Bone marrow trepanobiopsy

The instrumental method of extracting biomaterial for further histological evaluation is called "trepanobiopsy". This is a diagnostic procedure that helps to identify many diseases, including leukemia. Trepanobiopsy is not just a puncture, as it allows you to take a sufficient volume of trepanobiopsy without violating the integrity of the organ.

Trepanobiopsy is prescribed mainly to study bone marrow structures and the mammary gland. If necessary, during the manipulation it is possible to remove cystic neoplasms.

Is it painful to have a trephine biopsy?

Pain is the first thing a patient prepares for when coming for the procedure. The anticipation of pain scares many: it increases the stress level in the body, and trepanobiopsy is especially difficult - primarily psychologically. However, as doctors say, this type of diagnostics is low-trauma, although quite complex. The use of local anesthesia allows for trepanobiopsy to be performed as painlessly as possible. Mild discomfort may be felt only in the first seconds of the manipulation.

After the effect of the painkillers wears off, when the procedure is coming to an end, the pain may return a little, but it will also pass quickly. To be sure that the unpleasant sensations will not recur, it is important to follow all the doctor's recommendations regarding the rehabilitation period. Additional painkillers may be taken if necessary.

Indications for the procedure

Hematologists prescribe trephine biopsy to diagnose the following disorders:

• severe anemia;
• erythremia, polycythemia with a significant increase in the content of erythrocytes;
• Langerhans cell histiocytosis;
• malignant tumors with a high risk of bone marrow metastasis.

In addition, a trephine biopsy is indicated if a person has significant weight loss, fever of unknown origin, severe and prolonged hyperhidrosis, or an intense decline in immunity.

Oncologists prescribe trepanobiopsy to determine the dynamics of chemotherapy treatment: the study is conducted twice, before the start of the treatment course and after its completion. Another indication is the clinical picture of HIV infection.

A trephine biopsy may also be recommended if the usual removal of biomaterial using a thin needle does not produce an accurate result.

In general, the most common indications for trephine biopsy are:

• anemia that does not respond to standard treatment methods;
• pronounced disturbances of the blood picture;
• excess hemoglobin and red blood cells in the blood;
• severe deviation from the norm of the content of leukocytes and platelets in the blood; [ 1 ]
• constant high temperature, frequent infectious pathologies, sudden and pronounced loss of body weight, rash in the oral cavity, enlarged lymph nodes;
• leukemia treatment monitoring;
• diagnostics of thesaurismoses;
• histiocytosis;
• lung carcinoma, small cell lung cancer; [ 2 ], [ 3 ]
• suspected lymphoma due to the impossibility of examining the lymph nodes;
• a strong drop in immunity with a constantly high temperature;
• oncopathologies with probable bone marrow metastases; [ 4 ]
• cytopenia of unknown origin;
• hemoblastoses, bone cancer;
• bone marrow sarcoidosis: [ 5 ]
• multiple myeloma;
• secondary damage to the red bone marrow;
• histoplasmosis in patients with acquired immunodeficiency syndrome; [ 6 ]
• monitoring of bone marrow transplant operation.

In childhood, trephine biopsy is used to diagnose the following pathologies:

• Hodgkin's disease and non-Hodgkin's lymphomas; [ 7 ]
• Ewing's sarcoma;
• late stages of neuroblastoma or retinoblastoma; [ 8 ]
• rhabdomyosarcoma.
• A mammary gland trephine biopsy may be prescribed:
• in case of suspicious nipple discharge, compaction, or changes in the external appearance of the nipples;
• when ulcers and cracks appear without any reason;
• in case of mastopathy, fibroadenoma, mastitis, cystic formations to determine the risk of malignant transformation or to track the dynamics of pathology.

Trephine biopsy in aplastic anemia

Aplastic anemia is a pathology in which bone marrow structures in humans stop producing the main blood cells in sufficient quantities: erythrocytes, leukocytes, thrombocytes. The disease includes anemia and aplasia of hematopoiesis, accompanied by inhibition of blood cell production.

Aplastic anemia is considered a rare disease. It is confirmed by a clinical blood test, which shows a decrease in the levels of red blood cells, white blood cells and platelets. However, the final diagnosis is established only by examining a bone marrow sample taken by trephine biopsy of the iliac crest. Such diagnostics are necessary to exclude other most likely causes of blood cell deficiency - for example, leukemia, myelodysplastic syndromes, myelofibrosis, etc.

