本文選題：骨髓活檢 + 骨髓涂片�。� 參考：《青島大學(xué)》2017年碩士論文

【摘要】：目的比較骨髓活檢與骨髓涂片同步檢查在兒童血液病診斷中的價值,以提高兒童血液病診斷正確率及減少誤診率。方法采用同步雙標(biāo)本法獲取骨髓涂片及活檢切片標(biāo)本的方法,對青島大學(xué)附屬醫(yī)院血液兒科自2014年2月-2016年9月門診及住院資料完整的89例血液病患兒行骨髓涂片細(xì)胞形態(tài)學(xué)與骨髓活檢病理檢查,比較骨髓涂片和骨髓活檢在判斷骨髓增生程度、診斷符合率等方面的差異。結(jié)果1、骨髓涂片和骨髓活檢對血液病患兒骨髓增生程度的比較:(1)42例再生障礙性貧血(AA)患兒,骨髓涂片顯示增生減低占69%(29/42例),骨髓活檢為90.5%(40/42例),骨髓活檢明顯高于骨髓涂片(x2=9.82;P0.05)。(2)14惡性血液系統(tǒng)疾病初診患兒,骨髓涂片顯示增生活躍+極度活躍占85.7%(12/14例),增生減低14.3%(2/14例);骨髓活檢增生活躍+極度活躍為92.9%(13/14例),增生減低7.1%(1/14例),骨髓涂片與活檢比較無統(tǒng)計學(xué)差異(x2=1.20;P=0.48)。(3)15例維持治療期間中性粒細(xì)胞恢復(fù)延遲急性淋巴細(xì)胞白血病(ALL)患兒,骨髓涂片顯示增生活躍+極度活躍占66.7%(10/15例),增生減低33.3%(5/15例);骨髓活檢顯示增生活躍+極度活躍占93.3%(14/15例),增生減低6.7%(1/15例),骨髓涂片與活檢比較無統(tǒng)計學(xué)差異(x2=3.33;P=0.70)。(4)18例免疫性血小板減少癥(ITP)患兒,骨髓涂片顯示增生活躍+明顯活躍占94.4%(17/18例),增生減低5.6%(1/18例);骨髓活檢增生活躍+明顯活躍占77.8%(14/18例),增生減低22.2(4/18例),骨髓涂片與活檢比較無統(tǒng)計學(xué)差異(x2=2.09;P=0.03)。2、骨髓涂片和骨髓活檢對兒童血液病臨床診斷符合率比較:(1)AA患兒診斷符合率:1).42例初診AA患兒骨髓涂片與臨床診斷符合率61.9%,(26/42例),骨髓活檢診斷符合率83.3%(35/42例),骨髓活檢診斷符合率顯著高于骨髓涂片(x2=4.85;P0.05);二者相結(jié)合診斷41例(41/42例),診斷符合率為97.6%,高于單一一項檢查診斷率(x2分別為16.59和4.97;P均0.05)。2).42例AA患兒中18例不典型AA(血象中一系減少)骨髓涂片診斷符合率44.4%(8/18例),活檢符合率88.9%(16/18例),活檢明顯高于涂片(x2=8.00;P0.05)。二者結(jié)合診斷符合率為100%(18/18例),明顯高于骨髓涂片(x2=13.85;P=0),而與骨髓活檢比較無統(tǒng)計學(xué)差異(x2=2.12;P=0.49)3).42例AA患兒治療后20例再次行骨髓活檢與骨髓涂片同步檢查,其中血象完全正�；純�12例,骨髓涂片與臨床表現(xiàn)相符率為41.7%(5/12例),骨髓活檢組為91.7%(11/12例),骨髓活檢明顯高于涂片(X2=6.75;P0.05)。8例治療后加重時同步評估,骨髓涂片與臨床表現(xiàn)相符率37.5%(3/8例),骨髓活檢組為100%(8/8例),骨髓活檢明顯高于涂片((X2=7.27;P0.05)。(2)惡性血液系統(tǒng)疾病診斷符合率:14例惡性血液系統(tǒng)疾病患兒骨髓涂片與臨床診斷符合率42.9%(6/14例),骨髓活檢為85.7%(12/14例),骨髓活檢診斷率明顯高于骨髓涂片(X2=5.60;P0.05);二者相結(jié)合診斷率100%(14/14例),高于單一一項檢查診斷率(X2分別為19.07和X2=6.19;P均0.05)。