Bone marrow examination — comprising bone marrow aspiration (BMA) and bone marrow biopsy (BMB) is a fundamental diagnostic technique in haematology, designed to assess the composition, maturation patterns, and functional status of the bone marrow. The bone marrow serves as the primary site of haematopoiesis, producing red blood cells, white blood cells, and platelets that are essential for maintaining oxygen transport, host immunity, and haemostasis. When disorders of blood cell production or maturation are suspected, direct evaluation of the marrow becomes necessary to uncover pathological changes that cannot be detected through peripheral blood analysis alone. During bone marrow aspiration, a sample of the liquid marrow is withdrawn commonly from the posterior iliac crest using a specialized needle under sterile conditions. The aspirate is then subjected to a series of laboratory assessments, including cytological examination, differential cell counts, iron staining, and sometimes ancillary tests such as flow cytometry, cytogenetics, and molecular analysis. These investigations provide detailed insight into cell morphology, lineage distribution, and the presence of abnormal or malignant cell populations. Clinically, bone marrow aspiration plays a critical role in diagnosing hematologic malignancies such as leukaemia and lymphoma, evaluating unexplained cytopenias, staging cancers that may infiltrate the marrow, and monitoring the effectiveness of therapeutic interventions. It is also utilized in the assessment of infections, metabolic disorders, and systemic diseases that affect marrow function. Despite being minimally invasive, the procedure yields high diagnostic value, making it an essential component of comprehensive hematologic evaluation in both adult and paediatric populations. Evaluation of haematological & non-haematological disorders, even after detailed clinical history, physical examination & peripheral blood analysis the diagnosis is cryptic & crucial. This article presents an evaluation of bone marrow examination in a tertiary care centre in Rajkot, Gujarat, analysing its indications, diagnostic yield, and the spectrum of haematological disorders encountered. Aim and objectives: The aim of this study is to comprehensively evaluate the diagnostic significance of bone marrow examination and to characterize the pattern of bone marrow pathology in a defined patient population. The study seeks to analyse the distribution of marrow abnormalities with respect to age and sex, providing insight into demographic trends associated with various haematological disorders. It also aims to examine bone marrow findings in relation to the clinical indications for which the procedure is performed, thereby assessing the correlation between clinical findings, laboratory abnormalities, and underlying marrow pathology. In addition, to categorize the nature of the diseases identified—whether neoplastic or non-neoplastic and to determine their relative frequencies. The study further intends to compare peripheral blood examination results with bone marrow aspiration findings to evaluate the extent to which peripheral smears reflect marrow pathology. Finally, it incorporates other available confirmatory tests, such as cytogenetics, flow cytometry, and relevant biochemical or immunological assays, to enhance diagnostic accuracy and validate marrow-based interpretations. Through these objectives, the study aims to provide a detailed understanding of the clinical, demographic, and pathological factors that shape the spectrum of bone marrow disorders. It also clarifies how bone marrow aspiration and biopsy contribute to treatment planning and ongoing patient monitoring.

We evaluated a total number of 129 cases from September 2022 to July 2025 in the Central Clinical Laboratory, Department of Pathology, P.D.U Medical College & Hospital, Rajkot, Gujarat, India. Bone marrow aspiration/biopsy was performed in the patients as indicated by their clinicians or as per the pathological requirement. Clinical history, physical examination, complete blood count (CBC), peripheral smear, and other relevant laboratory or radiological findings were recorded. The patients were of different age groups of both genders. A detailed history along with systemic, general and local examination and routine haematological investigation was carried out prior to the procedure. Written consent was taken after the procedure was explained thoroughly to the patient or patient’s relative. The patient was given intravenous atropine wherever it was required. Patient was then placed in the lateral decubitus position, with the top leg flexed and the lower leg straight. The site (Most commonly Posterior Superior Iliac Spine) was prepared by cleaning with an antiseptic (usually Betadine) scrub, and draped, only the aspiration area was exposed. The skin and the area down to the periosteum was