Bone Marrow Aspiration and Biopsy

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The procedure known as trepanning, or trephination, of bone is the oldest surgical practice that continues to have clinical relevance in modern times. The method dates as far back as the Neolithic period and initially entailed the drilling of cranial bones as a form of medical intervention for headaches and mental illnesses. However it was not until 1905, when the Italian physician Pianese reported bone marrow infiltration by the parasite Leishmania, that this procedure was applied to clinical evaluation. ^[1]

Bone marrow consists of stem cells, which are large, “primitive,” undifferentiated cells supported by fibrous tissue called stroma. There are two main types of stem cells, and thus, bone marrow consists of two types of cellular tissue. One type of stem cell is involved in producing blood cells, and the other is involved in producing stromal cells, which are responsible for the supporting stroma. For more information about the relevant anatomy, see Bone Marrow Anatomy.

Sampling of the marrow consists of aspiration of the cellular component, acquisition of tissue fragments, or both. Aspiration of the marrow has been primarily utilized for cytologic assessment, with analysis directed toward assessing the morphology and obtaining a differential cell count. Further sampling allows material to be directed toward other ancillary tests, such as cytogenetics, molecular studies, microbiologic cultures, immunohistochemistry, and flow cytometry.

Biopsies, on the other hand, allow evaluation of the marrow’s overall cellularity, detection of focal lesions, and determination of the extent of infiltration by various pathologic entities. ^{[2, 3, 4]}

For patient education information, see the Osteoporosis Center and the Cancer Center, as well as Bone Marrow Biopsy.

Currently, inspection of bone marrow is considered one of the most valuable diagnostic tools for evaluating hematologic disorders. ^[5] Indications have included diagnosis, staging, and therapeutic monitoring for lymphoproliferative disorders such as chronic lymphocytic leukemia CLL), Hodgkin and non-Hodgkin lymphoma, hairy cell leukemia, myeloproliferative disorders, myelodyspladtic syndrome and multiple myeloma. Furthermore, evaluation of cytopenia, ^[6] thrombocytosis, leukocytosis, anemia, and iron status can be performed. Bone marrow inspection is also done to rule out inflitrative infectious diseases such as fungal infections, tuberculosis, and other granulomatoses.

The application of bone marrow analysis has grown to incorporate other, nonhematologic, conditions. For example, in the investigation for fever of unknown origin (FUO), specifically in those patients with autoimmune deficiency syndrome (AIDS), ^[7] the marrow may reveal the presence of microorganisms, such as tuberculosis, Mycobacterium avium intracellulare (MAI) infections, histoplasmosis, leishmaniasis, and other disseminated fungal infections.

Furthermore, the diagnosis of storage diseases (eg, Niemann-Pick disease and Gaucher disease ^[8] ), as well as the assessment for metastatic carcinoma and granulomatous diseases (eg, sarcoidosis) can be performed. Bone marrow analysis may reveal toxic effects of certain offending medications or substances, such as alcohol, or nutritional deficiencies, such as copper/zinc or vitamin B12/folate.

Bone marrow analysis can also be performed in patients with idiopathic thrombocytopenia purpura (ITP), incidental elevated serum paraprotein levels, iron deficiency anemia, polycythemia vera, essential thrombocytosis, or infectious mononucleosis; but these conditions are often more appropriately diagnosed by routine laboratory evaluation. ^[9] Thrombocytopenia is not in itself a contraindication for bone marrow aspiration and biopsy.

The safe and preferred sites for bone marrow aspiration, biopsy, or both are described below.

Aspiration and biopsy

The posterior superior iliac crest (see the image below) is the most commonly employed site for reasons of safety, decreased risk of pain, and accessibility. The posterior superior iliac crest site is localized to the central crest area.

The anterior superior iliac crest is an alternative site when the posterior iliac crest is unapproachable or unavailable as a result of 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, because of the dense cortical layer, which makes samples harder to obtain and smaller in size and creates a risk of a more painful event.

Aspiration only

The sternum is sampled only as a last resort in those older than 12 years and in those who are morbidly obese, but sternal sampling 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 second and third intercostal spaces.

The tibia is sampled only for infants younger than 1 year, and the procedure is conducted with the patient under general anesthesia. 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. ^{[2, 10]}

Sternal bone marrow aspiration has a higher risk of complications than other sites because of the delicate bone structure in this area (~1 cm thick in adults). Penetration of the underlying mediastinal organs can result in mediastinitis, pulmonary embolism, pneumothorax, cardiac tamponade, and cardiac tissue injury, and for these reasons, biopsies are not to be performed from the sternum.

Awareness of anatomic variations and pathologies that may affect bone density (eg, osteoporosis and multiple myeloma) can prevent further complications and injuries.

Application of sterile techniques is required in the prevention of infections.

Parapia LA. Trepanning or trephines: a history of bone marrow biopsy. Br J Haematol. 2007 Oct. 139(1):14-9. [Medline].

Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. 2001 Oct. 54(10):737-42. [Medline]. [Full Text].

Trewhitt KG. Bone marrow aspiration and biopsy: collection and interpretation. Oncol Nurs Forum. 2001 Oct. 28(9):1409-15; quiz 1416-7. [Medline].