Trepanobiopsy also allows to differentiate aplastic anemia from congenital Fanconi anemia. This is necessary, since the treatment tactics of these diseases are fundamentally different. In addition to biopsy, other specific studies are used for differential diagnostics - in particular, the DEB test.

Preparation

3-4 days before the trephine biopsy, it is necessary to avoid drinking alcohol and taking medications that thin the blood (for example, acetylsalicylic acid).

You should tell your doctor in advance about any allergic reactions you have and the presence of electronic implants.

A few days before the procedure, you need to do a blood test to assess coagulation and rule out inflammatory processes in the body. The next morning on the day of the procedure, you should have a very light breakfast. You should not drink a lot of liquids.

If the patient is obviously very worried, then after consulting a doctor, it is advisable for him to take the prescribed sedative.

If a bone marrow trephine biopsy is planned, you should tell the doctor in advance if you have previously had bone surgeries or fractures (especially of the pelvic bones or spinal column).

The manipulation is most often performed in the morning or in the first half of the day. No other special preparation is required. If necessary, the doctor will ask the patient to undergo fluorography and/or electrocardiography a few days before the procedure.

Trephine biopsy needle

The needles used for trephine biopsy may be different, depending on their purpose. The main instrument for isolating a biopsy core during bone marrow diagnostics is an auxiliary insertion stylet in the form of a "ladle" or "spoon". Over time, manufacturers of such needles have come up with a simple and quite effective method for separating a biopsy core. As already indicated, the needle contains an insertion stylet. When performing a trephine biopsy, the stylet is removed from the needle, a hollow stylet is inserted into it, which contains the necessary bone marrow biopsy. A small notch along the body of the stylet holds this material and "gives" it if you turn the needle 360°. Such a mechanism helps prevent rupture and loosening of the biopsy. The material is separated without any effort, it has sufficient volume and height. This method is minimally invasive and virtually painless, unlike the previously used rocking of the instrument. [ 9 ]

The design and functionality of modern trephine biopsy needles provide for:

• minimization of pain and trauma;
• obtaining high-quality biomaterial, undeformed, not loose, in the required quantity;
• the possibility of taking a biopsy under different conditions, even with bone softening.

Technique trepanobiopsies

For trepanobiopsy, special instruments are used, which have a wide handle, a needle with a stylet, and a cannula. The needle can be different, which depends on the area of its application and the thickness of the patient's subcutaneous fat layer.

The standard duration of such manipulation as bone marrow trephine biopsy is about 20-25 minutes. If necessary, the hair in the area of the procedure is shaved. Local anesthesia is used, sometimes in combination with general sedation. General anesthesia is used less often.

The skin in the puncture area is disinfected, an anesthetic is administered. Then the needle is inserted into the required area with a reciprocating-rotating motion, a column of biomaterial is extracted, which is then transferred to formalin. The area of exposure is disinfected again, a sterile bandage is applied. The results of the trepanobiopsy can be ready in a few hours or a few weeks - depending on the situation.

Trepanobiopsy of tumors refers to puncture methods of diagnosing a patient: a biopsy in the form of tissue or cells is removed for subsequent laboratory testing. Such diagnostics are mandatory for making a diagnosis if there is a suspicion of oncological pathology. Trepanobiopsy helps to evaluate and analyze the structural composition of the biological material. The procedure is necessary not only for making a diagnosis, but also for further determining the treatment tactics. Since the treatment regimen for oncopathology universally includes complex chemotherapy, radiation therapy, and surgical intervention, diagnostic studies in the form of cytological or histological analysis are necessarily performed beforehand, which can identify the type of neoplasm. [ 10 ]

A mammary gland trephine biopsy may involve partial or complete resection of the pathological lesion, so this procedure is often included in the category of surgical operations. A specific needle is used to remove biological material, which consists of a rod and a cutter, has a flexible cannula and a mandrin. First, a small scalpel incision is made, into which the cannula is inserted. After reaching the required depth, the mandrin is removed. Then the surgeon excises the pathological neoplasm using the rod and cutter. [ 11 ]

Bone marrow trephine biopsy for lymphoma involves the removal of biomaterial from one or two points in the ilium. The manipulation is performed under general anesthesia and is mandatory for all patients except those with stage I or IIa Hodgkin's lymphoma. [ 12 ]

