BIOPSY OF BONE MARROW WITH THE SILVERMAN NEEDLE IN CHILDREN

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BIOPSYOF BONE MARROW WITH THE SILVERMAN

NEEDLEIN CHILDREN

Howard A. Pearson, Lt. (MC) USN, William McFarland, Cmdr. (MC) USN, and Thomas E. Cone, Jr., Capt. (MC) USN

Pediatric and Hematology Services of the U. S. Naval Ho@ital, Bethesda, Maryland

E XAMINATIONof the bone marrow is an essential procedure in the complete evaluation of patients with hematologic dis orders. Simple aspiration yields adequate specimens in the majority of cases; and

when the selective particle technique1 is used on marrow aspirates, the problem of

dilution by peripheral blood is reduced to a minimum, thus yielding an even higher percentage of satisfactory results.

Even in experienced hands simple aspira tion is unsuccessful in a small number of children. The problem of the â€œ¿drytapâ€•has been well studied in adult hematologic

cases.2'3 In series from large hematologic

centers, 5 to 10% of inadequate marrow

aspirates are reported. When biopsy is per

formed in these cases, the bone marrow is found to be abnormal in almost every in stance. We believe that this is also true in hematologic disorders in childhood.

In an earlier communication, one of the present authors described a new technique for biopsy of the bone marrow.3 The Silver man needle,@ identical to that used for liver biopsy, was employed to obtain rela tively large biopsies from the posterior iliac crest. The present study has extended use of this technique into a series of hemato logic cases in children.

PROCEDURE

For sedation, a promethazine-merperidine promazine combination* j@ administered 45

minutes before the procedure is performed.

The child is usually quite drowsy, but responds

to commands and painful stimuli.

The child is held in the lateral recumbent

Kindly supplied by Wyeth Laboratories.

position with the head flexed and the knees drawn up on the abdomen, in a position similar to that used for diagnostic lumbar puncture. By this positioning, the posterior superior iliac

spine is brought into prominence. Except in

the markedly obese child, it can usually be

visualized as a subcutaneous bony â€œ¿knuckleâ€• cephalad and lateral to the intergiuteal cleft.

The skin is prepared with antiseptics and draped.

The posterior superior iliac spine is carefully palpated, and the skin over it is infiltrated with a local anesthetic solution. This is the only un comfortable part of the procedure, and subse

quently little discomfort is usually experienced

by the patient. The subcutaneous tissue and periosteum of a 1-cm area just cephalad to the

spine is then carefully infiltrated with the

anesthetic.

Without incision of the skin, a 2%-inch Silver man needle cannula, with obturator in place, is inserted through the skin. The midpoint of the

posterior iliac crest just cephalad to the pos

tenor superior spine is chosen for penetration of the bone. With gentle alternating rotatory motion, the needle is advanced through the cor tex into the substance of the iliac crest. The point of the needle is guided in the direction

of the anterior superior iliac spine which may

be palpated through the drapes with the opera

tor's free hand. As can be best realized by ex

amining the pelvis of a skeleton, this direction

ing assures that the needle's forward path is

between the tables of the iliac crest (Fig. 1).

When the needle has been advanced approx

imately 0.5 cm into the bone, it is firmly fixed. The obturator is then removed, and the biopsy blades are inserted the length of the needle by

employing firm, steady, forward pressure with

the thumb. A grating sensation is appreciated

as the biopsy blades encounter bony trabeculae

of the cancellous medullary space. If the biopsy

The opinions expressed in this article are the private ones of the authors and not to be construed as official or reflecting the views of the Navy Department.

ADDRESS: (H.A.P.) National Naval Medical Center, Bethesda 14, Maryland.

PEDIATRICS, August 1960

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ARTICLES

COMMENTS ON THE TECHNIQUE

When an experienced operator fails to obtain a satisfactory specimen by bone mar

row aspiration, abnormal marrow mor phology is usually present. Marrow aphasia, fibrosis or replacement by abnormal cells

are the usual reasons for â€œ¿drytapsâ€•in both pediatric and adult hematologic cases. Thus, it is in the very case that evaluation of marrow morphology is essential for diagno

sis that aspiration may be unsuccessful.

