Bone Marrow Examination- Bone Marrow Trephine Biopsy
Bone marrow examination is a procedure for studying blood diseases.
Bone marrow examination may be the next step after abnormal clinical findings (such as abnormal complete blood count (CBC) and/or abnormal peripheral blood smear).
It can also be performed after an abnormal bone image (such as finding a lesion on an X-ray).
Bone marrow examination includes:
1. Bone marrow aspiration
2. Clot section
3. Bone marrow Trephine biopsy
4. Biopsy imprint smears
Bone marrow Trephine biopsy:
• Removal of a small core of BM under local anesthesia.
• It is used to assess BM structure, the number & distribution of all types of blood cells.
• By rotating a special needle under pressure, a Trephine biopsy with a diameter of 1-2cm and a diameter of 2-3mm can be obtained.
You usually have Bone marrow aspiration and Biopsy tests done at the same time. They provided the doctor with some of the same information, but it was different.
Bone marrow trephine biopsy showed the structure of the bone marrow inside the bone, while suction only absorbed bone marrow cells.
A little less simple than aspiration and can be performed on outpatients or at the bedside.
It is very valuable for the diagnosis of diseases that produce "dry taps".
Indications for bone marrow Trephine biopsy:
1. Repeated failure to obtain adequate material by aspiration.
2. Aplastic anemia
3. In myelofibrosis biopsy for confirmation as fibrosis cannot be demonstrated with certainty on smears from aspirates.to study reticulin fibrosis in myelofibrosis
4. Myelodysplastic syndrome
5. Pre- and Post –bone marrow transplantation
6. Pyrexia of unknown origin
7. Staging – Lymphoma
8. To detect metastasis in cancer.
Requirements
1. Disinfectant: 70% alcohol.
2. Local anesthesia: 2% Xylocaine
3. Fixatives: 95% Zenker’s sol, 10% Formal saline, 10% Neutral buffered formalin
4. Gloves
5. Clean slides
6. Biopsy needle:
Bone marrow Trephine biopsy needles:
1. Jamshidi trephine: Tapering end to reduce crush artifact. It consists of a cylindrical needle with a constant diameter of 2mm but is concentrically tapered at the distal end. The end has a sharp beveled tip with a precisely fitting probe that exceeds the length of the needle by 1-2mm.
2. Islam trephine: The distal cutting edge is made to hold the core secure during the extraction of the material.
It has a core fixing device that can obtain a uniform bone marrow core without affecting the shape and anatomy.
- Larger specimens: trephine needles with bores of 4-5mm
3. Vim-Silverman needle: Occasionally used needles: 2-mm bore microtrephine, a Smaller yield of marrow specimen that are prone to fracturing.
Complications of bone marrow biopsy:
- Generally, a safe procedure
- Gluteal compartment syndrome
- Bleeding is due to impairment of platelet function than to thrombocytopenia or a coagulation factor defect.
Contraindications:
Biopsy in Coagulopathies: factor replacement therapy before procedure and observation should be done for the next 24-48 hours.
Sites of trephine biopsy
• Posterior superior iliac spine ( Most common)
• Anterior superior iliac spine
Procedure
1. Patient preparation is to be followed in the manner previously described for bone marrow aspiration.
2. The needle, with stylet locked in place, hold and reposition the needle with the palm of your hand and index finger to create a new insertion site for the biopsy sample. After the needle touches the bone surface, the probe is removed.
3. Ask the patient to lie on their prone or side (left or right).
4. Palpate the iliac crest and mark the better sampling site. Locate the exact point for aspiration and outline area between thumb and index finger.
5. Disinfect the area with the disinfectant. (large area of skin at the site of the procedure and allow to dry.
6. Infiltrate the skin, subcutaneous tissue, and periosteum covering the selected area with a local anesthetic. Wait 2-3 minutes for l anesthesia to take effect
7. Needle inserted in the skin then the subcutaneous tissue then cortex of the bone, which is sensed by a decreased resistance to the forward movement of the needle.
