Bone Marrow

Examination

Facilitate an efficient path towards diagnosis & management

Pathologic analysis of bone marrow obtained by aspiration (bone marrow aspiration )

& by biopsy (bone marrow biopsy)

Bone Marrow Examination

Bone marrow aspiration (BMA) and bone marrow trephine biopsy are important procedures for the diagnosis of hematological malignancies and non-malignant diseases in children.

• Relatively uncomplicated to perform
• The quick nature of the procedure
• Ability to perform the procedure on an outpatient basis

Types of Bone Marrow Sampling

1. Children with abnormal peripheral blood findings (e.g., atypical cells, pancytopenia, unexplained anemia, leukopenia, or thrombocytopenia
2. To diagnose malignant hematological disorders, hypoplastic anemia, inherited bone marrow failure syndromes and histiocytic disorders
3. To obtain microbiological cultures in children with fever of unknown origin
4. For investigation of hypersplenism, lymphadenopathy, hemophagocytic lymphohistiocytosis (HLH), mediastinal or abdominal masses
5. Response assessment after chemotherapy and /or hematopoietic stem cell transplant
6. As a part of metastatic work-up in solid tumors, e.g., sarcoma, neuroblastoma, retinoblastoma

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Indications of Bone Marrow Aspiration

1. Inadequate or failed marrow aspiration.
2. Suspected bone marrow fibrosis.
3. Investigation and staging of Hodgkin and non- Hodgkin lymphoma, and small blue round cell tumours of childhood (neuroblastoma, rhabdomyosarcoma and Ewing sarcoma)
4. Diagnosis of aplastic anemia, hemophagocytic lymphohistiocytosis (HLH), myelodysplastic syndromes

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Indications of Bone Marrow Biopsy

1. In patients with hemorrhagic disorders such as congenital coagulation factor deficiencies (e.g., hemophilia), disseminated intravascular coagulation, or those concurrently using anticoagulants
2. While severe thrombocytopenia is not a strict contraindication to BMA, it is essential to apply prolonged pressure at the site to prevent bleeding
3. Individuals with skin infections or recent radiation therapy at the sampling site

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• Bone disorders such as osteomyelitis or osteogenesis imperfecta

(These conditions may affect integrity of the bone structure & increase the risk of

complications during procedure)

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5. Hemodynamic instability.

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Contraindications

Most popular site: posterior superior iliac spine

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Others

• Anterior superior iliac spine
• Sternum (only aspirate>12 yrs of age)
• Proximal Tibia (<18 months of age)

Sites

Depends on:

• Age of patient
• Aspiration vs biopsy
• Other considerations like unhealthy local site,

obesity etc.

Sternum

Tibia

Posterior & anterior superior iliac spine

Preparation & Patient Assessment

1. Sterile tray skin prep (chlorhexidine or povidone iodine)
2. Requisitions
3. Consent forms
4. Procedure notes
5. Labels Specimen bags or containers
6. Gown
7. Sterile gloves
8. Sterile towels or drapes
9. Two 18-gauge drawing needles and one 25-gauge injecting needle

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10. Local anesthetic

11. Many 5 or 10 mL syringes

(to draw samples)

12. 18-gauge drawing needles and one 25-

gauge injecting needle

13. Local anesthetic

14. Slides, slide tray

15. EDTA/Heparin tubes

Equipments

Bone marrow aspiration (BMA) needles are generally available in 14, 16 or 18 gauge.

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BMB or Jamshidi needles are generally available in:

• Adult (11-gauge, 4-inch)
• Pediatric (13-gauge, 3.5-inch)
• Infant (13-gauge, 2-inch) sizes
• The most commonly used pediatric sizes for BMA and BMTB are 16/18 gauge and 13 gauge respectively

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Bone marrow examination needles �(Aspiration & Biopsy)

• Child would be kept nil per oral, start IV fluids for children less than five years/with poor oral intake / with persistent vomiting
• Site is prepared with spirit, betadine followed by spirit
• Position patient for procedure
• Local anesthesia using 1-2% lignocaine
• IV sedation is administered (ketamine + midazolam is most commonly used )
• Puncture selected site with BMA needle & advance to periosteum
• Enter the bone marrow space with a twisting motion until the needle is firmly anchored in the bone
• Stylet is removed and a syringe without anticoagulant is attached to needle to aspirate 0.3-0.5 ml of aspirate
• BM smears should be immediately prepared

Technique for BM Aspirate

A second syringe (10-20 ml plastic syringe without anticoagulants) should be attached

to draw samples for additional tests like

Morphology EDTA vial

Flowcytometry EDTA vial or Heparin vial

Cytogenetics (chromosomal analysis) :Heparin vial

Molecular studies (EDTA)

Microbiology, BM culture, EM (where required)

If it’s a ‘dry tap’, Procedure may be repeated at a different angle/ site

After proper samples are obtained, stylet is reinserted, needle removed, site is sealed

Post procedure monitoring of patient is done

• Correct colour coded vials must be used based on institutional practice
• EDTA (purple top tube) tube for molecular diagnostics and cell morphologic assessment
• Heparinized tube (sodium heparin)(green top tube) for cytogenetic (chromosome) analysis.

