Pavuls presentation bonemarrow aspiration techniques

Dr.Pavulraj.S
M.V.Sc., (Veterinary Pathologist)
Research fellow
National Research Centre of Equines, India
2/15/2015
Dr.Pavulraj. S., Veterinary Pathologist, Research
fellow, NRCE, India

 Bone marrow samples may be obtained by aspiration
through a bone marrow needle or by punch-type
biopsy through a trephine instrument (core biopsy).
2/15/2015
fellow, NRCE, India

I. Aspirate or core biopsy
 Nonregenerative anemias
 Suspected bone marrow disease: myeloid or erythroid
suppression, neoplasia
 Leukocytosis
 Polycythaemia
 Certain clotting disorders, especially involving
platelets
 Looking for organisms that cause systemic infection
 Histoplasma
 Leishmania
2/15/2015
fellow, NRCE, India

II. Core biopsy
 To study the structural architecture of the bone
marrow when aspiration biopsies have been
unsuccessful
 When searching for metastatic or occult neoplasia
 Certain metabolic disorders of bone
2/15/2015
fellow, NRCE, India

 Severe coagulopathy
 DIC
 Anti-vitamin k rodenticide toxicity
 Severe liver failure
 Severe anemia
 Severe thrombocytopenia
2/15/2015
fellow, NRCE, India

Two procedures
 Bone marrow aspirates
 Bone marrow core biopsy
Steps:
1. Preparing equipment
2. Patient preparation and sedation
3. Placement of the sampling needle
4. Procuring the sample
5. Preparing slides
6. Confirming adequate sampling
7. Submitting samples to the lab
2/15/2015
fellow, NRCE, India

1.Proximal
humerus
2. Proximal femur - Easier in the cat
3. Wing of the ilium
4. Rib 2/15/2015
fellow, NRCE, India

 Biopsy needle (12 g for large dogs, 14 g for small dogs
and cats)
 Surgical scrub
 10ml syringe
 Local anaesthetic
 Scalpel handle and blade
 Microscope slides
 Quick Stain (e.g., DiffQuick)
 Microscope
2/15/2015
fellow, NRCE, India

 Rosenthal needle
 Jamshidi needle
 13 to 8 gauge
 For core biopsy or aspiration
 Fine wire use to remove the core biopsy
 End of the needle is tapered to retain the core
2/15/2015
fellow, NRCE, India

I. Most biopsies may be performed using local anesthesia,
with or without mild sedation.
II. The position of restraining is determined by the site to be
biopsied.
 A. Wing of ilium
 1. Large dog: standing or sternal recumbency
 2. Small dog or cat: sternal recumbency with hind legs
drawn up alongside the abdomen
 B. Proximal femur: lateral recumbency
 C. Rib: sternal or lateral recumbency
 D. Proximal humerus: lateral recumbency
 E. Other less commonly used sites: ischial tuberosity,
sternum
2/15/2015
fellow, NRCE, India

 Shave the hair over the biopsy site, which is then
prepared aseptically and infiltrated with local
anesthesia down to periosteum.
 Make a small stab incision in the skin with a scalpel
blade.
2/15/2015
fellow, NRCE, India

A. Select a 16- or 18-gauge, 1.5-inch Rosenthal biopsy
needle.
B. With the stylet in place, advance the needle through
the soft tissues until it meets resistance at bone.
C. Push the needle through the bone by applying
pressure with a simultaneous rotating motion.
D. Decreased resistance indicates that the needle has
passed through the cortex into the marrow cavity.
2/15/2015
fellow, NRCE, India

E. After advancing the needle into the marrow, remove
the stylet, attach a 12-mL syringe, and exert negative
pressure on the syringe.
 Evidence of pain with aspiration usually indicates that
the needle is located within the marrow cavity.
 When marrow appears in the syringe, aspiration is
halted and the syringe disconnected.
 Over aspiration may lead to contamination of the
sample with peripheral blood.
2/15/2015
fellow, NRCE, India

 Smears are quickly made on glass slides, and any clot is
saved in formalin for histologic examination.
 A sample may also be submitted for culture.
F. If adequate marrow is retrieved, withdraw the needle.
G. The skin incision may be sutured or left to heal by
second intention.
2/15/2015
fellow, NRCE, India

 Bone marrow from the humerus is obtained by
palpating the bony prominence of the greater tubercle
lateral to the biceps tendon.
 The needle is inserted at a spot perpendicular to the
long axis of the bone.
2/15/2015
fellow, NRCE, India

