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Bone marrow trepanobiopsy
Medical expert of the article
An instrumental method of removing 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 select a sufficient volume of trepanobiopsy without violating organ integrity.
Trepanobiopsy is prescribed mainly for the study of bone marrow structures and the mammary gland. If necessary, during the manipulation, it is possible to eliminate cystic neoplasms.
Does trepanobiopsy hurt?
Pain is the first thing a patient tunes in when he comes to the procedure. The premonition of pain scares many: it increases the level of stress in the body, and trepanobiopsy is especially difficult - primarily psychologically. However, according to doctors, this type of diagnosis is less traumatic, albeit rather complicated. The use of local anesthesia allows trepanobiopsy to be performed as painlessly as possible. Slight discomfort can be felt only in the first seconds of manipulation.
Upon completion of the effect of painkillers, when the procedure comes to an end, the pain may return slightly, but it passes just as quickly. To gain confidence that discomfort will not recur, it is important to follow all the doctor's recommendations regarding the management of the rehabilitation period. It is allowed, if necessary, to take additional painkillers.
Indications for the procedure
Hematologists prescribe trepanobiopsy in order to diagnose the following disorders:
- severe anemia;
- erythremia, polycythemia with a significant increase in the content of red blood cells;
- langerhans cell histiocytosis;
- malignant formations with a high risk of bone marrow metastasis.
In addition, trepanobiopsy is indicated if a person has a marked loss of body weight, fever of unknown origin, severe and prolonged hyperhidrosis, and an intense drop in immunity.
Oncologists prescribe trepanobiopsy to determine the dynamics of chemotherapy treatment: the study is carried out twice, before the start of the treatment course and after its completion. Another indication is the clinical picture of HIV infection.
Also, trepanobiopsy can be recommended if the usual removal of the biomaterial with a thin needle did not lead to an accurate result.
In general, the indications for trepanobiopsy are most often:
- anemia that does not respond to standard treatment;
- severe violations of the blood picture;
- excessive content of hemoglobin and red blood cells in the blood;
- a strong deviation from the norm in the content of leukocytes and platelets in the blood; 
- constant high fever, frequent infectious pathologies, a sharp and pronounced loss of body weight, a rash in the oral cavity, an increase in lymph nodes;
- control of the treatment of leukemia;
- diagnostics of thesaurismosis;
- lung carcinoma, small cell lung cancer; , 
- suspected lymphoma against the background of the impossibility of examining the lymph nodes;
- a strong drop in immunity at a constantly high temperature;
- oncopathology with probable bone marrow metastases; 
- cytopenia of unknown origin;
- hemoblastosis, bone cancer;
- bone marrow sarcoidosis: 
- multiple myeloma;
- secondary lesion of the red bone marrow;
- histoplasmosis in patients with acquired immunodeficiency syndrome; 
- control of bone marrow transplant surgery.
In childhood, trepanobiopsy is used to diagnose the following pathologies:
- Hodgkin's disease and non-Hodgkin's lymphomas; 
- Ewing's sarcoma;
- late stages of neuroblastoma or retinoblastoma; 
- Trepanobiopsy of the breast can be prescribed:
- with suspicious nipple discharge, seals, changes in the appearance of the nipples;
- with the unreasonable appearance of ulcers and cracks;
- with mastopathy, fibroadenoma, mastitis, cystic formations to determine the risk of malignant transformation or to track the dynamics of pathology.
Trepanobiopsy for aplastic anemia
Aplastic anemia is a pathology in which the bone marrow structures in a person cease to produce the main blood cells in sufficient volume: erythrocytes, leukocytes, platelets. The disease includes anemia and aplasia of hematopoiesis, accompanied by inhibition of blood cell production.
Aplastic anemia is considered a rare condition. It is confirmed by a clinical blood test, where there is a decrease in the levels of red blood cells, leukocytes and platelets. However, the final diagnosis is established only by examining a bone marrow sample taken by trepanobiopsy of the iliac crest. Such a diagnosis is necessary to exclude other most likely causes of lack of blood cells - for example, leukemia, myelodysplastic syndromes, myelofibrosis, etc.
Trepanobiopsy can also distinguish aplastic anemia from Fanconi's congenital anemia. This is necessary because the treatment tactics for these diseases are fundamentally different. In addition to biopsy, other specific studies are also used for differential diagnosis - in particular, the DEB test.
3-4 days before the trepanobiopsy, it is necessary to exclude the use of alcoholic beverages and the intake of medications that help thin the blood (for example, acetylsalicylic acid).
The doctor should tell in advance about the existing allergic reactions, about the presence of electronic implants.
For several days, it is necessary to do a blood test to assess coagulability and exclude inflammatory processes in the body. The next morning, on the day of the procedure, you should have breakfast as light as possible. 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 trepanobiopsy of the bone marrow is supposed to be carried out, then you need to tell the doctor in advance if there were previously operations on bones, fractures (especially of the pelvic bones or spinal column).
Manipulation is most often performed in the morning or in the morning. No other special training is required. If necessary, the doctor will ask the patient for fluorography and / or electrocardiography a few days before the procedure.
