1 Division of Laboratory Services, Royal Childrens Hospital, Parkville; 2 Statistical Centre and 3 Department of Haematology and Medical Oncology, Peter MacCallum Cancer Institute, East Melbourne; 4 Department of Diagnostic Haematology, Royal Melbourne Hospital, Parkville, Victoria, Australia
Received 24 June 2002; accepted 17 July 2002
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Abstract |
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The National Cancer Institute has recommended a bone marrow biopsy length of 20 mm for the staging and surveillance of patients with non-Hodgkins lymphoma. However, there are few published data to support this recommendation, particularly the role of examining multiple levels.
Patients and methods:
Bone marrow biopsies from 172 patients with newly diagnosed diffuse large cell lymphoma (DLCL) entered in two consecutive trials of the Australasian Leukaemia and Lymphoma Group were analysed. The original haematoxylin and eosin-stained trephine biopsy and two or more deeper sections cut at 0.10.2 mm intervals were assessed with respect to the morphology, extent and pattern of lymphomatous involvement. The rate of positive diagnosis was correlated with the length of the biopsy specimen and the number of sections examined.
Results:
Forty-seven biopsies (27%) demonstrated marrow involvement on examination of a mean of four trephine biopsy sections. The rate of positivity increased with the examination of multiple levels and correlated with increasing trephine length but was not dependent on the number of sites sampled. Twenty per cent of biopsies <20 mm in length were positive for lymphoma; this increased to 35% for biopsies 20 mm (P = 0.023).
Conclusions:
Morphological bone marrow involvement in DLCL is optimally demonstrated by a 20-mm long trephine biopsy from a single site which is examined at multiple levels (four or more). This obviates the need for bilateral sampling, thereby reducing patient morbidity from the procedure. This study provides evidence to support the National Cancer Institute recommendations regarding trephine biopsy in the staging of DLCL, providing multiple levels are examined.
Key words: bone marrow involvement, bone marrow trephine, diffuse large cell lymphoma
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Introduction |
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Although bone marrow biopsy is accepted as a mandatory procedure and a valuable tool for the staging of patients with DLCL, there are few data regarding the amount of marrow that should be examined to assess accurately the presence or absence of lymphomatous involvement. In particular, discordant histological involvement (fewer than 50% large cells) is often limited to patchily distributed small foci of disease which may be missed if the area of the trephine biopsy examined is insufficient. This problem was addressed at a recent international working party convened by the National Cancer Institute (NCI) to develop standardised methods of assessment of staging and response in patients with non-Hodgkins lymphoma (NHL), at which a trephine length of at least 20 mm was recommended [8]. However, no evidence was provided to support this recommendation. Bain [9] has recommended a minimum trephine length of 16 mm. This was based on the findings of Bishop et al. [10], where a plateau in the rate of detection of metastatic tumour was observed once the trephine length exceeded 16 mm. Debate has existed for many years over the value of unilateral versus bilateral bone marrow aspirates in DLCL, with recent publications [8, 9] suggesting that overall trephine length may be more important than the number of sites sampled. Examination of serial sections of the trephine biopsy would allow a greater area of bone marrow to be assessed with no extra morbidity to the patient, while potentially increasing the likelihood that any marrow involvement would be detected. We have analysed serial sections of the trephine biopsy in patients with DLCL to determine the incidence, pattern and proportion of marrow involvement, the rate of discordant histology and the effect of serial sectioning on the frequency of recognition of marrow involvement.
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Patients and methods |
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Results |
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Impact of length of trephine core sampled
The median length of trephine core sampled was 19 mm. The length ranged from 6 to 73 mm, the latter being a bilateral biopsy with individual lengths of 32 and 41 mm. The number of positive cases increased significantly with increasing length of core (P = 0.042, CochranArmitage test for trend, one-sided test), although similar rates were observed for sampling between 22 and 30 mm and >30 mm (Table 2). The number of new positive cases following review of deeper sections was not strongly dependent on the length of core sampled (P = 0.16, CochraneArmitage test for trend, two-sided test). The NCI criteria for the staging of patients with NHL recommend a trephine biopsy length of at least 20 mm [8]. In our series, 89 patients had <20 mm of trephine core examined. Following examination of the original section and the deeper levels, these patients had a bone marrow positivity rate of 20%, compared with a rate of 35% in the 83 patients from whom 20 mm of bone marrow were obtained (P = 0.023, Fishers exact test, one-sided test).
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Discussion |
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The international working party convened by the NCI to standardise response criteria for NHL recommended that a minimum of 20 mm of trephine biopsy be examined for bone marrow involvement [8]. More recently, Bain [9] suggested a minimum trephine length of 16 mm, but stated that more focal lesions would be detected with larger biopsies. Other authors have recommended examination of at least five well-preserved marrow spaces [17], more than five high-power microscope fields [19], or evaluation of a total marrow area of 150 mm2 [20]. However, there is little direct evidence in the literature to support any of these recommendations. In an audit of bone marrow biopsy in 767 patients with malignant tumours conducted at a single institution, the rate of bone marrow involvement was related to trephine length, with a plateau occurring at 16 mm [10]. These results were unchanged when the analysis was restricted to the 295 patients with unspecified subtypes of NHL. In our series of patients with DLCL, the rate of positive diagnoses was also related to trephine length. Trephine biopsies <20 mm in length were positive in 20% of cases, compared with 35% of those >20 mm. Interestingly, these results only became statistically significant after the deeper trephine sections were examined (data not shown).
Because bone marrow involvement in DLCL is often focal, a number of authors have emphasised their preference for bilateral bone marrow biopsy in order to optimise the rate of positive results [7, 15]. Despite the high incidence of small, focal deposits in our patients, the likelihood of a positive diagnosis was clearly related to the trephine length, but no additional benefit was noted for bilateral biopsies once the trephine length was taken into account.
These data demonstrate that it is the overall trephine length that is critical, rather than whether the sample is taken from one or both sides of the pelvis and that the practice of examining serial biopsy sections from a single side can provide sufficient diagnostic information without the additional patient morbidity associated with bilateral biopsies. These findings provide evidence for the NCI recommendations regarding the optimum trephine length for the diagnosis of bone marrow lymphoma [8] providing that multiple sections are examined.
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Footnotes |
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References |
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