骨髓活检与骨髓涂片同步应用对儿童血液病诊断价值探讨

发布时间：2018-06-13 03:34

本文选题：骨髓活检 + 骨髓涂片　；参考：《青岛大学》2017年硕士论文

【摘要】：目的比较骨髓活检与骨髓涂片同步检查在儿童血液病诊断中的价值,以提高儿童血液病诊断正确率及减少误诊率。方法采用同步双标本法获取骨髓涂片及活检切片标本的方法,对青岛大学附属医院血液儿科自2014年2月-2016年9月门诊及住院资料完整的89例血液病患儿行骨髓涂片细胞形态学与骨髓活检病理检查,比较骨髓涂片和骨髓活检在判断骨髓增生程度、诊断符合率等方面的差异。结果1、骨髓涂片和骨髓活检对血液病患儿骨髓增生程度的比较:(1)42例再生障碍性贫血(AA)患儿,骨髓涂片显示增生减低占69%(29/42例),骨髓活检为90.5%(40/42例),骨髓活检明显高于骨髓涂片(x2=9.82;P0.05)。(2)14恶性血液系统疾病初诊患儿,骨髓涂片显示增生活跃+极度活跃占85.7%(12/14例),增生减低14.3%(2/14例);骨髓活检增生活跃+极度活跃为92.9%(13/14例),增生减低7.1%(1/14例),骨髓涂片与活检比较无统计学差异(x2=1.20;P=0.48)。(3)15例维持治疗期间中性粒细胞恢复延迟急性淋巴细胞白血病(ALL)患儿,骨髓涂片显示增生活跃+极度活跃占66.7%(10/15例),增生减低33.3%(5/15例);骨髓活检显示增生活跃+极度活跃占93.3%(14/15例),增生减低6.7%(1/15例),骨髓涂片与活检比较无统计学差异(x2=3.33;P=0.70)。(4)18例免疫性血小板减少症(ITP)患儿,骨髓涂片显示增生活跃+明显活跃占94.4%(17/18例),增生减低5.6%(1/18例);骨髓活检增生活跃+明显活跃占77.8%(14/18例),增生减低22.2(4/18例),骨髓涂片与活检比较无统计学差异(x2=2.09;P=0.03)。2、骨髓涂片和骨髓活检对儿童血液病临床诊断符合率比较:(1)AA患儿诊断符合率:1).42例初诊AA患儿骨髓涂片与临床诊断符合率61.9%,(26/42例),骨髓活检诊断符合率83.3%(35/42例),骨髓活检诊断符合率显著高于骨髓涂片(x2=4.85;P0.05);二者相结合诊断41例(41/42例),诊断符合率为97.6%,高于单一一项检查诊断率(x2分别为16.59和4.97;P均0.05)。2).42例AA患儿中18例不典型AA(血象中一系减少)骨髓涂片诊断符合率44.4%(8/18例),活检符合率88.9%(16/18例),活检明显高于涂片(x2=8.00;P0.05)。二者结合诊断符合率为100%(18/18例),明显高于骨髓涂片(x2=13.85;P=0),而与骨髓活检比较无统计学差异(x2=2.12;P=0.49)3).42例AA患儿治疗后20例再次行骨髓活检与骨髓涂片同步检查,其中血象完全正常患儿12例,骨髓涂片与临床表现相符率为41.7%(5/12例),骨髓活检组为91.7%(11/12例),骨髓活检明显高于涂片(X2=6.75;P0.05)。8例治疗后加重时同步评估,骨髓涂片与临床表现相符率37.5%(3/8例),骨髓活检组为100%(8/8例),骨髓活检明显高于涂片((X2=7.27;P0.05)。(2)恶性血液系统疾病诊断符合率:14例恶性血液系统疾病患儿骨髓涂片与临床诊断符合率42.9%(6/14例),骨髓活检为85.7%(12/14例),骨髓活检诊断率明显高于骨髓涂片(X2=5.60;P0.05);二者相结合诊断率100%(14/14例),高于单一一项检查诊断率(X2分别为19.07和X2=6.19;P均0.05)。(3)15例维持治疗期间中性粒细胞恢复延迟ALL患儿复发诊断率:临床复发前行骨髓涂片与骨髓活检同步检查,骨髓穿刺涂片显示早期复发2例,骨髓涂片与临床复发符合率13.3%(2/15例);骨髓活检显示早期复发8例,符合率53.3%(8/15例),骨髓活检与临床符合率明显高于骨髓涂片(X2=5.40;P0.05);两者相结合14例提示早期复发,符合率93.3%(14/15例),明显高于单一检测(X2分别为19.28和6.13;P均0.05)。(4)免疫性血小板减症患儿诊断符合率:18例ITP患儿骨髓涂片临床诊断符合率77.8%(14/18例)),骨髓活检为44.4%(8/18例),骨髓活检诊断率明显低于骨髓涂片(X2=6.41;P0.05);二者结合诊断17例,诊断率94.4%(17/18例),明显高于单一一项检查诊断符合率(X2=8.86和25.07;P均0.05)。3.骨髓涂片和骨髓活检在儿童血液病细胞学改变:(1)AA患儿骨髓涂片与活检细胞学改变:42例AA患儿骨髓涂片显示37例淋巴细胞比例增高,36例非造血细胞团易见,28例巨核细胞减少或缺如;骨髓活检40例淋巴细胞比例增高,40例巨核细胞减少或缺如。(2)初诊恶性血液系统疾病患儿骨髓涂片和骨髓活检细胞学改变:5例淋巴瘤患儿骨髓涂片和骨髓活检均未见异常。3例慢性粒细胞性白血病(CML)患儿涂片及活检原始幼稚细胞均低于5%,各系比例及分化正常;骨髓活检3例原始幼稚细胞均低于5%,2例网状纤维(++),1例网状纤维(+)。6例MDS患儿骨髓涂片5例出现病态造血,见超巨多分叶嗜酸性粒细胞畸变、巨大多核红细胞及单圆柱巨核细胞等形态改变。骨髓活检6例均出现病态造血,其中2例见幼稚前体细胞异常定位(ALIP)现象;3例原始幼稚细胞低于20%但大于5%,3例低于5%;免疫组化3例CD34+,CD117+;3例CD61圆核巨核细胞;1例CD34+;6例均有不同程度网状纤维阳性。(3)维持治疗期中性粒细胞恢复延迟ALL患儿骨髓涂片和骨髓活检细胞学改变:15例患儿骨髓涂片示2例原始幼稚细胞比例大于25%,核染色弥散,核仁多个,13例小于5%,核染较致密;15例有11例粒系受抑明显,6例红系受抑,4例巨核系受抑。15例患儿骨髓活检示有8例见中等大小的淋巴母细胞弥散性增生,8例免疫组化CD34(+)TDT(+);15例患儿14例粒系受抑明显,8例红系受抑,6例巨核系受抑;(4)ITP患儿骨髓涂片和骨髓活检细胞学观察:骨髓涂片18例ITP患儿6例巨核细胞数量正常,12例增多;18例中14例巨核细胞成熟障碍,产板型巨核细胞减少;18例中14例血小板散在,形态正常,2例见巨大型血小板。骨髓活检18例中8例巨核细胞数量增多,10例正常;18例中有8例巨核细胞成熟障碍。结论1、骨髓涂片的细胞形态学检查和骨髓活检切片病理检查在不同疾病中各有优势,前者以观察细胞形态变化为优势,而后者对观察组织结构及判断增生程度更佳。2、ALL患儿在维持治疗期持续性白细胞减少,在做骨髓涂片同时需要行骨髓活检以提高早期复发诊断率3、骨髓涂片与活检结合有助于继发性血小板减少症的诊断,减少ITP误诊率。4、骨髓涂片与骨髓活检二者结合可以显著提高儿童血液病的诊断率、减少误诊漏诊率,在血液儿科临床诊断中有重要意义。
