Haematologic malignancies are a heterogeneous group of cancers arising from malignant transformation of cells of the bone marrow and or the lymphatic organs. According to the most recent data. Haematologic malignancies are estimated to represent about 6.5 % of all cancers worldwide. They affect all ages and genders world over. The distribution of types may vary with age, sex, culture and the geographic region. Bone marrow aspiration examination is an important tool that aids in the diagnosis and management of various hematological malignancies. The aspirate smears are useful for studying the morphology of cells and for obtaining a differential cell count. Bone marrow aspiration specimens are useful in further diagnostic assays cytochemical and special staining, immune phenotyping cytogenetic analysis and molecular studies. It may be useful in establishing the diagnosis of storage diseases and metastatic non haemopoietic malignancies or when a leuco erythroblastic peripheral blood picture is present. Deviations from the normal may be qualitative with abnormal cell morphology or quantitative with aplasia, hypoplasia or hyperplasia. The aim of this study was to analyse the spectrum of malignant haematological disorders reported on BMA to formulate an effective and rapid method for diagnosing a wide spectrum of diseases. This study will highlight the diagnostic utility of BMA in various haematological disorders, as combined analyses are useful in achieving more accurate and informative data in some diagnostically challenging cases.

AIMS AND OBJECTIVES

To study the pattern and type of different hematological malignancies on bone marrow examination.

MATERIALS AND METHODS

This was a retrospective observational study aimed to document the prevalence and distribution of different haematologic malignancies at P.D.U. Medical college and Hospital, Rajkot over a 3 year period from January 2022 to January 2025 and included all the patients of haematological malignancies diagnosed on bone marrow examination. Patient’s age, sex, residence, bone marrow indication, clinical history, relevant laboratory and radiological investigations along with bone marrow diagnosis were noted for every case. The bone marrow aspiration was primarily done from posterior superior iliac spine and the trephine biopsy was mostly performed in the same sitting wherever required. The smears were then stained with Leishman stain or May Grunwald geimsa stain and were examined carefully. Special cytochemical stains like Myeloperoxidase (MPO), Sudan black B (SBB)  and Periodic acid-schiff (PAS) stain were also utilized for accurate staging and differentiating the type of leukemia.  All the data were then statistically analysed and the results were presented as tables and figures.

RESULTS

Out of total  210  bone marrow aspirations conducted over the duration of 3 years; hematological malignancies accounted for 58 cases of all hematological disorders. Out of those 58 cases; males constituted 31 cases (53.45%) and females constituted 28 cases(46.55%). Male to female ratio was 1.14:1. (Fig 1)

Fig 1: Sex wise distribution of hematological malignancies

In the present study, the age ranged from 9 months to 80 years. The maximum no. of cases were belonging from 0-20 years (39.65%) of  age group followed by 41-60 years (24.14%), 21-40 years (22.41%) ands 61-80 years (13.80%) respectively (Fig 2).

Fig 2: Age wise distribution of hematological malignancies

In the present study, the most common presenting symptom was fatigue, which was seen in 85.2% of patients followed by fever in 75% of cases. Other symptoms were loss of appetite (45%), loss of weight (38.5%), bone pain (28.4%), cough and cold (30.3%), petechiae (22%), and CNS symptoms (8 %). While most common presenting signs were splenomegaly and pallor, which were seen in 83% and 80%, respectively, other common signs found were hepatomegaly (62%) and lymphadenopathy (35%).

Table 1: Presenting symptoms and signs

In present study; Anemia was seen in majority of patients and among them 56.90% patients have severe anemia (<7 g%). These findings are correlating with clinical examination, which shows pallor in 82.7% of cases. Most of the patients (58.62%) had white blood cell (WBC) count >10,000/mm³ with 27.60% had >50,000/mm³. Two patients had WBC count <5000/mm³ (Table 2).

Table 2: Laboratory finidngs of all patients

The various hematological malignancies were majorly divided according to the cell lineages into Lymphoid disorders which constituted 29 cases (50%) and Myeloid disorders that constituted 21 cases (36.2%) and 8 (13.8%) cases were inconclusive (dry tap/ diluted).

Fig 3: Distribution of hematological malignancies according to cell lineage

The Lymphoid disorders were then classified into Lymphoma which constituted 6.89% (2 cases) , Chronic lymphocytic leukemia 10.34% (3 cases), Plasma cell myeloma(Multiple myeloma) 31.05% (9 cases) and Acute lymphoblastic leukemia 51.72% (15 cases) respectively.

