Bone Marrow Aspiration

Bone marrow refers to the spongy tissue that is found inside the larger bones such as spine, breast bone, hips, ribs, legs and skull. Marrow has two parts – both solid and liquid. If the solid portion of the bone is sampled, it is called biopsy. Aspiration procedure is used to collect the liquid part of the marrow.

Both the procedures show whether the bone marrow is healthy and making normal amounts of blood cells. This procedure is normally used by doctors to diagnose and monitor blood and marrow diseases, including cancer. In bone marrow aspiration, the doctor uses a needle to draw a sample of the fluid portion. For a biopsy, a larger needle is used to take the sample of the solid part.

Most often bone marrow aspiration and bone biopsy is done at once. Together, they make the bone marrow examination. Although they are different procedures, they offer complementary information about bone marrow cells.

Why is it done?

Bone marrow aspiration and biopsy offer detailed information about the condition of the bone marrow and blood cells. In case the blood tests indicate that cell counts are abnormal, and information is not sufficient about a suspected problem, this is done. The doctor may perform bone marrow exam to diagnose a disease condition involving the bone marrow or blood cells:

• To determine a disease progression
  
• To check the iron levels and metabolism and
  
• To monitor treatment of a disease.

Pre bone marrow aspiration procedure

It is imperative to inform the doctor about any medications and supplements the patient is consuming. This can increase the risk of bleeding after a bone marrow aspiration. In case of anxiety or worry, better talk to the health care provider so that a sedative medication could be given before the aspiration in addition to a numbing agent through local anesthesia at the site where the needle is inserted.

Bone marrow aspiration is done in a hospital, a clinic or in a doctor's room. A specialist in blood disorders – a hematologist – or an oncologist, who is a specialist in cancer does the procedure with a nurse and a trained technologist. It usually takes about half an hour for the exam and if any intravenous sedation is given, extra time is taken for pre and post procedure care.

The patient's blood pressure and heart rate are checked. Some form of anesthesia is administered before the bone marrow aspiration as it can be painful. For many, local anesthesia is sufficient. You will be fully awake during the aspiration, but the site is numbed to reduce pain. If you are quite anxious, intravenous IV sedation is given before the marrow procedure.

Bone marrow aspiration procedure

The area for inserting the biopsy needle is marked and cleaned. The bone marrow fluid (aspirate) is usually collected from the top ridge of the back of the hipbone, and if it is done from the breast bone or the front of the hip near the groin. In young children and kids, the sample is taken from the lower leg bone, just below the knee. The patient will be made to lie down on the abdomen or side.

The bone marrow aspiration is usually done before the biopsy. A small incision is made to insert the needle easier. A hollow needle is inserted through the bone and into the bone marrow. Several samples are taken and aspiration takes only a few minutes. While the health care team ensures that sufficient quantity of sample is drawn, sometimes a 'dry tap' may occur, that is fluid cannot be withdrawn. The needle is moved for another attempt.

Post aspiration procedure

After the bone marrow exam, pressure is applied to the where the needle was inserted to stop the bleeding. A smaller bandage is placed on the site. If local anesthesia had been administered the patient is asked to lie back for 10-15 minutes and apply pressure on the biopsy site. In case, IV sedation had been given, you are taken into a recovery area as sedatives may cause impaired judgment, memory lapses or slowed response.

Tenderness may be felt for a week or more after the bone marrow exam, and the doctor administers pain reliever. You need to keep the bandage dry for 24 hours and not shower or bathe, or swim or use the hot tub. It is okay to get the aspiration site wet after 24 hours. In case bleeding soaks through the bandage, or does not stop even with direct pressure, consult the doctor. The doctor also needs to be contacted if there is persistent fever, worsening pain, swelling at the procedure site and increasing redness or drainage at the procedure site. Also it is advised to avoid rigorous activity for a couple of days to minimize bleeding and discomfort.

Results from bone marrow aspiration

The sample is sent to a laboratory for analysis. The results are available in a few days. The pathologist or hematologist evaluates the samples to check the health of the marrow and if it has enough healthy blood cells and also for abnormal cells. The doctor confirms or rules out a diagnosis and how advanced the disease is or if the treatment is working. Sometimes, follow-up tests are done.

Risks of bone marrow examination

This is a safe procedure and complications are rare. But some complications include:

Excessive bleeding which can happen in people with low platelet count.
Infection in those with weakened immune systems.
Discomfort that could be long lasting in the biopsy site.
Heart and lung problems can be caused due to penetration of the breastbone.
Sedation can cause allergic reaction, nausea and irregular heartbeats in some.

Uses of bone marrow exams

These are used for many conditions including:

• Anemia
  
• Bone marrow disorders which include myelodysplastic syndrome and myelofibrosis.
  
• Blood cell conditions such as Leukopenia, leukocytosis, thrombocytopenia, thrombocytosis, pancytopenia and polycythemia – which produce too few or too many of certain types of blood.
  
• Cancers of the bone marrow or of blood including leukemia, lymphomas and multiple myeloma.
  
• Cancers that have spread to other areas including breast.
  
• Hemochromatosis and
  
• Infections.

While problems with bone marrow can create lasting and serious health problems, bone marrow exams, such as aspiration and biopsy are important to help determine the status and extent of problems in the cells to evaluate and determine further treatment and management.

