|Year : 2021 | Volume
| Issue : 3 | Page : 147-152
Bone marrow aspiration using 18g lumbar puncture needle: Can it be an alternative to conventional bone marrow needle?
Sasmita Panda1, Kusumbati Besra1, Asaranti Kar2, Goutami Dasnayak3, Sashibhusan Dash1, Sagarika Samantaray1, Niranjan Rout1
1 Department of Oncopathology, Acharya Harihar Postgraduate Institute of Cancer, Cuttack, Odisha, India
2 Department of Pathology, SCB Medical College and Hospital, Cuttack, Odisha, India
3 Department of Pathology, KIMS, Bhubaneswar, Odisha, India
|Date of Submission||06-Oct-2020|
|Date of Decision||15-Jan-2021|
|Date of Acceptance||06-Mar-2021|
|Date of Web Publication||21-Oct-2021|
Mr. Sashibhusan Dash
Department of Oncopathology, Acharya Harihar Postgraduate Institute of Cancer, 3rd Floor, Annex Building, Cuttack - 753 007, Odisha
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Bone marrow aspiration (BMA) has an important role in the investigation and diagnosis of hematologic as well as nonhematologic malignancies and various other diseases. The procedure varies from one setting and person to the other.
AIMS: The aim of the study is to study the role of 18G lumbar puncture (LP) needle in the diagnosis of bone marrow involvement in hematologic malignancies and metastasis for certain solid tumors.
MATERIALS AND METHODS: During this hospital-based retrospective study, 708 patients who clinically and histopathologically diagnosed with the malignant lesion and subsequently undergone BMA were included in this study.
RESULTS: BMA was done in 607 patients diagnosed with hematologic malignancies and 101 patients diagnosed with nonhematologic malignancies. Adequate marrow material was obtained in the first attempt in 683 (96.5%) cases. Multiple aspirations were needed in 25 (3.5%) cases. The majority (86.3%) of the patients experienced less pain by the 18 G LP needle compared to their previous experience with the conventional BMA needle. Needle breakage was not seen in any of the cases.
CONCLUSION: The results of this study suggest that the 18G LP needle can be easily adopted for BMA and could be a great help in significantly reducing pain and complications in patients undergoing BMA.
Keywords: Bone marrow aspiration, bone marrow neoplasm, procedural pain, lidocaine
|How to cite this article:|
Panda S, Besra K, Kar A, Dasnayak G, Dash S, Samantaray S, Rout N. Bone marrow aspiration using 18g lumbar puncture needle: Can it be an alternative to conventional bone marrow needle?. J Appl Hematol 2021;12:147-52
|How to cite this URL:|
Panda S, Besra K, Kar A, Dasnayak G, Dash S, Samantaray S, Rout N. Bone marrow aspiration using 18g lumbar puncture needle: Can it be an alternative to conventional bone marrow needle?. J Appl Hematol [serial online] 2021 [cited 2021 Dec 7];12:147-52. Available from: https://www.jahjournal.org/text.asp?2021/12/3/147/328718
| Introduction|| |
Bone marrow aspiration (BMA) has an important role in the investigation and diagnosis of hematologic as well as nonhematologic malignancies and various other diseases such as nutritional deficiency, suspected storage disorders, and infection.
It has also an important role in the management of these conditions particularly in the follow-up evaluation of patients undergoing chemotherapy, bone marrow (BM) transplantation, and other forms of medical treatment.
The procedures usually involve aspiration of a fluid suspension of BM from the iliac spine using the different BM needle which remains a painful procedure, with many patients reporting severe and unbearable pain and discomfort during the procedure. Despite several breakthroughs in medicine, limited work has been done to develop methods/measures that would better control pain in patients undergoing the procedure. BMA with 18G lumbar puncture (LP) needle is safe and economical with no absolute need of anesthesia. Hence, it finds better patient compliance.
Therefore, we aimed to study the advantages and efficacy of 18G LP needle to obtain BM from the anterior and posterior superior iliac spine. In addition, we also aimed to evaluate its role in the diagnosis of BM involvement in hematologic and nonhematologic malignancies. In clinical practice, adoption of better procedure to aspirate bone marrow in low resource countries not only help for diagnosis but also in reduction of pain.
| Materials and Methods|| |
This hospital-based retrospective study was carried out in 708 patients, in a tertiary cancer center, who were clinically and histopathologically diagnosed of the malignant lesion and subsequently undergone BMA, over a period of 4 years from January 2016 to December 2019.