The needles that are used for trepanobiopsy can be different, depending on their purpose. The main tool for isolating a biopsy column in the diagnosis of bone marrow is an auxiliary insertion mandrel in the form of a "ladle" or "spoon". Over time, manufacturers of such needles have thought of a simple and fairly effective method of separating a biopsy column. As already mentioned, the needle contains an insert mandrel. When the trepanobiopsy manipulation is performed, the stylet is removed from the needle, a hollow mandrel is inserted into it, in which the necessary bone marrow biopsy is present. A small notch along the body of the mandrel holds this material and "gives it away" when the needle is turned 360 °. This mechanism helps prevent rupture and loosening of the biopsy specimen. The separation of the material occurs without any effort, it has a sufficient volume and height. This method is less traumatic and practically painless, in contrast to the previously carried out rocking of the instrument. 
The design and functionality of modern trepanobiopsy needles includes:
- minimization of painful sensations 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 of the trepanobiopsy
For trepanobiopsy, special instruments are used with a wide handle, a needle with a stylet, and a cannula. The needle is different, depending on the area of its application and on the thickness of the patient's subcutaneous fat layer.
The standard duration of such manipulations as bone marrow trepanobiopsy is about 20-25 minutes. If necessary, the hair is shaved off in the area of the procedure. Local anesthesia is used, sometimes in conjunction with general sedation. Less commonly, general anesthesia is used.
The skin in the puncture zone is disinfected, anesthetic is injected. Next, the needle is inserted into the required area with a translational-rotational movement, a column of biomaterial is removed, which is then transferred to formalin. The affected area is disinfected again, a sterile bandage is applied. The results of trepanobiopsy can be ready within a few hours or several weeks, depending on the situation.
Trepanobiopsy of tumors refers to puncture methods for diagnosing a patient: a biopsy specimen is removed in the form of tissue or cells for subsequent laboratory research. Such a diagnosis is mandatory for making a diagnosis if there is a suspicion of oncological pathology. Trepanobiopsy helps to assess and analyze the structural composition of biological material. The procedure is necessary not only for the diagnosis, but also for the further determination of the treatment tactics. Since the treatment regimen for oncopathology everywhere includes complex chemotherapy, radiation therapy, surgical intervention, it is imperative that diagnostic studies are performed in the form of cytological or histological analysis that can identify the type of neoplasm. 
Trepanobiopsy of the breast may involve partial or complete resection of the pathological focus, therefore this procedure is often included in the category of surgical operations. To remove biological material, a specific needle is used, which consists of a rod and a cutter, has a flexible cannula and a mandrel. First, a small scalpel incision is made into which a cannula is inserted. After reaching the required depth, the mandrel is removed. Further, the surgeon excises the pathological neoplasm with the help of a rod and an incisor. 
Trepanobiopsy of the bone marrow with lymphoma involves the removal of biomaterial from one or two points in the ilium. Manipulation is performed under general anesthesia and is mandatory for all patients except stage I or IIa Hodgkin's lymphoma. 
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. 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 ilium with further immunohistochemical analysis of the biomaterial. 
Trepanobiopsy of the ilium takes longer than, for example, the same procedure in the breast area. The manipulations can last up to one hour. The patient is laid down on the couch. The surgeon treats the proposed puncture site with an antiseptic solution, inserts the needle, and removes the rod. Performing screw movements, he inserts the cannula to the required depth for material removal. Next, it extracts the sample. Trepanobiopsy of the femur can be accompanied by the introduction of an electrocoagulator, which allows you to treat the walls of the wound channel. The current is applied simultaneously with the withdrawal of the needle. Thanks to this method, it is possible to prevent bleeding and the possible spread of malignant structures through the circulatory system. There is no need for suturing: the puncture area is covered with a sterile bandage. 
Trepanobiopsy of the lymph node is prescribed by an oncologist, hematologist if malignant processes, mononucleosis, inflammatory diseases or tuberculosis are suspected. The resulting material is sent to the laboratory. The result can be obtained within a few days to two weeks. Usually, the study is subjected to enlarged and indurated lymph nodes in the groin, neck, armpits or above the collarbone.
Percutaneous trepanobiopsy of the liver is prescribed for diffuse and focal hepatic 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 manipulation, the doctor performs an ultrasound examination to accurately determine the puncture site. After processing the skin, the doctor performs anesthesia, makes a puncture and the required amount of biopsy is removed. At this time, the patient lies on his back with his right hand behind his head. At the time of taking the material, the patient is asked not to breathe or 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 state of the organ after diagnosis. If everything is in order, the patient is allowed to go home.
Biopsy and trepanobiopsy of the prostate gland is prescribed for 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 starting the procedure, an anesthetic (often a special lidocaine gel) is injected into the rectal cavity through the anus. After 6-8 minutes, an ultrasound probe is inserted into the rectum, equipped with a nozzle for introducing a needle: with its help, the points of manipulation are determined. This trepanobiopsy is usually well tolerated, with only occasional slight discomfort. 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, while the overwhelming majority of them are conditional (the procedure becomes possible after they are eliminated):
- pregnancy, menstruation and lactation (for trepanobiopsy of the mammary gland);
- allergic sensitivity to drugs that are supposed to be used for anesthesia;
- feverish condition;
- inflammatory foci, abscesses, eczematous rashes in the area of the alleged puncture;
- the presence in the body of artificial pacemakers and other devices that coordinate cardiac activity;
- acute soreness in the spinal column and shoulders;
- insufficient blood clotting;
- acute infectious diseases.
