Why Do MPNs Require a Bone Marrow Biopsy?

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Bone marrow biopsies have been described by some as “medieval torture.”  Certainly, they can be painful, so why do MPN patients need to have bone marrow biopsies?  What are doctors and researchers looking for? Drs. Srdan Verstovsek and Jason Gotlib discuss the necessities of bone marrow biopsies for MPN patients: why we need them, what they accomplish, and how they fit into the total diagnostic process.  

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Please remember the opinions expressed on Patient Power are not necessarily the views of MD Anderson Cancer Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Jeff Folloder:

Everyone that I’ve spoken to that’s been through a bone marrow biopsy has mentioned something along the lines of, this is medieval torture. It’s not pleasant, and some people tolerate it better than others. Why do we need to do bone marrow biopsies? Why do we need to do this to our hips?

Dr. Verstovsek:

So you see, these diseases are diseases of the bone marrow. This is the soft tissue inside the big bones around the body. The soft tissues make blood and everything that we see in the blood that is abnormal comes from the bone marrow. So it just makes sense, first of all, just to make sense to go there where the disease originates and see what’s wrong. Although, we can learn a lot about diseases from the blood, not everything can be found from the blood on its own.

Jeff Folloder:

So we have to go inside the bone to learn the whole story. 

Dr. Verstovsek:

And that’s just the common sense approach to go there. But the real reason is we don’t have one test that will say, okay, you have ET, you have PV, you have myelofibrosis. Or even, we don’t have one test that we would do in the blood to say you have myeloproliferative disease. There are criteria, usually five or six different factors that need to be fulfilled for one to be diagnosed with ET, PV or myelofibrosis, and this includes the bone marrow biopsy to see, for presence of the fibrosis, to look at the factors inside the bone marrow that are genetic or chromosomes.

These are finger-like structures that carry genes that may be broken. We know about many genetic abnormalities, to go back on that topic, that lead to a conclusion whether it’s one or the other disease. And it’s always good to have a baseline test, also, for the future. If you, God forbid, change and the disease gets worse, you would like to know, looking at that bone marrow, that you will have a second or a third time. And I’m sorry some patients have so many bone marrows, but the bone marrows are done when there is a change in the blood.

And you worry about the change in the bone marrow, so it’s always good to have a baseline one at the first time when diagnosis is made. So it is not just really, oh we, let’s do it, it’s common sense, which I said first. It is common sense to go where the disease comes, from but there are many reasons.

Diagnosis has to be established, and it should include the bone marrow biopsy along with the physical exam, looking at the spleen, along with the blood cell count, along with the chemistry, there is so-called LDH, or lactate dehydrogenase, one of the proteins that is from dead cells that comes from this disease. You look at all of those factors together, so it’s a diagnostic process that we are talking about.

Dr. Gotlib:

Yeah, I would just add to what Dr. Verstovsek said at, you know, these are diseases which exist at a continuum. And to borrow a phrase, you know, there are 50 shades of gray here. And so, you can have patients, for example, that start with a diagnosis of essential thrombocythemia or, for that matter, polycythemia vera. And using all the lab work and physical examination skills, we may get a sense that it’s moving toward or evolving towards myelofibrosis, and that is where the bone marrow biopsy can be helpful. So they are, they have overlapping presentations. They can change over time.

The bone marrow biopsy is very helpful in that sense, and you’re absolutely correct. This is a procedure that is somewhat medieval, but the information is often quite necessary. And I suspect that a large proportion of individuals in this audience, particularly those with myelofibrosis, have participated in clinical trials.

And as part of clinical trials, it’s almost always done that a bone marrow biopsy is done during a screening period with some differences within trials about whether they will be done on a repeated basis during the course of treatment on a clinical trial.

But that’s information that is important to see what the starting diagnosis is, to stage the disease, to see what effect the drug being investigated will have on the bone marrow itself.

So we take that information very seriously, and it’s information that we, as investigators and regulatory agencies, as the FDA, may need that information to make a good assessment of whether the drug is having the effects that were intended or were anticipated when it’s going through the registration process.

Dr. Verstovsek:

I think this is very important to understand. We advocate bone marrow biopsy at the beginning of the process, when there is suspicion for the disease to make a proper diagnosis to see which one of the three, or is it something else? We don’t want to scare people that the bone marrow biopsies are done all the time, just to check, is there some change?

Some people here had eight bone marrow biopsies done. They are usually reflective of a participation in a clinical study. That’s why I think Jason makes a very good point. In everyday practice, to do the bone marrow biopsy, one would need to have a good reason, not just to check, is there something different?

Let’s do it this year and then the next year and the next year. To me, that doesn’t really make sense and always trying to make good sense of what we are doing. If there is a change in our blood, let’s say the patient with ET, that is a good example, over time develops anemia and a big spleen, well, that’s not normal for ET patients, right?

It should be just the high platelets and not much of anything else, the symptoms, unfortunately. But if there is significant blood change, then I would say well, this is something different. Let’s check the bone marrow now—not just checking bone marrow, if there is no change in blood to see whether there is a change.

Unlikely there would be any. So if there is a good reason in everyday practice, that would be the reason to check bone marrow, not otherwise. In the studies, it’s different. That’s part of the study to assess the utility of the medication that the patient is taking.

Dr. Gotlib:

And I would just mention that I think, again, many of you know about these mutation studies that we get, for example, the JAK2 mutation or the MPL mutation or the calreticulin mutation. Those are studies that can be done on the circulating blood.

You do not need to do a bone marrow biopsy for that, because these are diseases, albeit, they originate in the bone marrow of the blood cells that are abnormal, or circulating in the blood. So you do not need a bone marrow biopsy to conduct those specific mutation studies. We’re doing the bone marrow biopsies to get a lot more information than that.

Please remember the opinions expressed on Patient Power are not necessarily the views of MD Anderson Cancer Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on January 6, 2015