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AUSTIN, Texas -- Of the different settings where bone marrow biopsy can be performed, the inpatient interventional radiology service is perhaps not the best, researchers suggested.

An interventional radiology service that offered to help out with bone marrow biopsies found itself taking on more and more of them without significantly reducing the proportion that end up non-diagnostic (6.7% with hematology/oncology service vs 5.9% with interventional radiology, not significant), according to Sean McLaughlin, a resident at Philadelphia's Perelman School of Medicine at the University of Pennsylvania.

Only with increasing patient BMI did interventional radiologists see better performance of their biopsies relative to those of hematology/oncology, especially once BMI crossed 40 (probability of non-diagnostic biopsy 3.8% vs 22.4%), McLaughlin said at the annual meeting of the (SIR).

Bone marrow biopsies had traditionally been performed bedside under local anesthesia by the hematology/oncology service. In 2014, the interventional radiology service started offering fluoroscopy-guided biopsies with sedation for patients with high BMIs or sedation requirements.

Interventional radiology handled 2% of these procedures in 2014, increasing to about 18% in 2018, McLaughlin estimated.

"Is [the] need for sedation a sufficient reason for IR [interventional radiology] to be doing a procedure that is usually performed with similar outcomes by another service?" he asked, suggesting instead that sedation services be offered bedside.

His group had collected data on bone marrow biopsies from 2014 to 2017 from an institutional database. The single-center and retrospective nature of the study was a major limitation, as was the inclusion of fewer than 30 patients with >50 BMI, he acknowledged.

"When IR performance of bone marrow biopsies is offered, it can overwhelm a practice," McLaughlin maintained.

After all, from an economic standpoint, it makes more sense for the inpatient interventional radiology service to schedule chest ports instead, which have a higher professional fee and technical fee, he said.

Consider ultrasound guidance

That doesn't mean IR services shouldn't perform marrow biopsies, however. In fact, even a small outpatient practice can perform them adequately using ultrasound, according to another interventional radiologist presenting at the same SIR session.

Syed Raza, MD, of Premier Vein and Vascular Center in Houston, said that he had done bone marrow biopsies with CT guidance before, but once he opened his own practice, he was left without a scanner in the office. Faced with the first request for a bone marrow biopsy in the office, he decided to try ultrasound guidance with a portable machine.

It's worked so far in 327 patients with zero non-diagnostic biopsies (dry tap on aspiration had been observed in five of those patients). There were no procedural complications either.

Moderate sedation and local anesthesia were administered in patients. Raza's "fenestration" anesthetic technique -- "jabbing" the periosteum with the needle -- makes the actual manual biopsy "virtually painless," he told the room.

"I've heard horror stories from patients who had biopsies somewhere else. They come in scared, fearful of bone marrow biopsy," he said.

In ultrasound-guided biopsy, one must be careful to correctly identify the anterior superior iliac spine, the presenter said. Second, the biopsy needle has to be centered right in the middle of the spine or slightly higher and perpendicular to the direction of the iliac crest. Finally, "controlled aggression" with the mallet is also important, Raza said.