Correspondence
Bone Marrow Aspiration and Biopsy
N Engl J Med 2010; 362:182-183January 14, 2010
- Article
To the Editor:
In their Video in Clinical Medicine, Malempati et al. (Oct. 8 issue)1 provide an excellent overview of bone marrow aspiration and biopsy procedures. However, I differ with some of their recommendations.
First, the practice of rolling and smearing the extracted bone marrow trephine-biopsy specimen on sterile gauze can cause disruption of a frail specimen and exposes it to a chance of loss. In my experience, placing the specimen directly into a formalin-filled tube with the use of a trephine-biopsy needle that will trap the specimen into a needle cannula is less risky.
Second, collecting bone marrow directly into vacuum tubes (rather than using manually heparinized syringes and aspirating the bone marrow by hand) may provide a more standardized operating procedure.
Third, when smears of the aspirate are made while holding both slides in the hands (as shown in the video), there is a risk of dropping a slide. I would suggest leaving one of the slides on a flat surface and anchoring it by finger pressure. I also find that smearing bone debris that has been isolated after absorbing serum (e.g., with a wooden match) can sometimes provide better cellularity than the normal bone marrow smear.
Finally, whenever a trephine-biopsy specimen is needed, I think it is less painful for the patient if the clinician performs the biopsy first and then uses the emptied trephine needle to aspirate blood.
Daniele Focosi, M.D.
University of Pisa, Pisa, Italy
dfocosi@tin.it No potential conflict of interest relevant to this letter was reported.
1 ReferencesAuthor/Editor Response
Focosi points out several appropriate alternatives to the methods depicted in our video of bone marrow aspiration and biopsy. Our experience does not suggest that the degree of pain associated with the procedure is lower when the biopsy is performed first, and the sequence probably does not matter in the sedated patient.
We agree that a frail biopsy specimen may be damaged by collection onto gauze; however, immediate inspection of the biopsy specimen is critical and requires placement onto gauze or a glass slide. It is not uncommon for an extracted biopsy specimen to contain exclusively cortical bone without marrow, which is an inadequate sample for evaluation. Immediate placement into formalin precludes the ability to inspect the specimen appropriately. In addition, a touch preparation may provide useful information.
Although collecting aspirate into anticoagulated vacuum tubes may be feasible, in certain conditions, marrow can be difficult to aspirate and requires substantial suction. There is no ability to modify the force or pull when using vacuum tubes. In regard to the preparation of slides, we agree that a slide should be appropriately anchored to create an evaluable aspirate smear.
Suman Malempati, M.D.
Oregon Health and Science University, Portland, ORSarita Joshi, M.D.
Ken Tegtmeyer, M.D.
Cincinnati Children's Hospital Medical Center, Cincinnati, OHSince publication of their article, the authors report no further potential conflict of interest.
