BONE MARROW ASPIRATION

Bone marrow aspiration, also called bone marrow sampling, is the removal by
suction of the soft, spongy semisolid tissue (marrow) that fills the inside of the long
and flat bones. Bone marrow biopsy, or needle core biopsy, is the removal of a small
piece (about 0.75 X 0.06 in, or 2 X 0.16 cm) of intact bone marrow. The bone marrow
is where blood cells are made.

Purpose

Examination of the bone marrow may be the next step that follows an abnormal
clinical finding, such as an abnormal complete blood count (CBC), and/or an
abnormal peripheral blood smear. It may also be performed following an abnormal
bone image such as the finding of a lesion on x rays.

A biopsy of bone marrow shows the intact tissue, so that the structure of the fat cells,
lymphocytes, plasma cells, fibrous connective tissue cells, and other cells, and their
relationships to each other, can be seen. A bone marrow biopsy is used to:

 diagnose and manage any form of leukemia or other myeloproliferative

condition such as multiple myeloma
 rule out or confirm bone marrow infiltration by malignancies such as
Hodgkin's disease, non-Hodgkin's lymphoma, and metastatic carcinoma
 monitor the effects of chemotherapy and the response or lack of response to
treatment of blood disease
 evaluate the success of bone marrow transplantation
 diagnose certain genetic diseases (e.g., lipid storage disease)
 investigate pancytopenia (a decrease of all blood cells in peripheral blood),
neutropenia (decreased phagocytic white blood cells), or thrombocytopenia
(decreased platelets)
 diagnose an infection of unknown origin
 investigate rare anemias for which a cause cannot be found or which does not
respond to treatment as anticipated
 obtain intact bone marrow for laboratory analysis
 diagnose some types of cancer or anemia and other blood disorders
  identify the source of an unexplained fever (e.g., granulomatous lesions)
 diagnose fibrosis of bone marrow and myeloma when bone marrow aspiration
has failed to provide an appropriate specimen

The combination of aspiration and biopsy procedures are commonly used to ensure
the availability of the best possible bone marrow specimen. The aspirate is collected
at the same time as the bone core biopsy by attaching a syringe to the bone marrow
needle and withdrawing the sample before the cutting blades are inserted and the
bone core is removed. The aspirate is the sample of choice for studying and
classifying the nucleated blood cells of the bone marrow (e.g., determining the ratio
of immature white blood cells to red blood cells (M:E ratio). The biopsy is the only
sample that shows the blood forming cells in relation to the structural and connective
tissue elements (i.e., the microarchitecture) of the bone marrow. It provides the best
sample for evaluating the cellularity of the bone marrow (the percentage of blood-
forming tissue versus fat).

Description

Bone marrow aspiration and biopsy are performed by a pathologist, hematologist, or

oncologist with special training in this procedure. The procedure may be performed
on an outpatient basis. In adults, the specimen is usually taken from the posterior
superior iliac crest (hip). The sternum (breastbone) may be used for aspiration, but is
less desirable because it carries the risk of cardiac puncture. Other sites that are
rarely used are the anterior superior iliac crest or a spinal column bone. When the
patient is a child, the biopsy site is generally the anterior tibia, the larger of the two
bones in the lower leg. A vertebra may also be used.

The skin covering the biopsy site is cleansed with an antiseptic, and the patient may
be given a mild sedative. The patient is positioned, and a local anesthetic such as
lidocaine is administered first under the skin with a fine needle and then around the
bone at the intended puncture site with a somewhat larger gauge needle. When the
area is numb, a small incision is made in the skin and the biopsy needle is inserted.
Pressure is applied to force the needle through the outer bone, and a decrease in
resistance signals entry into the marrow cavity. The needle most often used for bone
marrow biopsy is a Jamshidi trephine needle or a Westerman-Jensen trephine
needle. A syringe is placed on the top of the needle and 1–2 ml of the bone marrow is
aspirated into the syringe. In some instances, the marrow cannot be aspirated
because it is fibrosed or packed with neoplastic cells. The syringe is removed and the
medical technologist uses this sample to prepare several smears containing small
pieces of bone (spicules). Another syringe is fitted onto the needle hub and another
sample of 3 ml is removed and transferred to a tube containing EDTA for analysis by
flow cytometry, cytogenetic testing, or other special laboratory procedures. Following
aspiration, the cutting blades are inserted into the hollow of the needle until they
protrude into the marrow. The needle is then forced over the tips of the cutting
blades and the needle is rotated as it is withdrawn from the bone. This process
captures the core sample inside the needle. A wire probe is inserted at the cutting end
and the bone marrow sample is pushed through the hub of the needle onto sterile
gauze. The specimen is used to make several preparations on glass slides or
coverglasses and is transferred to a fixative solution.

In the laboratory, the aspirate slides are stained with Wright stain or Wright-Giemsa
stain. The biopsy material is sectioned onto glass slides and stained with
hematoxylin-eosin, Giemsa, and Prussian blue stains. Prussian blue stain is used to
evaluate the amount of bone marrow iron, and the other stains are used to contrast
cell structures under the microscope. In addition, special stains may be used that aid
in the classification of malignant white blood cells.

Diagnosis/Preparation

The physician should be informed of any medication the patient is using and any
heart surgery that the patient may have undergone.