If the patient took a course of blood thinners on the eve of the procedure, then the risk of bleeding after trepanobiopsy increases dramatically. To reduce the risks, it is necessary to completely stop taking such drugs, at least 24-48 hours before the study. If this is not done, then manipulation is prohibited.
Trepanobiopsy is not prescribed for elderly patients, as well as for decompensated renal, heart or hepatic failure, late stage of diabetes mellitus. The procedure can be problematic if the patient is severely obese.
In some cases, trepanobiopsy is not prescribed not because of contraindications, but due to inappropriateness: for example, if the manipulation does not help improve or prolong a person's life, or its results will not affect the already prescribed treatment.
The biological material removed during trepanobiopsy can be examined for several days or weeks. As a matter of urgency, 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, about the structural features of tissues, about the type of malignant process. 
Overall, the most common results are:
- norm: there are no malignant cells, all indicators are normal;
- the presence of non-cancerous changes without confirmation of the oncological process;
- benign tumor process without malignant tissue growths;
- a confirmed malignant process with an established stage and type of pathology.
Tissues obtained in the process of trepanobiopsy are examined in many ways - for example, histological and cytological analyzes are performed to help assess the development of cells. In the laboratory they are studied, the number of immature particles is calculated. In the course of histochemical diagnostics, the activity of enzymes is determined, their quantity is estimated, bone architectonics, 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. , 
The specialist describes all the information received in a special report. On its basis, appropriate therapy is prescribed. In some cases, it becomes necessary to conduct repeated trepanobiopsy - for example, to compare indications, clarify some points, assess the dynamics of treatment. 
Complications after the procedure
If trepanobiopsy is performed by a qualified specialist, then serious consequences are usually out of the question. Some of the standard natural post-procedural manifestations are sometimes:
- dizziness, nausea;
- slight bleeding from the wound;
- slight swelling, discomfort in the manipulation area.
All these phenomena go away on their own after some time.
As for more serious complications, they occur only in rare cases. In isolated patients, wound infection, the development of an inflammatory process, an increase in temperature, and the appearance of pathological secretions can occur. In such situations, it is necessary to urgently consult a doctor for advice.
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 trepanobiopsy is noted in almost all patients: we are talking about a slight transient soreness, which does not pose a threat to health and is associated only with mechanical tissue damage. If such pain is severe, then this may be due to nerve injury: in such a situation, it is better to consult a doctor.
With improper processing of the operating field, insufficient qualifications of the attending physician, bleeding may occur, purulent processes may develop. Damage to large-caliber vessels and nerves is also not excluded. 
The appearance of a slight edema in the area of the puncture is allowed, which is considered the norm and disappears within a few days.
Care after the procedure
Caring for the puncture zone involves adherence to the following recommendations:
- The dressing should not be removed until the next day after the procedure.
- You can take a shower no earlier than 24 hours after the manipulation. The area of the puncture should not be rubbed intensively with a washcloth or towel: it is enough to rinse with warm water and pat dry with a soft clean towel. If there is no discharge, then there is no need to reapply the bandage.
- If edema or hematoma appears in the puncture area, then it is necessary to apply an ice pack wrapped in a towel - for about 10 minutes, several times a day for the first 1-2 days. Completely edema and hematoma usually disappear on their own after a few days (up to a week).
- If blood is released from the wound, then you need to apply a tight bandage: if the bleeding increases or does not stop, then you need to call the treating doctor.
- After trepanobiopsy of the mammary gland, you need to wear a well-fitting bra that qualitatively supports the breast.
- For 3-4 days, you should not lift weights, do physical exercise intensively (including running).
- You cannot take a bath, swim in the pool, visit the bathhouse or sauna.
- If pain occurs, you can take a Paracetamol tablet. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) as pain relievers is undesirable because 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.
According to the patients themselves, who have already undergone the trepanobiopsy procedure, one should not particularly worry about this diagnosis. Since the manipulation involves the use of local anesthesia, the sensitivity in the puncture area disappears, and the patient himself practically does not feel anything.
The appearance of complications after trepanobiopsy is rare, and the patient can return to his usual way of life after the examination. Hospitalization is not needed, the person goes home immediately. If unwanted autonomic reactions occur (dizziness, nausea, shortness of breath, blurred consciousness, tachycardia), then you should remain under medical supervision for a while, until the condition stabilizes.
The main thing is not to worry in advance, if necessary, take sedatives and tune in to a positive result.
Trepanobiopsy is a relatively rare diagnostic technique that is used only in some medical and oncological centers. More often, doctors practice a conventional biopsy. Trepanobiopsy should be performed by qualified specialists, therefore, when choosing a clinic, it is necessary to focus not only on the pricing policy and quality of service, but also on the experience and qualifications of doctors, on the equipment used and, of course, on positive patient reviews.