Biopsy, Bone Marrow

Synonym/acronym: N/A.

Common use

To assist in diagnosing hematological diseases and in identifying and staging cancers such as leukemia.

Specimen

Bone marrow aspirate, bone core biopsy, marrow and peripheral smears.

Normal findings

(Method: Microscopic study of bone and bone marrow samples, flow cytometry) Reference ranges are subject to many variables, and therefore the laboratory should be consulted for their specific interpretation. Some generalities may be commented on regarding findings as follows:

Ratio of marrow fat to cellular elements is related to age, with the amount of fat increasing with increasing age.
Normal cellularity, cellular distribution, presence of megakaryocytes, and absence of fibrosis or tumor cells.
The myeloid-to-erythrocyte ratio (M:E) is 2:1 to 4:1 in adults. It may be slightly higher in children.

Differential Parameter	Conventional Units
Erythrocyte precursors	18–32%
Myeloblasts	0–2%
Promyelocytes	2–6%
Myelocytes	9–17%
Metamyelocytes	7–25%
Bands	10–16%
Neutrophils	18–28%
Eosinophils and precursors	1–5%
Basophils and precursors	0–1%
Monocytes and precursors	1–5%
Lymphocytes	9–19%
Plasma cells	0–1%

Description

This test involves the removal of a small sample of bone marrow by aspiration, needle biopsy, or open surgical biopsy for a complete hematological analysis. The marrow is a suspension of blood, fat, and developing blood cells, which is evaluated for morphology and examined for all stages of maturation; iron stores; and myeloid-to-erythrocyte ratio (M:E). Sudan black B and periodic acid–Schiff (PAS) stains can be performed for microscopic examination to differentiate the types of leukemia, although flow cytometry and cytogenetics have become more commonly used techniques for this purpose. Immunophenotyping by flow cytometry uses markers directed at specific antigens on white blood cell membranes to provide rapid enumeration and identification of white blood cell types as well as detection of abnormal increases or decreases in specific cell lines. Cytogenetics is a specialization within the area of genetics that includes chromosome analysis or karyotyping. Bone marrow cells are incubated in culture media to increase the number of cells available for study and to allow for hybridization of the cellular DNA with fluorescent DNA probes in a technique called fluorescence in situ hybridization (FISH). The probes are designed to target areas of the chromosome known to correlate with genetic risk for a particular disease. When a suitable volume of hybridized sample is achieved, cell growth is chemically inhibited during the prophase and metaphase stages of mitosis (cell division) and cellular DNA is examined to detect fluorescence, which represents chromosomal abnormalities, in the targeted areas.

This procedure is contraindicated for

high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site)

Indications

Determine marrow differential (proportion of the various types of cells present in the marrow) and M:E
Evaluate abnormal results of complete blood count or white blood cell count with differential showing increased numbers of leukocyte precursors
Evaluate hepatomegaly or splenomegaly
Identify bone marrow hyperplasia or hypoplasia
Identify infectious organisms present in the bone marrow (histoplasmosis, mycobacteria, cytomegalovirus, parvovirus inclusions)
Monitor effects of exposure to bone marrow depressants
Monitor bone marrow response to chemotherapy or radiation therapy

Potential diagnosis

Increased Reticulocytes

Compensated red blood cell (RBC) loss Response to vitamin B₁₂ therapy

Decreased Reticulocytes

Aplastic crisis of sickle cell anemia or hereditary spherocytosis

Increased Leukocytes

General associations include compensation for infectious process, leukemias, or leukemoid drug reactions

Decreased Leukocytes

General associations include reduction in the marrow space as seen in metastatic neoplasm or myelofibrosis, lack of production of cells, lower production of cells as seen in the elderly, or following suppressive therapy such as chemotherapy or radiation

Increased Neutrophils (total)

Acute myeloblastic leukemia Myeloid (chronic) leukemias

Decreased Neutrophils (total)

Aplastic anemia Leukemias (monocytic and lymphoblastic)

Increased Lymphocytes

Aplastic anemia Lymphatic leukemia Lymphomas Lymphosarcoma Mononucleosis Viral infections