Bone trepanobiopsy is included in the mandatory list of diagnostics for patients with non-Hodgkin's lymphomas, regardless of the immunomorphology of the disease. This is due to the fact that non-Hodgkin's lymphomas can affect the bone marrow without corresponding leukemic signs in the blood and aspirate. [ 13 ] Trepanobiopsy is prescribed to correctly determine the stage of the disease, for a competent choice of treatment tactics. The procedure is performed in the area of the iliac bones with subsequent immunohistochemical analysis of the biomaterial. [ 14 ]

A trephine biopsy of the ilium takes longer than, for example, the same procedure in the mammary gland area. The manipulations can last up to an hour. The patient lies down on a couch. The surgeon treats the intended puncture site with an antiseptic solution, inserts a needle, and removes the rod. Using screw movements, the cannula is inserted to the required depth to remove the material. Then the sample is removed. A trephine biopsy of the femur can be accompanied by the introduction of an electrocoagulator, which allows the walls of the wound channel to be treated. The current is supplied simultaneously with the needle being pulled out. This method helps prevent bleeding and the possible spread of malignant structures through the circulatory system. There is no need to apply stitches: the puncture area is covered with a sterile bandage. [ 15 ]

A trephine biopsy of a lymph node is prescribed by an oncologist or hematologist if malignant processes, mononucleosis, inflammatory diseases or tuberculosis are suspected. The obtained material is sent to the laboratory. The result can be obtained within several days to two weeks. Usually, enlarged and compacted lymph nodes in the groin, neck, armpits or above the collarbone are examined.

Percutaneous liver trephine biopsy is prescribed for diffuse and focal liver pathologies. Diffuse pathologies are chronic hepatitis of viral and non-viral origin. Focal pathologies are benign or malignant (primary or secondary) tumors in the liver. Before the procedure, the doctor performs an ultrasound examination to accurately determine the puncture site. After treating the skin, the doctor administers anesthesia, makes a puncture and removes the required amount of biopsy. At this time, the patient lies on his back with his right hand behind his head. When the material is taken, the patient is asked to hold his breath and not move for a few seconds. After the procedure, the patient remains in the clinic for another 1-2 hours: an ice pack is applied to the puncture area, then a control ultrasound examination is performed to assess the condition of the organ after diagnosis. If everything is in order, the patient is sent home.

A biopsy and trephine biopsy of the prostate gland is prescribed to all patients if there is a suspicion of prostate cancer. The results of such a study determine not only the treatment tactics, but also the prognosis for the patient. Before the procedure, an anesthetic is injected into the rectum through the anus (often a special lidocaine gel). After 6-8 minutes, an ultrasound sensor equipped with a nozzle for inserting a needle is inserted into the rectum: with its help, the points of the manipulation are determined. Such a trephine biopsy is usually well tolerated, only occasionally slight discomfort is noted. Important: before the study, it is imperative to cleanse the intestines with an enema. The procedure is carried out on an empty stomach, and after it, antibiotic therapy is prescribed to prevent inflammatory processes in the prostate (prostatitis, orchiepididymitis).

Contraindications to the procedure

There are several known contraindications to trepanobiopsy, and the vast majority of them are conditional (the procedure becomes possible after they are eliminated):

• pregnancy, menstruation and lactation (for mammary gland trephine biopsy);
• allergic sensitivity to the agents that are supposed to be used for anesthesia;
• feverish state;
• inflammatory foci, abscesses, eczematous rashes in the area of the intended puncture;
• the presence in the body of artificial pacemakers and other devices that coordinate cardiac activity;
• acute pain in the spine and shoulders;
• insufficient blood clotting;
• acute infectious diseases.

If the patient took a course of blood thinning medications the day before the procedure, the risk of bleeding after trepanobiopsy increases sharply. To reduce the risks, it is necessary to completely stop taking such medications at least 24-48 hours before the examination. If this is not done, the manipulation is prohibited.

Trepanobiopsy is not prescribed to elderly patients, as well as to patients with decompensated renal, cardiac or hepatic insufficiency, or late stage diabetes mellitus. The procedure may be problematic in patients with severe obesity.

In some cases, trephine biopsy is not prescribed not because of contraindications, but because it is inappropriate: for example, if the manipulation will not help improve or prolong a person’s life, or its results will not affect the treatment already prescribed.

Normal performance

The biological material removed during a trepanobiopsy can be examined for several days or weeks. In an emergency, the results can be obtained within a few hours. After studying the information received, the doctor makes a conclusion about the presence or absence of oncology, the structural features of the tissues, and the type of malignant process. [ 16 ]

In general, the results are most often like this:

• norm: malignant cells are absent, all indicators are within the norm;
• the presence of non-cancerous changes without confirmation of an oncological process;
• benign tumor process without malignant tissue growths;
• confirmed malignant process with an established stage and type of pathology.