There are several methods for obtaining

bone marrow when aspiration is unsuccess

ful. First is surgical curettage. Although a generous sample can be obtained in this manner, it entails a surgical procedure with general anesthesia and operating room fa cihities. Since prolonged decalcification of the specimen is often necessary, there may be considerable delay in arriving at a diag nosis. Curetting through a biopsy needle

yields fragmented specimens and general

anesthesia is necessary.5

In 1943, Turkel and Bethel6 devised a

needle-trephine instrument for marrow bi opsy. We have been dissatisfied with the results of this technique. Many of our speci

mens have consisted of cortical bone only, because of a tendency for the cancellous portion of the biopsy specimen to break off during withdrawal. In even the best speci mens, only a millimeter or two of actual marrow-bearing cancellous bone has been obtained. Other special needle trephine in

struments have been devised,7 but we have

had no personal experience with these; furthermore, they have not gained wide

usage.

Even before using the Silverman needle, we had adopted the posterior ilium as the site of choice for marrow aspiration. Except for the cases to be described, the posterior ilium has been invariably productive of a diagnostic marrow aspiration. We have ob tained aspriated specimens of good cellu larity from the posterior iliac crest in several newborn infants and even in a 2-pound pre mature infant who had neonatal thrombo cytopenia.

Fic. 1. Diagrani of position of needle with respect to the bony pelvis.

blades cannot be easily advanced, they are

usually encountering the inside table of corti

cal bone. Undue force must not be exerted, for bending of the biopsy blades may result. Rather, the blades should be withdrawn, the obturator re-inserted, and the direction of the

outer needle changed slightly without complete withdrawal.

When the biopsy blades are fully advanced, they are firmly held in place with one hand.

The needle cannula is then advanced forward,

over the greater part of the biopsy blades with the contained specimen. Since the retained biopsy specimen is always thicker distally than proximally, the needle cannula cannot be easily

passed all the way over the biopsy blades. In addition, if the cannula is advanced too far,

crushing and distortion of the marrow speci

men will result. The final relationship of can

nula to biopsy blade is maintained by firmly

grasping both hubs in the fingers and palm. The whole unit is rotated 180Â°and then with drawn. Firm digital pressure over the area is maintained for about 5 minutes by an attendant

and a tight dressing is applied.

After withdrawal, the biopsy blades are re

advanced their full length through the cannula.

With the point of a No. 25-gauge needle, the biopsy blades are separated. The contained marrow plug is removed distally and placed in

a container of Zenker's solution.

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F'ic. 2. Needle biopsy from Case 1. Marked liypocelluiarity and fatty replacement. ( x245)

that four of these children had significant thrombocytopenia, no excessive bleeding was observed.

In 95 consecutive marrow aspirations,

during the last 18 months, 6 instances of

â€œ¿drytapâ€• were encountered. Marrow bi

opsy was done in each case. These cases are briefly summarized:

CASE 1: An 18-month-old child was admitted for evaluation of pallor and bruising. In tile

preceding 7 months, he had received chloram

phenicol on 11 occasions for respiratory infec

tiolis. Studies of the peripheral blood revealed

pancytopenia. Attempted marrow aspirations

from sternum, tibia and anterior iliac crests

yielded only peripheral blood. A Silverman

needle biopsy revealed a markedly hypocellu lar marrow with fatty replacement consistent with aplastic anemia (Fig. 2).

CASE 2: A 9-year-old child with proved

acute leukemia of 4 months' duration was ad

mitted for evaluation. She had received 3

months of therapy with 6-mercaptopurine with

clinical remission. One month before admission, evidence of relapse was observed and treat

ment with amethopterin was instituted. Pro

found pancytopenia then occurred. Attempted

The Silverman-needle i)Ofle marrow bi

opsy technique does not have many of the diSadvantages of other biopsy techniques.

A specimen of marrow, measuring 0.7 to 1.0 cm by 2 mm can be obtained almost rou

tinely, making accurate evaluation of bone marrow structure and cellularity possible.

We now keep a sterilized Silverman needle available at the time of all diagnos

tic bone marrow aspirations. If the aspira tion is â€œ¿dry,â€•or if no macroscopic marrow particles are observed in the heparinized

aspirate, then needle biopsy is performed.

Our Pathology Department can process a fully irer@tre1 and Giemsa-stained marrow

section in less than 24 hours.

RESULTS

In order to perfect this technique, we obtained bone marrow biopsies by use of the Silverman needle in 10 children on whom we were performing diagnostic bone marrow aspiration. These children ranged in age from 2 to 10 years. Successful biop

sies were obtained in all cases. No compli

cations were encountered. Despite the fact

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Fic. .3. Marrow biopsy from Case 2. The dense fibrosis is apparent. No normal myeloid elements are seen.

(x284)

bone marrow aspirations from several sites at the referring hospital, and from the posterior ilium at this hospital, yielded no marrow parti des. Silverman-needle biopsy was done and re vealed advanced myelofibrosis with no normal marrow in the specimen (Fig. 3).