[Abstract]:Objective to compare the value of simultaneous examination of bone marrow biopsy and bone marrow smear in the diagnosis of hematological diseases in children, in order to improve the accuracy of diagnosis and reduce the rate of misdiagnosis in children. Methods the methods of obtaining bone marrow smears and biopsy specimens by synchronous double standard method were used. The clinic of pediatric department of Hematology, affiliated medical hospital of Qiingdao University, was in the outpatient department of February 2014 and September. 89 children with complete hospital data were examined by bone marrow smear cell morphology and bone marrow biopsy, compared with bone marrow smear and bone marrow biopsy in determining the degree of myelodysplasia and diagnostic coincidence. Results 1, bone marrow smears and bone marrow biopsy were compared in the degree of myelodysplasia in children with hematopathy: (1) 42 cases of aplastic disorder In children with anemia (AA), bone marrow smears showed 69% (29/42), bone marrow biopsy was 90.5% (40/42), bone marrow biopsy was significantly higher than bone marrow smear (x2=9.82; P0.05). (2) 14 malignant hematological diseases were diagnosed in newly diagnosed children, bone marrow smears showed hyperplasia active + polar activity 85.7% (12/14 cases), 14.3% (2/14 cases), bone marrow biopsy, and bone marrow biopsy increased life. The leaping + hyperactivity was 92.9% (13/14 cases) and the proliferation decreased by 7.1% (1/14 cases). There was no statistical difference between bone marrow smear and biopsy (x2=1.20; P=0.48). (3) 15 cases of neutrophils recovery delayed acute lymphoblastic leukemia (ALL) in 15 cases, bone marrow smears showed hyperplasia active + hyperactivity 66.7% (10/15 cases) and 33.3% (5/15). Bone marrow biopsy showed 93.3% (14/15 cases) with hyperactivity + hyperactivity (14/15 cases), 6.7% (1/15), no statistical difference between bone marrow smear and biopsy (x2=3.33; P=0.70). (4) 18 cases of immune thrombocytopenia (ITP) children, bone marrow smears showed that the increase of life jump + obviously active 94.4% (17/18 cases), hyperplasia 5.6% (1/18 cases); bone marrow live 77.8% (14/18 cases), 22.2 (4/18), no statistical difference between bone marrow smear and biopsy (x2=2.09; P=0.03).2, bone marrow smear and bone marrow biopsy were compared in the clinical diagnosis of children's hematological diseases: (1) the diagnostic coincidence rate of children with AA: 1) the coincidence rate of bone marrow smear and clinical diagnosis of AA children with primary AA was 61.9 % (26/42), bone marrow biopsy diagnostic coincidence rate was 83.3% (35/42), bone marrow biopsy was significantly higher than bone marrow smear (x2=4.85; P0.05); two combined diagnosis of 41 cases (41/42 cases), diagnostic coincidence rate was 97.6%, higher than single one examination diagnosis rate (x2 division 16.59 and 4.97; P 0.05).2).42 case of 18 cases of untypical AA (hemogram) The diagnostic coincidence rate of bone marrow smear was 44.4% (8/18 cases), the coincidence rate of biopsy was 88.9% (16/18 case), the biopsy was significantly higher than that of smear (x2=8.00; P0.05). The diagnostic coincidence rate