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Dalia Gamil BM Aspirate&Biopsy

Oct 15, 2014



Bone Marrow Aspiration And Biopsy

Objectives for BM aspirate & biopsy: By the end of this lecture, clinical pathology residents should be able to: List indications for performing BM studies Enumerate contraindication of BMA &BMB Enumerate possible sites for obtaining BMA& BMB Explain how to sterilize BM obtaining sites properly Explain the difference between core biopsy and BM aspirate

Clinical Indication:Un explained non regenerative anemia Un explained Leukopenia Thrombocytopenia Pancytopenia Non-Hodgkin's Lymphoma Hodgkin's disease Metastatic carcinoma Acute leukemia Myeloproliferative disease Myelodysplastic syndrome Lymphoproliferative disease Plasma cell dyscrasia Fever of unknown origin Hepatosplenomegaly Storage disease

Contraindications to bone marrow aspirate & biopsyIn acquired or congenital coagulation factor deficiencies & Patients receiving anticoagulants, (PT & aPTT) values should be within the accepted range prior to obtain BM specimen specially biopsy. Isolated thrombocytopenia is not a contraindication to the bone marrow examination

Contraindications to bone marrow aspirate & biopsyOther contraindications include infection or previous radiation therapy at the sample site & poor patient cooperation Sternal bone marrow aspiration is completely contraindicated in multiple myeloma

Check list: Bone Marrow Biopsy Identity of patient. Is patient under any medication such as anticoagulant therapy and/or aspirin? Have appropriate blood tests been carried out? Has the patient read, understood & signed an informed consent form? Is there any drug sensitivity or allergy to iodine or local anesthetic?

Check list: Bone Marrow Biopsy The patient is checked 0.5-1 h after the procedure before discharge or return to the ward. Has the patient received specific instructions and a printed form for avoidance of complications?

Check list: Bone Marrow Biopsy The patient must avoid driving a car on the day of the bone marrow biopsy. The patient must avoid taking anticoagulants and/or aspirin for 1-2 days after the bone marrow biopsy. Do not wet dressing for the next 2-4 days to avoid infection.

sites for bone marrow aspiration and/or biopsy: Aspiration and biopsy Posterior superior iliac crest: This is the most commonly employed site for reasons of safety, a decreased risk of pain, and accessibility. The posterior superior iliac crest site is localized to the central crest area.

sites for bone marrow aspiration and/or biopsy:Anterior superior iliac crest: This is an alternative site when the posterior iliac crest is unapproachable or not available due to infection, injury, or morbid obesity. The anterior superior iliac crest site is localized to the center prominence, under the lip of the crest. This location is generally not preferred due to the dense cortical layer, which makes obtaining samples more difficult and smaller in size, as well as creates a risk for an increased painful event.

Aspiration onlyThe sternum is sampled only as a last resort in those older than 12 years &in those who are morbidly obese ,but it should be avoided in highly agitated patients. To decrease the risk of penetrating the underlying soft-tissue organs, the sternal site is limited to a region that spans between the 2nd and 3rd intercostal spaces.

Aspiration onlyThe tibia is sampled only for infants younger than 1year. This site is localized to the proximal anteromedial surface, below the tibial tubercle. The tibial location is not utilized in older patients because the marrow cellularity is not consistent.

BM aspiration needle:The sternal guard (pictured next to the needle) can be removed when using the needle to obtain a specimen from the iliac crest.

BM biobsy needles:

The Jamshidi & Islam needles are a cylindrical needles with a tapered distal portion ending in a sharp, beveled cutting tip. The design avoids crushing of tissue and plugging of the needle.


Positioning the PatientThe patient is positioned depending on the location of the procedure: Posterior iliac crest (PIC) The patient is placed in a right or left lateral decubitus position with the top leg flexed & the lower leg straight and a pillow under their head.

Anterior iliac crest (AIC) - The patient is placed in the lateral decubitus position, with the top leg flexed and the lower leg straight., and eyes averted away. Sternum - Supine position, head and eyes away, Tibia Marrow aspiration from the anteromedial surface of the tibia is performed only in children less .than 18 months of age

Sterilization: The

skin surrounding the procedure site should be cleaned as follows: Use three sterile, disposable swabs soaked with 10% Betadine solution. wash the skin in a circular motion beginning with the marked site and working outward approximately four inches . Aseptic technique is employed, including sterile gloves and gown.

