Northern Lights: A Look Into The Bone Marrow
I recently noticed that one of the most active discussions in the Myeloma Beacon forums is one about experiences with bone marrow biopsies. I haven’t read of anyone who really was neutral to having that procedure done.
Whether it’s done under local anesthetics or with the help of a sedative, it is somewhat dreaded because it helps diagnose, confirm and stage multiple myeloma. However, most of us patients consent to the procedure because of the information it can yield.
When I had an initial appointment with my oncologist to review the results of various blood tests, I had been advised that a bone marrow biopsy might be done at that time.
Sure enough, after getting the unwelcome news that my blood held a high amount of monoclonal (M) protein, my oncologist suggested that I have the bone marrow biopsy that day. Otherwise, I would have had to make another appointment, which would have further delayed the definite myeloma diagnosis. I was anxious to start treatment as soon as possible, if I indeed had multiple myeloma.
In preparation for the procedure, a local anesthetic was injected into my left hip area. This reminded me of trips to the dentist, when I had needed ‘freezing’ for dental procedures.
As I waited nervously for the freezing to take hold, the attending nurses wheeled in a cart containing all of the items needed for the biopsy: two large needles with syringes, test tubes, a paper sterile drape, iodine swabs, a scalpel, frosted glass slides, gauze sponges, a large adhesive bandage, and test tubes. I looked at this cart with some apprehension, as I realized I was about to have a minor surgery and wasn't sure what that would be like.
The three nurses attending that morning had calm, soothing demeanors and reassured me that the procedure would be quick.
My doctor came in, and the procedure began. The first needle was used to remove a small sample of the bone marrow, the ‘aspirate,’ and the second was used to collect an actual sample of the bone, the ‘bone biopsy.’
I have to admit that I was not as calm as I should have been. The nurses told me to wiggle my toes and complimented me on my pink-flowered socks. They squeezed both of my hands tightly, and in return, I hope I did not bruise their hands with the pressure of my hand holding.
The feeling of pressure and pain as the doctor inserted the first needle did not last very long, but I did feel a slight crunching sensation as he took a small sample of bone with the second needle.
At the time, I barely noticed that the staff were preparing smears on the glass slides, which were sent off to a pathology lab for examination.
My next appointment with the doctor to discuss the results of the biopsy was not for another couple of weeks. In the meantime, I read up a little on the procedure because I wanted to know why we would need an invasive test such as the biopsy, with all the sophisticated blood tests available now.
I found that the bone marrow biopsy is meant to examine the actual bone to see how much the cancer has infiltrated into the bone.
I also learned that another very important aspect of bone marrow testing is to look for chromosomal abnormalities, which frequently occur in multiple myeloma. That testing was done on my bone marrow the second time I had the test.
Still hoping that my bone marrow test would come back normal, my husband and I returned for my next appointment. We found out that, alas, I really did have myeloma, and my treatments commenced soon after that.
I started induction therapy with Velcade (bortezomib) plus dexamethasone (Decadron) in August of 2010, and after four cycles, I achieved a very good partial response. I felt so much better. The tumor burden was lifted, my fractures were healing, and I had more energy too. I was back to walking about three kilometers a day.
In November 2010, I started the stem cell transplantation process, which my doctor recommended as a follow-up to the initial therapy. I needed to go through a lot of testing to determine that I could withstand that procedure. Those tests included heart, lung, more blood tests, and another bone marrow biopsy.
This time, I decided to take the easy way out and opted for sedation. An injection of midazolam (Versed) put me into a sort of half awake state, a state in which I definitely didn’t feel any pain. Quite a contrast from the first time.
Midazolam can make one really chatty and uninhibited too, but I don't remember much of it. To my complete relief, my biopsy showed very positive results, matching the blood and other tests.
I had a third biopsy after the stem cell transplant, in March of 2010.
At that point, I had a ‘central line’ catheter, which had been inserted before the transplant. So it was through the central line that the sedative was infused.
This time, I actually fell asleep before the procedure and must have slept right through it, for when I awoke, the nurses were tidying up the instrument cart and had several test tubes full of samples (I had donated a tube of aspirate for research).
I was grateful that one of my daughters had been patiently waiting for me outside the examining room, ready to drive me home. I could not have done it myself, and actually would not have been allowed to do so, because when you take the sedative, you are legally impaired for a day.
As you can see, my experiences with bone marrow biopsies have been mixed so far. I would say the first one was the one that had the most discomfort associated with it.
So I am somewhat relieved that I have not been scheduled for any more yet.
What has your experience been with bone marrow biopsies?
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The quotation for this month is from Soren Kierkegaard (1813-1855), a Danish philosopher, theologian, and poet, who wrote "Life can only be understood backward, but it must be lived forward."
Nancy Shamanna is a multiple myeloma patient and a columnist at The Myeloma Beacon.