CASE 3: A 3-month-old child with proved

congenital heart disease was referred for study of hepatosplenomegaly and rash. A bone mar row aspiration performed at another hospital

@â€”¿ yielded no marrow. A â€œ¿dry tapâ€• was also ob

tamed from tibia and iliac crest at this hospital.

A Silverman-needle marrow biopsy was easily

performed, even though the child weighed only

10 pounds. This specimen revealed a patchy

replacement of the marrow by sheets of cells

with large pale nuclei (Fig. 4). The diagnosis of disseminated reticuloendothehiosis was later

confirmed.

CASE 4: A 3-year-old child was admitted

because of bruising and pallor. Studies of the peripheral blood demonstrated pancytopenia. The leucocytes were predominantly small lym phocytes, although a few blast fornis were also observed. Aspiration of the iliac crest yielded

only peripheral blood. Silverman-needle biopsy

was done and showed complete replacement of

the marrow by dense sheets of leukemic lym phocytes.

CASE 5 : A 3-year-old girl was studied be

cause of pancytopenia. She had a laparatomy performed with the removal of an abdominal tumor 1 year previously at another hospital. Recurrence of the abdominal mass had oc curred within months after the surgical pro cedure and several courses of x-ray therapy had been administered. Records were unavailable from the other hospital as to the histologic ap pearance of the tumor. In order to evaluate the cause of the pancytopenia, marrow aspiration was unsuccessfully attempted. The Silverman needle biopsy then performed, demonstrated

marked hvpoplasia, probably postirradiation.

CASE 6: A 4-year-old boy was admitted be

cause of a large left abdominal mass. Intra venous pyelogram demonstrated depression of

the left kidney by a retroperitoneal mass. A

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Fic. 4. Marrow biopsy from Case :3. Fairly normal marrow architecture is seen at the top and l)OttOni of the section. The marrow spaces ill the center of the specimen are diffusely replaced by sheets of

reticuloendothelial cells. (x 245)

SUMMARY AND CONCLUSIONS

Biopsy of the marrow of the posterior

iliac crest with the Silverman flee(Ile is a Siiiil)le and safe I)r@ced11re in infants and childreii . Usi ng this techn ique, accurate

iiiarr@@w evaltiatioii has l)een possible in six

instances of dry tap,â€• and in each case the niarrow was al)nornial.

Because of the ease of performance, with

no fliO@Cpreparation tisamifor ordinary mar

ro@v aspiration, and because of the rapidity

with which a truly adequate marrow biopsy specimen can be made available for histo logic study, we believe that the Silverman needle biopsy is the method of choice for biopsy of time marrow in children.

Addendum

Since Slli)IIliSsiOIlof this article, foui more

instances of â€œ¿drytapâ€• have 1)een eneountere(1

ill our 1)rItic'@. Silvernianâ€”needle biopsy re vealed acute leukemia an(1 aplastic anemia iii two of these cases. The third case was a 36-pound child who had unexplained leukopenia. The initial needle biopsy showed only cortical

bone and fat @vitliout idleutifial)le Iliveloid tis sue. Repeat needle l)iopsv denlonstrate(l an es sentiallv nornial mnarro@v. The fiuial case is a 25â€”pound child with mon golism ai@i sui)acnte k'tikeiiiia. Repeated attellil)tS to secure miiarrow

froni the posterior ileuiii 1)0th 1)>' aspiration

and Il('('dlle i)iops\ have l)('('I) unsuccessful.

REFERENCES

1 . Propp, S. : Iniproved technic of bone iiiar

fl)@@ aspiration. Blood, 6:585, 1951.

2. \Veisberger, A. S. : Significance of (Iry tap

l)oIie harrow asj)iratiolls. Am. J. \Ied.,

229:63, 1955.

:3. McFarland. \V., and I)ameshek, \V. : Biopsy

of i)oll(' Ili@lrlO\V @vitii the \â€˜iITlâ€”Silyerniaii

needle. J. A. \I. A., 166: 1464, 1958.

4. Silverman, I. : Ne\s i)iopsv Il('e(ll('. Am. J. Surg., 40:671, 1938.

5. i)o@vning, \â€˜.: Bone inarro@v (â€˜XdOiiIatid)n in

children. Pediat. Clin. North America,

Feb., 1955, PP 243-256.

6. â€˜¿t'iirkel,H., and Bethell, F. H. : Biopsy of i)One miiario@v 1)erforlliedl l)\' a ne@@ and

simiiple instrunient. j. Lal). & Cliii. NIed.,

28:1246, 1943.

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1960;26;310

Pediatrics

Howard A. Pearson, William McFarland and Thomas E. Cone