Technique for BM Aspirate Contd

Push Slide Technique:

• This technique is similar to that used to make cytology or hematology slides
• Marrow is collected and a drop (containing marrow particles) is placed toward the end of one slide
• It is then spread in an even film using a second glass slide (held at an angle) as a spreader
• The spreader slide is slid forward the length of the slide to produce a smear

Making a good quality Smear

Technique for BM Biopsy

• A marrow biopsy and aspiration can be carried out through the same skin site
• Hold the needle with the proximal end in the palm and the index finger against the shaft near the tip
• With the stylet locked in place, introduce the needle through the skin pointing toward the anterior iliac spine
• Using gentle pressure, advance the needle with a slight twisting motion until it feels anchored to the bone; remove the stylet, then using alternating clockwise and counter-clockwise motion, advance the needle slowly for 2 mm to 10 mm into the bone; the depth of the insertion depending on the size of the patient.
• Rotate the needle with three twists to the right and then to the left without advancing; repeat once again, then withdraw the needle using a rotary motion.
• Using a sterile gauze pad, apply manual pressure to the site until the bleeding stops.

Technique for BM Biopsy Contd

• Remove the bone specimen from the biopsy needle by introducing a probe through the distal end (this prevents specimen crushing).
• An adequate biopsy in children should contain at least 0.5 cm of well-preserved bone marrow.
• Drop the specimen in formalin and label.
• If uncertain whether marrow particles have been obtained with the aspirate, before placing it in formalin, roll the biopsy specimen along a slide to obtain touch imprints.
• Minimum recommended core biopsy lengths for improved diagnostic yield: 2 cm (International Council for Standardization in Hematology) and 1.5 cm (World Health Organization)

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Imprint:

If uncertain whether marrow particles have been obtained with the aspirate,

before placing it in formalin, roll the biopsy specimen along a slide to obtain touch

imprints

Sample Handling

BM aspirate: Check for marrow particles

• make smears immediately
• send samples for morphology and lineage ascertainment (EDTA)
• Cytogenetics karyotyping (heparin)
• Molecular tests EDTA

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BM biopsy :

Drop sample in formalin and label

Complications

1. Common adverse events include hemorrhage, infection, and persistent pain at the marrow site.

• Hemorrhage predominantly occurs in the buttocks, thighs, and retroperitoneum.
• Increased risk of bleeding is observed in patients undergoing both BMA and BMTB, as well as those diagnosed with myeloproliferative disorders or osteoporosis.
• Patients with severe thrombocytopenia, platelet dysfunction, coagulopathy, von Willebrand's disease, renal impairment, obesity, or on anticoagulant therapy are at higher risk.

2. Breakage of the marrow needle is a rare occurrence.

3. Rare Complications Include

• Gluteal compartment syndrome
• Arteriovenous fistulizations
• Pseudoaneurysmformation
• Internal iliac artery injury

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• Sciatica with neurological deficit
• Osteomyelitis
• Sacroiliac septic arthritis
• Septicemia

Post Procedure Instructions

Post-procedure

documentation of procedure along with the details of analgesia/sedation used

Patients are instructed to remove the bandage the following day, with no specific bed rest required.

A discharge summary must be provided to patients.

Clear instruction on timeline and how to access the reports should be given to the family.

An algorithm for the bone marrow procedure in children

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Contributors

Dr Rachna Seth

Dr Seema Mishra

Dr Manisha Jana

Dr Jagdish Prasad Meena

Dr Priyanka Naranje

Dr Aditya Kumar Gupta

Dr Raghav Gupta 

Dr Nivedita Pathak

Catherine Lam, MD, MPH

Saman Hashmi, MD

Monnie Abraham, PhD, MSN

Asya Agulnik, MD, MPH

Kavitha Raghavan, MBBS

Leeanna Fox Irwin, MA

Daniel Moreira, MD, Med

Hafeez Abdelhafeez, MD

St. Jude Children's Research Hospital

World Health Organization

Dr. Roberta Ortiz

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Dr. Bishnu Rath Giri

SEAR - CCN

Dr. Suchita Tuladhar, MD

Nepal

AIIMS Faculty

AIIMS Fellows

AIIMS Staff Nurses

AIIMS Administrative Support

Dr Amitabh

Dr Sharan Shanubhogue

Dr Shivani Deep Singh

Dr Ruksana Sidhique P R

Dr Satyendra Batra

Dr Prateek Maurya

 Ms.Tincy Thomas

Ms. H. Vungenimoi

Ms. Priya Siradhana

Developed by

Pediatric Oncology Division, Department of Pediatrics

AIIMS, New Delhi

As a common resource for the South-East Asia

Regional Childhood Cancer Network (SEAR-CCN)

With Support From

WHO Regional Office for South East Asia and

St. Jude Children’s Research Hospital

through the Global initiative for childhood cancer