Bone Marrow Collection Procedure.fm - Mayo Medical Laboratories

Bone Marrow Collection ProcedureBONE MARROW COLLECTION PROCEDUREProcedure for bone marrow preparations evaluated at Rice Laboratory.*BEFORE STARTING THE BONE MARROW COLLECTION PROCEDURE,PROPER IDENTIFICATION OF YOUR PATIENT AND A TIME OUT CHECK MUST BE PERFORMED*After the pathologist introduces him/herself and the assistant, we need to ask the patient to state their name,DOB and why they are here, and then check name and DOB on wristband. For documentation, patientidentification and procedure confirmation should be performed in the presence of two personnel (pathologist andlab assistant or nurse.)I. Fixative for marrow aspirates and marrow core biopsiesA. B-Plus (obtained from Rice Laboratory)B. 10% Formalin: May be used if B-Plus fixative is not availableC. Please indicate which fixative was used and the time it was placed into the fixativeII.III.Vials: Prepare before marrow aspirationA. For Bone Marrow Aspirate:1. Heparin Tube (If required for special testing)2. For Clot Preparation--an Accuvette chamber or red top 7 mL vacutainer tube3. Document the total volume of aspirate collectedB. For Marrow Core Biopsy:1. An Accuvette chamber or 7 mL red top vacutainer tube2. Have two core containers ready in the event right and left core biopsies are obtained.Label tube(s) "CORE(S)", indicate "right" or “left" if appropriate3. Measure and document the length of each core biopsyC. For Special Studies:1. Check with the pathologist at the time the procedure is scheduled to ask if specialstudies will be needed. Note: If the procedure is to be performed by a nonpathologist,check with a pathologist for any other special testing that they may wantcollected. See Section VIII of this procedure for materials needed for special testing assome materials may need to be obtained from Rice Laboratory or another referencelaboratory prior to bone marrow sampling.2. Notify Rice Laboratory as soon as possible of the need for special collectionMarrow Aspirate: (Do not use heparized marrow to make slide preparations)A word of caution: Marrow aspirate will clot almost immediately after it is removed from thepatient. Clotted marrow is very difficult to work with and is also very difficult for thepathologist to interpret. The next four steps must be performed very quickly by the technician.A. "Squash or Slant Smears"Take the syringe containing the marrow aspirate from the physician and immediatelyexpel some aspirate onto three or four slant smear slides (slides supported at a 60°angle). Let blood drain down the slant while step 2 is performed.a. See technique for making slant squash smears in Appendix #1