8. Using firm pressure, slowly rotate the needle in a clockwise and counterclockwise alternating motion, and then advance it into the bone marrow cavity to obtain a sufficient bone marrow specimen, which is approximately 1.6-3 cm in length.
9. 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.
10. Following this procedure, slowly pull out the needle while rotating it alternately clockwise and counterclockwise.
11. Remove the specimen from the needle and introduce a probe through the distal cutting end. If the aspirate was unsuccessful (i.e., a "dry tap"), a core biopsy can be used to prepare for touch. This must be done before placing the sample in formalin.
12. To create a fresh biopsy touch preparation, the fresh bone marrow core is gently rolled between two slides. When using this method, there should be enough cell components for laboratory professionals to evaluate.
13. Place the specimen in a labeled formalin solution containing tube for histologic processing with request form including the patient’s name and number.
14. Remove the bone marrow needle and apply pressure to the area with gauze until the bleeding stops.
Post biopsy care
- When the procedure of the biopsy completed applies pressure over the posterior Ilium for about 60 min.
- Pressure is obtained through pressure dressing and flat position in bed.
- Thereafter, assuming no bleeding is observed, the patient can get up and perform normal activities.
- Patients are advised to avoid washing the procedure site for at least 24 hours after the procedure is complete. After Obtaining the marrow specimens, the bleeding must be stopped, the procedure site must be cleaned up, the needle must be correctly placed in the Sharps container, and bandaged
- A procedure description must be placed on the patient’s medical record.
Imprints from bone marrow trephine biopsy:
• Can be taken before transferring the specimen to the fixative
• Gently tap or scroll the Bony core onto the slide
• Fixed and stained
• Permits immediate examination of cells that fall out of the specimen onto the slide
•May provides a diagnosis several days before the trephine biopsy has.
Importance of touch/ imprint smear:
- Gives cytological details when aspirate is not obtained.
- Shows more marrow infiltration and neoplastic cells than aspirate.
Adequacy of biopsy:
- Length-1.6cm ( 1.5- 2.5cm)
- 25% shrinkage during processing
- 5-6 Trabecular spaces
- Good quality Staining
Processing of bone marrow trephine biopsy Specimens:
- Fixation
- Decalcification
- Processing
- Sectioning
- Staining
• Fixed in 10% formal saline
• Buffered to ph. 7, for 12-48 hours
• Decalcifying, dehydrating, and embedding in paraffin wax
• Cell shrinkage and deformation during decalcification may deform cell details
•Methyl methacrylate(plastic)Embedding
Staining of Bone Marrow Trephine Biopsy Specimens Sections:
• Routinely stained for H& E
• Silver impregnation method for reticulin
• Romanoski dye: MGG-hematopoietic cells may be easier to identify
• Perls' reaction for iron
•H&E staining: excellent for demonstrating the
cellularity and pattern of the marrow.
• Immunohistochemistry: paraffin/plastic embedded specimens
• Silver impregnation: stains the glycoprotein matrix
• Reticulin: an early form of collagen
• Increased bone marrow reticulin: increased fiber number and thickness. E.g. Myeloproliferative
• In myelofibrosis or myelosclerosis, a more "mature" form of collagen is present
Bone marrow aspirate V/S Biopsy
Aspiration and trephine biopsy are complementary to each other.
|
Bone marrow aspirate |
Bone marrow biopsy |
|
Better cytological detail. |
Topographical details, cellularity and infiltration. |
|
More range for cytochemical stains, flow cytometry and IHC. |
Less range. |
|
Ideal for cytogenetics and molecular genetics. |
Can be used for both. |
|
Dry tap in fibrosis |
Essential for diagnosis in the dry tap. |
|
Can be performed alone in iron-deficiency anemia, anemia of chronic disease, megaloblastic anemia and acute leukemia.
|
Helpful for aplastic hypoplastic anemia, lymphoma, metastatic carcinoma, myeloproliferative neoplasms and diseases of the bones.
|
|
Less painful |
More painful |
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