Adults require no special preparation for this test. As for infants and children, they
need physical and psychological preparation depending on the child's age, previous
medical experiences, and level of trust.

Infant preparation
Before the test, parents should know that their child will most probably cry, and that
restraints may be used. To provide comfort, and help their child through this
procedure, parents are commonly asked to be present during the procedure. Crying
is a normal infant response to an unfamiliar environment, strangers, restraints, and
separation from the parent. Infants cry more for these reasons than because they
hurt. An infant will be restrained by hand or with devices because they have not yet
developed the physical control, coordination, and ability to follow commands as
adults have. The restraints used thus aim to ensure the infant's safety.

Toddler preparation

Parents should prepare a toddler for bone marrow aspiration directly before the
procedure, because toddlers have a very short attention span. Some general
guidelines for parents include the following:

 Explain the procedure in a simple language, using concrete terms and

avoiding abstract terminology.
 Make sure that the child understands where on his body the procedure will be
performed and that it will be limited to that area.
 Allow the child to yell, cry, or express anything, especially pain, verbally.
 Describe how the test will feel.
 Stress the benefits of the procedure and anything that the child may find
enjoyable afterwards, such as feeling better or going home.

Preschooler preparation

Parents should prepare a preschooler for bone marrow aspiration directly before the
procedure, so that the child does not worry about it for days in advance. Explanations
should be limited to 10 or 15 minutes, because preschoolers also have a limited
attention span. Parents should also ensure that the child understands that the
procedure is not a punishment. Some general guidelines for parents include the
following:

 Explain the procedure in a simple language, using concrete terms and

avoiding abstract terminology.
  Make sure that the child understands where on his or her body the procedure
will be performed and that it will be limited to that area.
 Allow the child to yell, cry, or express anything, especially pain, verbally.
 Describe how the test will feel and be honest about any pain that may be felt.
 Allow the child to practice different positions or movements that will be
required for the procedure.
 Stress the benefits of the procedure and anything that the child may find
enjoyable afterwards, such as feeling better or going for a treat on the way
home.
 Practice deep breathing and other relaxing exercises. Practice also to have the
child hold your hand and tell him or her to squeeze it when he or she feels
pain during the procedure.

School-age child preparation

Explanations should be limited to 20 minutes, and repeated if required. School-age

children have a good concept of time, allowing for preparation in advance of the
procedure. The older the child, the earlier a parent can start preparation. Guidelines
for parents include the ones provided for preschoolers as well as the following:

 Suggest ways for maintaining control during the procedure. For example,
counting, deep breathing, and relaxation (thinking of pleasant thoughts).
 Include the child in the decision-making process, for example, the time of day
or the body site where the procedure will be performed. These of course
depend on the scheduling constraints of your physician and the type of
procedure being performed, but where possible, involve the child in the
decisions.
 Encourage the child to participate in the procedure, for example by holding an
instrument, if allowed by the attending hospital staff.
 Encourage the child to hold your hand or the hand of a nurse. Physical contact
does help reduce pain and anxiety.

Adolescent preparation

An adolescent is best prepared by being provided with detailed information and

reasons for the procedure. Adolescents should be encouraged to make as many
decisions as possible. An adolescent may or may not wish a parent to be present
during the procedure, and such wishes should be respected, since privacy is
important during adolescence. Other guidelines include the following:

 Explain the procedure in correct medical terminology, and provide the reason
for it. Ask the physician about the specific reason if you are not sure.
 To the best of your ability, describe the equipment that will be involved in
concrete terms.
 Discuss potential risks because adolescents are usually quite concerned about
any effects on appearance, mental function, and sexuality. These concerns
should be addressed honestly and openly.

Aftercare

After the needle is removed, the biopsy site is covered with a clean, dry pressure
bandage. The patient must remain lying down and is observed for bleeding for one
hour. The patient's pulse, breathing, blood pressure, and temperature are monitored
until they return to normal. The biopsy site should be kept covered and dry for
several hours.

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

Risks

A small amount of bleeding and moderate discomfort often occur at the biopsy site.
Rarely, reactions to anesthetic agents, infection, and hematoma (blood clot) or
hemorrhage (excessive bleeding) 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. Bone marrow is evaluated for cellularity,
megakaryocyte production, M:E ratio, differential (classification of blood forming
cells), iron content, lymphoid, bone, and connective tissue cells, and bone and blood
vessel abnormalities. The bone marrow of a healthy infant is primarily red (75–100%
cellularity), but the distribution of blood forming cells is very different than adult
marrow. Consequently, age-related normal values must be used.

Microscopic examination of bone marrow can reveal leukemia, granulomas,

myelofibrosis, myeloma, lymphoma, or metastatic cancers, bone marrow infection,
and bone disease. Bone marrow evaluation is usually not needed to diagnose anemia,
but may be useful in cases that cannot be classified by other means.

Read more: Bone Marrow Aspiration and Biopsy - procedure, test, blood, tube,
removal, pain, adults, time, infection, medication, heart, cells, types, risk, children,
cancer, Definition, Purpose http://www.surgeryencyclopedia.com/A-Ce/Bone-
Marrow-Aspiration-and-Biopsy.html#ixzz0wCx4Ce00