Local AnesthesiaOnce a sterile site has been achieved, a local anesthetic is utilized to numb the skin and periosteum over the chosen area of the posterior iliac crest. Lidocaine or a similar local anesthetic can be used without adrenaline providing the patient has no history of an allergic reaction to this medication (BE SURE TO ASK!).

Local Anesthesia

During this process, local anesthetic is first injected into the skin and subcutaneous tissue to anesthetize an area approximately 1 cm. in diameter. After the skin is numb, lidocaine is injected directly over the periosteum to numb an area approximately 2-3 cm in diameter

Technique of BM aspiratebone marrow aspiration needle, with a stylet locked in place, is inserted. Angle the needle 15 degrees caudad (PIC) or cephalad (AIC). Once the needle contacts the bone, it is advanced by rotating clockwise and counterclockwise until the cortical bone is penetrated and the marrow cavity is entered.

Technique of BM aspirateThe depth of the penetration should not extend beyond an initial 1 cm. Note:in sternal aspirate only, the attached guard is not to be removed; rather, it is adjusted to allow for the maximum depth of needle penetration to 0.5 cm. This prevents needle slippage& injury to the underlying organs. Once within the marrow cavity, the stylet is removed. Using a 20 mL syringe, approximately 0.3 mL of bone marrow is aspirated. A volume greater than 0.3 mL may dilute the sample with peripheral blood The material collected for bone marrow slides is generally not mixed with an anticoagulant, and processed immediately

Technique of BM aspirateIf additional marrow is needed for ancillary studies, subsequent specimens are obtained by attaching a separate syringe, collecting 5 mL at a time. The samples are then transferred into an anticoagulantcontaining tube that is appropriate to the requested study: heparin for cytogenetic analysis; either heparin or EDTA for immunophenotyping. The marrow needle is removed, and pressure is applied to the aspiration site with gauze until any bleeding has stopped.

Technique of Bone marrow biopsy: several needle can be utilized; however, the Jamshidi dispo needle is the most popular. The needle, with stylet locked in place, is held with the palm and index insertion site is created for biopsy. Once the needle touches the bone, stylet is removed.

Technique of Bone marrow biopsy

Using firm pressure, slowly rotate the needle in an alternating clockwisecounterclockwise motion,& advance it into the bone marrow cavity to obtain an adequate specimen measuring 1.6-3 cm in length. Determining length of biopsy core in needle by reinserting obturator. Rotate the needle along its axis to help loosen the sample, pull back approximately 2-3 mm, and advance the needle again slightly, at a different angle, to help secure the specimen.

Technique of Bone marrow biopsy:

slowly pull the needle out, while rotating in an clockwise& counterclockwise motion. Remove the specimen from the needle and introduce a probe through the distal cutting end.

Delivery of biopsy core unto a glass microscope slide. The core has been forced through the hub of the needle using a small blunt obturator

If the aspirate was unsuccessful (ie, a "dry tap"), the core biopsy may be used to make touch preparations before placing the specimen in formalin. Place the specimen in formalin solution for histologic processing. A normal biopsy core is dark red with a fine white trabecular network. In patients with a markedly hypocellular marrow the trabecular network remains but reddish marrow is not visible. Cartilage is white, and glistening, while cortical bone is white.

Unilateral Versus Bilateral Iliac Crest Biopsy Controversy exists in the application of bilateral iliac biopsies.Studies have indicated that this increases the probability of detecting focal lesions, (carcinoma and lymphoma), where 11-16% of cases may be missed with unilateral biopsies. Postprocedure Care After the procedure, firm pressure is applied for 5 minutes to several layers of sterile gauze placed over the wound site. Remove residual antiseptic to avoid further skin irritation by the solution. If hemorrhage from the wound persists, then place the patient in the supine position, with gauze over the wound site, so that consistent pressure can be applied for a minimum of 30 min. Rarely, bleeding may be present; consider placing a pressure dressing, again with the patient in a supine position, for 1 hour. The patient is to be discharged with orders that the wound dressing is to be maintained in a dry state for 48 hours. The wound site is to be checked frequently, and if persistent bleeding or worsening pain occurs, these findings are to be reported to clinicians.

Refrences: 1-Illustrated Guide to