BONE MARROW BIOPSY/ ASPIRATION

PRESENTED BY DIBO SAMA

BScN INTERN

NOVEMBER, 2020.
 
 
OBJECTIVES
 
By the end of this presentation, the
students will be able to;
 
 Define Bone marrow Biopsy/Aspiration

 Identify indications of BMA/Biopsy

 Identify contraindication of BMA/Biopsy

 Preparation of the procedure

 Identify complications of BMA/Biopsy

 
 
INTRODUCTION
• Bone marrow is soft, gelatinous tissue
that fills the medullary cavities, the
centers of bones.
• The two types of bone marrow are red
bone marrow (myeloid tissue), and
yellow bone marrow (fatty tissue).
• Red marrow is mainly found in flat bones
such as your hip and vertebrae. 
• Bone marrow contains immature cells,
called stem cells which help produce
blood cell, fat, cartilage and bones.
 
BONE MARROW EXAMINATION
• Bone marrow examination refers to the pathologic
analysis of samples of bone marrow obtained by bone
marrow aspiration and bone marrow biopsy (often
called a trephine biopsy).
• Bone marrow tests are usually done for cancers that
are most likely to affect the bone marrow, such as:

lymphomas

leukaemia
• myeloma
TYPES OF BONE MARROW EXAM
 There are 2 main types of bone marrow
test: 

Bone marrow aspiration

Bone marrow trephine biopsy
 Bone marrow Aspiration is aspirate of
content of the bone marrow drawn
under pressure by puncturing marrow
cavity.

 Bone marrow biopsy (trephine) is

removal of small core of bone marrow
under local anaesthesia.
Both of these tests can be done at the
same time.
INDICATIONS OF BONE MARROW
ASPIRATION
• Red cell disorders
• Leucocytic disorders
• Megakaryocyte and platelet disorders
• Myeloproliferative disorders and
myelodysplastic syndrome with BMB
• Paraproteinemias
• Infection
• Storage disorders
• Iron assessment
• Metastasis
 
 
INDICATIONS OF BONE MARROW BIOPSY
 To accurately assess marrow cellularity.
 To diagnose
o
Aplastic anemia
o
Hypoplastic myelodysplastic
syndrome
o
Hypoplastic leukemia.
 
 Lymphoproliferative disorders
o
Hairy cell leukemia
o
CLL
 Myeloproliferative disorders
 Unexplained leukoerythroblastic picture.
In suspected cases of multiple
myeloma and serum paraproteins
 
Indications ct….
 Diagnosis and staging of
o
Non-Hodgkin’s lymphoma
o
Hodgkin’s lymphoma
o
Malignancy
o
Metastatic carcinoma
o
Small round cell tumors of childhood
 Stromal changes
o
Fibrosis
o
Necrosis
o
Gelatinous marrow transformation
 Pyrexia of unknown origin
 Focal lesions –Metastasis, Granuloma
 Amyloidosis
 Metabolic bone diseases
 
CONTRAINDICATIONS
 Sternal aspirate - Osteoporosis and
children
 Biopsy in coagulopathies (For aspiration
factor replacement therapy prior to
procedure and observation should be
done for next 24-48 hrs.)
COMPLICATIONS
 Hemorrhage (Risk factors-
coagulopathies, myeloproliferative
disorders, aspirin and warfarin therapy,
thrombocytopenia, DIC, liver disease and
disease)
 Pain
 Infection
 Perforation of major vessels
BONE MARROW ASPIRATE V/S BIOPSY

Aspiration biopsy and trephine biopsy are complementary

to each other.

Aspiration biopsy Trephine biopsy

Better cytological detail Topographical details,
cellularity and infiltration
More range Less range.
Ideal for cytogenetics and Ideal for both
molecular genetics
Dry tap in fibrosis Essential for diagnosis in
dry tap.
Can be performed alone in Helpful for aplastic
  iron deficiency anemia, hypoplastic anemia,
anemia of chronic disease, lymphoma, metastatic
megaloblastic anemia and carcinoma,
acute leukemia. myeloproliferative
neoplasms and diseases of
the bones.
Less painful More painful
SITE FOR BONE MARROW ASPIRATION
1. Posterior superior iliac spine- most
preferred.
2. Anterior superior iliac spine. (The iliac
spines have the advantage that if no
material is aspirated, a trephine biopsy can
be performed immediately.)
3. Sternum (about 1cm above the
sternomanubrial angle, to one side of
midline). Should be avoided in babies.
4. Medial aspect of tibia just below tibial
tubercle (small babies).
5. Spinous process of vertebrae
SITE FOR BONE MARROW BIOPSY
1. Posterior superior iliac spine- most
preferred.
2. Anterior superior iliac spine.

