Matching Bone Marrow Biopsy Technique to the Clinical Scenario: A Decision Framework for Practice

Bryon Allen: Hi, I'm Bryon Allen. I'm a nurse practitioner, and I've worked in bone marrow transplant for over 23 years, and I work at a large academic institution in Portland, Oregon. And I'm joined today by Jeremy Heinerich. Want to introduce yourself, Jeremy?

Jeremy Heinerich: My name is Jeremy Heinerich, and I'm a physician assistant, and I've been practicing for over 25 years. I work at three major academic centers. And I'm a supervisor, but my primary focus is on procedures, and so I am very skilled in doing bone marrow biopsies.

Bryon Allen: Why does the technique selection matter for bone marrow biopsies? The goal of bone marrow biopsy is obtained representative marrow tissue for the histopathologic, immunohistochemical, cytogenetic and molecular analysis to support diagnosis, staging, and disease monitoring for our patients. The bone marrow biopsy technique should be individualized to patient-specific clinical factors, disease context, and operator experience, rather than treated as a one-size-fits-all procedure. Selecting the most appropriate bone marrow biopsy approach may improve specimen adequacy, reduce complications, and decrease the need for repeated procedures. APPs perform a substantial proportion of bone marrow biopsy procedures and are often responsible for establishing procedural standards within neuro institutions.

Jeremy Heinerich: Okay. The first step in understanding why the bone marrow biopsy is performed, which could include unexplained cytopenias, unexplained cytosis, suspected hematologic malignancies, fever of unknown origin, or systemic illness, staging or monitoring disease, such as lymphoma or neuroblastoma staging, checking remission status in leukemia or myeloma. Additional pediatric considerations, congenital marrow failures. They evaluate children with inherited cytopenias or leukemia suspicion. In other words, Down syndrome, neonates, marrow blast counts, solid tumor metastases, routine bilateral marrows, and neuroblastoma, and some sarcomas to detect spread. Anesthesia needs, children almost always require sedation or general anesthesia for comfort during a biopsy. Adults typically receive local anesthesia only with or without mild sedation. So the clinical objective influences the amount of marrow sample needed, whether a core biopsy and/or aspirate is preferred, and how specimens should be handled for ancillary testing. Communication among health care practitioners, including pathology, hematology, oncology, and referring providers, can help align the bone marrow biopsy plan with downstream management and specimen handling needs. So, Bryon, can you share an example of how the intended diagnostic goal changed your biopsy approach or specimen requirements?

Bryon Allen: Yeah. In my myeloma patients, the clinical question often drives everything. If we're confirming a diagnosis rather than monitoring treatment response, the specimen-handling requirements can be quite different, and that shapes how we approach the procedure from the start.

Jeremy Heinerich: Yeah, I've had cases where the pathology team needed additional material for flow cytometry or cytogenetics. And so once you understand that upfront, you can plan accordingly rather than repeat the procedure.

Bryon Allen: Yeah, that's a great point, Jeremy. We actually, at our institution, have standardized the MRD testing as the second pool, so that it's always that for our myeloma patients, and that we have a consistency that way and get better samples for them. Bone marrow core biopsy preserves marrow architecture and supports histologic grading, immunohistochemistry, cytogenetics, and ancillary molecular studies. Specimen adequacy is an important consideration, as published literature has reported that a substantial proportion of bone marrow core biopsy specimens fall below internationally recognized size guidelines. Bleeding risks, anticoagulant or antiplatelet use, and relevant comorbidities should be assessed as part of pre-procedural bone marrow biopsy planning. Medication review and coagulation assessment are important pre-procedural steps.

In my practice, bone marrow biopsy is usually performed under local anesthesia only. Patients requiring sedation are typically referred to interventional radiology or another appropriate procedural setting. Analgesic medications may be offered as well. Disease-specific factors influence approach selection. In multiple myeloma, marrow involvement may be focal. Biopsy site selection and specimen adequacy are particularly important. In myelofibrosis, fibrotic marrow increases the likelihood of a dry tap or inadequate aspirate; technique and device selection may affect specimen quality. In pediatric patients, sedation or general anesthesia is typically required. Bilateral biopsies may be indicated for staging in certain diagnoses. Jeremy, can you share an example of how patient-specific characteristics influence your choice of a biopsy technique?

Jeremy Heinerich: Yeah. So with myelofibrosis patients, I've learned to set expectations differently from the start. The fibrotic marrow changes the procedural feel entirely, and the likelihood of a dry tap is real.

Bryon Allen: Anticoagulation status is something I always review before scheduling. We've had cases where we needed to coordinate a hold with a managing team, and catching that pre-procedurally is much better than discovering at the time of the procedure.

Jeremy Heinerich: So, technique selection and practice. So a trephine core biopsy is the standard approach when marrow histology, cellular architecture, and ancillary testing are required for diagnosis or disease assessment. Technique selection, including the choice of manual or powered approach, should reflect patient clinical factors, disease context, bone characteristics, operator experience, and available equipment. The following considerations highlight key design features of the BD Trek Powered Bone Biopsy System that may be relevant when assessing powered bone marrow biopsy technologies. The variable-speed control has a lower speed for initial access and a higher speed for core acquisition. The scored needle is designed to help facilitate sample retention; the manual driver option included in every kit is interchangeable at any point. In simulated use testing, the BD Trek Powered Bone Biopsy System provides an average sample mass that was 82.6% greater than the BD Jamshidi Evolve manual bone marrow biopsy needle of the same gauge. When performing bone biopsy procedures, the quieter operation of the BD Trek Powered Bone Biopsy System, compared with a first-generation powered device, is a feature I value, particularly when considering the overall patient experience. Operator training and familiarity with the selected technique contribute to procedural consistency and specimen quality. So, Bryon, what factors most influence your choice of biopsy technique, and do you follow a standard approach or tailored decision, case by case?

Bryon Allen: For most of our patients, we've standardized on a powered approach as a default, but I still tailor within that. The speed I use to get through the cortex in a dense myelofibrosis marrow is different from that of a straightforward staging biopsy. The flexibility or variable speed control makes it easier to manage. A successful bone marrow biopsy begins with understanding the clinical question, why the biopsy is being performed, and what diagnostic information is needed, and matching the technique and approach to the specific patient context. A thoughtful, individualized approach can improve tissue adequacy, safety, and diagnostic confidence. Jeremy, looking back, what guidance would you offer APPs developing their approach to bone marrow biopsy technique selection?

Jeremy Heinerich: I think you start with a clear understanding of why the biopsy is being done. That single question will shape almost every other decision you make and build a consistent default approach, one that you can adjust for complex cases, but that gives you a reliable starting point.

Bryon Allen: And getting comfortable with both your technique and your device is important. There's a learning curve, regardless of which approach you use, and the best thing you can do for patients is to invest that training upfront rather than figuring it out case by case.

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