Relevant clinical history such as any allergies, comorbidities, and any premedication was documented, and the procedure of BMA was explained to the patient. Information regarding other tests such as liver function tests, reticulocyte count, serum urea and creatinine, lymph node cytology, and biopsy were documented from the laboratory records.
Informed consent was obtained from each patient or a close relative or legal guardian according to local guidelines. A complete blood count was done using a seven-part hematoanalyzer (Sysmex, Transasia), and a peripheral blood smear study was performed if it was not done in the previous 2 days. Patients with known coagulopathies or a total platelet count <20,000/μl were deferred from the procedure until adequate blood component supports were given.
The patients were positioned in the left lateral knee-chest position. Two to three milliliters of lidocaine (1%) were drawn into a 5 ml syringe and given a skin test for any hypersensitivity on the volar aspect of the forearm. The exact location of the iliac spine was located, and lidocaine was injected perpendicularly into the subcutaneous tissue and into the periosteum. Two-three minutes were allowed for lidocaine to take effect. In cases of thin patients whose iliac spine was very prominent, lidocaine was not administered. In the case of children <7 years, they were given an oral sedative by the treating physician 1 h before the BMA.
Preferably, BMA was done from the right posterior superior iliac spine, but in cases of obese patients, aspirations were done from the anterior superior iliac spine.
Before aspiration, the skin over the BMA site was swabbed with povidone-iodine, applying some friction, working in a circular motion beginning in the center, and moving outward. Povidone-iodine was removed with an alcohol swab using concentric motion beginning in the center. Sterile drapes were placed over the site. With a sterile 18G LP needle with its stylet, the skin was punctured and advanced through the subcutaneous tissue, periosteum up to the marrow cavity using steady controlled pressure with a twisting motion. When the needle is firmly in place and a slight give in pressure is felt, the cavity has been entered. The stylet was removed, and a 10 ml syringe without the needle was attached to the LP needle hub. Approximately 0.5 ml marrow was obtained by applying a strong and quick suction. The LP needle with the syringe was removed with a slight twisting motion. Smears were made on clean glass slides and allowed to air dry. Then, the slides were stained with Leishman stain and observed under the microscope. The relevant cytochemical staining was performed in the required cases.
The patients (above 14 years age) those who had previously undergone BMA by other BM needle were asked to compare the difference of pain intensity; they experienced with previous BMA procedure and the present procedure and scored as “less pain,” “similar pain,” and “more pain.” Patients were followed up for a minimum period of 1 week for postprocedure complications. The advantages and adequacy rate of this procedure were studied.
The data were analyzed using Microsoft office Excel 2007. The mean, median, standard deviation, range, and percentage were calculated.
| Results|| |
A total of 708 patients have undergone BMAs in the present study. A BM study was done in 607 patients diagnosed with hematologic malignancies and 101 patients diagnosed with nonhematologic malignancies. The mean age of our patients was 36 years with age ranged from 5 to 87 years. The number of patients belonging to the pediatric age group (<18 years) was 87 (12.28%). In this study, males were predominated, 502 (70.9%), with a male-to-female ratio of 2.4:1 [Table 1].
|Table 1: Age- and sex-wise distribution of bone marrow aspiration using 18G lumbar puncture needle|
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BMA was done from the posterior superior iliac spine in 527 cases (74.4%) and from the anterior superior iliac spine in 181 cases (25.6%) [Figure 1]. Adequate marrow material was obtained in the first attempt in 683 (96.5%) cases. The quality of marrow aspiration by 18G needle was found good. Fourteen (0.56%) cases yielded dry tap in the first attempt and 11 (1.5%) cases yielded bloody aspirate. In all these 25 (3.5%) cases, adequate marrow material was procured on repeat aspiration from the anterior superior iliac spine on the next day [Table 2]. As the quality and quantity of marrow aspiration were good, the reporting was presumptive.
|Figure 1: Clinical picture-bone marrow aspiration from the posterior superior iliac spine by 18 G lumbar puncture needle|
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For staging workup of malignancy, BMA was done in 379 (53.53%) cases of non-Hodgkin lymphoma (NHL) and 69 (9.7%) cases of Hodgkin's Lymphoma (HL) among which BM involvement was seen in 37 (9.76%) cases of NHL [Figure 2]a.
