Medical and Pediatric Oncology 6:57-64 (1979)
Bone Marrow Biopsy in Children: A Study of 111 Patients C. Cozzutto, MD, 6. De Bernardi, MD, A. Comelli, MD, and M. Guarino,
MD
Department of Pathology (C.C.and M. G.), Department of Hematology-Oncology (B. De B. and A.C.), Giannina Gaslini Institute and Children‘s Hospital, Genoa, Italy
Closed trephine needle biopsy of the bone marrow has become an established procedure in the evaluation of many malignant and benign diseases in adults; however, its role in pediatric pathology has not yet been defined. In the period from February 1974 to April 1978 we have performed 164 such biopsies in 1 1 1 children under 15 years of age. A representative specimen has been obtained in over 80% of cases. This series included, in order of frequency, non-Hodgkin lymphomas, Hodgkin lymphomas, aplastic anemias, rhabdomyosarcomas, neuroblastomas, miscellaneous solid tumors, and single cases of histiocytosis X,malignant histiocytosis, sarcoidosis, malignant histiocytoma, and Castleman lymphoma of the hyaline-vascular type. Histology has been found superior to cytology in the detection of neuroblastoma invasion; the evaluation of the true cellularity in aplastic anemia, and the detection of granulomatous tissue in the only case of sarcoidosis. In other diseases histology and cytology gave similar information, except for the few cases of acute leukemia in partial relapse, which has been better defined in the aspirate smears than in the core specimen. Further evaluation of this technique in other patient series appears advisable. Key words: bone marrow biopsy, children’s tumors, diagnostic procedures
INTRODUCTION
A notable interest has arisen during the last few years in the application of closed trephine needle biopsy generally performed in the posterior superior iliac spine by means of, originally, the Westermann-Jensen needle, and, thereafter, the Jamshidi needle. This practice has been directed essentially to the evaluation of localized bone marrow involvement in non-Hodgkin lymphoma, especially in the nodular variety [ 1-51 , Hodgkin disease [ 3 , 6 , 7 ] , granulomatous and metastatic lesions [8-151, and recently, even for leukemic processes, above all in regard to hairy-cell leukemia [ 16-19].
Address reprint requests to Dr. Cozzutto, Department of Pathology, Giannina Gaslini Institute and Children’s Hospital, 16148, Genoa, Italy. 0098-1532/79/0601-0057$01.70 @ 1979 Alan
R. Liss, Inc.
Cozzutto et al
58
The use of trephine needle biopsy in children to ascertain the diagnosis of aplastic anemia, leukemia, lymphoma, metastatic tumors, myelofibrosis, and granulomatous lesions has been reviewed recently by McKenna [20]. The diagnosis of neuroblastoma on bone marrow smear aspirates has been studied in the past by Gaffney et a1 [21], whereas McKay et al have described the initial diagnosis of neuroblastoma at the onset of the disease by means of ultrastructural studies on bone marrow aspirates [22]. Finklestein et a1 [23] have analyzed bone marrow aspirates of 213 children with solid tumors. However, we are unaware that a study of a series of trephine biopsies in children has been published up to the present time. From February 1974 to April 1978, we reviewed 164 trephine needle biopsies performed on the iliac crest of children affected with hematologic malignancies, solid tumors, and various other diseases who were hospitalized at the Giannina Gaslini Children’s Hospital for the diagnosis and cure of their disease. The results are the subject of this report. MATERIALS AND METHODS
The patients in our series were subjected to bone marrow biopsy of the posterior iliac creast by a Jamshidi needle. The original biopsy technique described by Jamshidi and Swaim was followed [24]. The cylindrical samples of bone marrow 2 mm in diameter and 12-18 mm in length were fixed in 10% neutral buffered fonnol saline for 24 hours before decalcification for one hour in formic acid-citrate solution. The specimens were then processed in the same manner as routine histology material. Multiple serial sections were stained with hematoxylin-eosin and Bielchowski reticulum stain. Before biopsy, a needle aspiration was usually performed at approximately the same site, and the smears were stained with Wright-Giemsa, PAS, Sudan black B, peroxidase, and alpha-naphtholesterase for cytochemical analysis. Therefore, the histological and histochemical features of the biopsies obtained were always compared with the cytological and cytochemical findings. For the histopathology of bone marrow in acute leukemia, we have referred to the studies of various authors [25-281. TABLE I. Diagnosis Leukemia Non-hodgkin lymphoma Hodgkin lymphoma Neuroblastoma Rhabdomyosarcoma Miscellaneous solid malignant tumors Histiocytosis X Malignant histiocytosis Sarcoidosis Malignant histiocytoma Aplastic anemia Castleman disease
No.