of the two cases was 100% (18/18 cases), obviously higher than that of bone marrow smear (x2=13.85; P=0), but there was no statistical difference between the bone marrow biopsy (x2=2.12; P=0.49) 3), 20 cases of.42 AA children after treatment. Simultaneous examination of bone marrow biopsy and bone marrow smear, of which 12 cases were completely normal, 41.7% (5/12), 91.7% (11/12), bone marrow biopsy group, 91.7% (11/12), bone marrow biopsy was significantly higher than smear (X2=6.75; P0.05).8 cases with aggravation, synchronous evaluation, the coincidence rate of bone marrow smear and clinical manifestation was 37.5% (3/8 The bone marrow biopsy group was 100% (8/8 cases), bone marrow biopsy was significantly higher than that of smear (X2=7.27; P0.05). (2) the diagnostic coincidence rate of malignant blood system disease: 14 cases of malignant hematological diseases, bone marrow smear and clinical diagnosis coincidence rate 42.9% (6/14 cases), bone marrow biopsy 85.7% (12/14 case), bone marrow biopsy was significantly higher than bone marrow smear (X2=5.60; P0). .05); two patients were combined with a diagnostic rate of 100% (14/14), higher than a single examination (X2 19.07 and X2=6.19, X2=6.19, P 0.05). (3) 15 cases of neutrophils recovery delayed ALL in the diagnosis rate of recurrence: bone marrow smear and bone marrow biopsy were performed before the recurrence of clinical recurrence, and 2 cases of early recurrence of bone marrow smear showed bone marrow. The coincidence rate of smear and clinical recurrence was 13.3% (2/15 cases); bone marrow biopsy showed 8 cases of early recurrence, 53.3% (8/15), bone marrow biopsy and clinical coincidence rate was significantly higher than bone marrow smear (X2=5.40; P0.05); both of them were combined with 14 cases of early recurrence, the coincidence rate was 93.3% (14/15), obviously higher than that of X2 (19.28 and 6.13 respectively, P 0.05 respectively). Diagnostic coincidence rate of children with immune thrombocytopenia: 18 cases of ITP children's bone marrow smear clinical diagnosis rate of 77.8% (14/18), bone marrow biopsy 44.4% (8/18 cases), bone marrow biopsy was significantly lower than bone marrow smear (X2=6.41; P0.05); two combined diagnosis of 17 cases, the diagnostic rate of 94.4% (17/18 cases), obviously higher than a single one examination diagnostic coincidence rate (X2 =8.86 and 25.07; P 0.05).3. bone marrow smear and bone marrow biopsy in children's hematological changes: (1) bone marrow smear and cytological changes in AA children: 42 cases of AA children's bone marrow smears showed that 37 cases of lymphocyte proportion increased, 36 cases of non hematopoietic cells were easy to see, 28 cases of megakaryocyte decreased or absent; bone marrow biopsy 40 cases of lymphocyte ratio increased High, 40 cases of megakaryocyte decreased or absent. (2) bone marrow smears and bone marrow biopsy cytology changes in children with primary malignant hematological diseases: 5 cases of children with lymphoma, bone marrow smear and bone marrow biopsy, had no abnormal.3 cases