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Bone Marrow Biopsy Systematic Interpretation

Bone Marrow Biopsy Systematic Interpretation: Bone Marrow Evaluation → Specimen Assessment → Cellularity Assessment → Trilineage Assessment → Dysplasia ...

Interactive Decision Tree

Mini Map

Algorithm Steps

  1. ▶
    Start

    Bone Marrow Evaluation

    Systematic approach to BM interpretation

    1. ●
      Action

      Specimen Assessment

      Evaluate adequacy

      • Core biopsy length (≥1.5 cm)
      • Aspirate quality (spicules present)
      • Touch prep available
      • Flow cytometry specimen
      • Cytogenetics/molecular specimen
      1. ●
        Action

        Cellularity Assessment

        Age-adjusted (100-age = expected %)

        • Hypercellular, normocellular, hypocellular
        • Distribution: patchy vs diffuse
        • Consider aplastic anemia if very hypocellular
        • Consider MPN if hypercellular with fibrosis
        1. ●
          Action

          Trilineage Assessment

          Erythroid, myeloid, megakaryocyte

          • M:E ratio (normal 2:1 to 4:1)
          • Erythroid maturation and dysplasia
          • Myeloid maturation and dysplasia
          • Megakaryocyte number and morphology
          • Left shift or maturation arrest
          1. ◆
            Decision

            Dysplasia Assessment

            ≥10% in lineage = significant

            • Erythroid: nuclear irregularity, megaloblastoid, ring sideroblasts
            • Myeloid: hypogranulation, pseudo-Pelger-Huet
            • Megakaryocyte: micromegakaryocytes, hypolobation
            • Multilineage dysplasia supports MDS
            1. ●
              Action

              Integrated Diagnosis

              Correlate all findings

              • Clinical history and CBC
              • Flow cytometry results
              • Cytogenetics/FISH
              • Molecular studies (NGS if available)
              • WHO 5th Edition classification
              1. ✓
                Outcome

                Final Report

                Synoptic format with diagnosis, staging if applicable

        2. ◆
          Decision

          Blast Assessment

          Aspirate differential

          • Count on aspirate (500 cells)
          • CD34 IHC on biopsy if needed
          • <5% normal
          • 5-9% MDS with excess blasts-1
          • 10-19% MDS-EB2
          • ≥20% Acute leukemia
          1. ●
            Action

            Fibrosis Grading

            Reticulin/trichrome staining

            • MF-0: Scattered linear reticulin
            • MF-1: Loose network, no collagen
            • MF-2: Diffuse, coarse reticulin ± collagen
            • MF-3: Coarse reticulin with collagen bundles
            • Suggests MPN if grade 2-3 with megakaryocyte atypia
        3. ●
          Action

          Abnormal Populations

          Identify infiltrates

          • Plasma cells: CD138 for quantification
          • Lymphoid aggregates: assess clonality
          • Metastatic carcinoma: CK, site-specific markers
          • Granulomas: infectious or immune
          • Mast cells: CD117, tryptase

Guideline Source

WHO Classification and CAP Bone Marrow Guidelines

DOI: 10.1182/blood-2016-03-643544View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Requires integration with clinical, lab, flow, and cytogenetics
  • Some diagnoses need molecular confirmation
  • Specimen adequacy affects interpretation
  • WHO classification evolves
  • Staging may require specific IHC

Applicable Regions

USAUUKEU

AU: RCPA bone marrow standards

UK: BCSH bone marrow guidelines

US: CAP synoptic reporting templates

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Bone Marrow Biopsy Systematic Interpretation?

The Bone Marrow Biopsy Systematic Interpretation is a diagnostic clinical algorithm for Pathology. It provides a structured decision tree to guide clinical decision-making, based on WHO Classification and CAP Bone Marrow Guidelines.

What guideline is the Bone Marrow Biopsy Systematic Interpretation based on?

This algorithm is based on WHO Classification and CAP Bone Marrow Guidelines (DOI: 10.1182/blood-2016-03-643544).

What are the limitations of the Bone Marrow Biopsy Systematic Interpretation?

Known limitations include: Requires integration with clinical, lab, flow, and cytogenetics; Some diagnoses need molecular confirmation; Specimen adequacy affects interpretation; WHO classification evolves; Staging may require specific IHC. Individual patient factors may require deviation from these recommendations.

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