A. Bone Marrow Request Form (To include CBC/Diff and any other related clinicalinformation with the clinician's reason for request.)B. Peripheral Smears: 2 to 3C. Squash Slant Smears: 6 to 8 for each side biopsiedD. Direct Smears: 3 to 4 for each side biopsiedE. Core smears: 2 to 4 for each side biopsiedF. Core tube(s): 1 to 2 (depending on whether both right and left biopsies are obtained.)G. Aspirate tubes(s): As needed for special testing if necessaryH. Patient's age/date of birth is important for a diagnosis. Also include patient's address,insurance/Medicare information if applicable and a brief summation of the requestingphysician's diagnostic impression of the patient's illness.VIII.Special Tests (Extra Aspirate Smears Required): Note: a separate syringe should be used tocollect special studies. Pre-heparinize the syringe with 2-4 mL of heparin 1000 U/ml for flowcytometry and chromosome (cytogenetic) analysis. These two may be collected together ifboth are indicated. Check with pathologist as to which reference lab they want specimenssent, Clarient or MayoA. Flow Cytometry: Mayo #3287--Leukemia/Lymphoma Immunophenotyping by FlowCytometry requires 1.0-2.0 mL bone marrow aspirate in sodium heparin green toptube. Include 4-5 unstained bone marrow aspirate smears, if possible. Make everyeffort to keep the specimen from clotting. Partially clotted or clotted specimens areNOT acceptable. Include Mayo T357 Information form.B. Chromosome Analysis (Cytogenetics): Mayo #8506--1.0-2.0 mL bone marrow aspiratein sodium heparin green top tube. Clotted bone marrow is not accepted. IncludeMayo T357 Information Form.C. Cultures:1. Routine: 1.0-2.0 mL bone marrow aspirate in a Pediatric Blood Culture bottle2. Fungus: 1.0-2.0 mL bone marrow aspirate in a sterile screw top tube, Mayo#500193. AFB: 1.0-2.0 mL bone marrow aspirate in SPS yellow top tube or heparin tube,send to MDH4. Viral: Not available on bone marrow specimens. A CMV specific rapid test canbe ordered, Mayo #81240D. Plasma Cell Proliferation Disorder Mayo #83358 FISH – 1.0-2.0 mL of bone marrow inheparin tubeE. JAK2 V617F Mutation Detection: Mayo #31155 - 2.0 mL of bone marrow in a lavendertop (EDTA) tube(s) and sent ambient temperature only. Specimen cannot be frozen.This test may be requested on a peripheral blood sample as well, Mayo#88715 –4.0mL EDTA whole blood. Collect peripheral sample and process the same as for bonemarrow. Recommended for aiding in the distinction between a reactive cytosis and achronic myeloproliferative disorder such as for myelofibrosis, polycythemia vera, andessential thrombocythemiaF. B Cell gene rearrangement Mayo #31141 for bone marrow or #83123 for peripheralblood 1-4 mL EDTA lavender top tubeG. T Cell gene rearrangement Mayo #31139 for bone marrow or #83122 for peripheralblood 1-4 mL EDTA lavender top EDTA tube

H. BCR/ABL Mayo#89006 PCR Qualitative for initial diagnosis – 3.0 – 4.0 mL EDTA bonemarrow or peripheral bloodAppendix #1SLANT SMEAR TECHNIQUE FOR BONE MARROWBone marrow aspiration smears should be made at the patient's bedside, usually by the technologistassisting the pathologist/physician. Since bone marrow aspirations are not always easy to obtain andsince some aspirates yield few spicules, making smears at bedside is preferable to having theanticoagulated aspirations brought down to the laboratory for smearing. One disadvantage of thebedside smearing technique is that the smearing must be performed immediately and correctly toprevent clotting and to produce a good smear. Time cannot be wasted and the person making thesmear of the marrow spicules must be experienced or the end result will be a difficult smearevaluation. An actual aspiration is performed by inserting a special aspirating needle into the marrowof such bones as the sternum and the iliac crest, and then drawing out blood containing spicules fromthat marrow. Our technique for the actual smearing is to place drops of the spicule-laden marrow onslides which are tilted at 60º. The blood runs down the slide, leaving behind the spicule(s). Theexcess blood then is wiped or blotted away quickly and the spicule(s) smeared by placing anotherclean slide across the specimen slide parallel to it. The slides are then gently pulled away in oppositedirections as the spicule is spreading under the gentle pressure of the upper slide. Fan slides toquickly air dry.TRAINING TECHNIQUE:The training technique involves scrapings from a slightly softened bar of soap. The scrapings shouldbe small to simulate a spicule and should range in size from a "period" in a type-written article to alower case "o" in that article. Place the scrapings into a test tube and add anticoagulated blood tothe tube. Place some glass microscope slides at 60º angles and pour or dispense a few drops of theblood on the slides. Allow the blood to run down the slides and blot away the excess. The soap"spicules" will remain behind. Place a clean slide parallel to the specimen slide and gently lower ituntil it touches the "spicule". Exert a little back and forth pressure upon the particle until it begins tospread out. When it is spread approximately three times its original size, pull the slides in oppositedirections gently. The resulting smear will appear oval with tapered ends and will give a glisteningappearance surrounded by a thin layer of blood. This technique closely simulates the technique usedin actual bone marrow smears.