About Lymphoma

Bone Marrow Biopsy

A bone marrow biopsy is a procedure used to diagnose and stage various types of lymphoma, Chronic Lymphocytic Leukemia (CLL) and other blood cancers. 

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Who needs a bone marrow biopsy?

Lymphoma and CLL are types of cancer affecting a type of white blood cell called a lymphocyte. Lymphocytes are made in your bone marrow, then move into your lymphatic system. They are important cells of your immune system that help fight infection and protect you from disease.

Lymphoma usually starts in your lymphatic system which includes your lymph nodes, lymphatic organs and vessels. However, rarely lymphoma or CLL can start in your bone marrow. More commonly though, it starts in your lymphatic system, and as it progresses travels to your bone marrow. Once lymphoma/CLL is in your bone marrow, you may not be able to make new healthy blood cells as effectively as usual. 

If you doctor suspects you may have lymphoma or CLL, they may recommend you have a bone marrow biopsy. The samples from the biopsy can show if there is any lymphoma in your bone marrow. Bone marrow biopsies can be performed by a specially trained doctor or nurse practitioner.

You may need more that one bone marrow biopsy as they can also be used to check if your disease is stable, if you are responding to treatment, or to check if your lymphoma/CLL has relapsed after a time in remission.

Not everyone with lymphoma will need a bone marrow biopsy though. Your doctor will be able to talk to you about whether a bone marrow biopsy is the right type of test for you.

bone marrow biopsy is used to take a sample of bone marrow
Your blood cells are made in your bone marrow before moving in to your lymphatic system includes your lymph nodes, spleen, thymus, other organs and lymphatic vessels. A bone marrow biopsy takes a sample of this bone marrow to test for lymphoma or CLL cells.

What is a bone marrow biopsy?

Bone Marrow sample are taken during a bone marrow biopsy
Your bone marrow is a softer, spongey part in the middle of your bones.

Bone marrow is found in the centre of all your bones. It is a spongey red and yellow looking area where all your blood cells are made.

A bone marrow biopsy is a procedure where samples of your bone marrow are taken and checked in pathology. The bone marrow biopsy, is usually taken from your hip bone, but can also be taken from other bones such as your breast bone (sternum) and leg bones.

When you have a bone marrow biopsy, two different types of samples are usually taken. They include:

  • Bone marrow aspirate (BMA): this test takes a small amount of the liquid found in the bone marrow space
  • Bone marrow aspirate trephine (BMAT): this test takes a small sample of the bone marrow tissue

When your samples get to pathology, the pathologist will check them under a microscope to see if any lymphoma cells are present. They may  also do some other tests on your bone marrow biopsy samples to see if there are any genetic changes that may have contributed to your lymphoma / CLL developing, or that may impact what treatment will work best for you. 

What happens before I have a bone marrow biopsy?

Your doctor will explain to you why they think a bone marrow biopsy is needed. They will give you information about the procedure, what you need to do before the procedure and how to care for yourself after the procedure. Any risks and benefits of the procedure should also be explained to you in a way that you understand. You will also be given an opportunity to ask any questions you may have. 

Questions for your Doctor before you sign your consent

Some questions you may like to consider asking include:

  1. Can I eat and drink before the bone marrow biopsy? If not what time should I stop eating and drinking?
  2. Can I still take my medications before the procedure? (Take a list of all your medications, vitamins and supplements to your appointment to make this easier. If you are diabetic or on blood thinners it is important to mention this to your doctor).
  3. Can I drive myself to and from the clinic on the day of my bone marrow biopsy?
  4. How long will the procedure take, and how long will I be in hospital or at the clinic on the day of my bone marrow biopsy?
  5. How will you make sure I am comfortable, or do not feel pain during the procedure
  6. When can I go back to work or school?
  7. Will I need anyone with me after the procedure?
  8. What can a take for pain relief if I get pain after the procedure?

Consent

After you receive all the information and get the answers to your questions, you need to make the decision about whether you will have the bone marrow biopsy or not. This is your choice.
 
If you decide to have the procedure, you will need to sign a consent form, which is an official way of giving the doctor permission to do a bone marrow biopsy on you. Part of this consenting needs you to state that you understand and accept the risks and benefits of the procedure, including before, during and after the procedure. Your doctor cannot do a bone marrow biopsy on you unless you, your parent (if you under the age of 18) or an official carer signs the consent form.

Day of bone marrow biopsy

If you are not already in hospital you will be given a time to come into the day unit for your bone marrow biopsy.

You may be given to a gown to change into or wear your own clothes. If you wear your own clothes, make sure the doctor will be able to to have enough room near your hip to perform the biopsy. A shirt or blouse with loose fitting pants or skirt may work  well.

Do not have anything to eat or drink unless your doctor or nurse has said it is ok. It is common to fast before a bone marrow biopsy – that is not have anything to eat or drink for several hours before you procedure. If you are not having sedation, you may be able to eat and drink. Your doctor or nurse will be able to let you know what time you need to stop eating and drinking.

It is common to have a blood test before the bone marrow biopsy to make sure your blood is able to clot properly after the procedure. Some other blood tests may also be taken if needed.

Your nurse will ask you many questions and do your blood pressure, check your breathing, oxygen levels and heart rate (these are called observations or obs, and sometimes also called vital signs).

