Published on March 14, 2017
MPN experts, Dr. Michael Grunwald from Carolinas HealthCare System's Levine Cancer Institute and Dr. Srdan Verstovsek from The University of Texas MD Anderson Cancer Center, share insights on the purpose of the bone marrow biopsy and how the test affects overall care and treatment decisions. Each expert weighs in on how they monitor patients in their own practice, including why and how frequently their patients are tested.
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Transcript | What Does a Bone Marrow Biopsy Reveal About Your MPN?
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That leads to our next thing of treatment decisions, Dr. Verstovsek. So who gets what when? Many of us have had bone marrow biopsies, to give you an initial picture of what’s going on in our blood factory. Do we have scarring? Yes, no? What’s cockeyed in the blood factory?
You often having us get regular blood tests to monitor what's floating around. So how do you decide about treatment? You mentioned a little bit about some people get aspirin, some people get hydroxyurea (Hydrea). We may have more some people get phlebotomy, we can go on. Is it all about the blood counts, or is it about the quality of the cells. Is it about the rate of change? It sounds complicated.
It does sound complicated, and things are changing as we speak. Let’s focus on ET and PV first, briefly. What do we do? First is just to say that, of course, for each of these conditions there is no one test that would say you have ET, you have PV or you have myelofibrosis. It is a criteria that needs to be fulfilled. We are talking about five or six factors that need to be looked at to make a diagnosis. So bone marrow biopsy is only one of the factors.
For example, for myelofibrosis you should have a bone marrow compatible with myelofibrosis disease, and then you look for anemia. You look for bone marrow cells in blood. You look for systemic symptoms. You look for some other factors like a splenectomy on physical exam and high LDH, the protein in blood that comes from dead cells.
So, in fact, you have to combine the bone marrow results with the physical exam with the blood cell count and the blood chemistry to make a diagnosis of myelofibrosis. Just an example. So it’s not one test for each of these conditions. Let’s say that we do that exam, and you have a patient who has ET or PV. We are concerned not about longevity of the patients. We are concerned about risk of blood clotting. Unfortunately, a number of patients, a quarter, maybe even a third of the patients present with a blood clot already at a time of a diagnosis.
The diagnosis is made at the presentation with the blood clot. Our goal is to decrease that risk of blood clot, not really to decrease at the moment the risk of a change that can happen to more aggressive types or any other risks. It is about the risk of blood clot. Here, we have age usually and a history of blood clot as determining factors. The new factor that we look at is a mutation. These are factors that are not yet in everyday practice in majority of community settings.
Or very high white cell count. Is that a factor that contributes to blood clotting? It’s not quite clear yet. So standard guidelines are only two factors: age over 60 or history of blood clot. To identify patients with ET or PV at a high risk of blood clot. Then we do cytoreductive therapy that we discussed to control those numbers and decrease that risk.
For myelofibrosis, I’m happy to say that we now have, not even a month old, National Cancer comprehensive guidelines for doctors around the United States what to do with patients that are confirmed to have myelofibrosis. They are looking forward next year to have national guidelines for management of ET and PV. We don’t have it yet but for myelofibrosis we do. The first goal, usually is to assess the risk of disease affecting the life expectancy, risk of dying. We know five factors from the historical perspective that would affect the patient’s outcome. New factors are being identified looking at genetics, looking at chromosomes that carry genes. Perhaps other factors will come along. We still, however, are focused on those five factors that we know for a long bit of time to be established.
We identify patients at a high risk of having unfortunate risk of dying early and those that do not. So we talk about low risk, intermediate and high-risk patients basically. This is where the decision is first made who to refer to bone marrow transplant. Because if the disease is meant to shorten life expectancy based on these factors to less than five years, that’s not very good at all, right?
We want people to experience life fully for as long as possible. The transplant is the first choice in people who are at that risk. If they are able to do that and there is a donor. If not, then we go by what troubles the patient. Since we don’t have medications to give to eliminate disease, we treat patients for symptoms and signs. So if there is a big spleen that causes problems, we try to eliminate it. If there are systemic symptoms, night sweating, bone aches and pains, itching, we try to eliminate those. If there is a bone marrow failure, meaning anemia, we try to improve the anemia.
There is a fraction of patients that are so-called low-risk without any symptoms or signs. We would observe those people: watch and wait. People don’t like it. I don’t like it. I like to have a status or medications that I would give to prevent from progressing. Studies are being done in Europe, prevention studies for myelofibrosis patients to prevent progression. But at this moment in time, in the United States at least, we don’t have those studies, and the guidelines would suggest watch and wait until the patient has a symptomatic spleen or symptomatic disease or clinically relevant anemia. Then you treat for that.
In my case, there was about 10 months before I started any medicine.
Because your spleen got bigger, and you got symptoms.
Yeah, I developed symptoms. So we checked earlier about people who’d had a bone marrow biopsy. I get regular blood tests. So monitoring. How often are we going to be subjected to a bone marrow biopsy? When is that needed again? Or just blood tests to help you see how we’re doing?
In my patients who are not undergoing allogeneicstem cell transplants, I do not perform bone marrow biopsies very often. I find that the biopsy aides in diagnosis, and oftentimes we get a sense of how patients are doing on therapy by their blood counts and their symptoms, how they're feeling. We can get a subjective or objective measure of the spleen size from symptoms by physical examination and by radiology.
Oftentimes, ultrasound is used to measure the size of the spleen. It can measure it fairly accurately, so we can follow that over time. If I can use that information to follow a patient’s response to therapy, then I use that information. If I am confused about whether a patient is responding well to therapy or not, I might suggest getting another bone marrow biopsy to see what’s going on inside the marrow.
So if we suspect that a patient’s disease might be transforming, for example, to acute leukemia, that would be a time to do a bone marrow biopsy. If we’re looking to see if a patient qualifies for a clinical trial, we would suggest a bone marrow biopsy as part of the clinical trial, and then there might be subsequent bone marrow biopsies while on the clinical trial agent to see how the patient is responding.
Finally, in patients who are undergoing transplantation, there are frequent biopsies, definitely a biopsy before the transplant to make sure the disease is as well-controlled as possible. Then we have certain set intervals after the transplant about two to three months after the transplant, then six months, 12 months, 18 months, 24 months after the transplant where we are assessing the patient’s response to the transplant.