Table3: Distribution of Lymphoid neoplasms: (n=29)

The myeloid disorders were divided into Acute myeloid leukemia which constituted 33.33% , Chronic myeloid leukemia (19.04%), myelodysplastic syndrome (33.33%) and myeloproliferative neoplasm (14.30%)

Table 4: Distribution of Myeloid neoplasms: (n=21)

Out of all hematological malignancies (50 cases); majority cases were leukemic disorders (58%) whereas 42%  were non leukemic disorders (Fig 4) and further the distribution of all leukemic disorders is given as below in Fig 5.

Fig 4: Types of hematological malignancies

Fig 5: Distribution of various leukemic disorders

In present study, out of all cases of ALL;  L1 type of lymphoblast was seen in 80% case, L2 type in 13.33% cases, and L3 type in 6.67% of cases. Hence, L1 is predominant type of lymphoblast in ALL, comprising three-fourth of the cases. In AML, 14.28% of cases had blasts of M1 type, 71.44% had M2 type, and 14.28% had M3 type of myeloblast. 

Table 5: Blast typing in bone marrow examination:

Special cytochemical staining was done in cases of Acute leukemias (AML & ALL). Out of all cases of Acute myeloid leukemia; 85.71% cases were positive for MPO stain, 100% positive for SBB stain and PAS stain was positive in 28.57% cases.

Out of all cases of ALL, 93.33% cases showed PAS positivity whereas MPO and SBB stains were negative in 100% of cases. (Table 6)

Table 6: Cytochemical staining in acute leukemias

DISCUSSION

Bone marrow aspiration(BMA) is a cytologic preparation of bone marrow cells obtained by aspiration of marrow and a smear of the cells. BMA plays a very important role both in determining the cause of a disease as well as reaching a definitive final diagnosis. It is used to diagnose, confirm, and/or stage hematologic malignancies. The present study was carried out at the Department of Pathology at P.D.U. Medical college and Hospital, Rajkot over a period of 3 years . Total of 58 cases of BMA smears were studied. The observations of the present study were compared and correlated with various other studies.

In the present study, the participating patient’s ages ranged from 9m to 80 years, which were in concordance with the findings of N Sangeetha et al (2020), where age ranged from 11m-70 years, Nirali V et al (2020) where cases age ranging from 11m-67 years, and Pudasaini et al (2012) with age group belonging to 9m-75 years. The present study found that the maximum number of cases belonged to the 0-20 years age group. This was in concordance with the findings of Satyasri K et al  (2018) where the maximum number of cases belonged to the 0-10 years age group. However, in the study conducted by Renuka Verma et al (2024), Fatima Arshad et al (2021)and N Sangeetha et al (2020) the maximum number of cases belonged to the age group 21-30 years.

Table 7 : Comparison of peak age of presentation in various studies.

In the present study, a total of 58 cases were included out of which 31 were male and 27 were female. Male preponderance was observed in the present study and the male: female ratio was 1.14:1 which was in concordance with the study conducted by Renuka Verma et al (2024), Gupta C et al (2023), Pudasaini S et al (2012) and Satyasri K et al (2018) were male: female ratio was1.3:1, 1.6:1, 1.1:1and 1.4:1 consecutively. However, in studies conducted by Fatima Arshad et al (2021) female preponderance was observed, and the male: female ratio was 1:1.25 which was discordant with the present study. (Table No. 8)

Table 8: Sex-wise distribution of study population in various studies

In the present study; the most common malignancy was Acute lymphoblastic leukemia which was similar to Satyasri K et al and Renuka Verma et al. However, M. Atchyuta et al and Fatima Arshad et al showed the most common malignant haematological disorder was Chronic leukemia which was discordant with current study. (Table 9)

Table 9: Comparison of the spectrum of BMA among various studies

CONCLUSION

The Bone marrow aspiration study remains an important diagnostic tool for many hematological disorders. A complete clinical examination, patient history, and investigations like peripheral blood examination along with bone marrow examination complete the diagnostic workup for many hematological conditions. In present study, leukaemias  were  the most prevalent haematologic malignancies and ALL was the predominant leukaemia as well as the most prevalent haematological malignancy in our centre.

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