bone marrow aspiration and biopsy

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Bone Marrow Aspiration and Biopsy

Definition

Bone marrow aspiration, also called bone marrow sampling, is the removal by suction of fluid from the soft, spongy material that lines the inside of most bones. Bone marrow biopsy, or needle biopsy, is the removal of a small piece of bone marrow.

Purpose

Bone marrow aspiration is used to:

pinpoint the cause of abnormal blood test results
confirm a diagnosis or check the status of severe anemia (abnormally low numbers of red blood cells in the bloodstream) of unknown cause, or other irregularities in the way blood cells are produced or become mature.
evaluate abnormalities in the blood's ability to store iron.
diagnose infection

In a bone marrow aspiration, a needle is inserted beneath the skin and rotated until it penetrates the cortex, or outer covering of the bone. A small amount of marrow is suctioned out of the bone by a syringe attached to the needle.

(Illustration by Electronic Illustrators Group.)

Bone marrow biopsy is used to:

obtain intact bone marrow for laboratory analysis
diagnose and stage some types of cancer or anemia and other blood disorders
identify the source of an unexplained fever
diagnose fibrosis of bone marrow or myeloma (a tumor composed of cells normally found in the bone marrow) when bone marrow aspiration has failed to provide an appropriate specimen

Bone marrow aspiration and bone marrow biopsy are also used to gauge the effectiveness of chemotherapy and other medical treatments. These procedures are often used together to ensure the availability of the best possible bone marrow specimen.

Key terms

Aspiration — A procedure to withdraw fluid from the body.

Connective tissue — Material that links one part of the body with another.

Fibrosis — A condition characterized by the presence of scar tissue or fiber-containing tissues that replace normal tissues.

Hematologist — A medical specialist who treats diseases and disorders of the blood and blood-forming organs.

Hematoma — Blood that collects under the skin and causes swelling.

Hemorrhage — Heavy bleeding.

Myeloma — A tumor that originates in bone marrow and usually spreads to more than one bone.

Nurse practitioner — A registered nurse who is qualified to perform some specialized duties.

Precautions

Allergies or previous adverse reactions to medications should be discussed with the doctor. Any current medications, including herbal or nutritional supplements, should be evaluated for the potential to interfere with proper coagulation (clot formation). These would include coumadin, aspirin, and other agents used as blood thinners. Caution should be used when the herbs gingko, ginger, garlic, br ginseng have been utilized as supplements, due to a risk of bleeding.

Pregnancy, lactation (production and secretion of milk), and preexisting platelet or bleeding disorders should be evaluated before either procedure is undertaken.

Description

Bone marrow aspiration and biopsy should be performed by a physician or nurse clinician. Each procedure takes about 20 to 30 minutes and is usually performed on an outpatient basis, but can be done in a hospital if necessary.

The skin covering the biopsy site is cleansed with an antiseptic, and the patient may be given a mild sedative. A local anesthetic is administered. The hematologist or nurse clinician performing the procedure will not begin until the anesthetic has numbed the area from which the specimen is to be extracted. In both adults and children, aspiration and biopsy are most commonly performed on the rear bone of the hip (posterior iliac crest). In adults, sampling from the sternum (breastbone) is sometimes done. The latter location is technically easier, but is somewhat more painful for the patient and presents the risk of heart injury. On rare occasions, a long bone of the leg (tibia) may be used as a sample site for an infant.

In a bone marrow aspiration, a special needle is inserted beneath the skin and rotated until it penetrates the cortex, or outer covering of the bone. At least half a teaspoon of marrow is withdrawn from the bone by a syringe attached to the needle. The patient may experience discomfort when the needle is inserted or when the marrow is aspirated. If more marrow is needed, the needle is repositioned slightly, a new syringe is attached, and a second sample is taken. The samples are transferred from the syringes to slides and vials, then sent to a laboratory for analysis.

Bone marrow biopsy may be performed immediately before or after bone marrow aspiration. The procedure utilizes a special large-bore needle that is used to drill out a core of marrow. In bone marrow biopsy, the needle is inserted, rotated from side to side, withdrawn, and reinserted at a different angle. This procedure is repeated if needed until a small core, about 0.4 inches (1 cm) long, is separated from the bone marrow. The needle is again removed, and a piece of fine wire threaded through its tip transfers the specimen onto sterile gauze. The patient may feel discomfort or pressure when the needle is inserted and experience a brief, pulling sensation when the marrow is withdrawn. Unlike aspiration specimens, which are smeared, these samples contain structurally intact bone marrow. Microscopic examination can show what material its cells contain and how they are alike or different from one another. The bone may either be embedded intact in paraffin (a type of wax), or be decalcified (a process which takes place overnight) for a different type of staining and examination. Each type of preparation has certain advantages.