|Figure 2: (a) Predominance of mononuclear cells in bone marrow aspiration smear of non-Hodgkin Lymphoma patient (Leishman stain, ×40). (b) Metastatic neuroblastoma cells having round nucleus with rosettes in bone marrow aspiration smear (Leishman stain, ×40). (c) Metastatic adenocarcinoma nest in bone marrow aspiration smear of breast carcinoma patient (Leishman stain, ×40). (d) Metastatic prostate adenocarcinoma cells in bone marrow aspiration smear (Leishman stain, ×40)|
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BMA was done in nonhematologic solid tumors such as 77 (10.8%) cases of malignant small-round cell tumor, six (0.8%) cases of breast carcinoma, four (0.5%) cases of carcinoma rectum, one (0.1%) case of carcinoma palate, four (0.5%) cases of nasopharyngeal carcinoma, five (0.7%) cases of prostate carcinoma, one (0.1%) case of sarcoma, one (0.1%) case of phyllodes tumor of breast, and two (0.3%) cases of germ cell tumor of the ovary.
Of the above cases, eight (10.38%) malignant small-round cell tumors (six cases of Ewing's sarcoma and two cases of neuroblastoma), two cases of breast carcinoma, and three cases of prostate adenocarcinoma showed marrow involvement [Figure 2]b, [Figure 2]c, [Figure 2]d.
For diagnosis and monitoring purpose, BM study was done in 63 (8.9%) cases of multiple myeloma, 20 (2.8%) cases of plasmacytoma, 39 (5.5%) cases of acute lymphoblastic leukemia, 12 (1.7%) cases of chronic lymphocytic leukemia (CLL), 13 (1.8%) cases of acute myeloid leukemia (AML), and 12 (1.7%) cases of chronic myeloid leukemia (CML) [Figure 3]a and [Figure 3]b.
|Figure 3: (a) Lymphoblasts in bone marrow aspiration smear in acute lymphoblastic leukemia patient (Leishman stain, ×40). (b) Predominance of plasma cells with binucleate forms in bone marrow aspiration smear of multiple myeloma (Leishman stain, ×40)|
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Follow-up BMA was done in 158 (41.68%) cases of NHL, 45 (65.21%) cases of HL, and 28 (33.73%) cases of multiple myeloma patients undergoing therapy.
The complete blood count done before BMA revealed that anemia was present in 118 cases (81.4%) of all the malignant BM involvement. Leukocytopenia was observed in 20 (13.8%) cases and thrombocytopenia was seen in 46 (31.7%) patients. Leukocytosis was seen in 47 (32.4%) patients. The peripheral smear showed a leukoerythroblastic blood (LEB) picture in 17 (11.7%) patients.
The BMA smears were hypercellular in 97 (66.9%) cases, hypocellular in 3 cases (2.1%), and normocellular in 45 cases (31.0%). Hypocellular marrow was seen in two cases of multiple myeloma and one case of metastatic rectal adenocarcinoma [Figure 2]d.
A total of 329 patients (above 14 years) who had previously undergone BMA by other procedure were asked to give their feedback on the difference of pain intensity experienced by them. Comparatively, 284 (86.3%) patients experienced less pain, similar pain by 37 (11.2%) patients, whereas only two (2.4%) patients felt comparatively more pain.
| Discussion|| |
Diagnosis and management of many hematologic diseases and malignancies depend on the examination of the BM. It has also been increasingly useful in documenting metastatic involvement of tumors and for accurate staging of many malignant diseases. However, the BMA procedure with the conventional BMA needle is accompanied by discomfort and pain with complications of bleeding and infection in some cases. The reusable conventional BM needle needs sterilization after every use and which will eventually lead to the weakening of the needle. Furthermore, the unavailability of special BM needles is a major problem in resource-poor centers and it is not possible to use expensive disposable needles every time.
We reviewed the literature and found that,a Russian physician,obtained BM from the sternum using an LP needle. He published the results of 103 procedures in the Russian “news of surgery” journal. No complications were reported. Later, Grunke (1938) also recommended a short LP needle for marrow aspiration with the help of a wooden mallet on the sternum.,, The method of BM sampling was standardized in the early 1970s and it has remained unchanged ever since. In the present study, we have conducted BMA by the 18G LP needle in 708 patients with less pain and without compromising specimen retrieval and quality.
The most preferred site for BMA was the left posterior superior iliac spine. We observed that in obese patients, the anterior superior iliac spine was the most convenient site for BMA. Our finding was similar to the study done by Adewoyin et al. who did BMA in the posterior iliac spine and anterior superior iliac spine in 83% and 14.8%, respectively. Because the LP needle is a thin bore, the pain elicited by it, which is similar to that of the needle used for infiltrating the local anesthetic. Hence, in 10.4% of cases whose iliac spine was very prominent, no anesthetics were used and BMA was done in a quick single go, saving the patient from undergoing the pain of two pricks, first of the needle of the local injectable anesthetic and second of the aspiration needle.
