Positivity rate of systematic bone marrow smear in patients over 60 years old with newly diagnosed immune thrombocytopenia

Abstract

Recently, Blood Advances published an updated international consensus report (ICR) by Provan et al 1 and American guidelines (supported by the American Society of Hematology [ASH]) by Neunert et al 2 on managing immune thrombocytopenia (ITP). The 2019 ICR is an update of the first report published in 2010. 3 By using the same methodology as that used in the first report, Provan et al selected those who have recognized clinical and research expertise in ITP (international adult and pediatric hematologists, experts in methodology, and a patient representative) to help with their review and report. The ICR consists of a literature search with a final review by the authors. Evidence levels for the articles were assigned recommendation grades (A, B, or C), which were determined at the end of the review and were assigned and reviewed by the authors following the same scoring system as that used in the first report.

Incidence of adult primary immune thrombocytopenia in England—An update

“…Only 7% patients aged under 40 years have bone marrow tests performed. The percentage patients having bone marrow, unsurprisingly increases with age such that 13.6% of those aged 50–59, 2.5% of those aged 60–69, 26.8% aged 70–79 and 16.2% >80 year olds had bone marrow investigations performed at diagnosis This potentially reflects anxiety around the increased probability of other causes of low including dysplasia and malignancy, in this group however a recent paper has shown that the detection rate of abnormalities is low and therefore unfounded need 31 …”

Frequency and utility of bone marrow examination in relapsed/refractory immune thrombocytopenia

“…More recently, Comont and colleagues examined the rates and diagnostic yield of BME in older ITP patients (>60 years) from the CARMEN registry in an era following the publication of 2011 ASH guidelines (2013–2018) 9 . Although BMEs were frequently performed at time of diagnosis (114/197; 58%), the rate of abnormal bone marrow examination results was very low (0.8%) 9 . A blinded study of BMEs in ITP and normal controls has found poor interrater reliability of ITP identification, and demonstrated that BME had little utility in confirming ITP in typical patients 15 .…”

“…Three studies published before the 2011 ASH guidelines found that routine BMEs at the time of suspected ITP diagnosis were unnecessary and overly performed for patients younger than 60–65 years of age 6–8 . More recently, Comont and colleagues examined the rates and diagnostic yield of BME in older ITP patients (>60 years) from the CARMEN registry in an era following the publication of 2011 ASH guidelines (2013–2018) 9 . Although BMEs were frequently performed at time of diagnosis (114/197; 58%), the rate of abnormal bone marrow examination results was very low (0.8%) 9 .…”

“…Although both American Society of Hematology (ASH) and international consensus report guidelines state that a BME is not necessary in typical ITP regardless of age, ASH guidelines state that it is not necessary before splenectomy, whereas international consensus report recommends consideration of BME before a splenectomy 2,4,5 . Several studies evaluating routine BME at the time of ITP diagnosis have confirmed current recommendations and reported very low rates of abnormal bone marrow in those under and over 60 years of age 6–9 . Although current guidelines and expert opinions recommend BMEs in relapsed or refractory ITP, no study to date has examined the rates and utility of BME in this setting 5,10 .…”

“…2,4,5 Several studies evaluating routine BME at the time of ITP diagnosis have confirmed current recommendations and reported very low rates of abnormal bone marrow in those under and over 60 years of age. [6][7][8][9] Although current guidelines and expert opinions recommend BMEs in relapsed or refractory ITP, no study to date has examined the rates and utility of BME in this setting. 5,10 In this retrospective cohort study, we sought to examine both the frequency and predictors of BME in a large ITP cohort who received second-line therapies.…”