Wilkins BS. Pitfalls in bone marrow pathology: avoiding errors in bone marrow trephine biopsy diagnosis. J Clin Pathol. 2011 May. 64(5):380-6. [Medline].

Fend F, Tzankov A, Bink K, et al. Modern techniques for the diagnostic evaluation of the trephine bone marrow biopsy: methodological aspects and applications. Prog Histochem Cytochem. 2008. 42(4):203-52. [Medline].

Desalphine M, Bagga PK, Gupta PK, Kataria AS. To evaluate the role of bone marrow aspiration and bone marrow biopsy in pancytopenia. J Clin Diagn Res. 2014 Nov. 8(11):FC11-5. [Medline]. [Full Text].

Quesada AE, Tholpady A, Wanger A, Nguyen AN, Chen L. Utility of bone marrow examination for workup of fever of unknown origin in patients with HIV/AIDS. J Clin Pathol. 2015 Mar. 68(3):241-5. [Medline].

Sokolowska B, Skomra D, Czartoryska B, Tomczak W, Tylki-Szymanska A, Gromek T, et al. Gaucher disease diagnosed after bone marrow trephine biopsy – a report of two cases. Folia Histochem Cytobiol. 2011. 49(2):352-6. [Medline].

Mazzella FM, Perrotta G. Peripheral blood and bone marrow. Schumacher HR, Rock WA, Stass SA, eds. Handbook of Hematologic Pathology. New York: Marcel Dekker; 2000. 1-26.

Knowles S, Hoffbrand AV. Bone-marrow aspiration and trephine biopsy (1). Br Med J. 1980 Jul 19. 281(6234):204-5. [Medline]. [Full Text].

Zahid MF. Methods of reducing pain during bone marrow biopsy: a narrative review. Ann Palliat Med. 2015 Oct. 4 (4):184-93. [Medline]. [Full Text].

Bain BJ. Bone marrow aspiration. J Clin Pathol. 2001 Sep. 54(9):657-63. [Medline]. [Full Text].

Knowles S, Hoffbrand AV. Bone-marrow aspiration and trephine biopsy (2). Br Med J. 1980 Jul 26. 281(6235):280-1. [Medline]. [Full Text].

Barekman CL, Fair KP, Cotelingam JD. Comparative utility of diagnostic bone-marrow components: a 10-year study. Am J Hematol. 1997 Sep. 56(1):37-41. [Medline]. [Full Text].

Wang J, Weiss LM, Chang KL, et al. Diagnostic utility of bilateral bone marrow examination: significance of morphologic and ancillary technique study in malignancy. Cancer. 2002 Mar 1. 94(5):1522-31. [Medline]. [Full Text].

Riley RS, Hogan TF, Pavot DR, et al. A pathologist’s perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination. J Clin Lab Anal. 2004. 18(2):70-90. [Medline].

Bain BJ. Morbidity associated with bone marrow aspiration and trephine biopsy – a review of UK data for 2004. Haematologica. 2006 Sep. 91(9):1293-4. [Medline]. [Full Text].

Jain S, Enzerra M, Mehta RS, Smith R, Djokic M. Bone marrow biopsies performed by both the powered OnControl drill device and the Jamshidi needle produce adequate specimens. J Clin Pathol. 2017 Jan 6. [Medline].

Lewandowski K, Kowalik MM, Pawlaczyk R, Rogowski J, Hellmann A. Microscopic examination of bone marrow aspirate in healthy adults – comparison of two techniques of slide preparation. Int J Lab Hematol. 2012 Jun. 34(3):254-61. [Medline].

Smock KJ, Perkins SL. Examination of the blood and bone marrow. Greer JP, Arber DA, Glader B, et al, eds. Wintrobe’s Clinical Hematology. 13th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. 1-17.

Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol. 2003 Jun. 121(6):949-51. [Medline].

Neetu Radhakrishnan, MD Associate Professor (Adjunct) of Medicine, Division of Hematology/Oncology, University of Cincinnati Medical Center; Hematology/Oncology Medical Director, West Chester Outpatient Clinics

Neetu Radhakrishnan, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Ronald A Sacher, MBBCh, FRCPC, DTM&H Professor of Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MBBCh, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Dimitrios Vergidis, MD Head, Department of Hematology and Medical Oncology, Northwestern Ontario Regional Cancer Centre; Clinical Associate Professor, Department of Medicine, McMaster University School of Medicine, Canada

Dimitrios Vergidis, MD is a member of the following medical societies: Alberta Medical Association, American Society of Hematology, Canadian Society of Internal Medicine, College of Physicians and Surgeons of Alberta, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Koyamangalath Krishnan, MD, FRCP, FACP Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine, James H Quillen College of Medicine at East Tennessee State University

Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, Royal College of Physicians

Disclosure: Nothing to disclose.

Trisha Wise-Draper, MD, PhD Fellow in Hematology and Oncology, University of Cincinnati Medical Center; Research Fellow, The Division of Experimental Hematology and Cancer Biology, The Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center

Trisha Wise-Draper, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians

Disclosure: Nothing to disclose.

Corinne Goldberg, MD Fellow in Transfusion Medicine/Blood Banking, Transfusion Medicine Department, Hoxworth Blood Center, University of Cincinnati

Disclosure: Nothing to disclose.

Bone Marrow Aspiration and Biopsy

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