Almost all solid organ malignancies can metastasize to BM, but the common ones are malignancies of the prostate, breast, and lungs., In our study, breast cancer and prostate cancer were the most frequent tumors in adults, to metastasize to BM which is in concordance with other studies that were done by Chauhan et al., Kaur et al., Sreelakshmi et al., and Syed et al.
In the pediatric age group (<18 years), Ewing's sarcoma was the most common tumor with bone metastasis followed by neuroblastoma which is similar to the study conducted by Anner and Drewinko.
Leukemias accounted for 10.6% of BMA in our study, which was similar to the study by Gohil and Rathod, who reported 8.8% leukemia. Adewoyin et al. and Ahmad et al. reported a higher prevalence of 25% and 21.3%, respectively. This difference can be attributed to regional variations in the prevalence. The different leukemias diagnosed in our study were 6.6% acute lymphoblastic leukemia, 2.2% AML, 1.9% CLL, and 2.0% CML which was comparable with that of Gohil and Rathod, and slightly higher figures were reported by Adewoyin et al. and Ahmad et al.
We encountered 10.8% cases of multiple myeloma compared to Ahmad et al., Pudasaini et al., and Bedu-Addo et al. who reported an incidence of 1.2%, 3.5%, and 3.75% in their studies, respectively.
BM infiltration was observed in 9.7% of cases of NHL patients, which was higher than that found by Vala and Shrinivasan who reported marrow involvement in 1.25% of cases of NHL.
We did not detect BM involvement in any of the 69 cases of HL patients in comparison to a study by Bedu-Addo et al. who found one case of HL with BM involvement.
In our study, anemia was present in 81.6% of cases, leukocytosis was seen in 32.3% of cases, and thrombocytopenia was seen in 32.3% cases of all the malignant BM involvement patients which were comparable to the study conducted by Chauhan et al., Kaur et al., and Kilickap et al. Leukocytopenia was observed in 14% of cases which were similar to the study done by Kilickap et al.
LEB picture is the term used to describe the presence of nucleated red cells (erythroblasts) and immature myeloid precursors (myelocytes and myeloblasts) in the peripheral blood film. BM examination should be considered if there is LEB in a case of suspected malignancy. Different studies have reported different rates of Leukoerythroblastosis (LEB) consisting of cancer patients with BM metastases. Mohanty and Dash, Chauhan et al., and Sreelakshmi et al. reported LEB in 35.6%, 43.7%, and 31% cases, respectively. Our study showed the leukoerythroblastic picture in 11.9% of patients inclusive of both hematologic malignancies and nonhematologic solid tumors metastatic to the marrow. However, LEB in solid tumors metastatic to the marrow in our study was 57.89%, which was similar to Chauhan et al.
Dry tap is a term used to describe the failure to obtain BM on an attempt to aspiration of marrow or in cases where the material is obtained but no, or inadequate marrow cells are obtained either because of extensive fibrosis or hypercellularity. The most usual cause of a dry tap is faulty positioning of the aspiration needle in the marrow cavity. In this event, the stylet is replaced in the BMA needle and the needle is further advanced, and a second aspirate specimen is obtained. However, repeated dry taps may indicate the presence of aplastic anemia, myelofibrosis, Paget's disease, or a marrow densely packed with leukemia cells, metastatic tumor, or malignant lymphoma.
The overall incidence of dry tap BMAs is about 4%–7%.,,,, In our study, 14 (0.56%) cases yielded dry tap on the first attempt but adequate marrow was obtained by repeating the procedure from the anterior iliac spine which indicated a technical fault in doing the aspiration procedure in the initial attempt.
A study conducted by Adewoyin et al. reported one case of needle breakage, which they attributed to the reuse of needles following requisite sterilization. Needle breakage was not seen in any of the cases in our study. Hematoma or local sepsis was not seen in any case in our study.
The majority (86.3%) of the patients experienced less pain by the 18 G LP needle compared to their previous experience with the conventional BMA needle. Hence, this simple effective method of BMA by 18 G LP needle is a quick and convenient method of BM sampling associated with less pain and no complications.
| Conclusion|| |
The results of this study suggest that the 18G LP needle can be easily adopted for BMA and could be a great help in significantly reducing pain and complications in patients undergoing BMA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]