Positive histology
26 16 16 12 13
22
8
0 0
2 1
1 1 14 1
3 0 1 1
Negative histology
Positive cytology
Negative cytology
4 13 16 5 12
26 4 0 3 1
0 12 16
8
0 0 1 0 0 14 0
8
2
1 1 0 14 0
0 1
0 1
9 12
2 1 1 0
1
Bone Marrow Biopsy in Children
59
Fig. 1. Acute lymphoblastic leukemia. Bone marrow infdtration characterized by collections of small round monomorphic cells with hyperchromatic nuclei (hematoxylin and eosin, X 85).
RESULTS
Table I lists all patients in our series according to their respective diagnosis. A total of 111 children were studied. All of the children presented to the Giannina Gaslini children’s Hospital for their initial diagnostic evaluation or with a diagnosis already ascertained at another medical center. Leukemia
Acute leukemia was diagnosed in 26 patients (22, acute lymphoblastic leukemia; 2, acute promyelocytic leukemia; and 2, acute myeloblastic leukemia). The histology demonstrated a degree of bone marrow infiltration comparable to that seen by cytology. This infiltration was characterized by areas of cellular monomorphism. These areas consisted of sheets and collections of cellular elements closely resembling one another, with round or elongated hyperchromatic nuclei and scarce cytoplasm (Fig. 1). Four patients, who were in partial relapse, had blasts in the bone marrow ranging from 10%to 20%. The histology was reported as inconclusive, in that the leukemic infiltration was not of such degree as to be histologically recognizable. Non-Hodgkin Lymphoma
Fifteen patients in our series were affected by a primary lymphnodal or extranodal (tonsil, intestine, ovary, testicle, skin) lymphoma. In all cases the diagnosis was ascertained by histological examination of tissue obtained from the primary organ involved. Twelve cases had poorly differentiated lymphocytic lymphoma, and two patients were diagnosed
60
Cozzutto et a1
as having reticulum-cell lymphoma. A histological partial involvement was found in all cases, some normal bone marrow being recognizable among the areas of atypical lympho-
matous inflltration. Cytological examination revealed the presence of atypical cells in four cases. Hodgkin Lymphoma
Fifteen patients in our series were diagnosed as having Hodgkin disease, histologically documented by lymph node biopsy. In all cases, trephine closed needle biopsy was performed at the onset and during the initial phases of the disease. Bone marrow involvement was not found in any case. This finding is in accordance with that of the literature regarding the studies of bone marrow involvement in clinical stages 1 and 2 of Hodgkin disease, the incidence of which is indeed very low. These patients underwent surgical staging, which did not include wedge marrow biopsy. Therefore, we cannot compare the efficacy of wedge marrow biopsy versus trephining. Neuroblastoma
Twelve patients in our series had neuroblastoma, ascertained by histological examination of the primary tumor. Seven of these patients had bone marrow involvement of the iliac crest, the histology of which presented as nodular or cord-like collections of pleomorphic cells with hyperchromatic nuclei and scanty cytoplasm. In two cases typical neuroblastoma rosette formations were seen (Fig. 2). There was a discrete surrounding stromal reaction, which probably is responsible for the fact that in only three of the 12 cases did the cytological examination reveal the presence of neuroblasts. The bone marrow
Fig. 2. Neuroblastoma. A small X 340).
typical rosette is seen in the center of the field (hematoxylin and eosin,
Bone Marrow Biopsy in Children
61
cavity, rather devoid of marrow elements, contained fibrillar connective tissue in which very narrow neuroblasts were entwined. This feature also can explain the major difficulty in finding such cells on a cytological smear. In our experience, the nuclear pleomorphism and irregularity of neuroblasts easily distinguishes this entity from the monomorphism of leukemic and lymphomatous infiltrations. The frequency of metastatic bone marrow involvement in neuroblastoma in our series is similar to that reported by Gaffney et a1 on bone marrow smears [21]. However, our experience shows a significant superiority of bone marrow biopsy over bone marrow aspirates. Rhabdomyosarcoma
Thirteen patients in our series were histologically diagnosed on study of the primary tumor as having rhabdomyosarcoma. In only one case, that of a four-year-old female child with alveolar rhabdomyosarcoma of the face, was metastatic bone involvement visible on both histological and cytological preparation (Fig. 3). In eight other patients suffering from malignant solid neoplasm (Wilms tumor, Ewing sarcoma, malignant fibrohistiocytoma, retinoblastoma, hepatic carcinoma, embryonal carcinoma of the mediastinum, malignant mesenchymoma of the liver, and undifferentiated retroperitoneal tumor) never was bone marrow involvement evidenced by trephine bone marrow biopsy. Only one biopsy was performed for each of these patients. Finally, we have seen a partial bone marrow infiltration in one case of malignant histiocytosis, in one case of Nieman-Pick disease, and in one case of neonatal sarcoidosis
Fig. 3. Alveolar rhabdomyosarcoma. Clusters of small atypical cells distributed in a somewhat alveolar fashion (hematoxylin and eosin, X 340).