Preparation

A current history and physical are obtained from the patient, along with proper consent. The patient is generally placed in a prone position (lying face down) for preparation, and local anesthetic, with or without sedation, is administered.

Aftercare

After the needle is removed, the biopsy site will be covered with a clean, dry bandage. Pressure is applied to control bleeding. The patient's pulse, breathing, blood pressure, and temperature are monitored until they return to normal, and the patient may be instructed to remain in a supine position (lying face up) for half an hour before getting dressed.

The patient should be able to leave the clinic and resume normal activities immediately. Patients who have received a sedative often feel sleepy for the rest of the day; driving, cooking, and other activities that require clear thinking and quick reactions should therefore be avoided.

The biopsy site should be kept covered and dry for several hours. Walking or taking prescribed pain medications usually ease any discomfort felt at the biopsy site, and ice can be used to reduce swelling.

A doctor should be notified if the patient:

feels severe pain more than 24 hours after the procedure.
experiences persistent bleeding or notices more than a few drops of blood on the wound dressing.
has a temperature above 101 °F (38.3 °C). Inflammation and pus at the biopsy site and other signs of infection should also be reported to a doctor without delay.

Risks

Bleeding and discomfort often occur at the biopsy site. Infection and hematoma may also develop. In rare instances, the heart or a major blood vessel is pierced when marrow is extracted from the sternum during bone marrow biopsy. This can lead to severe hemorrhage.

Normal results

Healthy adult bone marrow contains yellow fat cells, connective tissue, and red marrow that produces blood. The bone marrow of a healthy infant is primarily red due to active production of red cells necessary for growth.

Abnormal results

Culture of bone marrow aspirate may yield information about an infectious agent. Microscopic examination of bone marrow can reveal granulomas, myelofibrosis, lymphomas, leukemias, or other cancers. Analyzing specimens can help doctors diagnose iron deficiency, vitamin B12 deficiency, and folate deficiency, as well as anemia.

Obesity can affect the ease with which a bone marrow biopsy can be done, and the results of either procedure can be affected if the patient has had radiation therapy at the biopsy site.

bone marrow aspiration and biopsy

A diagnostic procedure in which tissue is obtained from bone marrow to diagnose haematologic disorders or assess efficacy of therapy.

Indications
Chronic anaemia, leukopeania, thrombocytopeania, aplastic anaemia, leukaemias and lymphomas, polycythemia vera, myelodysplastic syndromes, myeloma.

Adverse effect
Intense (“gnawing”) bone pain.

bone marrow aspiration and biopsy

The removal of a small amount of tissue (bone marrow biopsy) and fluid filled with blood cells (bone marrow aspiration) from the central core of a bone. The aspiration and biopsy are used to diagnose blood disorders such as anemias and cancers, infectious diseases that affect the marrow, or to gather cells for later infusion into a patient (e.g., in bone marrow transplantation).

Patient care

The purpose of the test is explained to the patient (and family as necessary). The patient is advised that some discomfort or pressure may be felt, e.g., a crunching or popping sound may be heard as the needle penetrates the bone. A signed, informed consent must be obtained before the procedure. The patient’s history is reviewed, including risk for bleeding, coagulation studies, platelet count, anticoagulant therapy, and use of drugs or supplements that interfere with clotting. The patient is also assessed for allergies to antiseptic or anesthetic solutions. The patient is advised that he or she must remain still throughout the procedure, and the ability to do so is assessed. Baseline signs are recorded, and a sedative is administered as prescribed. The patient is assisted to the appropriate position for the insertion site: the lateral decubitus position for the posterior iliac crest and the supine position for the sternum or anterior iliac crest. The health care provider helps the patient maintain the desired position. The patient is encouraged to take deep breaths and use relaxation techniques during the procedure.

A sterile prepackaged set is used for the aspiration, and the practitioner is assisted as necessary. The patient is assessed throughout the procedure for pallor, diaphoresis, or other changes. After the aspiration, direct pressure is applied to the puncture site for 5 to 10 minutes or according to agency policy until bleeding is controlled; the wound is then covered with a sterile dressing. The patient is helped into a comfortable position, and vital signs are checked. The puncture site is reassessed as necessary for bleeding. All specimens are labeled and transported to the laboratory. Postprocedure pain intensity is evaluated, and analgesia is provided as prescribed. The patient is advised to watch for and report any signs of infection and is warned to avoid any drugs containing acetylsalicylic acid (aspirin), which may cause bleeding.

Specimens of marrow and aspirate are sent to the cytology or pathology laboratory for microscopic analysis, to the microbiology laboratory if cultures are needed, and/or to the clinical laboratory for chromosomal analysis or staining. A biopsy or aspirate that does not yield adequate material for analysis is known colloquially as a “dry tap.”