Value of bilateral bone marrow biopsy specimens in non-Hodgkin's lymphoma.

OverviewNon-Hodgkin's lymphomas (NHLs) are a heterogeneous group of lymphoproliferative disorders originating in B-, T-, or natural killer (NK) lymphocytes. In the United States, B-cell lymphomas represent 80% to 85% of all cases, with 15% to 20% being T-cell lymphomas; NK lymphomas are very rare. In 2009, an estimated 65,980 new cases of NHL will be diagnosed and 19,500 will die of the disease.1 NHL is the sixth leading site of new cancer cases among men and fifth among women, accounting for 4% to 5% of new cancer cases and 3% to 4% of cancer-related deaths. Non-Hodgkin's Lymphomas Clinical Practice Guidelines in OncologyKey Words NCCN Clinical Practice Guidelines, non-Hodgkin's lymphoma, chronic lymphocytic leukemia, follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, peripheral T-cell lymphoma, cutaneous T-cell lymphoma, mycosis fungoides, Sézary syndrome, marginal zone lymphoma, mucosaassociated lymphoid tissue lymphoma, diagnosis, treatment, hematopathology, immunohistochemistry, treatment guidelines, staging evaluation, lymphoma pathology (JNCCN 2010;8:288-334) NCCN Categories of Evidence and ConsensusCategory 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lowerlevel evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lowerlevel evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. Please NoteThese guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representation or warranties of any kind regarding their content, use, or application and disclaims any responsibility for their applications or use in any way.These guidelines are copyrighted by the National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of the NCCN © 2010. Disclosures for the NCCN Non-Hodgkin's Lymphomas Guidelines PanelAt the beginning of each NCCN guidelines panel meeting, panel members disclosed any financial support they have received from industry. Through 2008, this information was published in an aggregate statement in JNCCN and online. Furthering NCCN's commitment to public transparency, this disclosure process has now been expanded by listing all potential conflicts of interest respective to each individual expert panel member.Individual disclosures for the NCCN Non-Hodgkin's Lymphomas Guidelines Panel members can be found on page 334. (To view the most recent version of these guideli...

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“…Some panel members advocate bilateral core biopsies in this situation. 62 Bilateral cores are recommended if radioimmunotherapy is considered.…”

Section: Workupmentioning

confidence: 99%

Non-Hodgkin’s Lymphomas

Ad¹,

Js²,

Rh³

et al. 2010

J Natl Compr Canc Netw

223

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“…However, localized or patchy intramedullary involvement at initial presentation of myelodysplastic syndrome (MDS) or AML with discrepant results from sampling bilateral iliac crests has been assumed to be rare, in contrast to the relatively frequent pattern of focal marrow involvement by lymphoplasmacytic neoplasms or solid tumors [3][4][5][6]. In AML, the marrow is usually diffusely hypercellular throughout the axial skeleton due to massive expansion of clonal myeloid blasts [7], and this is reflected in results of imaging studies that visualize the red marrow, including magnetic resonance imaging (MRI) [8,9] (MRI was not performed in this case).…”

