Adequacy of megakaryocytes in bone marrow

[Dr Rahul Naithani]

Dear friends,

What are your criterias for adequacy of megakaryocytes in bone marrow
aspirate and biopsy?
What is the cutoff number to say low, normal or high?

Dr Rahul Naithani
MD (Pediatrics); DM (Clinical Hematology)
Pediatric Hematology/Oncology & Bone Marrow Transplant Unit
Rajiv Gandhi Cancer Institute & Research Centre
Delhi, India.

[M Joseph John]

Dear Rahul,
              Great question and no definite answers in usual practise. Eager to hear from our hemato-pathology friends.
Thanks
Joseph John

--
Dr M Joseph John, MD, DM
Assistant Professor
Clinical Haematology, Haemato-Oncology

& Bone Marrow Transplant Unit

Christian Medical College
Ludhiana-141 008
(M): 9878659525
(O): 0161-2600270 Ext 5022/4823
Fax:0161-2609958

[kunal sehgal]

hi

thats a good question with not many straight answers in common textbooks

this is one i found in a text book called Hematology: clinical
principles and applications
by Bernadette F. Rodak, George A. Fritsma, Kathryn Doig

you can preview it on Google

it says that BM biopsy is better than aspirate and for aqequacy of
megakarycytes there should be 2-8 megakaryocytes per low power
field(10x) and 1-3 per high power field( 40x)

Anything above 10 per every low power field is increased

well this is what the text book says

what we practically follow at tata memorial is on aspirates we look
for around 1-3 megakaryocytes per particle for it to be called
adequate

i personally label it increased on aspirate when you start finding
megakaryocytes in small clusters and groups as is commonly seen in CML

i am sure this is a highly subjective issue and would definitely like
to have opinions from oothers.

Kunal Sehgal.

--
Kunal Sehgal,M.D
Senior Resident
Hematopathology
Tata Memorial Hospital
Mumbai
+91-9819586190

[NEERAJ ARORA]

 
Well i agree with kunal to an extent.
Some of the books like williams and hoffman do describe the adequacy criteria ranging from 1-5 megakaryocyte per particle,please note that it is per particle.Williams says that even if you have a single megakaryocyte in a paticle it is adeuate.It also mentions that at least 5 megakaryocytes should be present in the optimal portion of the  But still i feel it has a bit of subjective thing to it.
For all practical things i think a smear with more than 5 megakaryocytes is adequate.

Dr Neeraj Arora(MD Pathology)
Sr Registrar,Dep. of Immunohaematology and
Transfusion Medicine,
CMC Vellore

[Sunil Dabadghao]

The question of how many megs should be called as adequete, reduced or increased is a very fluid one and as a registrar I often used to question my supervisors about it. i never got a satisfactory answer. Only one of my supervisor, Dr Geoff Dart at the IMVS,  used an objective method of counting the no of megs on a trephine using a grid and report the average no of megs per sq mm on a trephine core. Since that kind of eyepiece was not available to me, I did not bother to do that exercise. Most of us use subjective judgement to report. Barbara Bain's book is silent on this issue.

What Kunal has given should be good to follow in practice. i will look it up on the net.

Sunil

---

From: kunal sehgal <drkuna...@gmail.com>
To: hematol...@googlegroups.com
Sent: Wednesday, 1 April, 2009 10:50:14 PM
Subject: Re: Adequacy of megakaryocytes in bone marrow

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[Nikhil Patkar]

Dear All,

I think Kunal and Neeraj and sunil sir, have nicely answered this question, i will add another reference. This is a quote from Henry's textbook of lab medicine" In scanning areas of films with good cellularity under LOW POWER (10x), an average of one to 3 megakaryocytes should be found IN EACH FIELD in a normal marrow.
Barbara bain's bone marrow pathology states that on an aspirate this can only be a subjective assessment in reporting that the megs are increased, adeq or decreased.

I think this is a sensible approach as there are are simply too many variables on the making of an aspirate (how many particles are present, if only one or two, are they representative, dilution with blood etc,).Also in case of fibosis in marrow, the megs are not appreciable in the aspirate but are present in the trephine.
Bain's book further states that megs should be counted on a trephine (number/mm2) the mean meg number on a trephine should vary between 7-15/mm2. This number is 25 if IHC is used (more megs are recognized). I have not seen anybody reporting in this format in India. (Others may pls opine)
What is consistent is that there is no consensus on this issue.