of chronic granulocytic leukemia (CML), the smear and biopsy original infantile cells were lower than 5%, the proportion of the various lines and normal differentiation; Medullary biopsy 3 cases of primitive naive cells were lower than 5%, 2 cases of reticular fiber (+ +), 1 cases of reticular fiber (+).6 cases of MDS bone marrow smears in 5 cases of abnormal hematopoiesis, super megakarylobular eosinophil aberration, giant multinucleated erythrocytes and monocytic megakaryocyte, 6 cases of bone marrow biopsy showed pathological hematopoiesis, 2 cases were naive precursors Abnormal cell location (ALIP), 3 cases of primitive naive cells were lower than 20% but more than 5%, 3 cases were lower than 5%, 3 cases of immunohistochemistry, CD117+, 3 cases of CD61 rounded nucleus megakaryocytes, 1 cases of CD34+, 6 cases with different degree reticular fiber positive. (3) maintenance of neutrophils delayed ALL in children with delayed ALL bone marrow smear and bone marrow biopsy cytological changes: 15 cases Bone marrow smears showed that the proportion of 2 cases of primitive naive cells was more than 25%, nuclear dye diffusion, nucleolus multiple, 13 cases less than 5%, and nuclear dye more compact, 15 cases with 11 cases of myeloid inhibition, 6 cases of red system inhibition, and 4 cases of megakaryocytic.15 children's bone marrow biopsy showed that 8 cases of moderate size lymphoblastic hyperplasia, 8 cases of immunohistochemical CD34 (+) TDT (+); 15. 14 cases of children were suppressed in 14 cases, 8 cases of red and 6 megakaryocytes were suppressed. (4) bone marrow smear and bone marrow biopsy cytology of children with ITP: 6 cases of megakaryocyte in 18 cases of ITP, 12 cases, 14 cases of megakaryocyte maturation, plate type megakaryocytes in 18 cases, and 18 cases of platelet scattered, normal form in 18 cases. There were 2 cases of giant platelets. 8 cases of megakaryocytes were increased in 18 cases, 10 cases were normal, 8 cases of megakaryocyte maturation disorder in 18 cases. Conclusion 1, the morphological examination of bone marrow smear and pathological examination of bone marrow biopsy section have advantages in different diseases. The former is superior to observation of cell morphological changes, and the latter is observed in the latter. The tissue structure and the judgment of the degree of hyperplasia were better.2, children with ALL in the maintenance period of continuous leukocyte reduction, bone marrow smear and bone marrow biopsy were required to improve the early diagnosis rate of 3. The combination of bone marrow smear and biopsy helped the diagnosis of secondary thrombocytopenia, reduced the misdiagnosis rate of ITP.4, bone marrow smear and bone marrow biopsy. The combination can significantly improve the diagnostic rate of children's hematological diseases, reduce the rate of misdiagnosis and missed diagnosis, and is of great significance in the clinical diagnosis of pediatric hematology.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R725.5

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