If you are interested in writing a regular column to be published by The Myeloma Beacon, please contact the Beacon team at
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I have had six bone marrow biopsies, they are painfull, and do I hate having them done. One thing that helped was having the doctor change locations. It helped with letting the site heal longer. I was sore on the right side for a long time. They did the first three biopsies on the right hip,while setting up for number four I asked that they use the left side. They did and it was still painfull but not as bad as on the right side.
Hi Nancy,
I am glad your last 2 biopsies have been relatively easy.
I have had 5 so far. The first one, to confirm diagnosis, was done by an elderly Dr who informed me that as there are no pain receptors in bone the procedure wouldn't hurt. NOT HURT - you have got to be joking. It was the build up of pressure just before the bone plug comes out that really hurt. Might be something like a cork out of a champagne bottle - so much better to think of it that way. Never again (and I try never to say never) will I have one WITHOUT sedation. The following 4 (with sedation) were all a breeze. I also recommend sedation to any newly diagnosed MM patient.
Hi Nancy, I have had three and the worst for me was the anxiety beforehand....a xanax each time worked fairly well and should be part of the protocol.
I've had three so far (four?).. and the first was the worst. After that I knew what was coming, so there was no psychological stuff going on to build up the drama. Now, I do have to admit that I have a relatively high pain threshold (losing fingertips and a few laterally-fractured vertebrae will do that, I guess), so perhaps my experience isn't normative, but I have to say that the "cost" is far outweighed by the data.
Greetings! I had #15 just a few weeks ago. I never look at the "tools" they are about to use on me. I'm surprised they did not have them covered in order to keep them out of site. I take two ibuprofen approx. 45 min. before they start the biopsy. Seems to take the edge off of the pain, for me. I never worry about having a bone marrow biopsy. I just show up, go to my "happy place" and get it done. I do worry about the results, of course. A cool, moist wash cloth, placed across the back of the neck, seems to help (me) as well! We wish each of you much success in your journey! Today.... is a Good Day!
hi Everyone!! Thanks for the sharing going on here. Mike, I agree that biopsies should be alternated from one side to the other..they did that for me too. Good luck with your treatments.
Libby, you have been through a LOT in the time since you got diagnosed, and you have such a positive attitude too. I agree that sedation makes the BMB's go a lot easier.
Terry, good that xanax works for you...good to find a medication that can help one to get through what can be quite a difficult procedure.
Hi Snip....the psychological stuff is half the battle isn't it? I was so devastated to find out my diagnosis, and it took me a long time to come to terms with that. The BMB's were part of the information gathering as to my progress, so just had to go along with that. I have a high pain threshold sometimes, but not always, so since I could see a way around having a painful biopsy, opted for sedation.
Wow Ted, #15! Hope all is going well with you. You must also have a high pain threshold, if ibuprofen worked for you. That's what I take before going for a dental check-up!
Hi everyone,i"ve had two bone marrow biopsys the first was horrible i took two ativans on my second one which was a breeze.Although after i slept for the rest of the day but ativan works ask your dr to give it a try,Lou.
In my first bone marrow aspiration I drove in myself so I they only did a local anesthesia. At this time I had not yet been told I had multiple myeloma and the purpose of the bone marrow biopsy was for confirmation of what the doctor suspect from my other lab results. I had only seen the Oncologist for the first time a few days earlier and my general physician had only referred me to him the week before after seeing abnormal results in a CBC I had done. Things were happening fast and I was still a bit overwhelmed by going from presuming I was healthy with no real problems to learning I likely had a terminal disease in just a week. I was ready to move forward aggressively with whatever needed to be done.
I had one doctor and one nurse attend. They also had a tray with a bunch of slides vials etc. The first attempt to draw some bone marrow come up dry and failed. A second site was tried and that was dry too. This was not a good sign. The third attempt was successful. I remember looking over at the tray and seeing a bunch of slides that were yellow and red with bone marrow and blood. I was given a Xanax which seemed to help relax me a bit. The taps hurt quite a bit but when it was over I felt no pain afterword. The second one was done a few months later just before about a month or two before my SCT. This was done with one doctor and one nurse and I again drove myself in. Local anesthesia only with a Xanax. This time I was in very good partial remission and the first attempt to draw and aspiration was successful. This time they also took a bone sample. I asked if I could see the sample and I was shown a vial that had a small bone chip in it. I was surprised how small it was, but it must have been enough. The procedure hurt quite a bit again but no pain afterword and I drove myself home with no latter problems or complications.
Hi , I have had 9 BMB. Because I am a respiratory therapist, one of the nurse practitioners told me to ask for concious sedation. The first one was done in the office. Then my oncologists left and I got a new one. She has a small frame and was not able to get the specimen for the second one, so my next two were done with sedation in the radiology department. My transplant physician has done the other five in his office using concious sedation and alternating sites. The experience wasn't so bad but was necessary .
