Red Flags in Bone Marrow Biopsy
The most significant red flags associated with bone marrow biopsy are hemorrhage risk (especially in patients with myeloproliferative disorders or on antiplatelet therapy), infection, and procedural complications that can lead to significant morbidity or mortality. 1, 2
Bleeding Risk Factors
Hemorrhage is the most common and serious adverse event associated with bone marrow biopsy:
- Myeloproliferative disorders (highest risk factor) 1, 2
- Antiplatelet therapy, particularly aspirin 1, 2
- Anticoagulant therapy (e.g., warfarin) 1
- Thrombocytopenia (especially platelet counts <20,000) 3
- Disseminated intravascular coagulation 1
- Obesity (may complicate procedure and increase bleeding risk) 1
- Acquired von Willebrand syndrome (particularly in myeloproliferative neoplasms) 4
Infection Risk Factors
- Active systemic infections requiring antibiotics (these patients should be excluded from clinical trials until resolution) 5
- HIV positive status (poor tolerance to chemotherapy and immunosuppressive effects) 5
- Immunocompromised status 5
Procedural Complications
- "Dry tap" (inability to aspirate bone marrow) - may indicate bone marrow fibrosis or densely packed marrow 6
- Needle insertion complications (improper technique leading to inadequate sampling) 6
- Specimen collection issues (improper anticoagulation or handling) 6
- Inadequate sample volume for required diagnostic tests 6
Disease-Specific Considerations
Secondary bone marrow fibrosis from:
Myelofibrosis grading (MF-0 to MF-3) affects diagnostic yield and interpretation 5
Mortality Risk
- Although rare, death directly attributable to bone marrow biopsy has been reported (estimated at <0.05%) 1, 2
- Overall incidence of significant hemorrhage is very low (0.007-1.1%) 4
- Clinically relevant non-major bleeding incidence approximately 0.19% 3
Procedural Recommendations to Minimize Risk
- Posterior iliac crest is the optimal site for bone marrow biopsy 6
- Specimens should be collected under sterile conditions 6
- For adults, approximately 1-3 mL of bone marrow should be collected 6
- When large sample volumes are required, changing the bone marrow aspiration site is necessary to avoid hemodilution 6
- Image guidance (CT or fluoroscopy) may improve safety in difficult cases 7
When to Defer Bone Marrow Biopsy
- When cytopenias have a clear alternative explanation (e.g., documented iron deficiency) 8
- When PET scan is negative or shows homogeneous bone marrow uptake in suspected Hodgkin lymphoma 5, 9
- When the clinical picture does not support a bone marrow disorder 8
When Bone Marrow Biopsy is Essential
- Unexplained cytopenias without a clear cause 8
- Suspected myelodysplastic syndrome with persistent unexplained cytopenias 8
- Suspected hematologic malignancy 8, 9
- Pyrexia of unknown origin with suspected lymphoma 9
- Diagnosis and prognostic assessment in multiple myeloma 9
Anticoagulation Management
- Routine interruption of anticoagulation is not consistently recommended 4
- Assessment and optimization of bleeding risk factors should be done on a patient-by-patient basis 4
- No major bleeding events were reported in patients on antithrombotic therapy in recent studies 3
Bone marrow biopsy remains a generally safe procedure with low complication rates, but awareness of these red flags can help minimize risks and improve patient outcomes.