Regards
Nikhil


--
Dr. Nikhil Patkar
MD.(Pathology)
Diplomate, National Board
Senior Registrar
Division of Molecular Haematology
Department of Clinical Haematology
Christian Medical College
Vellore
Tamil Nadu
632004
Ph: (+91)9944397742

[Archana Vazifdar]

Hi Rahul,   This question can be answered in 2 ways; If one purely follows theoretically....3-8 megs / low power field, or 1-3 megs/high power field is considered adequate. Less than 1 meg/hpf or more than 5-6 megs/hpf....or more than 10 megs/lpf are considered increased in  number. (these criteria are mentioned in standard textbooks) However this criteia is very difficult to follow on bone marrow aspirate as they have scattered particles owing to variable spreading techniques, etc.  Thus counting per high/low power field is not practical. Practically one would rather count megs per particle. We find 2-3 megs per particle as adequate. However even megs spread quite irregularly around particles, so one may find few particles with just 1-2 megs, an occassional particle with no meg. So, things become a bit subjective, unfortunately with no hard and fast rules, practically speaking. Clustering of megs is a significant finding, suggesting an increrase. MICROMEGAKARYOCYTES in excessive numbers is significant (seen frequently in CMPD's). Accompanying dysmegakaryopoeisis is also significant. Bone marrow biopsies are far more accurate for megakaryocyte numbers. This is a difficult question and  would like to know what the others think.   Regards, Archana --- On Wed, 1/4/09, Dr Rahul Naithani <drra...@gmail.com> wrote:

From: Dr Rahul Naithani <drra...@gmail.com> Subject: Adequacy of megakaryocytes in bone marrow To: "hematologyindia" <hematol...@googlegroups.com> Date: Wednesday, 1 April, 2009, 10:06 PM

Dear friends, What are your criterias for adequacy of megakaryocytes in bone marrow aspirate and biopsy? What is the cutoff number to say low, normal or high? Dr Rahul Naithani MD (Pediatrics); DM (Clinical Hematology) Pediatric Hematology/Oncology & Bone Marrow Transplant Unit Rajiv Gandhi Cancer Institute & Research Centre Delhi, India.

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[apalle]

Dear All,
Like Nikhil has said 1-3 megs should be there in every field when
scanning under 10x.And that is true. In a patient with a normal
platelet count and a normocellular marrow you find megs practically in
every field.When megs are increased in number it is fairly easy to
make out. But to say that they are decreased by looking at the
aspirate slide alone is difficult.Megs are the kind of cells you dont
have to search for because they catch your eye.While scanning the
slide for megs if you dont find them in 2-3 fields in a row the
chances are that the megs are decreased in that marrow provided that
the other marrow elements are distributed evenly throughout the slide.
I hope what I said makes some sense.
Arpana.

> Dear Rahul,
>               Great question and no definite answers in usual practise.
> Eager to hear from our hemato-pathology friends.
> Thanks
> Joseph John
>

[Prashant S]

Dear all,

Its already been said but bears repetition. If criteria for something
aren't in routine use, there's usually a good reason.

The problem with counts per particle and per HPF or LPF or scanner (4x
field, where I usually decide adequacy of numbers in routine cases,
before confirming in higher powers) is the inherent subjectivity, not
just in the pathologist's eyes and brain, but in the infinite number
of ways that marrow can be aspirated, smeared and, of course,
examined.

I am sure everyone has seen cases with <1 mgk'cyte per particle but a
normal platelet count. Or cases that ALMOST got reported as
amegakaryocytic thrombocytopenia till the biopsy showed what were felt
to be normal numbers of mgk.

Which is why the answer to Naithani's question has to nuanced beyond
just a number. Its (perhaps) OKAY to have cut-off's in cases where you
don't have a biopsy, or the aspirate is being done to investigate
thrombocytopenia and mgk's appear borderline, but otherwise these
numbers are really just yardsticks to be borne in the pathologist's
mind, rather than statistic # 5000 to be mandatorily included in the
aspirate report. And although everyone agrees that a biopsy is better
than an aspirate before concluding that they are markedly reduced /
increased, in the absence of morphometry that too is not free from
subjectivity.

So, till such time that we do uniform CD61 immunostain on all biopsies
and routinely get image analysis / stereology to count the critters in
uniformly obtained, uniformly shrunk, uniformly cut, uniformly counted
using systematic random sampling sections... you will (probably) have
to live with the reports that say adequate / diminished / prominent...