I've had it both ways. There's a huge difference in the two, though the ealing was the same. The difference is the pain, pressure and the ick factor. I would also recommend anesthetic for first biopsies as well as for all thereafter.
Julia
I've had 2 BMBs. The first was under a local and I was sore for months after. The MD took 2 rest periods while trying to penetrate the bone. The second was done with Propofol and they did 2 samples while under using a "gun". The only pain was the bandaid removal.
I've had 10 now. The one thing that truly bothers me is that involuntary leg jerking thing that happens only for an instance, but still..... That same feeling also tells me we're almost done, because it seems to come close to the end. Of course, I could be lying to myself.
Hi Nancy -- I hate them. Enough said.
hi again All and thanks for posting..we can all learn from each other's experiences in this regard!
Lou, Ativan alsos ounds like a good drug to try.
Eric, you are always very observant! it's truly amazing what the pathologists can see from a small sample of bone/marrow. more infi on Xanax too from you!
music Meme, sorry you have had to have so many BMB's. my second two were also done at the transplant unit...I guess it is a 'before and after' check on how the transplant went.
jubyanne..thanks for your wise counse..you are such a calming influence on us!
kent, thanks for sharing. at least you can say you have strong bones, and with MM, that is a real plus!
mike, you sound like a real trooper..from your picture a fighter too..good luck to you!
Lou, thanks for posting..yes, it's true..who on earth wants a BMB unless it were deemed to be medically necessary? I wonder if the new serum free light chain tests will take the place of BMB's for many patients? I think that there was an article to that effect here last week.
Before my first bone marrow biopsy, my friend and fellow MM patient Don told me that he always found BMBs done with sedation to be "very relaxing". That comment established my attitude toward BMBs, and I go into them almost laughing to think that someone could call such a procedure "relaxing". Sadly Don died earlier this year, but I will always remember his courage and good humor in the face of this disease.
You had a good friend, with a great sense of humor, Holt. hope you are doing well.
I have had about 11 biopsies since being dx in 8/10. My first was under sedation and performed by a doctor but due to the sedation It was a 4 hour process at out patient clinic and I was sleepy rest of the day. I had minor soreness for several days after. All my others have seen at UNiv of Arkansas (UAMS) where I am being treated. There they send you to the BMB clinic where, unti recently, they had pairs of techs perform the procedure. Most, but not all were very good. Each time you are scheduled for biopsy you are asked if you want fentenyl pops to take just before the procedure. I have used that all but once and find it really takes the edge off. I still hate the feel of the pressure during the procedure, and the occasional short stab of pain, but neither are severe. They also alternate sides there. I did have one tech that decided he was ready for me before I had my fentenyl but he knew I would be just fine if I sucked on the med during the procedure. Wrong! I won't do that again. Also, once when I couldn't have fentenyl due to a Pet scan following my BMP(due to sugar in the fentenyl pop), my APN, told me to take Ativan and that worked very well. UAMS now uses an APN and tech team with a physician on site to perform the BMP and gene arrays. I find it is mostly the person performing the procedure that makes the biggest difference in pain during BMP and during recovery, but I find the pre-meds to be a must. I will also say that about 8 of the 11 procedures I have had minor soreness for 4 or 5 days following, but significant aching and soreness after 3. Even though having the BMP done under full sedation was great, I prefer the speediness of just taking a premed, being done in about half an hour and getting on with my day.
hi Angela, I appreciate you sharing your experiences with the BMB's. I am not sure if we have Fentanyl Pops available here, but they do sound like a good idea! t here is definitely an edginess to have any type of invasive procedure.. I am not keen on getting dental work done either, although I have not had anything done besides cleaning work since taking bisphosphonates. luckily haven't needed any fillings, crowns or the like in the last three years! if I may digress, have now finished up with the Aredia, so that is one less thing to worry about!
first biopsy was under no sedation - uber painful. The should give you a piece of wood to bite down on.
Since I've been going to the Mayo clinic who use light sedation. Much better.
Four BMB since diagnosis 5/2011. 3 before & 1 after ASCT. First 3 were manual procedure. Kent mentioned a 'gun' and my 4th was with a small electric drill. Very Fast & less manual pressure. I'd recommend it. Very funny that the Dr. showed me the drill before hand and turned it on so I'd be familiar with the sound. He commented that too many people associate the sound with a dental visit so he always 'preps' the patient with the drill demo beforehand. Humor, going to my happy place, and a little pain med sees me through.
hi Sean ... Glad to hear that your BMBs are going better now.
Hi Paul..Isn't that interesting that there is a drill similar to a dentists drill now being used for that biopsy! the sound of a drill can conjure up nervousness, so it's great that the dr. explained that.
Hi, Nancy:
Ah, bone marrow biopsies.