injected with a local anaesthetic agent (1% Xylocaine; approximately 10 cc of 1% Xylocaine). A skin incision was made with a small surgical blade, through which the bone marrow aspiration needle (Salah’s Bone Marrow Aspiration Needle) was inserted with the stylet in place. As the needle contacts the bone, it was advanced further by rotating clockwise and anticlockwise gradually until the cortical bone was penetrated and the marrow cavity was entered. A sudden loss of resistance is noted once the marrow cavity is reached. After reaching the marrow cavity, the stylet was removed and by a 10 cc or 20 cc syringe bone marrow was aspirated. The aspirated marrow was then spread on the slides and smears were prepared. The marrow aspiration needle was removed, and pressure was applied to the site with gauze until bleeding stopped. Thus, the Bone marrow aspiration/biopsy was done under aseptic condition. The slides prepared were fixed with methanol after drying. Smears prepared were stained with field’s stain & Leishman stain. Field staining and Leishman staining are two commonly used Romanowsky-based techniques for the evaluation of bone marrow aspiration smears, each serving distinct diagnostic purposes. Field staining was performed as a rapid screening technique to allow immediate assessment of bone marrow cellularity and morphology. Freshly prepared, air-dried marrow smears were first fixed using absolute methanol and then dried. The smears were then immersed in Solution A (containing methylene blue and phosphate buffer) for approximately 2–3 seconds, ensuring complete coverage. Excess stain was gently drained, after which the slides were transferred to Solution B (containing eosin and buffer) for another 2–3 seconds. The slides were then rinsed briefly with clean buffered water to remove residual stain and were left to air-dry. This rapid staining protocol enabled quick visualization of overall cell distribution, presence of blasts, and major cytological abnormalities; however, fine nuclear and cytoplasmic details were less distinct compared with Romanowsky stains. The method was particularly useful in situations requiring urgent preliminary interpretation. Leishman staining was employed for detailed cytomorphological evaluation of marrow elements. Air-dried smears were placed horizontally on a staining rack and flooded with undiluted Leishman stain, allowing the methanol component of the stain to fix the smear for 1–2 minutes. After fixation, double the volume of buffered water (pH 6.8) was added to dilute the stain gently without disturbing the smear surface. The diluted stain was allowed to act for 8–12 minutes to ensure adequate differentiation of cellular components. Following staining, the slides were rinsed carefully with buffered water until a pale pinkish sheen appeared, then air-dried in an upright position. This controlled staining process enhances differentiation of nuclear chromatin, cytoplasmic granules, and lineage-specific features, making Leishman stain ideal for detailed morphological analysis, classification of haematological disorders, and correlating marrow findings with peripheral blood abnormalities. Together, these staining methods complement each other by providing both rapid screening capabilities and high-resolution diagnostic morphology in the evaluation of bone marrow aspiration smears. Inclusion criteria: All the patients suspected of having their bone marrow involvement by any haematological or non-haematological disorders were included. Patients were investigated for complete blood count, coagulation profile, reticulocyte count and peripheral blood film (PBF) examination. Exclusion criteria: All the patients with risk of bleeding like severe thrombocytopenia (<20000/ul), haemophilia, patients on anticoagulants, severe systemic illness (uncontrolled heart/lung/kidney/liver disease, sepsis, psychosis), patient unable to give consent, uncooperative behaviour were excluded.

From September 2022 to July 2025, 129 patients underwent bone marrow examination. Out of the total of 129 Bone marrow Examination was indicated for Pyrexia of Unknown Origin in 20 cases (15.5 %), Weakness & fatigue in 43 cases (33.3 %), weight loss in 24 cases (18.6 %), Hepatosplenomegaly/Organomegaly in 12 cases (9.3%), anaemia in 14 cases (10.8%) and Others in 8 cases (6.2 %). (Table 1). Table 1: Distribution of Patients according to the clinical presentation of patients. Presenting signs/symptoms Number of cases Percentage (%) Fever of unknown origin 20 15.5% Weakness/Fatigue 43 33.3% Weight loss 24 18.6% Hepatosplenomegaly/Organomegaly 12 9.3% Anaemia 14 10.8% Others 08 6.2% Total 129 100% Among the total of 129 patients ranging from age 1 months to 85 years of age, most common age group was 21 years to 30 years of age 27 cases (20.93%). (Chart 1). Out of 129 cases studied, 56(43.4%) were male and 73(56.6%) were female with age group ranging from 1 