62
Cozzutto et a1
in which the bone marrow involvement substantiated the diagnosis (Fig. 4). In the first two cases both histology and cytology were positive, whereas in the case of neonatal sarcoidosis the aspiration smears were negative. One patient with Castleman lymphoma was included in our series, and in this case both histology and cytology were negative. DISCUSSION
On the basis of our limited experience regarding 11 1 patients in the pediatric age range who underwent a trephine needle bone marrow biopsy in the posterior iliac crest, we wish to emphasize several points. Generally, the results of our study indicate that the efficacy of this procedure for any malignancy is similar to that found in adults, with the exception of lymphoma. In this disorder the bone marrow biopsy did not prove superior to aspiration cytological examination in ascertaining bone marrow involvement, a finding contrary to reports of various authors [2,4,5, 11,291. This observation may be explained by the fact that none of our cases included nodular lymphomas but demonstrated lymphomas of the diffuse type, in which the bone marrow infiltration is comparable to that of leukemia. Therefore, there is no reason to believe that the cells would not aspirate as easily as cells that occur in the leukemias. In the previously published literature, the superiority of histological over cytological examination refers especially to nodular lymphomas, whereas no significant difference exists in the lymphomas of the diffuse type. When, in some cases, there initially existed an uncertainty between the diagnosis of bone marrow
Fig. 4. Sarcoidosis. A granulomatous nodule is seen at about the center of the field. A giant cell of the Langhans type is present inside the nodule (hematoxylin and eosin, X 85).
Bone Marrow Biopsy in Children
63
aplasia and acute lymphocytic leukemia, the dilemma was solved by both cytological and histological examination. Another important finding that emerges from our study is the particularly high frequency of bone marrow involvement in neuroblastoma, revealing that the histological examination by trephine needle biopsy is more efficacious than aspirate cytological evaluation. The relatively high frequency with which neuroblasts are found in the bone marrow has been placed in evidence in the past by bone marrow smear studies. It is apparent that bone marrow biopsy is a good complementary diagnostic tool for the assessment of bone marrow aplasia. In our series the diagnosis was confirmed in 14 children. From our experience it is feasible to conclude that bone marrow biopsy of the posterior iliac crest is a useful diagnostic tool in children and should be adopted as a complementary measure to cytological examination. However, it does not appear necessary to employ it routinely in all patients, but rather reserve it for use in the following situations: 1) confirm bone marrow aplasia; 2) establish the clinicopathological staging of neuroblastoma; 3) define systemic illnesses such as granulomatous disease; 4) diagnose or eliminate the possibility of metastatic bone marrow involvement in solid tumors [30, 3 1,321 or in the noninitial staging of Hodgkin disease; 5) evaluate the bone marrow status in systemic diseases in which the bone marrow may constitute an important diagnostic element, such as in histiocytosis, lipidosis, and chronic illnesses with hepatosplenic and lymphnodal involvement.