The tissues obtained during the trepanobiopsy are examined in a variety of ways, such as histological and cytological analysis, which helps to assess the development of cells. They are studied in the laboratory, and the number of immature particles is calculated. During histochemical diagnostics, the activity of enzymes is determined, their quantity is assessed, bone architecture, and the activity of osteocytes and osteoblasts are studied. An important diagnostic sign is a change in bone structure, which indicates a pathological process. In addition, during the procedure, it is possible to detect metastases, vascular pathologies, etc. [ 17 ], [ 18 ]

The specialist describes all the information received in a special report. Based on it, the appropriate therapy is prescribed. In some cases, there is a need to conduct a repeated trepanobiopsy - for example, to compare indications, clarify certain points, or assess the dynamics of treatment. [ 19 ]

Complications after the procedure

If a trephine biopsy is performed by a qualified specialist, then serious consequences are usually out of the question. Among the standard natural post-procedural manifestations, the following are sometimes encountered:

• dizziness, nausea;
• slight bleeding from the wound;
• slight swelling, discomfort in the area of manipulation.

All of these phenomena go away on their own after some time.

As for more serious complications, they occur only in rare cases. In isolated patients, the wound may become infected, an inflammatory process may develop, the temperature may rise, and pathological discharge may appear. In such situations, it is necessary to urgently consult a doctor.

Consequences after the procedure

Trepanobiopsy is a surgical procedure, albeit minimally invasive. Therefore, it is impossible to completely guarantee the absence of negative consequences after the procedure, although they are relatively rare.

Pain after trephine biopsy is observed in almost all patients: we are talking about a slight transient soreness that does not pose a threat to health and is associated only with mechanical damage to tissues. If such pain is severe, it may be due to nerve injury: in such a situation, it is better to consult a doctor.

If the surgical field is not treated correctly or the attending physician is not qualified, bleeding may occur and purulent processes may develop. Damage to large-caliber vessels and nerves is also possible. [ 20 ]

A slight swelling in the puncture area is allowed, which is considered normal and goes away within a few days.

Care after the procedure

Caring for the puncture area involves following these recommendations:

• The bandage should not be removed until the next day after the procedure.
• You can take a shower no earlier than 24 hours after the procedure. The puncture area should not be rubbed vigorously with a washcloth or towel: it is enough to rinse with warm water and blot dry with a soft, clean towel. If there is no discharge, then there is no need to reapply the bandage.
• If swelling or hematoma appears in the puncture area, it is necessary to apply an ice pack wrapped in a towel - for about 10 minutes several times a day during the first 1-2 days. Swelling and hematoma usually disappear completely on their own after a few days (up to a week).
• If blood is coming out of the wound, you need to apply a tight bandage: if the bleeding increases or does not stop, you need to call your doctor.
• After a mammary gland trephine biopsy, you should wear a well-fitting bra that provides good breast support.
• For 3-4 days, you should not lift weights or engage in intensive physical exercise (including running).
• You cannot take a bath, swim in a pool, or visit a bathhouse or sauna.
• If pain occurs, you can take a Paracetamol tablet. Taking non-steroidal anti-inflammatory drugs as painkillers is not advisable, as they can contribute to bleeding.

You should definitely call your doctor if:

• the puncture area increases in size;
• bleeding appears that cannot be stopped;
• the puncture area turned red, the temperature rose, and other signs of infection and intoxication appeared.

Reviews

According to patients who have already undergone the trepanobiopsy procedure, there is no need to worry about this diagnostic. Since the manipulation involves the use of local anesthesia, sensitivity in the puncture area disappears, and the patient feels practically nothing.

Complications after trepanobiopsy are rare, and the patient can return to his usual way of life after the examination. Hospitalization is not necessary, the person goes home immediately. If undesirable vegetative reactions occur (dizziness, nausea, difficulty breathing, clouding of consciousness, tachycardia), then you should remain under medical supervision for some time until the condition stabilizes.

The main thing is not to worry in advance, take sedatives if necessary and set yourself up for a positive result.

Trepanobiopsy is a relatively rare diagnostic method, which is used only in some medical and oncology centers. More often, doctors practice the usual biopsy option. Trepanobiopsy should be performed by qualified specialists, so when choosing a clinic, you need to focus not only on pricing and quality of service, but also on the experience and qualifications of doctors, the equipment used and, of course, on positive patient reviews.