months to 85years. Peripheral blood smear finding in case of bone marrow aspiration cases, most common was pancytopenia 46(35.65%), second most common was dimorphic anaemia 23(17.82%), some peripheral smears show hypochromic microcytic anaemia 17(13.17%) & normochromic normocytic anaemia 12(9.30%), thrombocytopenia 13(13.95%), myeloproliferative and lymphoproliferative disorders were also seen 8(6.20%) & 5(3.87%) respectively. (Table 2). Table 2: Peripheral blood smear findings in cases PERIPHERAL SMEAR FINDINGS Bone marrow case Percentage (%) Hypochromic microcytic anaemia 17 13.17% Normochromic normocytic anaemia 12 9.30% Pancytopenia 46 35.65% Dimorphic anaemia 23 17.82% Thrombocytopenia 13 13.95% Macrocytic anaemia 3 10.07% Myeloproliferative disease 8 6.20% Lymphoproliferative disease 5 3.87% Myelodysplastic syndrome 2 1.55% Total 129 100% Bone marrow aspiration findings in which most common was megaloblastic anaemia 38(29.45%), followed by dimorphic anaemia25(19.37%), second most common, other findings ITP 9(6.97%) myeloproliferative and lymphoproliferative disorders were also seen8(6.20%) & 5(3.87%) respectively. (Table 3). Table 3: Haematological disorders in bone marrow aspiration. Bone marrow aspiration findings Number of cases Percentage% Megaloblastic anaemia 38 29.45% Dimorphic anaemia 25 19.37% Normochromic normocytic anaemia 15 11.62% Hypochromic microcytic anaemia 20 15.50% Aplastic anaemia 7 5.42% Hypersplenism 2 1.55% Myeloproliferative disorder 8 6.20% Lymphoproliferative disorder 5 3.87% ITP 9 6.97% Total 129 100% The microscopic examination of the bone marrow aspirate/biopsy show wide distribution in terms of cellularity. Among the total of 129 cases, Hyper cellular marrow was 54(41.86%), Normocellular marrow 24(18.60%), Hypocellular marrow 15(11.62%), Blood mix marrow 33(25.58 %), dry tap 3(2.32%). (Chart 3). Chart 3: Cellularity of bone marrow Among all the indications of bone marrow aspiration, pancytopenia was most common indication 46(35.65%), second most common was anaemia29(22.48%) and other ones were as mentioned in table respectively. (Table 4). Table 4: Indications for bone marrow aspiration. INDICATIONS Number of Cases PERCENTAGE % Pancytopenia 46 35.65% Anaemia 29 22.48% Thrombocytopenia 13 10.07% Malignancy 8 6.20% Bi cytopenia 19 14.72% Miscellaneous 11 8.52% Total cases 129 100% MEGALOBLASTIC ANAEMIA: Bone marrow aspiration smear shows erythroid hyperplasia along with sieve like nucleus megaloblast also seen. (Image 1) CONGENITAL DYSERYTHROPOIETIC ANAEMIA: Bone marrow examination shows ineffective erythropoiesis & megaloblastic proliferation as well as binucleated and trinucleated erythroblast. (Image 2 & 3) CHRONIC LYMPHOPROLIFERATIV DISORDER: In chronic lymphoproliferative disorder the bone marrow aspirate smear shows megakaryocyte along with many mature lymphocytes with precursor cells. Few myeloid cells can also be seen. (Image 4) IDIOPATHIC THROMBOCYTOPENIC PURPURA: ITP was seen in 9 cases (6.97 %) with maximum number of cases in the age group of 21-40 years showing high female preponderance.

Bone marrow aspiration remains an indispensable diagnostic tool in haematology, providing critical insights into haematopoietic disorders, marrow infiltration, and unexplained cytopenias. The findings highlight both the patterns of clinical presentation in a regional population and the practical impact of marrow examination on patient management. In the present study, pancytopenia emerged as the leading indication for bone marrow aspiration, accounting for 46 (35.65%) of cases, followed by anaemia 29 (22.48%). Less frequent indications included thrombocytopenia 13(10.07%) and bi cytopenia 19 (14.72%). This pattern closely aligns with observations reported by Pudasaini et al.(Kathmamdu,2012) and Bashawri L et al.(Saudi Arabia,2002) in their respective studies, where pancytopenia was also the predominant reason for marrow evaluation. In contrast, other investigators such as Kumar K et al. and Aljadeyeh et al. documented anaemia as the most common indication for bone marrow examination, reflecting variability in referral patterns and population characteristics across different regions. Although pancytopenia is often associated with serious underlying pathology, the most frequent diagnosis in our study was megaloblastic anaemia, which constituted 38(29.45%) of cases. This finding is in concordance with the study by Gayathri and Rao (2011) conducted in India, where megaloblastic anaemia was similarly identified as the leading cause of pancytopenia. These observations underscore the continued prevalence of nutritional deficiencies as a major contributor to haematological abnormalities in the Indian population. Our analysis further demonstrated that nutritional anaemias formed the largest group among non-malignant disorders, with megaloblastic anaemia being the most frequent subtype. Similar trends have been reported by Okinda et al.