Bone marrow aspiration & trephine biopsy

Bone marrow aspiration & trephine biopsy, Complication of BM Aspiration, Clinical significance, Indication of Bone Marrow Aspiration and Biopsy, Types Of Needles, Site for Bone Marrow Biopsy And Aspiration, types Of Smear for Bone Marrow, Advantages of Bone Marrow Trephine Biopsy

1. BONE MARROW ASPIRATION & TREPHINE BIOPSY GUIDED BY:- Mr. S.K. Bose Sir Mr. Ishwar Bihana Sir PRESENTED BY:- Sanjeev Kumar BSC MLT 2 ND year 1 DEPARTMENT OF HAEMATOLOGY

2. INTRODUCTION BONE MARROW ASPIRATION Aspiration is aspirate of the contents of bone marrow drawn under pressure by puncturing marrow cavity. When there is abnormal finding in routine blood film, bone marrow evaluation become important to know the exact cause. TREPHINE BIOPSY Removal of a small core of BM under local anesthetic. It is used to assess BM structure, the no. & distribution of all types of blood cell . Trephine biopsy is 1-2cm long 2-3mm in dia. Of the marrow containing bone taken by rotating specialized needle under pressure 2

3. BONE MARROW ASPIRATION 3

4. Historical Events 4

5. Indication for B M aspiration D etermine the cytological types and proportions of haematopoietic cells in the marrow Study and classify nucleated blood cells of the bone marrow Determine the ratio of immature white blood cells to red blood cells (M:E ratio, myeloid:erythroid precursors) Assess number and morphology of megakaryocytes Investigate anaemia (abnormally low number of red blood cells in the bloodstream) Evaluate abnormalities in the blood’s ability to store iron 5

6. Diagnose an infection with an unknown cause, blood disorders, chromosomal or genetic diseases, cancer of the blood cells, such as leukaemia, lymphoma, multiple myeloma, neutropenia (low neutrophils count), thrombocytopenia (low platelet count), Polycythaemia (high red blood cell count), pancytopenia (reduction in the number of red and white blood cells, as well as platelets) A bone marrow aspiration may be performed in people with certain types of cancer to: monitor the side effects of chemotherapy see whether the treatment is working. 6

7. requirements Aspiration needle Should be stout and made of hard stainless steel. About 7-8cm in length with a well fitting stylet provided with a adjustable guard to prevent over penetration. The most commonly used needle is Salah / Klima. Bore size 0.2mm. Spirited swab Betadine Local anaesthesia (2% lignocain and Xylocaine) Two 10-20ml syringe Clean grease free and iron free glass slide Smooth edge glass slide spreader to make aspirate film. 7

8. Types of Needles Salah Needle: has a guard with a side screw Klima Needle: has a guard which screw along the length of the needle. The needle is advanced into the marrow cavity with the stylet locked is place, the stylet is then removed and syringe used to aspirate the marrow. Jamshidi Needle: which is longer can be used for both aspiration & biopsy from iliac crest. 8 Salah Needle Klima Needle

9. Anticoagulant for different studies 9

10. fixative 10

11. Sites for BMA Iliac spines or crest: This is the most commonly employed site for reason of safety, has a large reservoir of marrow, a decreased risk of pain and accessibility. There is no large blood vessels or nerve to this area. Sternum: Last resort in those older than 12 year. Avoided since causes more pain for the patient and present the risk of heart injury. Tibia: Sampled only for infants younger than one year. Spinous process of lumber vertebra: This is an additional site for aspiration in adults. 11 Site for Bone Marrow Aspiration

12. Site for Bone Marrow Aspiration Posterior Superior iliac crest :- This is the most commonly employed site for reason of safety, a decreased risk of pain and accessbilty. Anterior Superior iliac Crest :- This is an alternate site when the posterior ilia crest is unapproachable or not available due to infection, injury or morbid obesity. Aspirate only Sternum :- Last resort in those older than 12 year. Avoided since causes more pain for the patient and present the risk of heart injury. Tibia: - Sampled only for infants younger than one year. 12

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14. PROCEDURE The patient is placed in the lateral position, with the top leg flexed and the lower leg straight. Palpate the iliac crest, and mark the preferred sampling site with a pen. Aseptic technique is employed, including sterile gloves and gown. The site is prepared with an antiseptic (eg, povidone-iodine or chlorhexidine gluconate), scrubbed, and draped, exposing only the site to be sampled. 14 From Posterior iliac crest (PIC) Skin preparation

15. The skin and the underlying tissue to the periosteum are infiltrated with a local anesthetic (eg, approximately 10 mL of 1% Xylocaine ). A 10-mL syringe with a 25-gauge needle is used to inject an initial 0.5 mL directly under the skin, raising a wheal. A 22-gauge needle is used to penetrate deeper into the subcutaneous tissue and the underlying periosteum, an area roughly 1 cm in diameter. Local anaesthetic injection 15