Best regards,

Prashant

PS: "For all practical things i think a smear with more than 5
megakaryocytes is adequate. " Personally, I like this one best.

[Dr Rahul Naithani]

Thanks everybody. I guess till this point of discussion it still
remains subjective. Sunil sir your answer was great as ever but as far
as technical quantifying is concerned, we are still at some distance
(you already agree to it).

My query was predominantly for 2 patients.

One with multisystem LCH (last chemo 2 months back) and another High
risk ALL (5 weeks from CCG protocol consolidation). In both patients
other 2 lineages have regenerated long back. Child with ALL had many
other issues also like long ICU admission, Hickman infection. ALL
patient has megakaryocyte numbers which according to criterias raised
by some of us are adequate. So to treat like ITP, wait further (High
brisk ALL already 5 weeks gap)or go ahead with chemo at platelet count
of 32000 I am not sure.

I am specially tempted to treat the LCH patient (9 cm liver and 9
cmspleen bcm) as immune thrombocytopenia but holding on. The LCH
child (last chemo-Cladirabine Ara-C 2 months back)has variable number
of megakaryocytes in smear. I did count 6 in one diluted aspirate
smear (biopsy not done this time) but previous biopsies cellular with
adequate megakaryocyte.she has platelet count of 5,000 with
alloimuunization. Interestingly she never had platelet count >100,000/
cmm even at diagnosi. Serial bone marrow biopsies show no evidence of
LCH. Liver biopy is also non-contributary.

I understand theoretically some of the options sound weird but this is
a practical problem.
Both patients and I are waiting.

Dr Rahul Naithani
MD (Pediatrics); DM (Clinical Hematology)
Pediatric Hematology/Oncology & Bone Marrow Transplant Unit
Rajiv Gandhi Cancer Institute & Research Centre
Delhi, India.

[Deepak Singhal]

Hi friends,

How many of us would anticoagulate a 71 year old mild Haemophilliac B (Fac IX - 14%, No Inhibitors) with Atrial Fibrillation and with what??

Deepak

[Dharma Choudhary]

I will give just aspirin, no anticoagualtion.

Dharma

Dharma R Choudhary
MD(Internal Medicine)  DM(Clinical Hematology)
Clinical Hematologist & Bone Marrow Transplant Physician

B. L. Kapur Memorial Hospital,

5 Pusa Road,

New Delhi.

India.

Pin - 110005

Mobile: +91-9971003605
email: drdh...@hotmail.com
web: www.blkhospital.com  



          

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Date: Fri, 3 Apr 2009 08:41:06 +1030
Subject: Re: Adequacy of megakaryocytes in bone marrow
From: kris...@gmail.com
To: hematol...@googlegroups.com

Hi friends,

How many of us would anticoagulate a 71 year old mild Haemophilliac B (Fac IX - 14%, No Inhibitors) with Atrial Fibrillation and with what??

Deepak

---

How fun is this? IMing with Windows Live Messenger just got better.

[Archana Vazifdar]

Well said Prashant, I think you've hit the nail on the head. I agree .   Archana --- On Thu, 2/4/09, Prashant S <prash...@gmail.com> wrote:

Add more friends to your messenger and enjoy! Invite them now.

[Prashant S]

Thanks Dr. A. Only a friend would have read through all of that!

Best regards,

Prashant

[Sunil Dabadghao]

I agree with Prashant that sampling (site, amount, smears etc) may be a significant determinant of the numbers of megs seen in aspirates. That is the reason that there is no clear consensus on what is normal. However, we all agree that trephine cores are better for assessment. CD 61 will be useful but will not resolve the dilemma about  whether the no. are reduced/normal/ increased. However it will be of particular use to rule out condition like amegakaryocytic thrombocytopaenia. But IHC is not available routinely and everywhere. In this context,  I remember reading that megs stain well with PAS and this may be of use to bring out their presence in smears and trephines. Has anyone tried that ??
Sunil

---

From: Prashant S <prash...@gmail.com>
To: hematologyindia <hematol...@googlegroups.com>
Sent: Thursday, 2 April, 2009 7:28:04 PM

Subject: Megakaryocyte numbers and all that jazz...

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[Dr Rahul Naithani]

I agree Prash.

> > I think you've hit the nail on the head. I agree .- Hide quoted text -
>
> - Show quoted text -