REFERENCES 1. Dick F, Bloomfield CD, Brunning RD: Incidence, cytology, and histopathology of non-Hodgkin’s lymphomas in the bone marrow. Cancer 33: 1382-1398, 1974. 2. McKenna RW, Bloomfield CD, Brunning RD: Nodular lymphoma: Bone marrow and blood manifestations. Cancer 36:428-440, 1975. 3. Dee JW, Valdivieso M, Drewinko B: Comparison of the efficacies of closed trephine biopsy, aspirated paraffin-embedded, clot section, and smear preparation in the diagnosis of bonemarrow involvement by lymphoma. Am J Clin Pathol65:183-194, 1976. 4. Jones ES, Rosenberg SA, Kaplan HS: Non-Hodgkin’s lymphomas. 1 Bone marrow involvement. Cancer 29:954-960, 1972. 5. Pasmantier M, Coleman M, Silver RT: Value of biopsy in diagnosis of primary lymphosarcoma of marrow. Arch Intern Med 13752-54, 1977. 6. Diebold J, Temmin L, Bernadou A: La biopsie mddullaire osseuse on cows de la maladie de Hodgkin. Sem Hop Paris 53:103-111, 1977. 7. Lukes RJ: Criteria for involvement of lymph node, bone marrow, spleen, and liver in Hodgkin’s disease. Cancer Res 31:1755-1767, 1971. 8. Contrerars E, Ellis LD, Lee RE: Value of the bone marrow biopsy in the diagnosis of metastatic carcinoma. Cancer 29:778-783, 1972. 9. Pieron E, Duhamel G, Roland J, Chatelet F, Van den Akker M: IntdrEt de la biopsie ostdo-medullaire systematique dam les tumeurs solides. A propos de 96 observations. Sem Hop Paris 5 3: 361-368, 1977. 10. Mills AE: A study of the value of closed bone marrow biopsy. SA Med J 50:1928-1931, 1976. 11. Ellmann L: Bone marrow biopsy in the evaluation of lymphoma, carcinoma, and granulomatous disorders. Am J Med 6O:l-7, 1976. 12. Landys K, Stenram U: Bone marrow biopsy of the posterior iliac crest with Gidlund’s instrument in malignant diseases. Scand J Haematol 15:104-108, 1975. 13. Rywlin AM: The importance of bone marrow histology. Hum Pathol6:523-525, 1975. 14. Gower ND: Marrow biopsy in the diagnosis of pirexia of undetermined origin. J Clin Pathol 16: 227-231,1963.
64
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15. Boyd JF, Reid D: Bone marrow in nine cases of clinical glandular fever and review of the literature. J Clin Pathol21:683-690, 1968. 16. Vykoupil KF, Thiele J, Georgii A: Hairy cell leukemia. Bone marrow findings in 24 patients. ViChOWS Arch 370:273-289,1976. 17. Diebold J, Chomette G, Reynes M: Aspects morphologiques de la moelle osseuse dans la leudmie i tricholeucocytes. Sem Hop Paris 53:113-118,1977. 18. Devred C, Bendata J, Diebold J, Bernadou A, Bilskipasquier G: La biopsie medullaire dans le leudmie mydloide chronique. Sern Hop Paris 53:119-124, 1977. 19. Devred C, Bentata J, Diebold J, Bernadou A, Bilskipasquier G: La biopsie medullaire dans la leudmie myiloide chronique. 11. IntirCt au cours de I’dvolution. Sem Hop Paris 53: 125- 13 1, 1977. 20. McKenna RW: Bone marrow. In: Dehner L (ed): “Pediatric Surgical Pathology.” Saint Louis: CV Mosby, 1975. 21. Gaffney PC,Hansman CF, Fetterman GH:Experience with smears of aspirates from bone marrow in the diagnosis of neuroblastoma. Am J Clin Pathol 31:213-221, 1959. 22. MacKay B, Masse SR,King OY,Butler JJ: Diagnosis of neuroblastoma by electron microscopy of bone marrow aspirates. Pediatrics 56:1045-1049, 1975. 23. Finklestein JZ, Ekert H, Isaacs H, Higgins G: Bone marrow metastases in children with solid tumors. Am J Dis Child 119:49-52,1970. 24. Jamshidi K, Swaim WR: Bone marrow biopsy with unaltered architecture: A new biopsy device. J Lab Clin Med 77:335,1971. 25. Thomas LB, Forkner CE, Frei E, Besse BE, Stabenau JR: The skeletal lesions of acute leukemia. Cancer 14:608-621, 1961. 26. Amromin GD: Bone marrow and peripheral blood. In: “Pathology of Leukemia.” New York: Harper & Row, 1968. 27. Rappaport H: Tumors of the hematopoietic system. In: “Atlas of Tumor Pathology.” Washington DC: Armed Forces Institute of Pathology, 1966. 28. Pease G L Bone-marrow Tidings in disorders of the hemopoietic system. Am J Clin Pathol25: 654-678,1955. 29. Brunning RD, Bloomfield CD, McKenna RW,Peterson L: Bilateral trephine bone marrow biopsies in lymphoma and other neoplastic diseases. Ann Intern Med 82:365-366, 1975. 30. Beardere JD, Ratkin GA, Coltman C A Comparison of the diagnostic value of bone marrow biopsy and bone marrow aspiration in neoplastic disease. J Clin Pathol 27:738-740, 1974. 31. Broghamer WL, Keeling MM: The bone marrow biopsy osteoscan, and peripheral blood in nonhematopoietic cancer. Cancer 40:836-840, 1977. 32. Sngh G, Krause JR, Breitfeld V: Bone marrow examination for metastatic tumor. Aspirate and biopsy. Cancer 40:2317-2321, 1977.