The posterior iliac spine is said to provide

samples that are longer and larger, and the
aspiration is less uncomfortable for the
patient.
 
 
BONE MARROW PUNCTURE NEEDLES
 Jamshidi needle
 Islam needle
 Salah needle
 Klima needle
If larger specimens are needed, trephine
needles that have bores of 4-5 mm may be
used.
Other needles occasionally used for
trephine biopsy specimens are a 2-mm bore
“microtrephine” needle and a Vim–
Silverman needle.
PROCEDURE
BEFORE

A written consent should be taken from
patient.

An appropriate clinical history should
accompany the bone marrow, as they
relate to possible findings within the
bone marrow examination.

Relevant laboratory data such as Iron
studies, Folate or Vitamin B-12 studies,
transfusion therapy, hematinic or history
of chemotherapy should be obtained.

The physician’s clinical impression
should be included on the form.

Lignocaine sensitivity test should be
done.
DURING

Either aspirate or biopsy may be
performed first.

But the two should be performed through
the same incision, approx. 0.5-1 cm away
from the other.

This is done to avoid clotting of aspirate
and hemorrhagic or damaged biopsy.

It is recommended that the aspirate and
biopsy be obtained using respective
needles separately, and not through a
trephine needle.

Skin at the site should be cleaned with
70% alcohol or 0.5% chlorhexidine.
Procedure ct …

 Infiltrate the skin, subcutaneous tissue and periosteum over the

site with 2-5ml of lignocaine.
 Children are either sedated or given general anaesthesia.
 With boring movement pass the needle perpendicularly at center
of PSIS.
 When bone has been penetrated, remove the stilette, attach 30 ml
syringe and suck up marrow contents (0.3ml) for making smears
immediately.
  If large sample is needed for cytogenetics and
immunophenotyping attach another 5 or 10 ml syringe and aspirate.
(should be kept in preservative free heparin than in EDTA).
 Dry tap- is failure to aspirate marrow (suggests bone marrow
fibrosis or infiltration.)
 If there has been a “dry tap,” insert the stilette into the needle and
push any material in the lumen of the needle onto a slide; in
lymphomas and carcinomas, especially, sufficient material can be
obtained to make a diagnosis.
After the procedure
 Pressure will be applied to the area
where the needle was inserted to stop
the bleeding. Then a bandage will be
placed on the site.

 If the patient had local anesthesia, he/

she will be asked to lie on your back for
10 to 15 minutes and apply pressure to
the biopsy site.

 If the patient had IV sedation, will be

taken to a recovery area. The patient can
go home with a company. Rest for 24
hours.
 
 
BIOPSY (Procedure)
• The trephine specimen is obtained by
inserting the biopsy needle into the bone
and using a to- and-fro rotation to obtain a
core of tissue.

• If an aspirate has been performed first, the

needle should be inserted through the
same incision but the needle should be
advanced at a slightly different angle.
 
Biopsy procedure ct…
• The bony core is gently dabbed or rolled
across the slide to form imprint smears,
which is then fixed and stained as for
bone marrow aspiration smears.
This allows immediate examination of cells that fall out of the
specimen onto the slide and may provide a diagnosis several
days before the trephine biopsy specimen has been processed.

• Bilateral trephine biopsies may be

performed to increase the yield of
detecting focal lesions.
 
CRITERIA FOR ADEQUATE BONE
MARROW BIOPSY
 Length at least 1.5 cm

 At least 10 partially preserved

trabecular spaces seen

 Sections of 3-4 micron in

thickness cut at a distance of 50
micron each. (WHO Classification
of tumors of haematopoietic and
lymphoid tissue 2008)
COMPLICATIONS OF BONE MARROW EXAM
Bone marrow exams are generally safe procedures.
Complications are rare but can include:
Hemorrhage esp. people with low numbers of

platelets

Infection, especially in people with weakened


immune systems


Pain, Long-lasting discomfort at the biopsy site


Perforation of major vessels

Penetration of the breastbone (sternum) during


sternal aspirations, which can cause heart or lung
problems.


Risk of general anaesthesia and sedation