2/15/2015
fellow, NRCE, India

 To retrieve a sample from the marrow cavity of the
proximal femur, a bone marrow needle is advanced
through the trochanteric fossa caudal and medial to
the greater trochanter and directed laterally in a line
parallel to the shaft of the femur.
2/15/2015
fellow, NRCE, India

 Insertion of bone marrow needle through the dorsal
iliac spine into the marrow cavity of the wing of the
ilium.
 The medial and lateral aspects of the spine are
localized with the thumb and forefinger of one hand.
With the other hand, the needle is directed ventrally
and slightly laterally into the central portion of the
wing of the ilium.
2/15/2015
fellow, NRCE, India

 Bone marrow aspiration from a rib. Usually the 7th,
8th, or 9th rib is chosen.
 The biopsy needle is inserted at a slightly ventral angle
at a point midway from the neck of the rib to the costal
cartilage.
2/15/2015
fellow, NRCE, India

 Using a core biopsy instrument (e.g., Jamshidi bone marrow
needle), advance the needle, with the stylet in place. As soon
as the needle is well seated through the cortex, remove the
stylet, and replace the cap and handle
 Advance the needle 1-2 cm further, rotating in a single
direction
 Stir the needle to break loose the core
 Remove the needle rotating in a single direction
 Pass the wire or stylet backward to pop the core out the
top of the needle
 Core 0.75-1 cm long is sufficient
 Cytologies can be made by rolling the core on slides, or
scraping it
 Place cores in formalin for histopathology
2/15/2015
fellow, NRCE, India

 Pipette flecks out of the petri dish and put on glass
slides immediately
 Elevate one end of the slide to let extra blood run off
2/15/2015
fellow, NRCE, India

 Prepare gentle horizontal smears as well as vertical pull apart
preps
 Use a very light touch for the horizontal preps
2/15/2015
fellow, NRCE, India

I. Complications are rare.
II. Damage to adjacent structures may occur.
 A. Poor positioning of the needle in the trochanteric
fossa may damage the sciatic nerve.
 B. Accidental pneumothorax or laceration of
intercostal vessels may accompany rib biopsies.
III. Infiltration of the trochanteric fossa with local
anesthetic may result in transient paresis of the sciatic
nerve.
2/15/2015
fellow, NRCE, India

Advantages of aspiration
 Cellular morphology is more clear
 Better identification of cell lineages
 Characteristics of malignancy
 Can calculate E:M ratios
 Estimate regenerative responses
 Interpret with respect to CBC and reticulocyte count
 Normal 3:1 to 5:1
 Maturation sequence counts are easier
 More mature cell stages should be present in successively greater
numbers
 More younger cells means leukemia, maturation arrest or
immune mediated destruction of the next stage
2/15/2015
fellow, NRCE, India

Advantages of core biopsy
 If repeated attempts to aspirate produce no fluid (“packed
marrow”)
– myelophthisic disease
 Myelofibrosis
 (artifact)
 If repeated attempts to aspirate produce blood only with flecks
of fat
 Aplastic anemia (hypocellular marrow)
 Can evaluate marrow cellularity
 Can evaluate tissue architecture
 Invasion by normal looking lymphocytes indicates lymphoma
 Can detect myelofibrosis or myelonecrosis
2/15/2015
fellow, NRCE, India

1. Hypo-, normo- or hypercellular
2. Are all three cell lines present?
 Erythroid, myeloid, megakaryocytes
3. Is the normal maturation pyramid present in
each cell line?
 Fewest blast
 Higher numbers in each stage of maturity
4. What is the M:E ratio?
 Count 100-200 erythroid and myeloid cells
 Divide # or M by # of E
5. Decreased, normal or increase iron stores
6. Are abnormal cells present?
2/15/2015
fellow, NRCE, India

Abnormal Bone Marrow Cells
 Atypical cells – characteristics of malignancy
 leukemia or myelodysplasia
 Malignant cells in clusters – metastasis
 Mast cell tumors
 Mast cells can be present in normal marrow
 Clusters suggests neoplasia
 Plasma and Mott cells – chronic antigenic stimulation
 Ehrlichiosis or immune mediated disease
 Large numbers may indicate plasma cell myeloma
 Osteoblasts and osteoclasts - rare
2/15/2015
fellow, NRCE, India

Pavuls presentation bonemarrow aspiration techniques

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