Bone Marrow Biopsy in Children: A Study of 111 Patients C. Cozzutto, MD, 6. De Bernardi, MD, A. Comelli, MD, and M. Guarino,
MD
Department of Pathology (C.C.and M. G.), Department of Hematology-Oncology (B. De B. and A.C.), Giannina Gaslini Institute and Children‘s Hospital, Genoa, Italy
Closed trephine needle biopsy of the bone marrow has become an established procedure in the evaluation of many malignant and benign diseases in adults; however, its role in pediatric pathology has not yet been defined. In the period from February 1974 to April 1978 we have performed 164 such biopsies in 1 1 1 children under 15 years of age. A representative specimen has been obtained in over 80% of cases. This series included, in order of frequency, non-Hodgkin lymphomas, Hodgkin lymphomas, aplastic anemias, rhabdomyosarcomas, neuroblastomas, miscellaneous solid tumors, and single cases of histiocytosis X,malignant histiocytosis, sarcoidosis, malignant histiocytoma, and Castleman lymphoma of the hyaline-vascular type. Histology has been found superior to cytology in the detection of neuroblastoma invasion; the evaluation of the true cellularity in aplastic anemia, and the detection of granulomatous tissue in the only case of sarcoidosis. In other diseases histology and cytology gave similar information, except for the few cases of acute leukemia in partial relapse, which has been better defined in the aspirate smears than in the core specimen. Further evaluation of this technique in other patient series appears advisable. Key words: bone marrow biopsy, children’s tumors, diagnostic procedures
INTRODUCTION
A notable interest has arisen during the last few years in the application of closed trephine needle biopsy generally performed in the posterior superior iliac spine by means of, originally, the Westermann-Jensen needle, and, thereafter, the Jamshidi needle. This practice has been directed essentially to the evaluation of localized bone marrow involvement in non-Hodgkin lymphoma, especially in the nodular variety [ 1-51 , Hodgkin disease [ 3 , 6 , 7 ] , granulomatous and metastatic lesions [8-151, and recently, even for leukemic processes, above all in regard to hairy-cell leukemia [ 16-19].
Address reprint requests to Dr. Cozzutto, Department of Pathology, Giannina Gaslini Institute and Children’s Hospital, 16148, Genoa, Italy. 0098-1532/79/0601-0057$01.70 @ 1979 Alan
R. Liss, Inc.
Cozzutto et al
58
The use of trephine needle biopsy in children to ascertain the diagnosis of aplastic anemia, leukemia, lymphoma, metastatic tumors, myelofibrosis, and granulomatous lesions has been reviewed recently by McKenna [20]. The diagnosis of neuroblastoma on bone marrow smear aspirates has been studied in the past by Gaffney et a1 [21], whereas McKay et al have described the initial diagnosis of neuroblastoma at the onset of the disease by means of ultrastructural studies on bone marrow aspirates [22]. Finklestein et a1 [23] have analyzed bone marrow aspirates of 213 children with solid tumors. However, we are unaware that a study of a series of trephine biopsies in children has been published up to the present time. From February 1974 to April 1978, we reviewed 164 trephine needle biopsies performed on the iliac crest of children affected with hematologic malignancies, solid tumors, and various other diseases who were hospitalized at the Giannina Gaslini Children’s Hospital for the diagnosis and cure of their disease. The results are the subject of this report. MATERIALS AND METHODS
The patients in our series were subjected to bone marrow biopsy of the posterior iliac creast by a Jamshidi needle. The original biopsy technique described by Jamshidi and Swaim was followed [24]. The cylindrical samples of bone marrow 2 mm in diameter and 12-18 mm in length were fixed in 10% neutral buffered fonnol saline for 24 hours before decalcification for one hour in formic acid-citrate solution. The specimens were then processed in the same manner as routine histology material. Multiple serial sections were stained with hematoxylin-eosin and Bielchowski reticulum stain. Before biopsy, a needle aspiration was usually performed at approximately the same site, and the smears were stained with Wright-Giemsa, PAS, Sudan black B, peroxidase, and alpha-naphtholesterase for cytochemical analysis. Therefore, the histological and histochemical features of the biopsies obtained were always compared with the cytological and cytochemical findings. For the histopathology of bone marrow in acute leukemia, we have referred to the studies of various authors [25-281. TABLE I. Diagnosis Leukemia Non-hodgkin lymphoma Hodgkin lymphoma Neuroblastoma Rhabdomyosarcoma Miscellaneous solid malignant tumors Histiocytosis X Malignant histiocytosis Sarcoidosis Malignant histiocytoma Aplastic anemia Castleman disease
No.