I was diagnosed in Nov. '08 and have had 15 or 16 BMBs/aspirations at a major, out-of-state MM center. The first one at the time of the my diagnostic work-up was rough, but I had MAJOR, under-medicated bone pain (thanks to my ill-informed docs back home), coupled with the fact that for the several previous weeks, I was able to lie face down, or face up for that matter. I had been sleeping in an easy chair. That initial procedure was scary and pretty painful, but there was not nearly as much pain as was caused by the collapsed vertebrae, fractured ribs, etc that I was enduring.
The next 9 were well tolerated. The 11th was extremely painful, I think in part because I wasn't given enough sub Q lidocaine and we didn't wait long enough for the fentanyl lollipop to take effect. I politely complained to my primary MM physician and we ended up laughing about it - believe it or not. I led the laughter, by the way. My doc said "Mr. Murray, your attitude is admirable and that is one reason you will get through this with much grace.' I hope that he's right!
I guess that my doc intervened, because my next BMB was performed by the clinic's most experienced technician. Almost no discomfort. Of the next 5 or 6, only 1 was more than temporarily uncomfortable. This time I believe that I was at the hands of a fairly rookie tech. They have to learn on someone, I suppose.
This clinic performs approximately 30-35 BMBs each day. Their technicians get plenty of practice and are quite skilled. When you walk into the proceure rooms, you see none of the frightening implements. They pull them out after you're prostrate and your buns are exposed.
There was talk of a retired master technician lovingly known as 'Bone Marrow Bob' who apparently possessed the magical skills of a Wizard. I'll just have to satisfy myself with his legendary tales told.
For me, the pain of the lidocaine injections are not significant, capturing the bone specimens is usually not bad, but the aspirations are a bit more painful at the pull, but only temporarily. My recovery is quick, with soreness only lasting a few hours.
Everyone is different and should be able to undergo these procedures however they desire. Everyone faces potential pain and fear in their own way. There is certainly no shame in using conscious sedation. Maybe if I tried it, I'd like it. I tend to take most things in stride and chalk up the BMBs as a necessary evil. I've met fellow patients whom have had 35+ BMBs in their longer term treatments and now look at them as 'non-events'. Amazing.
My last BMB was six months ago and the next one is scheduled during a check-up in late November that will signal the end of my 4 year clinical trial.
BTW - my treatment center was enlisting employees, caregivers, etc to submit to a BMB collection from non-MM diagnosed subjects- I don't remember the exact study endpoint. When my wife, a truly altruistic person, read the posting she looked at me with a deer-in-headlights stare and asked 'Should I do it?' Without missing a beat I said 'Do you want to?' She asked 'Well, should I?' With uncharacteristic bluster I exclaimed 'Hell no, are you kidding? I wouldn't, I've done it enough for you and me both!' The blood flowed back into her face, she kissed me on the cheek, and we went on our way into the sunset. Well, not really a sunset. I think it was to a full body MRI.
Blessings to you, Nancy! Hang in there!
hi Sean..so nice to hear from you and learn of your experiences with those darned biopsies! that's
Quite amazing to me that you would have gone through so many of them, and without sedation either! perhaps the fentanyl is as good as sedation in some ways. I don't blame your good wife for not wanting to have one done also..although I guess there were some volunteers to do that, for how else would we know what healthy bone marrow looked like? ah well, hope you don't need to have too many more of them. I can relate to what you said about the first one also, since I was in a lot of pain from the fractures, which were the tip-off to my diagnosis.
I think it all depends on your pain threshold. After being completely out for the first one (close to 10 years ago), to conscious sedation, to having nothing but a local for the last three years, I prefer the latter. The treatment center I go to has PA's perform them and they do several a day. They are very skilled and the recovery time is minimal. Every time I still anticipate pain 100 times that of a toothache, but it ends up being minimal and after recovery with a bag of ice, I am fully recovered for a long drive home. Knock on wood, but I have never had an infection or problems associated with one. I am younger than most who have this disease and continue to battle and win like the rest of you. Keep up the good fight!
Thanks Lee for your input. If you don't need the sedation, you are able to drive home yourself, which is good. I am not sure if one's pain threshold is really the entire answer though...sometimes the biopsy needle just hits a nerve or something and can be very painful. I got through the first one without sedation, but it scared me away from further ones like that. My oncologist has undoubtedly done a lot of them also! As I recall, I was offered sedation, but it would have taken longer and we were all in too much of a hurry! This has been a good string of comments, and I have learned a lot about the biopsy procedure from everyone who posted in, so thanks to everyone for sharing!
Just had my 9th pain free bone marrow biopsy today. Was told 6 years ago when trying to get the courage to get one that if done correctly they will not hurt. I am proof of that. Waiting for the result.
Thanks Linda...that's awesome that you are managing to have pain free biopsies and I hope that the results are really good too!