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CLINICAL PERSPECTIVES ON BONE MARROW BIOPSY: A NURSING APPROACH

ELLEN ROVNER, CNP

IU SIMON CANCER CENTER

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DISCLOSURES

Member of APP speaker’s bureau for Pfizer

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LEARNING OBJECTIVES

Define bone marrow biopsy
Explain how a bone marrow biopsy is performed
Explain why a bone marrow biopsy is done
Describe testing performed on bone marrow biopsy samples

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WHAT IS A BONE MARROW BIOPSY

Bone marrow biopsy is a diagnostic tool
Three components of bone marrow biopsy

Bone marrow aspirate
Bone marrow core
Bone marrow clot section

https://www.hematology.org/education/trainees/fellows/hematopoiesis/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer

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RATIONALE FOR PERFORMING BONE MARROW BIOPSY

Assessment of hematopoietic system
Evaluate abnormalities in hematopoietic system
Further evaluation of abnormalities in physical exam; for example splenomegaly or lymphadenopathy
Hematopoiesis is the process of blood cell production which takes place in the bone marrow

Bone Marrow Aspiration and Biopsy, October 2017; Available from https://www.the nurseszone.com

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WHO PERFORMS PROCEDURE

Typically a provider specializing in hematologic or oncologic disorders
Can be physician or advanced practice provider (NP or PA)
Can be performed by radiologist as a CT guided biopsy

Advantage is use of twilight anesthesia for patient who cannot tolerate procedure though this is rarely required

https://my.clevelandclinic.org/health/diagnostics/17735-bone-marrow-biopsy

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HOW A BONE MARROW IS PERFORMED

Generally performed in the outpatient setting but can be done inpatient as well
Most common location to perform procedure is iliac crest but sternum can be used for aspirate only
Can collect biopsy, aspirate, clot section and touch preps with single procedure
At completion of procedure pressure dressing is applied

https://www.hematology.org/education/trainees/fellows/hematopoiesis/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer

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https://my.clevelandclinic.org/health/diagnostics/17735-bone-marrow-biopsy

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HOW I PERFORM BONE MARROW BIOPSY PROCEDURE

Explain procedure and obtain consent
Place patient in prone or side lying position
Identify landmarks and posterior iliac crest; mark area to be biopsied
Cleanse area with chlorhexidine or iodine
Using 22 gauge needle initiate numbing with 1% or 2% lidocaine
Verify anesthesia and initiate procedure with bone marrow needle
Pass through periosteum to bone marrow and obtain aspirate sample (verify presence of bone spicules)
Once aspirate obtained proceed with core biopsy
Remove bone marrow needle and apply pressure to site
Apply pressure dressing

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COMPLICATIONS OF PROCEDURE

Potentially (will be) painful
Bleeding at biopsy site
Local infection or infection of bone (very rare)
Retroperitoneal bleeding from penetration into bowel cavity with too deep penetration of iliac crest
Unsuccessful biopsy-dry tap

Bone Marrow Aspiration and Biopsy, October 2017; Available from https://www.the nurseszone.com

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COMPLICATIONS

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POST PROCEDURE PATIENT INSTRUCTIONS

Call clinic with fever or signs of local infection
Call clinic with any bleeding at procedure site
Call clinic with prolonged pain greater then 1-2 days not relieved with acetaminophen
Patient should avoid overexertion for at least 24 hours after procedure

https://www.uptodate.com/contents/search?search=post%20procedure%20instructions%20post%20bone%20marrow%20biopsy&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&autoComplete=false

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CONTRAINDICATIONS TO PERFORMING BONE MARROW BIOPSY

Coagulation disorders
Anticoagulation use-only if out of therapeutic range for INR physician preference
Prior radiation at biopsy site
Bone disorders such as osteoporosis
Severe thrombocytopenia rarely considered contraindication

https://www.dynamedex.con/procedure/bone-marrow-biopsy-and-aspiration

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INDICATIONS FOR BONE MARROW BIOPSY AND ASPIRATION

Unexplained cytosis, cytopenias or atypical cells noted on peripheral blood smear
Diagnosing and staging of hematopoietic malignancies
Evaluation of osseous lesions noted by radiologic exam concerning for malignancy
Investigating hepatomegaly on physical exam or fever of unknown origin
Assessment of storage disorders such as iron deposition

Jain S, Sharma R. Laboratory Evaluation of Bone Marrow. [Updated 2024 Mar 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603716/

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NON-HEMATOLOGIC INDICATIONS FOR BONE MARROW BIOPSY

Diagnosis of neuroblastoma in children
Diagnosis of rhabdomyosarcoma in children
Diagnosis of Ewing sarcoma in children

https://www.dynamedex.con/procedure/bone-marrow-biopsy-and-aspiration

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TESTING PERFORMED ON BONE MARROW ASPIRATE

Assessment of cellular morphology-how cells look(too big, too small, irregular etc.)
Cell lineage assessment-what cell line do cells belong to
Perform differential count typically 500 cells are counted and can be compared to peripheral cell count done at same time
Flow cytometry, cytogenetics and molecular testing such as Next Generation Sequencing (NGS)

https://www.hematology.org/education/trainees/fellows/hematopoiesis/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer

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TESTING PERFORMED ON BONE CORE BIOPSY

Overall marrow cellularity, trilineage hematopoiesis and marrow architecture
Immunohistochemical stains for cell phenotyping
Assess cellular distribution of maturing hematopoietic elements-precursor and mature blood cells

Jain S, Sharma R. Laboratory Evaluation of Bone Marrow. [Updated 2024 Mar 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603716/

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TESTING PERFORMED ON CLOT SECTION

Initially set in formalin and embedded in paraffin blocks for preservation
Allows for two dimensional cross sections
Highly useful if core biopsy is suboptimal as can be used for data on morphology, architecture of bone marrow, cellularity and hematopoietic lineage assessments
Can also be used for immunohistochemical stains and analysis

https://www.hematology.org/education/trainees/fellows/hematopoiesis/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer

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DEFINITIONS

Cytogenetics-testing samples for changes in chromosomes including broken, missing or extra chromosomes
Flow cytometry-measures the number of cells, percentage of live cells, characteristics of cells such as size and shape
Immunohistochemistry-uses antibodies to check for certain markers to provide data in addition to that found in traditional morphology exams.
Next Generation Sequencing (NGS)-sequences DNA and RNA to study genetic mutations and variations. More precise than traditional cytogenetics
Minimal residual disease (MRD)-Measurement used in hematologic malignancies to describe a deep remission in which no abnormal cells are seen on sample

https://www.cancer.gov/NCI Dictionary of Terms

https://www.pmc.ncbi.nlm.nih,gov

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SUMMARY

Bone marrow biopsy used to provide information for diagnosis and treatment response evaluation in benign and malignant hematologic diseases
Most often performed in outpatient setting on posterior iliac crest
Samples include core biopsy, aspirate and clot section
Complications are rare
Testing is complex and becoming more precise and informative
Though nurses are not generally immediately involved in procedure can assist provider with procedure if needed and patient in understanding procedure and expectations

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QUESTIONS?

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