Positive histology
26 16 16 12 13
22
8
0 0
2 1
1 1 14 1
3 0 1 1
Negative histology
Positive cytology
Negative cytology
4 13 16 5 12
26 4 0 3 1
0 12 16
8
0 0 1 0 0 14 0
8
2
1 1 0 14 0
0 1
0 1
9 12
2 1 1 0
1
Bone Marrow Biopsy in Children
59
Fig. 1. Acute lymphoblastic leukemia. Bone marrow infdtration characterized by collections of small round monomorphic cells with hyperchromatic nuclei (hematoxylin and eosin, X 85).
RESULTS
Table I lists all patients in our series according to their respective diagnosis. A total of 111 children were studied. All of the children presented to the Giannina Gaslini children’s Hospital for their initial diagnostic evaluation or with a diagnosis already ascertained at another medical center. Leukemia
Acute leukemia was diagnosed in 26 patients (22, acute lymphoblastic leukemia; 2, acute promyelocytic leukemia; and 2, acute myeloblastic leukemia). The histology demonstrated a degree of bone marrow infiltration comparable to that seen by cytology. This infiltration was characterized by areas of cellular monomorphism. These areas consisted of sheets and collections of cellular elements closely resembling one another, with round or elongated hyperchromatic nuclei and scarce cytoplasm (Fig. 1). Four patients, who were in partial relapse, had blasts in the bone marrow ranging from 10%to 20%. The histology was reported as inconclusive, in that the leukemic infiltration was not of such degree as to be histologically recognizable. Non-Hodgkin Lymphoma
Fifteen patients in our series were affected by a primary lymphnodal or extranodal (tonsil, intestine, ovary, testicle, skin) lymphoma. In all cases the diagnosis was ascertained by histological examination of tissue obtained from the primary organ involved. Twelve cases had poorly differentiated lymphocytic lymphoma, and two patients were diagnosed
60
Cozzutto et a1
as having reticulum-cell lymphoma. A histological partial involvement was found in all cases, some normal bone marrow being recognizable among the areas of atypical lympho-
matous inflltration. Cytological examination revealed the presence of atypical cells in four cases. Hodgkin Lymphoma
Fifteen patients in our series were diagnosed as having Hodgkin disease, histologically documented by lymph node biopsy. In all cases, trephine closed needle biopsy was performed at the onset and during the initial phases of the disease. Bone marrow involvement was not found in any case. This finding is in accordance with that of the literature regarding the studies of bone marrow involvement in clinical stages 1 and 2 of Hodgkin disease, the incidence of which is indeed very low. These patients underwent surgical staging, which did not include wedge marrow biopsy. Therefore, we cannot compare the efficacy of wedge marrow biopsy versus trephining. Neuroblastoma
Twelve patients in our series had neuroblastoma, ascertained by histological examination of the primary tumor. Seven of these patients had bone marrow involvement of the iliac crest, the histology of which presented as nodular or cord-like collections of pleomorphic cells with hyperchromatic nuclei and scanty cytoplasm. In two cases typical neuroblastoma rosette formations were seen (Fig. 2). There was a discrete surrounding stromal reaction, which probably is responsible for the fact that in only three of the 12 cases did the cytological examination reveal the presence of neuroblasts. The bone marrow
Fig. 2. Neuroblastoma. A small X 340).
typical rosette is seen in the center of the field (hematoxylin and eosin,
Bone Marrow Biopsy in Children
61
cavity, rather devoid of marrow elements, contained fibrillar connective tissue in which very narrow neuroblasts were entwined. This feature also can explain the major difficulty in finding such cells on a cytological smear. In our experience, the nuclear pleomorphism and irregularity of neuroblasts easily distinguishes this entity from the monomorphism of leukemic and lymphomatous infiltrations. The frequency of metastatic bone marrow involvement in neuroblastoma in our series is similar to that reported by Gaffney et a1 on bone marrow smears [21]. However, our experience shows a significant superiority of bone marrow biopsy over bone marrow aspirates. Rhabdomyosarcoma
Thirteen patients in our series were histologically diagnosed on study of the primary tumor as having rhabdomyosarcoma. In only one case, that of a four-year-old female child with alveolar rhabdomyosarcoma of the face, was metastatic bone involvement visible on both histological and cytological preparation (Fig. 3). In eight other patients suffering from malignant solid neoplasm (Wilms tumor, Ewing sarcoma, malignant fibrohistiocytoma, retinoblastoma, hepatic carcinoma, embryonal carcinoma of the mediastinum, malignant mesenchymoma of the liver, and undifferentiated retroperitoneal tumor) never was bone marrow involvement evidenced by trephine bone marrow biopsy. Only one biopsy was performed for each of these patients. Finally, we have seen a partial bone marrow infiltration in one case of malignant histiocytosis, in one case of Nieman-Pick disease, and in one case of neonatal sarcoidosis
Fig. 3. Alveolar rhabdomyosarcoma. Clusters of small atypical cells distributed in a somewhat alveolar fashion (hematoxylin and eosin, X 340).