Neutrophilia

High levels of neutrophil in the blood results in neutrophilia; neutrophils are White Blood Cells or WBC that are assigned the task of killing/fighting off foreign matter like fungi and bacteria in the body. They are an important part of the body's defense force. An adequate amount of production and distribution of neutrophils is very important. However during an infection in the body, an elevated level of neutrophils can be found, with equal numbers in marginal and circulating pool.

The site of infection generates chemotactic agents and attracts neutrophils to the affected part. During recovery the flow of cells decreases from the marrow and this in turn decreases the amount of neutrophils. Neutrophilia is the most common form of leukocytosis - a condition wherein the blood has an increased number of leukocytes. When the cells shift from the marginal to circulating pool without an increase in the total blood granulocyte pool or if there is an increase in size of the TGBP, it could result in Neutrophilia.

Women in their childbearing age have a higher neutrophil count when compared to men. Pregnancy also leads to high neutrophil count and this may tend to increase during childbirth.

Neutrophilia occurrence

True Neutrophilia: True Neutrophilia occurs in most cases of infection and total blood granulocyte pool, the TGBP, may increase 5-6 times the normal level. At the onset of the infection, Neutrophilia count decreases and then it rises to very high levels.

Shift Neutrophilia: Shift Neutrophilia as the name indicates is transient (e.g. during heavy exercise) and may occur in association to other conditions. The change in numbers may last only for a few minutes. There is no change in the inflow of neutrophils from the bone marrow.

Causes for Neutrophilia

Neutrophilia is caused due to increase in bone marrow output or redistribution of white cells. Though there are numerous possibilities for an elevated level of neutrophils in the blood, the most common causes include:

• Infections, caused by cocci, certain fungi, bacteria (local or generalized), viruses (chickenpox, herpes simplex) and parasites (hepatic amebiasis, Pneumocystis carinii) lead to Neutrophilia
  
  
• Non-infectious inflammation like burns, post surgery, acute attack of gout, asthma, rheumatic fever, autoimmune conditions, any kind of trauma, tissue damage, myocardial infarction can also lead to Neutrophilia
  
• Acute and sudden hemorrhage can lead to inflammation and thus lead to Neutrophilia.
  
  
• Poisoning from sources like mercury, lead, digitalis, camphor, quinidine and certain insects can also lead to Neutrophilia
  
  
• Metabolic changes in the body like diabetic ketoacidosis, uremia, etc can cause Neutrophilia
  
  
• Malignancies and other kinds of spreading cancer, where the tumor outgrows the blood supply can lead to neutrophilia
  
  
• Physiologic Neutrophilia is also caused by heavy exercise, epinephrine injections, etc
  
  
• Other causes for Neutrophilia could include seizures, anemia, increase or decrease in platelet count, short or long term usage of corticosteroids, Cushing disease etc
  
  
• Cigarette smoking can cause inflammation and thus lead to Neutrophilia.
  
  
• High levels of stress can also lead to increase in levels of neutrophils and thus cause Neutrophilia.
  
  
• Neutrophilia may be present without any particular cause that can be identified, this type of neutrophilia is called chronic idiopathic neutrophilia.

Diagnosis

Most often neutrophilia is a reactive phenomenon and can be diagnosed through blood tests. A physical examination is done and the medical history of the patient is studied. A complete blood count investigation and a series of blood tests are ordered for. In a few cases bone marrow aspiration is ordered for. The commons symptoms reported include decreased body temperature or hypothermia, dyspnea (labored breathing) or tachypnea (rapid breathing) and sometimes bleeding.

Hodgkin's Disease

Hodgkin's Disease refers to a condition that was first described by British physician Thomas Hodgkin. Hodgkin's disease or Hodgkin's lymphoma is a malignant growth of lymph cells. This uncommon form of cancer of the lymph system is characterized by abnormal growth of cells in the lymph system thereby spreading beyond it. It progressively compromises the body's immune system. While Hodgkin's disease can occur to a person at any time of his life, it is noticed in early adulthood or late adulthood. Usually, Hodgkin's disease begins in the lymph nodes and may spread to other parts of the body. The difference between Hodgkin's disease and non-Hodgkin's lymphoma is that tumors in Hodgkin's syndrome contain large cells called Reed-Sternberg cells.

Patients suffering from Hodgkin's disease notice painless swelling in the lymph nodes of the neck, armpit or groin. There may be fever and fatigue. The patient loses weight and feels drained of energy. Unexplained itching and lower back pain may also be noticed.

Most often diagnosis of Hodgkin's lymphomas is made during physical check-ups. A biopsy is done to test for the presence of Reed-Sternberg cells that are characteristic to Hodgkin's lymphomas. Blood test will reveal abnormal blood cell count and ESR. Bone marrow aspiration is done to aid diagnosis and treatment. Cellular activity can be traced with Positron Emission Tomography (PET) scan. Treatment for Hodgkin's disease depends on the stage that the disease is in. This determines the extent and region of lymph nodes that have been affected.

Radiation therapy is resorted to when a limited area is affected by Hodgkin's disease. Here high-energy rays are used to kill cancer cells and stop their proliferation. Often it is used in combination with chemotherapy. Chemotherapy may involve a combination of drugs that work together.