16. Adequacy of the anesthesia is tested by gently prodding the periosteum with the tip of the needle and questioning the patient for any painful sensation. Once the needle contacts the bone, it is advanced by slowly rotating clockwise and anticlockwise until the cortical bone is penetrated and the marrow cavity is entered. Contact with the marrow cavity is usually noted by a sudden reduction in pressure. The depth of the penetration should not extend beyond an initial 1 cm. Aspiration needle placement 16

17. Once within the marrow cavity, the stylet is removed. Using a 20 mL syringe, approximately 0.3 mL of bone marrow is aspirated. The material collected for bone marrow slides is generally not mixed with an anticoagulant, and it is processed immediately; this avoids any cellular morphologic artefacts. Bone marrow aspiration 17

18. 18 Risk involved in bone marrow aspiration Risk Involved In Bone Marrow Aspiration People with bleeding problems have a higher chance of bleeding from biopsy site. If patients have bleeding problems, pressure will be put on the biopsy site for at least 10 minutes after the biopsy. In rare cases, patients may be given a blood product (clotting factor or platelets) in a vein in arm before the aspiration to prevent bleeding after the aspiration/biopsy. Infection of skin or the bone at the biopsy site, especially in people with compromised immune system. Injury to heart, a lung, or a major blood vessel if the sample is taken from the sternum. This complication is very rare. Pain after the procedure.

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21. Preparation of aspirated smear 21

22. CONCENTRATION 22

23. STAINING ROUTINE STAINS SPECIAL STAINS 23 Romanowsky Stain’s May Grunwald Giemsa stain Giemsa stain Leishman stain Haematoxylin & Eosin stain Perl’s stain Reticulin stain Cytochemical stain (for Leukemia classification)

24. Advantages of Marrow Aspiration 24

25. Disadvantages of Marrow Aspiration 25

26. TREPHINE BIOPSY 26

27. Indications of BM Biopsy Repeated failure to obtain adequate material by aspiration. In myelofibrosis biopsy for confirmation as fibrosis cannot be demonstrated with certainty on smears from aspirates. In case of metastatic tumor, lymphoma or granulomatous disease may be observed in aspirated material, but they are easily found in sections from biopsy specimens. An end point of aplasia. 27

28. REQUIREMENTS Disinfectant : 70% alcohol. Local anthesia : 2% Xylocaine Fixatives : 95% Zenker sol, 10% Formal saline, 10% NBF Gloves Clean slides Biopsy needle : Jamshidi needle Turkel & Bethell Vim-Silverman needle Islam trephine 28

29. Jamshidi Trephine It consist of a cylindrical needle of 2mm bore size constant except tapered concentrically at the distal position. Ending in a sharp beveled cutting tip with a precisely fitting stylet which extends 1-2mm beyond the length of needle. 29

30. ISLAM TREPHINE VIM-SILVERMAN It has a core securing device which obtain a uniform core of marrow without disturbing morphology & anatomy It consists of an outer cannula, an obturator, and an inner split needle with longitudinal grooves in which the tissue is retained when the needle and cannula are withdrawn. 30

31. SITES FOR BM TREPHINE BIOPSY 1. Anterior superior iliac spine. 2. Posterior superior iliac spine (commonly used this site) 31 Place for the procedure:- Under aseptic conditions(minor OT) .

32. PROCEDURE 32

33. conti……. 33

34. Determining length of biopsy core in needle by carefully reinserting obturator. Ideally, the core length should be 2 cm or greater. 34

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36. POST BIOPSY CARE FINISHING UP:- After procurement of the marrow specimens, bleeding must be stopped, the procedure site must be cleaned up, needles properly disposed of in a Sharps container, and the site bandaged. A procedure note must be placed on the patient’s chart. After procedure is completed apply pressure over the posterior Ilium for about 60 min. Pressure is obtained by a pressure dressing & by having the patient lie recumbent(flat position) in bed. After that assuming no bleeding is observed the patient can getup & go about their normal activities . Patients are advised to avoid washing the procedure site for at least 24 hr after the procedure is complete. 36

37. TREPHINE PREPARATIONS Touch smear:- Collected specimen extruded in rough the hub of needle & touched gently across the slide by using the forceps. Put the smears in the fixative jar. 37 Touch smears have special value because cells of primitive type tend to be present in compact clusters and thus may be missed if only the more fluid portions of the marrow are examined.

38. Histology section preparation:- Fixation Decalcification Processing Sectioning Staining 38

39. ADVANTAGES OF TREPHINE BIOPSY 39

40. Precautions of BONE MARROW Bone marrow procedure is preffered with strict attention to ASEPTIC technique & UNIVERSAL precautions for the transmission of BLOODBORNE pathogens. Fixatives fluids, slides, tubes with the proper ANTICOAGULANT should be at bed side so the specimen can be preserved immediately & slides preparations that are of suitable quality. ALLERGIES or previous adverse reaction to medicine should be discussed with doctor. 40

41. Conti… Any med. Including Herbal or Nutritional supplements should be evaluated to interfere with proper coagulation(clot formation). Caution should be used when the Herbs gingto , garlic, have been utilize as supplement due to risk of bleeding. Pregnancy, lactation & pre- exesting , platelets or blood disorder should be evaluated before procedure is undertaken. 41

42. THANK YOU 42