Section: Discussionmentioning

confidence: 99%

An extreme example of focal bone marrow involvement in acute myeloid leukemia

et al. 2012

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A 59-year-old man presented to the Emergency Department (ED) with a 2 month history of progressive fatigue, dyspnea, and exertional chest pain. For 9 years, he had had chronic, mild fluctuating cytopenias of uncertain etiology. A bone marrow biopsy of the left iliac crest at the onset of the cytopenias demonstrated aplasia, but a followup biopsy of the contralateral iliac crest 2 months later revealed a hypercellular marrow with mild erythroid hyperplasia and no dysplasia. Given these discrepant results, an extensive investigation for potential causes of cytopenias was undertaken, but failed to yield a specific diagnosis. Several subsequent bone marrow biopsies from both iliac crests showed only a severely hypocellular marrow with a normal male karyotype, but a sternal aspirate performed 8 years prior to presentation was hypercellular and without morphologic abnormalities. Four months prior to ED presentation, the patient had a normal complete blood count (CBC).On presentation to the ED, CBC revealed hemoglobin of 7.8 g/dL, hematocrit of 21.7%, white cell count of 0.81 3 10 9 /L (absolute neutrophil count 190/mm 3 ), and platelets of 103 3 10 9 /L. Peripheral blood smear showed evidence of dysplasia, with poikilocytosis, anisocytosis, basophilic stippling, and hypogranular neutrophils, but no circulating blasts. Bone marrow aspirate and biopsy of the left iliac crest was performed, which was again hypocellular and non-diagnostic, but a few suspicious blasts were observed. Due to the patient's unusual history, [18 F] fluorodeoxyglucose positron emission tomography (FDG-PET) was performed, with concurrent non-contrast helical computed tomography (CT) to enable anatomic correlation and attenuation correction of the PET images.FDG-PET/CT revealed scattered, patchy high-intensity FDG uptake in the sternum, part of the right ilium and pelvis, and 8 of 24 vertebral bodies, as seen in the coronal section PET image in Fig. 1A. The remainder of the marrow, including the left iliac crest (Fig. 1B) was markedly photopenic, in keeping with the findings of a hypocellular marrow on previous aspirates. Figure 1C,D demonstrates different FDG uptake in two adjacent vertebrae, showing how the T12 vertebral body (Fig. 1C) is highly FDG-avid, while the L1 vertebral body (Fig. 1D) is not. Normal marrow shows low metabolic activity on FDG-PET and appears nearly black.Bone marrow aspirates targeted to FDG-avid areas of the right ilium and sternum showed 51% and 56% blasts, respectively, with a myeloid phenotype (expressing CD34, dim CD45, HLA-DR, and the myeloid markers CD13, Image 1. Panels A-D depict FDG uptake in several vertebral bodies and patchy areas of the pelvic bones, including the right iliac crest, on PET/CT scanning of a patient with focal involvement by AML. Other vertebral bodies (panel D) and the left iliac crest are photopenic, and the left iliac crest was hypocellular (panel G) and non-diagnostic upon biopsy. Panels E and F depict a cellular marrow with myeloblasts, obtained from a PET-avid area of the pelvis; panel G...

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“…There are several variables that affect adequacy of routine histological diagnosis on BMs. It was previously believed that bilateral trephine biopsies increased the yield from staging BMs in NHL (Juneja et al 1990). However, it is now established that bilateral sampling is not required if adequate tissue (including adequate trephine length and number of levels examined) is available for diagnosis (Campbell et al 2003).…”

Section: Discussionmentioning

confidence: 99%

Role of Immunohistochemistry in Staging Diffuse Large B-cell Lymphoma (DLBCL)

Talaulikar

Dahlstrom

Shadbolt

et al. 2008

J Histochem Cytochem.

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(AM) S U M M A R Y The use of immunohistochemistry (IHC) in staging bone marrow in nonHodgkin's lymphoma (NHL) is largely limited to ambiguous cases, particularly those with lymphoid aggregates. Its role in routine clinical practice remains unestablished. This study aimed to determine whether the routine use of IHC in diffuse large B-cell lymphoma (DLBCL) would improve the detection of lymphomatous involvement in the bone marrow. It also sought to determine the impact of IHC on predicting survival compared with routine histological diagnosis using hematoxylin and eosin (H&E), Giemsa, and reticulin staining. The bone marrow trephines of 156 histologically proven DLBCL cases were assessed on routine histology, and IHC using two T-cell markers (CD45RO and CD3), two B-cell markers (CD20 and CD79a), and k and l light chains. IHC detected lymphomatous involvement on an additional 11% cases compared with histology alone. Although both routine histology and IHC were good predictors of survival, IHC was better at predicting survival on stepwise multivariate Cox regression analysis. IHC performed routinely on bone marrow trephines has the ability to improve detection of occult lymphoma in experienced hands. Furthermore, it is a better predictor of survival compared with routine histological examination alone.

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Value of bilateral bone marrow biopsy specimens in non-Hodgkin's lymphoma.

Cited by 92 publications

References 9 publications

Non-Hodgkin’s Lymphomas

Non-Hodgkin’s Lymphomas

An extreme example of focal bone marrow involvement in acute myeloid leukemia

Role of Immunohistochemistry in Staging Diffuse Large B-cell Lymphoma (DLBCL)

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