Increased Plasma Cells

Cancer Cirrhosis of the liver Connective tissue disorders Hypersensitivity reactions Infections Macroglobulinemia Ulcerative colitis

Increased Megakaryocytes

Hemorrhage Increasing age Infections Megakaryocytic myelosis Myeloid leukemia Pneumonia Polycythemia vera Thrombocytopenia

Decreased Megakaryocytes

Agranulocytosis Cirrhosis of the liver Pernicious aplastic anemia Radiation therapy Thrombocytopenic purpura

Increased M:E

Bone marrow failure Infections Leukemoid reactions Myeloid leukemia

Decreased M:E

Anemias Hepatic disease Polycythemia vera Posthemorrhagic hematopoiesis

Increased Normoblasts

Anemias Chronic blood loss Polycythemia vera

Decreased Normoblasts

Aplastic anemia Folic acid or vitamin B₁₂ deficiency Hemolytic anemia

Increased Eosinophils

Bone marrow cancer Lymphadenoma Myeloid leukemia

Critical findings

Classification or grading of tumor
Identification of malignancy
It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.
Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

Recent blood transfusions, iron therapy, or administration of cytotoxic agents may alter test results.
Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of bone marrow and immune system disease.
Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
Obtain a history of the patient’s hematopoietic and immune systems, especially any bleeding disorders and other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
Note any recent procedures that can interfere with test results.
Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort prior to the percutaneous biopsy. Explain to the patient that any discomfort with the needle biopsy will be minimized with local anesthetics and systemic analgesics. Explain that the patient may feel some pain when the lidocaine is injected and some discomfort at the stage in the procedure when the specimen is aspirated. Inform the patient that the biopsy is performed under sterile conditions by an HCP specializing in this procedure. A needle biopsy usually takes about 20 min to complete.
Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
Explain that an IV line may be inserted to allow infusion of IV fluids, anesthetics, or sedatives.
Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Protocols may vary among facilities.
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

Potential complications:
Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners)
Ensure that the patient has complied with dietary restrictions.
Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld.
Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
Have emergency equipment readily available.
Have the patient void before the procedure.
Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location.
Assist the patient to the desired position depending on the test site to be used. In young children, the most frequently chosen site is the proximal tibia. Vertebral bodies T10 through L4 are preferred in older children. In adults, the sternum or iliac crests are the preferred sites. Place the patient in the prone, sitting, or side-lying position for the vertebral bodies; the side-lying position for iliac crest or tibial sites; or the supine position for the sternum. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement during the local anesthetic and the procedure.
Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
After the administration of local anesthesia, use clippers to remove hair from the biopsy site if appropriate, cleanse the site with an antiseptic solution, and drape the area with sterile towels.

Needle Aspiration

The HCP will anesthetize the site with procaine or lidocaine, and then insert a needle with stylet into the marrow. The stylet is removed, a syringe attached, and a 0.5-mL aliquot of marrow withdrawn. The needle is removed, and pressure is applied to the site. The aspirate is applied to slides, and, when dry, a fixative is applied.

Needle Biopsy

Instruct the patient to take slow deep breaths when the local anesthetic is injected. Protect the site with sterile drapes.
Local anesthetic is introduced deeply enough to include periosteum. A cutting biopsy needle is introduced through a small skin incision and bored into the marrow cavity. A core needle is introduced through the cutting needle, and a plug of marrow is removed. The needles are withdrawn, and the specimen is placed in a preservative solution. Pressure is applied to the site for 3 to 5 min, and then a pressure dressing is applied.

General

Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
Place tissue samples in properly labeled specimen container containing formalin solution, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
Instruct the patient to resume preoperative diet, as directed by the HCP.
Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
Instruct the patient in the care and assessment of the site.
Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site. Instruct the patient to immediately report chills or fever.
Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient and family members regarding access to counseling and other supportive services. Provide contact information, if desired, for the National Marrow Donor Program (www.marrow.org).
Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of a follow-up appointment for removal of sutures, if indicated. Answer any questions or address any concerns voiced by the patient or family.
Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

Related tests include biopsy lymph node, CBC, LAP, immunofixation electrophoresis, mediastinoscopy, and vitamin B₁₂.
Refer to the Hematopoietic and Immune systems tables at the end of the book for related tests by body system.