From the Guidelines
A bone marrow biopsy is not always required to check for lymphoma involvement in the bone, especially if a PET-CT scan demonstrates bone or marrow involvement indicating advanced-stage disease. This is based on the most recent and highest quality study, which suggests that PET-CT is more sensitive than bone marrow biopsy (BMB) for detecting bone marrow involvement in certain types of lymphoma, such as diffuse large B-cell lymphoma (DLBCL) 1.
The procedure of bone marrow biopsy involves removing a small sample of bone marrow, usually from the hip bone (posterior iliac crest), using a specialized hollow needle. The bone marrow biopsy provides both the liquid marrow (aspiration) and a small core of bone containing marrow for examination. This allows pathologists to examine the cells under a microscope and perform additional tests like flow cytometry, immunohistochemistry, and molecular studies to detect lymphoma cells.
However, according to the Lugano classification, if a PET-CT scan is performed, a bone marrow aspirate/biopsy is no longer required for the routine evaluation of patients with Hodgkin lymphoma (HL) 1. Similarly, in DLBCL, PET-CT is also more sensitive than BMB, but may miss low-volume diffuse involvement of 10% to 20% of the marrow 1.
In some cases, if there is a specific bone lesion suspected of lymphoma involvement, a targeted bone biopsy of that lesion might be performed instead of or in addition to the bone marrow biopsy. The decision to perform a bone marrow biopsy should be based on the individual patient's circumstances, including the type of lymphoma, the stage of the disease, and the presence of symptoms or other evidence of advanced-stage disease 1.
Some key points to consider when deciding whether to perform a bone marrow biopsy include:
- The sensitivity and specificity of PET-CT for detecting bone marrow involvement in different types of lymphoma
- The potential for PET-CT to miss low-volume diffuse involvement of the marrow
- The importance of bone marrow involvement in staging and treatment decisions
- The individual patient's circumstances, including the type of lymphoma, the stage of the disease, and the presence of symptoms or other evidence of advanced-stage disease.
From the Research
Types of Biopsy for Lymphoma Involvement in the Bone
To check for lymphoma involvement in the bone, the following types of biopsies are considered:
- Bone marrow biopsy (BMB) is the standard method for investigating bone marrow involvement in lymphoma patients 2, 3, 4, 5.
- Positron emission tomography/computed tomography (PET/CT) scan is a non-invasive technique that can detect bone marrow involvement and has been shown to have good sensitivity, specificity, and diagnostic accuracy in certain types of lymphoma, such as diffuse large B cell lymphoma (DLBCL) and Hodgkin lymphoma (HL) 2, 4, 5.
Diagnostic Accuracy of Different Biopsy Methods
The diagnostic accuracy of BMB and PET/CT scan in identifying bone marrow involvement varies depending on the type of lymphoma:
- In DLBCL patients, PET/CT scan has been shown to have a sensitivity of 93.61%, specificity of 93.93%, and diagnostic accuracy of 93.84% 4.
- In HL patients, PET/CT scan has been shown to have a sensitivity of 96.7%, negative predictive value (NPV) of 99.3%, and accuracy of 99.3% 5.
- In high-grade non-Hodgkin B-cell lymphoma (HG B-NHL) patients, BMB has been shown to have a sensitivity of 77.6%, NPV of 90.2%, and accuracy of 90.7% 5.
Recommendations for Biopsy Methods
Based on the available evidence, the following recommendations can be made:
- PET/CT scan may replace BMB in detecting bone marrow involvement in aggressive lymphoma subtypes such as DLBCL and HL 2, 4, 5.
- In HG B-NHL patients, bone marrow status should be assessed firstly by means of PET/CT, and only in cases with focal or diffuse PET/CT with low borderline SUV max values or in negative cases, should BMB be carried out afterwards 5.
- BMB is not mandatory in every patient with non-Hodgkin's lymphoma, and the clinician should weigh up the potential benefit of this procedure in each case in terms of changing therapeutic approach and prognosis 3.