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LETTER TO EDITOR Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 2  |  Page : 290-291
Relapse of multiple myeloma: Diagnosis by clot section alone with negative bone marrow aspirate and trephine biopsy


Department of Pathology, Christian Medical College and Hospital, Ludhiana, Punjab, India

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How to cite this article:
Kakkar N, Das S. Relapse of multiple myeloma: Diagnosis by clot section alone with negative bone marrow aspirate and trephine biopsy. Indian J Pathol Microbiol 2009;52:290-1

How to cite this URL:
Kakkar N, Das S. Relapse of multiple myeloma: Diagnosis by clot section alone with negative bone marrow aspirate and trephine biopsy. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Apr 8];52:290-1. Available from: http://www.ijpmonline.org/text.asp?2009/52/2/290/48957


Sir,

Bone marrow aspiration is a common procedure in hematology practice. [1] A biopsy in addition is usually also performed to study marrow architecture, to look for fibrosis or in conditions like myeloma, lymphoma or tuberculosis, when the involvement can be focal. [2] The blood obtained along with the bone marrow aspirate is usually discarded but can be used to prepare a clot section similar to the cell block that is already used extensively in cytological practice. The clot section may add additional diagnostic information at times. [3]

A 45-year-old gentleman presented with low back ache since 2 months. He was diagnosed as having multiple myeloma 5 years back and had received multidrug chemotherapy for the same. He had been on regular follow-up and a marrow check performed 2 years back was unremarkable. General physical and systemic examination was unremarkable.

Investigations showed hemoglobin of 12.3 gm/dL, total leukocyte count of 12,000/cumm, unremarkable differential count and normal platelets. The peripheral blood smear showed normal red blood cells and mild neutrophilic leukocytosis. Bilateral bone marrow aspiration and trephine biopsy were performed and clot sections were also prepared. The aspirate smears were normocellular and showed normoblastic erythropoiesis, normal granulopoiesis and adequate megakaryocytes. A 500-cell differential count was unremarkable except for a mild increase (5-8%) in plasma cells in aspirates from both the sides. Bilateral trephine biopsies [Figure 1] and clot sections [Figure 2] from both the sides had findings in agreement with the aspiration with no significant plasmacytosis. However, the clot section from the right side in addition showed an isolated focus, forming a micronodule, with 100% plasmacytosis [Figure 3]. The plasma cells had moderate cytoplasm and eccentric nuclei. A diagnosis of recurrence of active disease was made.

Conditions like lymphoma, multiple myeloma, metastatic tumors and granulomatous disorders may have focal bone marrow involvement. The bone marrow aspirate alone in these conditions may result in a false-negative diagnosis and an added trephine biopsy sometimes from two sites is vital to establish the diagnosis. [1] The clot sections can be valuable accompaniments to aspirate smears from which cellularity and relative cytological composition of the marrow cavity cannot be readily assessed. The clot section is prepared from the blood left over after aspirate smears have been made. The blood containing admixed marrow particles is transferred to a container with 10% formal saline for fixation. Further processing is carried out as for routine histopathology specimens. Clot sections can also be used for specialized procedures like immunohistochemistry. Compared with the trephine biopsy sections, the clot sections have a better antigenic retrieval for immunohistochemistry as decalcification is not required. In situ hybridization studies too have shown better results with clot sections as compared with the conventional trephine biopsy. [4] Also, in conditions that require frequent marrow sampling as part of treatment monitoring protocols, e.g. acute leukemia or chronic myeloid leukemia, clot section can suffice as an alternative to trephine biopsy. At times, the clot sections have been diagnostic while the bone marrow aspirate and trephine biopsy failed to show the pathology. [5]

Clot sections should be used as an adjunct to bone marrow aspirate and trephine biopsy to increase the diagnostic yield of these procedures.

 
   References Top

1.Bain BJ. Bone marrow aspiration. J Clin Pathol 2001;54:657-63.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Dee JW, Valdivieso M, Drewinko B. Comparison of the efficacies of closed trephine needle biopsy, aspirated paraffin-embedded clot ­section, and smear preparation in the diagnosis of bone-marrow involvement by lymphoma. Am J Clin Pathol 1976;65:183-94.  Back to cited text no. 2  [PUBMED]  
3.Barekman CL, Fair KP, Cotelingam D. Comparative utility of diagnostic bone-marrow components: A ten year study. Am J Hematol1997; 56:37-41.  Back to cited text no. 3    
4.Miranda RN, Mark HF, Medeiros LJ. Fluorescent in situ hybridization in routinely processed bone marrow aspirate clot and core biopsy sections. Am J Pathol 1994;145:1309-14.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Tkachuk DC, Hirschmann JV. Approach to microscopic evaluation of blood and bone marrow. In: Tkachuk DC, Hirschmann JV, editors. Wintrobe's Atlas of Clinical Hematology, 1 st ed. Philadelphia; Lippincott Williams and Wilkins; 2007. p. 275-328.  Back to cited text no. 5    

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Correspondence Address:
Naveen Kakkar
Department of Pathology, Christian Medical College and Hospital, Brown Road, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.48957

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  [Figure 1], [Figure 2], [Figure 3]



 

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