62
Cozzutto et a1
in which the bone marrow involvement substantiated the diagnosis (Fig. 4). In the first two cases both histology and cytology were positive, whereas in the case of neonatal sarcoidosis the aspiration smears were negative. One patient with Castleman lymphoma was included in our series, and in this case both histology and cytology were negative. DISCUSSION
On the basis of our limited experience regarding 11 1 patients in the pediatric age range who underwent a trephine needle bone marrow biopsy in the posterior iliac crest, we wish to emphasize several points. Generally, the results of our study indicate that the efficacy of this procedure for any malignancy is similar to that found in adults, with the exception of lymphoma. In this disorder the bone marrow biopsy did not prove superior to aspiration cytological examination in ascertaining bone marrow involvement, a finding contrary to reports of various authors [2,4,5, 11,291. This observation may be explained by the fact that none of our cases included nodular lymphomas but demonstrated lymphomas of the diffuse type, in which the bone marrow infiltration is comparable to that of leukemia. Therefore, there is no reason to believe that the cells would not aspirate as easily as cells that occur in the leukemias. In the previously published literature, the superiority of histological over cytological examination refers especially to nodular lymphomas, whereas no significant difference exists in the lymphomas of the diffuse type. When, in some cases, there initially existed an uncertainty between the diagnosis of bone marrow
Fig. 4. Sarcoidosis. A granulomatous nodule is seen at about the center of the field. A giant cell of the Langhans type is present inside the nodule (hematoxylin and eosin, X 85).
Bone Marrow Biopsy in Children
63
aplasia and acute lymphocytic leukemia, the dilemma was solved by both cytological and histological examination. Another important finding that emerges from our study is the particularly high frequency of bone marrow involvement in neuroblastoma, revealing that the histological examination by trephine needle biopsy is more efficacious than aspirate cytological evaluation. The relatively high frequency with which neuroblasts are found in the bone marrow has been placed in evidence in the past by bone marrow smear studies. It is apparent that bone marrow biopsy is a good complementary diagnostic tool for the assessment of bone marrow aplasia. In our series the diagnosis was confirmed in 14 children. From our experience it is feasible to conclude that bone marrow biopsy of the posterior iliac crest is a useful diagnostic tool in children and should be adopted as a complementary measure to cytological examination. However, it does not appear necessary to employ it routinely in all patients, but rather reserve it for use in the following situations: 1) confirm bone marrow aplasia; 2) establish the clinicopathological staging of neuroblastoma; 3) define systemic illnesses such as granulomatous disease; 4) diagnose or eliminate the possibility of metastatic bone marrow involvement in solid tumors [30, 3 1,321 or in the noninitial staging of Hodgkin disease; 5) evaluate the bone marrow status in systemic diseases in which the bone marrow may constitute an important diagnostic element, such as in histiocytosis, lipidosis, and chronic illnesses with hepatosplenic and lymphnodal involvement.