(Nairobi,2010), Patel et al.(Jodhpur,2022), and Kibria et al.(Faridpur,2010), reinforcing the importance of early recognition and treatment of nutritional deficiencies to prevent severe haematological manifestations. Immune thrombocytopenic purpura (ITP), an autoimmune disorder known to show female predominance, constituted 9(6.97%) of cases in the present study. Among the nine patients diagnosed with ITP, females outnumbered males, consistent with the established gender distribution of autoimmune conditions. Studies from Nepal have reported a female-to-male ratio of approximately 1.6:1, while international literature documents ITP prevalence rates ranging from 5% to 14.5%, comparable to our findings. Non-neoplastic disorders overwhelmingly dominated the diagnostic spectrum in this study, accounting for nearly 90% of cases, while malignant conditions comprised approximately 10%. These proportions are similar to those reported by Pudasaini et al. from Nepal. However, other studies from the same region have documented a higher incidence of neoplastic disorders, ranging between 18% and 19%, highlighting geographical and institutional variations in disease burden. Among malignant conditions identified in our study, leukaemia was the most frequently diagnosed entity. Acute myeloid leukaemia was the predominant subtype, followed by chronic myeloid leukaemia and acute lymphoblastic leukaemia. This distribution mirrors findings from previous studies conducted other parts of India, including the work by Atla et al. (Vishakhapatnam,2015), where acute myeloid leukaemia was also reported as the most common haematological malignancy diagnosed on bone marrow examination. The demographic distribution observed with a slight female predominance and a peak incidence in middle-aged adults, is consistent with existing literature from similar studies (Table 5). This likely reflects the referral patterns to the centre, where both haematological malignancies and chronic systemic conditions are frequently evaluated. The broad age distribution also underscores the diverse spectrum of diseases requiring marrow evaluation, from nutritional anaemias to myelodysplastic and neoplastic disorders. Table 5: Comparison of age and sex with various studies: STUDY NAME AGE RANGE M:F RATIO Kumar K et al(2020,Patna) 29 days to 75 years 1.02: 1 Pudasaini S et al(2012, Nepal) 39 months to 75 years 1.1: 1 Gilotra M et al (2020, Rohtak) 41 years to 88 years 1.2 :1 Thiyagarajan P et al (2015, Kolar) 8 years to 90 year 1.3 :1 Present Study (2025, Rajkot) 1 month to 85 years 1.5: 1 The findings also underscore the persistent burden of anaemia in the Indian subcontinent, often compounded by nutritional deficiencies, chronic infections, and underlying haematological conditions. Importantly, a substantial proportion of cases initially suspected to be iron deficiency or chronic disease anaemia revealed alternative diagnoses such as megaloblastic changes, aplastic features, or even early marrow infiltration, emphasizing the indispensable role of marrow aspiration in differential diagnosis when routine investigations are inconclusive. Similarly, marrow infiltrations observed in haematological malignancies such as acute leukaemia and lymphomas reinforce the utility of aspiration not only as a diagnostic modality but also as a means for disease classification and prognostication. Sometimes bone marrow aspiration may initially suggest limited diagnostic value, but normal findings are equally important—they exclude marrow pathology as a cause of the presenting symptoms and direct clinicians to consider alternative diagnoses or sites of disease. Such results support the use of bone marrow aspiration as a rule-out investigation in complex clinical scenarios. The diagnostic yield in this study was high, demonstrating that a significant proportion of marrow examinations provided actionable insights that influenced clinical decision-making. The data suggest that marrow aspiration, when guided by appropriate clinical and laboratory indicators, remains a highly valuable procedure in tertiary care practice.

In conclusion, bone marrow aspiration examination proved to be a highly relevant diagnostic tool, particularly for anaemias, haematological malignancies, and infiltrative disorders. Its integration with clinical evaluation and ancillary investigations enhanced diagnostic clarity and informed therapeutic strategies.However, bone marrow sample cannot be obtained (dry tap) in a proportion of cases. In such cases, a bone marrow biopsy needs to be performed. Given the persistence of both nutritional and complex haematological disorders in the Indian context, marrow aspiration should continue to be prioritized where indicated, with efforts to standardize indications and maximize diagnostic yield through clinician–pathologist collaboration.

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