Haematology Watch, Vol 2, Issue 2.
USING GUIDELINES
Bone Marrow Trephine Biopsy Reporting
Dr. Mehmood-ul-Hasan
Every aspect of science and its education and practice is being standardized now a days. In the field of haematology, it is highly important to standardize reporting of different procedures so that nothing to be reported is missed, everything which is mentioned is understandable over the globe, and all the patients get similar health care where ever they are.
Guidelines are available to report Bone marrow trephine biopsy findings, as given by International Council for Standardization in Haematology (ICSH) based on preferred best practices. [Refer. A review article published in International Journal of Laboratory Haematology 2008: ICSH guidelines for the standardization of bone marrow specimens and reports]. It is important to quote here a few paragraphs from the guidelines:
"The final interpretation requires the integration of peripheral blood, bone marrow aspirate, and trephine bopsy findings, together with the results of supplementary tests such as immunophenotyping, cytogenetic analysis and molecular genetic studies as appropriate, in the context of clinical and other diagnostic findings."
"The conclusion should summarize the findings and diagnosis or differential diagnosis, with reference to international concensus guidelines (Jaffe et al., 2001) where applicable. An appropriate disease code may be entered as required by national regulatory guidelines. The trephine biopsy report should be correlated with the aspirate findings, and any discrepancies accounted for. The findings should be compared to previous results in the same patient when relevant. Any further investigations that are pending should be mentioned and results may be appended in a Supplementary Report at a later date. The report should be signed manually or electronically and dated."
Following is a modified form of the reporting of bone marrow trephine biopsy. I hope that this will be useful for the students of Haematology. As it is "born" from a guideline, there is space for further changes as required keeping in view the essence of the job.