REFERENCES 1. Dick F, Bloomfield CD, Brunning RD: Incidence, cytology, and histopathology of non-Hodgkin’s lymphomas in the bone marrow. Cancer 33: 1382-1398, 1974. 2. McKenna RW, Bloomfield CD, Brunning RD: Nodular lymphoma: Bone marrow and blood manifestations. Cancer 36:428-440, 1975. 3. Dee JW, Valdivieso M, Drewinko B: Comparison of the efficacies of closed trephine biopsy, aspirated paraffin-embedded, clot section, and smear preparation in the diagnosis of bonemarrow involvement by lymphoma. Am J Clin Pathol65:183-194, 1976. 4. Jones ES, Rosenberg SA, Kaplan HS: Non-Hodgkin’s lymphomas. 1 Bone marrow involvement. Cancer 29:954-960, 1972. 5. Pasmantier M, Coleman M, Silver RT: Value of biopsy in diagnosis of primary lymphosarcoma of marrow. Arch Intern Med 13752-54, 1977. 6. Diebold J, Temmin L, Bernadou A: La biopsie mddullaire osseuse on cows de la maladie de Hodgkin. Sem Hop Paris 53:103-111, 1977. 7. Lukes RJ: Criteria for involvement of lymph node, bone marrow, spleen, and liver in Hodgkin’s disease. Cancer Res 31:1755-1767, 1971. 8. Contrerars E, Ellis LD, Lee RE: Value of the bone marrow biopsy in the diagnosis of metastatic carcinoma. Cancer 29:778-783, 1972. 9. Pieron E, Duhamel G, Roland J, Chatelet F, Van den Akker M: IntdrEt de la biopsie ostdo-medullaire systematique dam les tumeurs solides. A propos de 96 observations. Sem Hop Paris 5 3: 361-368, 1977. 10. Mills AE: A study of the value of closed bone marrow biopsy. SA Med J 50:1928-1931, 1976. 11. Ellmann L: Bone marrow biopsy in the evaluation of lymphoma, carcinoma, and granulomatous disorders. Am J Med 6O:l-7, 1976. 12. Landys K, Stenram U: Bone marrow biopsy of the posterior iliac crest with Gidlund’s instrument in malignant diseases. Scand J Haematol 15:104-108, 1975. 13. Rywlin AM: The importance of bone marrow histology. Hum Pathol6:523-525, 1975. 14. Gower ND: Marrow biopsy in the diagnosis of pirexia of undetermined origin. J Clin Pathol 16: 227-231,1963.
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15. Boyd JF, Reid D: Bone marrow in nine cases of clinical glandular fever and review of the literature. J Clin Pathol21:683-690, 1968. 16. Vykoupil KF, Thiele J, Georgii A: Hairy cell leukemia. Bone marrow findings in 24 patients. ViChOWS Arch 370:273-289,1976. 17. Diebold J, Chomette G, Reynes M: Aspects morphologiques de la moelle osseuse dans la leudmie i tricholeucocytes. Sem Hop Paris 53:113-118,1977. 18. Devred C, Bendata J, Diebold J, Bernadou A, Bilskipasquier G: La biopsie medullaire dans le leudmie mydloide chronique. Sern Hop Paris 53:119-124, 1977. 19. Devred C, Bentata J, Diebold J, Bernadou A, Bilskipasquier G: La biopsie medullaire dans la leudmie myiloide chronique. 11. IntirCt au cours de I’dvolution. Sem Hop Paris 53: 125- 13 1, 1977. 20. McKenna RW: Bone marrow. In: Dehner L (ed): “Pediatric Surgical Pathology.” Saint Louis: CV Mosby, 1975. 21. Gaffney PC,Hansman CF, Fetterman GH:Experience with smears of aspirates from bone marrow in the diagnosis of neuroblastoma. Am J Clin Pathol 31:213-221, 1959. 22. MacKay B, Masse SR,King OY,Butler JJ: Diagnosis of neuroblastoma by electron microscopy of bone marrow aspirates. Pediatrics 56:1045-1049, 1975. 23. Finklestein JZ, Ekert H, Isaacs H, Higgins G: Bone marrow metastases in children with solid tumors. Am J Dis Child 119:49-52,1970. 24. Jamshidi K, Swaim WR: Bone marrow biopsy with unaltered architecture: A new biopsy device. J Lab Clin Med 77:335,1971. 25. Thomas LB, Forkner CE, Frei E, Besse BE, Stabenau JR: The skeletal lesions of acute leukemia. Cancer 14:608-621, 1961. 26. Amromin GD: Bone marrow and peripheral blood. In: “Pathology of Leukemia.” New York: Harper & Row, 1968. 27. Rappaport H: Tumors of the hematopoietic system. In: “Atlas of Tumor Pathology.” Washington DC: Armed Forces Institute of Pathology, 1966. 28. Pease G L Bone-marrow Tidings in disorders of the hemopoietic system. Am J Clin Pathol25: 654-678,1955. 29. Brunning RD, Bloomfield CD, McKenna RW,Peterson L: Bilateral trephine bone marrow biopsies in lymphoma and other neoplastic diseases. Ann Intern Med 82:365-366, 1975. 30. Beardere JD, Ratkin GA, Coltman C A Comparison of the diagnostic value of bone marrow biopsy and bone marrow aspiration in neoplastic disease. J Clin Pathol 27:738-740, 1974. 31. Broghamer WL, Keeling MM: The bone marrow biopsy osteoscan, and peripheral blood in nonhematopoietic cancer. Cancer 40:836-840, 1977. 32. Sngh G, Krause JR, Breitfeld V: Bone marrow examination for metastatic tumor. Aspirate and biopsy. Cancer 40:2317-2321, 1977.