Your nurse will ask about when you last ate and had something to drink, and what medications your are taking. If you are diabetic, please let your nurse know so they can monitor your blood sugar levels.

Before your bone marrow biopsy

You will have local anaesthetic before your bone marrow biopsy, which is a needle with medicine that numbs the area so you will feel little if any pain. Each facility is a little different in the way they prepare you for the procedure, but your nurse or doctor will be able to explain the process to you. They will also let you know about any medications you may have during or before your bone marrow biopsy.

If you have anxiety or feel pain easily, talk to your doctor or nurse about this. They will be able to make a plan to give you medication to help make you as comfortable and safe as possible.

In some cases, you may be offered sedation before your procedure. Sedation makes you sleepy (but not unconscious) and helps you not remember the procedure. But this is not suitable for everyone, and you cannot drive or operate machinery, or make important decisions for 24 hours (a full day and night) after the procedure if you have sedation.

Other types of medication you may be offered before or during your bone marrow biopsy include:

  • Gas and air – Gas and air gives short-acting pain relief that you breathe in yourself when you need it.
  • Intravenous medication – medication is given to make you sleepy but not completely asleep.
  • Penthrox inhaler – is a medicine used to reduce pain. It is breathed in using a special inhaler. Patients usually recover afterwards faster from this type of sedation. This is sometimes known as the “green whistle”.

What happens during my bone marrow biopsy?

Bone marrow biopsies are usually taken from your pelvis (hip bone). You will be asked to lie on your side and curl up, with your knees pulled up toward your chest. On rare occasions the sample may be taken from your sternum (breastbone). If this is the case you would lie on your back. It is important to be comfortable and make sure you tell the staff if you are uncomfortable. The doctor or nurse will clean the area and inject the local anaesthetic into the area.

Bone marrow biopsy
During a bone marrow biopsy your doctor or nurse practitioner will put a needle into your hip and take a sample of your bone marrow.

The bone marrow aspirate is done first. Your doctor or nurse practitioner will insert a special needle through the bone and into the space in the middle. They will then withdraw a small amount of the bone marrow fluid. You may feel a brief sharp pain when the sample is being drawn. This takes just a few minutes.

On very rare occasions a sample of the fluid can not be withdrawn. If this happens they will need to take the needle out, and try again in a different area.

Your doctor or nurse will then take a sample of the harder bone marrow tissue. The needle is specially designed to take a small core of the bone marrow tissue, about as wide as a matchstick.

What happens after my bone marrow biopsy?

You will need to stay lying down for a short amount of time (around 30 minutes). The staff will check to make sure there is no bleeding. Most people who need a bone marrow biopsy have the procedure as an outpatient and do not have to stay in hospital overnight.

The care you get after your bone marrow biopsy will depend on whether you had any sedation or not. If you have had sedation, the nurses will monitor your blood pressure and breathing every 15-30 minutes for a while – often about 2 hours after the procedure. If you had no sedation, you will not need to have your blood pressure and breathing monitored so closely.

If you’ve had sedation

Once you have fully recovered from any sedation, and your nurses are confident your wound is not going to bleed, you will be able to go home. However, you may need someone else to drive – check with your nurse about when it safe for you to drive again – if you’ve had sedation this will likely not be until the next day.

Will you have pain?

After a few hours, the local anaesthetic will wear off and you may have some discomfort where the needle was inserted. You can take pain relief such as paracetamol (also called panadol or panamax). Paracetamol is usually effective at controlling any pain after your procedure but if it is not, or if you cannot take paracetamol for any reason, please talk to your nurse or doctor about other options. 

The pain should not be severe, so if it is, please contact your doctor or nurse.

You will have a small dressing covering the site, keep this on for at least 24 hours. You can usually return to your usual activities once the pain has settled.

Before you go home, make sure you know who to contact and how to contact them if you have any concerns overnight.

What are the risks with bone marrow biopsies?

A bone marrow biopsy is usually a very safe procedure. 

Although you will have a local anaesthetic, it is common to experience some pain during the procedure. This is because it is not possible to numb the area inside your bones, but you should not feel and pain from the needle going through your skin. If you do get pain when the sample is taken, it is usually short sharp pain that settles very quickly.

 You may also have after the procedure as the local anaesthetic. This should not be severe and should be easily managed with paracetamol. Check with your doctors about what pain relief you can take if you need to. 

You may have some bleeding where the needle was put in and a little bit of bleeding is quit normal. However,  it may start to bleed again when you go home. This too is usually only small amount, but if you notice it bleeding a lot, hold  something firmly against the area. If you have cold pack press that against the area too as the cold helps to stop the bleeding and can help with any pain as well. 

if the bleeding does not stop once you have applied pressure then you will need to contact your doctor. In rare circumstances bleeding may be more serious.

Infection is a rare complication of the procedure. You must contact your doctors if you have any signs of infection such as;

  • Fever (temperature above 38 degrees Celsius)
  • Increased pain at the injection site
  • Swelling or redness at the injection site
  • Any pus or oozing other than blood from the site

Occasionally the procedure is unsuccessful or the sample does not give a diagnosis. If this happens you may need another bone marrow biopsy. Your medical team should give you more information about when to seek advice.

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