Global guidance updates bone marrow practice

Article published by the Limbic - read full publication here.

Professor Wendy Erber

An expanded range of indications for bone marrow examination, the need for closer monitoring of response to treatment particularly in haematological cancers, and the increased number of investigations ancillary to cytology, provide the context for new International Council for Standardisation in Haematology (ICSH) Guidance on Bone Marrow Examination and Reporting.

The guidance, published in the International Journal of Laboratory Haematology, updates and extends 2008 guidelines on standardisation of bone marrow specimens and reports.

While it has been “a long time between drinks”, the revision provides a contemporary resource that is fit for purpose, clinically useful and relevant, according to Professor Wendy Erber, lead author of the guidance and past chair of the ICSH.

“We had to take note of different ways of doing things in different countries… plus acknowledging that there are other countries that were not represented, and we had to be sure that what we wrote would be practical for them,” she said.

“In effect we’re saying this is what we recommend you should or could do, depending on the resources available. Everyone was very committed to the project, and we’re all very proud of what we’ve achieved.”

Professor Erber, from the University of Western Australia and PathWest Laboratory Medicine, told the limbic that each section of the guidance is summarised with key points representing high-level statements of intention without being unnecessarily specific and proscriptive.

Given the guidance has involved an international effort over about 18 months, she said she hoped it would be widely adopted by national bodies such as the Royal College of Pathologists Australasia.

“I would like to think that the College of Pathologists will take this as an important document, so that when it comes to examination of haematology trainees, they would want to know that the trainees are aware of this document and what it says about the indications, how to use a sample, the various tests performed, and how to provide an integrated report by putting all the data together which is part of what we think is best practice.”

Professor Erber said haematologists were no longer just looking down a microscope in 2026 but increasingly using ancillary investigations including flow cytometry, immunohistochemistry, cytogenetics and molecular testing.

“With modern treatments, we may decide that there’s a need to take a sample of bone marrow at additional time points or more often than we used to, because we’re really paying closer attention to how much residual disease remains after treatment.”

“The current document really makes a point of that, and that we should be collecting the appropriate specimens for the appropriate tests required for that particular patient – so really, a personalised approach to sampling and then the testing that is to be performed,” she said.

Professor Erber said the guidance also emphasised the complementary role of the bone marrow aspirate and trephine biopsy. “Same specimen, same patient, same site, but processed differently, and they can give slightly different pieces of information. We’ve put in a table to make that really clear, which I think is very important for trainees who don’t always get it as to why we take two samples.”

Professor Erber added that the guidance also highlighted the importance of a single, integrated report combining all relevant bone marrow investigations.

She said she was confident that most Australian practice was consistent with the guidance but that it was an important, detailed and practical resource.

The guidance deferred on including a comprehensive analysis of the state of play regarding digital tools incorporating machine learning and artificial intelligence.

“The ICSH is currently considering the AI aspects of morphology review, and in the upcoming ICSH General Assembly (14-15 October, Shanghai), there’s a whole session on AI with a view to forming a working group to come up with some guidance about AI in reporting of morphology in haematology, which would probably include both blood and bone marrow.”

Article published by the Limbic - read full publication here.