gene
• BM samples were collected from an entry site on the posterior iliac
crest of the patients in the prone position
BM examination
Bone marrow is collected from an entry site on
the posterior iliac crests of the donor in the
prone position (on his or her abdomen)
The skin is cleansed, and a local anesthetic
(e.g., lidocaine) is injected to numb the area
The posterior iliac crests (arrows) are common sites
for bone marrow aspiration and biopsy
BM examination
Bone Marrow Aspiration Needle
Bone marrow aspiration needles are smaller than
needles used to obtain bone marrow biopsies
1 - T-Lok™ Biopsy Needle
2 - Extraction Cannula
3 - Marked Obturator / Probe
T-Lok™ Bone Marrow Biopsy Needle
Spicules obtained from the BM aspirate
are smeared on glass slides
Bone marrow aspiration
Core biopsy obtained with BM biopsy needle
Bone marrow biopsy
BM examination
After the procedure is complete, the patient is typically asked to lie flat for 5–10 minutes to
provide pressure over the procedure site. After that, assuming no bleeding is observed, the
patient can get up and go about their normal activities
Material and Methods (2)
• differential counts of BM-S were estimated in the ×40 objective of
Olympus BX 40 microscope
• each patient sample consisted of 2 slides where 500 nucleated cells
were counted on each slide
• assessment of the composition of BM-TB (i.e., proportion of
hematopoietic tissue, Gaucher cells, fat tissue, and trabecular bone)
was carried out using digital photographs analyzed on a computer
utilizing the Gimp 2 software
• photographic documentation of BM-S and BM-TB was made with a
digital camera (Nikon DX m 1200F) in the Nikon Elipse E1000
microscope, using x40 objective for the BM-S and x2 respective x20
objectives for the BM-TB
Results
Results
Cytological and histological picture of bone marrow taken through the aspiration
and trephine biopsy. GD type 1 (hematoxylin-eosin staining)
Results
The results of cytological analyses of BM-S including identified GCs are showed in Table 1.
The median number of GCs identified in one patient was 4 (range 1–18), and the median
percentage of GCs was 0.4% (range 0.1–1.8%)
Results (2)
The proportions of hematopoiesis, GCs, fat tissue, and trabecular bone in the BM-TBs from
the patients are presented in Table 2. The absolute proportion of GCs in BM-TB ranged
from 22–36% (median value 28%). The proportion of GCs to hematopoietic tissue ranged
from 34–54% (median value 47%)
Results (3)
• In all 6 patients, the the median proportion of identified
GCs to hematopoietic tissue were much larger in the BMTB (range 34–54%) than in the BM-S (range 0.1–1.8%),
and this difference was significant in Wilcoxon signedrank test (P=0.028)
Conclusions
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The majority of the studied patients (4/6, 67%) had ≤6
GCs among 1,000 counted nucleated hematopoietic cells
on BM-S
Of note, routine differential counts of BM-S are usually
performed on only 200 nucleated hematopoietic cells
GCs are often tightly packed within the regions engaged
by GCs in BM and thus are difficult to aspirate, which
can explain our finding. Additional problems with
aspiration of GCs can result from an increased reticulin
fibrosis of the BM
Our results indicate that fine needle aspiration of BM is
an unreliable diagnostic method to detect GCs in sporadic
cases of GD1. There is a serious risk of not diagnosing
GD when using only fine needle aspiration
Conclusions (2)
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The sensitivity of trephine biopsy for detecting GCs in
BM is high and, in our study, detected GCs burden was
approx. 100 times higher compared with fine needle
aspiration
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However, trephine biopsy is a more advanced procedure,
it should be performed by an experienced physician, and
is not recommended for the sole diagnostic purpose in
GD
Conclusions (3)
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Patients with unclear splenomegaly and/or
thrombocytopenia, who display a negative result in BM-S
assessment should proceed routinely to enzymatic
diagnostics of GD (β-glucosidase and chitotriosidase
activity assays)
Thanks to collaborators at Karolinska Institutet
and Karolinska University Hospital in Stockholm
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Dr. Monika Klimkowska
Prof. Jan Palmblad
Prof. Per Svenningsson
Dr. Björn Wahlin
Assoc. Prof. Hans Hägglund