(3)15例維持治療期間中性粒細(xì)胞恢復(fù)延遲ALL患兒復(fù)發(fā)診斷率:臨床復(fù)發(fā)前行骨髓涂片與骨髓活檢同步檢查,骨髓穿刺涂片顯示早期復(fù)發(fā)2例,骨髓涂片與臨床復(fù)發(fā)符合率13.3%(2/15例);骨髓活檢顯示早期復(fù)發(fā)8例,符合率53.3%(8/15例),骨髓活檢與臨床符合率明顯高于骨髓涂片(X2=5.40;P0.05);兩者相結(jié)合14例提示早期復(fù)發(fā),符合率93.3%(14/15例),明顯高于單一檢測(X2分別為19.28和6.13;P均0.05)。(4)免疫性血小板減癥患兒診斷符合率:18例ITP患兒骨髓涂片臨床診斷符合率77.8%(14/18例)),骨髓活檢為44.4%(8/18例),骨髓活檢診斷率明顯低于骨髓涂片(X2=6.41;P0.05);二者結(jié)合診斷17例,診斷率94.4%(17/18例),明顯高于單一一項檢查診斷符合率(X2=8.86和25.07;P均0.05)。3.骨髓涂片和骨髓活檢在兒童血液病細(xì)胞學(xué)改變:(1)AA患兒骨髓涂片與活檢細(xì)胞學(xué)改變:42例AA患兒骨髓涂片顯示37例淋巴細(xì)胞比例增高,36例非造血細(xì)胞團(tuán)易見,28例巨核細(xì)胞減少或缺如;骨髓活檢40例淋巴細(xì)胞比例增高,40例巨核細(xì)胞減少或缺如。(2)初診惡性血液系統(tǒng)疾病患兒骨髓涂片和骨髓活檢細(xì)胞學(xué)改變:5例淋巴瘤患兒骨髓涂片和骨髓活檢均未見異常。3例慢性粒細(xì)胞性白血病(CML)患兒涂片及活檢原始幼稚細(xì)胞均低于5%,各系比例及分化正常;骨髓活檢3例原始幼稚細(xì)胞均低于5%,2例網(wǎng)狀纖維(++),1例網(wǎng)狀纖維(+)。6例MDS患兒骨髓涂片5例出現(xiàn)病態(tài)造血,見超巨多分葉嗜酸性粒細(xì)胞畸變、巨大多核紅細(xì)胞及單圓柱巨核細(xì)胞等形態(tài)改變。骨髓活檢6例均出現(xiàn)病態(tài)造血,其中2例見幼稚前體細(xì)胞異常定位(ALIP)現(xiàn)象;3例原始幼稚細(xì)胞低于20%但大于5%,3例低于5%;免疫組化3例CD34+,CD117+;3例CD61圓核巨核細(xì)胞;1例CD34+;6例均有不同程度網(wǎng)狀纖維陽性。(3)維持治療期中性粒細(xì)胞恢復(fù)延遲ALL患兒骨髓涂片和骨髓活檢細(xì)胞學(xué)改變:15例患兒骨髓涂片示2例原始幼稚細(xì)胞比例大于25%,核染色彌散,核仁多個,13例小于5%,核染較致密;15例有11例粒系受抑明顯,6例紅系受抑,4例巨核系受抑。15例患兒骨髓活檢示有8例見中等大小的淋巴母細(xì)胞彌散性增生,8例免疫組化CD34(+)TDT(+);15例患兒14例粒系受抑明顯,8例紅系受抑,6例巨核系受抑;(4)ITP患兒骨髓涂片和骨髓活檢細(xì)胞學(xué)觀察:骨髓涂片18例ITP患兒6例巨核細(xì)胞數(shù)量正常,12例增多;18例中14例巨核細(xì)胞成熟障礙,產(chǎn)板型巨核細(xì)胞減少;18例中14例血小板散在,形態(tài)正常,2例見巨大型血小板。骨髓活檢18例中8例巨核細(xì)胞數(shù)量增多,10例正常;18例中有8例巨核細(xì)胞成熟障礙。結(jié)論1、骨髓涂片的細(xì)胞形態(tài)學(xué)檢查和骨髓活檢切片病理檢查在不同疾病中各有優(yōu)勢,前者以觀察細(xì)胞形態(tài)變化為優(yōu)勢,而后者對觀察組織結(jié)構(gòu)及判斷增生程度更佳。2、ALL患兒在維持治療期持續(xù)性白細(xì)胞減少,在做骨髓涂片同時需要行骨髓活檢以提高早期復(fù)發(fā)診斷率3、骨髓涂片與活檢結(jié)合有助于繼發(fā)性血小板減少癥的診斷,減少ITP誤診率。4、骨髓涂片與骨髓活檢二者結(jié)合可以顯著提高兒童血液病的診斷率、減少誤診漏診率,在血液兒科臨床診斷中有重要意義。
[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.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R725.5

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