Indications for bone marrow examination

Bone marrow examination, including both aspiration and biopsy sampling, can be performed on virtually any patient. However, patients with coagulation deficiencies or profound thrombocytopenia may experience prolonged bleeding, which cannot be controlled by pressure bandages. In these rare cases, specific treatment (e.g., platelet transfusion) may be indicated. Indications for performing bone marrow examination are summarized in Table 1.1. In the vast majority of cases, both a bone marrow aspiration and biopsy should be performed. Bone marrow aspiration and bone marrow biopsy are complementary (Bain, 2001a, 2001b). Bone marrow aspiration provides excellent cytologic detail; however, marrow architecture cannot be assessed. Bone marrow core biopsy allows for an accurate analysis of architecture; however, cytologic details may be lost. Table 1.2 shows the accepted indications for performing a bone marrow biopsy. This includes cases with inadequate or failed aspiration, need for accurate assessment of cellularity, cases in which the presence of focal lesions (e.g., granulomatous disease or metastatic carcinoma) is suspected, suspected bone marrow fibrosis, need to study bone marrow architecture, need to study bone structure, bone marrow stroma, or assessment of bone marrow vascularity. In general, patients with hypocellular marrows or bone marrow fibrosis are likely to need a trephine biopsy for adequate assessment. In such patients, an aspirate would probably be inadequate or even impossible. Unexplained pancytopenia and unexplained leukoerythroblastic blood pictures are further indications for a biopsy, because they are likely to indicate the presence of bone marrow metastatic disease or fibrosis.