Retroperitoneal hemorrhage associated with bone marrow trephine biopsy.

PATIENT: Male, 19 FINAL DIAGNOSIS: Hyperleukocytosis • thrombocytosis SYMPTOMS: Hyperleukocytosis • retroperitoneal hemorrhage • thrombocytosis MEDICATION: - Clinical Procedure: Bone marrow trephine biopsy Specialty: Hematology • Radiology.
OBJECTIVE: Diagnostic/therapeutic accidents.
BACKGROUND: Bone marrow (BM) trephine biopsy is generally a safe procedure, but adverse events such as retroperitoneal hemorrhage (RPH) may occur. We report 3 cases of this complication. CASE REPORT: A 19-year-old male with thrombocytopenia and coagulopathy underwent BM trephine biopsy to confirm relapse of acute lymphoblastic leukemia. Two hours later, he developed severe hypotension and a CT scan revealed a massive RPH, and was treated conservatively. The RPH recurred 2 weeks after chemotherapy and was successfully treated with gel foam embolization. A 55-year-old male with coagulopathy underwent BM trephine biopsy for hyperleukocytosis and thrombocytosis. He developed a large RPH preceded by left lumbar dermatome sensory neuropathy. He was treated conservatively. A 56-year-old overweight woman on aspirin underwent BM trephine biopsy for polycythemia. Twelve hours later she developed severe abdominal pain with hypotension. A CT scan showed a massive RPH and secondary hemothorax. She was treated conservatively and the RPH resolved after several months.
CONCLUSIONS: We and others showed that myeloproliferative neoplasm, quantitative or qualitative platelet abnormalities, aspirin, coagulopathy, and obesity are associated with development of RPH following BM trephine biopsy. Early diagnosis and intervention are crucial. Correction of coagulopathy and cessation of anti-platelet treatment prior to biopsy can prevent this serious complication.

Background

BM biopsy is a routine yet vital diagnostic tool used widely in hematological conditions. It provides important information on response to treatment, prognosis, and hematopoietic involvement in systemic diseases. Generally it is considered a safe procedure, with a low risk of morbidity. Common complications include mild pain at the biopsy site and occasional oozing, and rarely serious events may occur, such as infections, needle tract seeding, pressure neuropathy, retropneumoperitoneum, iliac bone fracture, needle break, fluid leak, and RPH [1]. Fatalities due to RPH following BM biopsy are well described in the literature [2-5].

Case Report

Patient 1

A 19-year-old Malay male who weighed 50 kilograms, with a previous history of acute lymphoblastic leukemia presented to hematology ward with neutropenic sepsis. The hemoglobin was 9.5 g/dL, total white cells were 1.2×109/L, and platelets were 24×109/L. The coagulation profile was later revealed to be abnormal, with PT 13.9s (ratio 1.12) and APTT 180s (ratio >4.5). A BM trephine biopsy was performed to confirm disease relapse. Two hours later, the patient became hypotensive (50/30 mmHg). A CT scan of the abdomen showed a large (20×4×4 cm) retroperitoneal hematoma (Figure 1A). At that time, no contrast extravasation was reported. He was stabilized with mechanical ventilation, inotrope agents, and blood products. A modified BMF-90 protocol without the intrathecal component was administrated 2 weeks later. Five days into chemotherapy, he complained of severe left iliac fossa pain radiating to the groin and associated with hypotension (80/50 mmHg). The hemoglobin dropped to 4.2 g/dL and platelets were 11×109/L. A repeat CT scan of the abdomen revealed a massive (19×8×9 cm) hematoma anterior to the left internal iliac vessels, with contrast extravasation from a branch of the left internal iliac artery (Figure 1B, 1C). An attempt at angiographic coiling was unsuccessful, and the hemorrhage was terminated using gel foam embolization. A repeat angiogram 24 hours later revealed no further active bleeding and the patient recovered well.

Figure 1.

CT angiography of abdominal aorta in axial section for Patient 1. (A) Twenty-four hours after bone marrow trephine biopsy from the left PSIS, demonstrating a 20×4×4 cm hypo-isodense mass (white arrow) consistent with a retroperitoneal hematoma. (B) Two weeks after the initial scan, demonstrating a pool of extraluminal contrast (straight arrow) medial to a branch of left internal iliac artery (curved arrow) and; (C) a 19×8×9 cm retroperitoneal hematoma which has increased in size.

Patient 2

A 55-year-old Chinese male who weighed 78 kilograms was referred for investigation of hyperleukocytosis and thrombocytosis. The total white cell count was 355×109/L, hemoglobin was 9.3 g/dL, and platelets were 577×109/L. The PT was 18.6s (ratio 1.67) and APTT was 48s (ratio 1.26). A BM trephine biopsy with repeated attempts was performed on the left posterior superior iliac spine (PSIS). Three hours later, the patient complained of pain and oozing at the biopsy site and numbness in the left lumbar dermatome. Power was graded 4/5 at the hip and knee joints. A CT scan revealed an extensive retroperitoneal, pelvic, left gluteus maximum, and intramuscular hematoma without contrast extravasation. He was treated conservatively and recovered well. The bone marrow findings were consistent with chronic myeloid leukemia in chronic phase.

Patient 3

A 56-year-old, overweight and postmenopausal Malay female was referred for polycythemia (hemoglobin 22.6 g/dL, hematocrit 68.6%) and transient ischemic attacks. She had been taking 75 mg of aspirin daily. There was no associated coagulopathy. BM trephine biopsy with repeated attempts was taken from the right PSIS. Twelve hours later, she developed severe right-sided abdominal pain with hypotension (90/50 mmHg). A CT scan showed a massive (12×14×10 cm) hematoma at the right iliac fossa, with concomitant displacement of the inferior vena cava and iliac vessels, and compression of the right ureter, with subsequent hydronephrosis, and complicated by secondary hemothorax. She was treated conservatively and the RPH resolved after several months.

Discussion

BM biopsy is a routine yet vital diagnostic tool used widely in hematological conditions. It provides important information on response to treatment, prognosis, and hematopoietic involvement in systemic diseases. It is generally considered a safe procedure, with a low risk of morbidity. Common complications include mild pain at the biopsy site and occasional oozing, and serious adverse events may rarely occur, such as infections, needle tract seeding, pressure neuropathy, retropneumoperitoneum, iliac bone fracture, needle break, fluid leak, and RPH [1]. Fatalities due to RPH following BM biopsy are well described in the literature [2-5].

The risks of RPH in our patients were myeloproliferative neoplasm (MPN), quantitative or qualitative platelet abnormalities, anti-platelet therapy, coagulopathy, and obesity. Putative platelet dysfunction in MPN, myelodysplastic syndrome, or disturbance of platelet function by fibrin degradation product, also contribute to the risk of bleeding [2]. In thrombocytopenia, the risk of significant hemorrhage is approximately 1:500 [6]. The procedure itself can cause direct penetration of the biopsy needle through the iliac crest, or malposition with the needle tip slipping over the iliac crest, both of which cause trauma to the retroperitoneal vessels [7]. Operator expertise may also be a contributory factor, although a previous survey did not find a clear relationship between inexperience of the operator and the occurrence of hemorrhage [8].

In the UK, a fatality from RPH following a BM biopsy led to a national audit that identified a diagnosis of MPN as a risk factor for hemorrhage, together with aspirin, warfarin, obesity, disseminated intravascular coagulopathy, probable platelet dysfunction, and thrombocytopenia [6]. A follow-up survey revealed the rate of adverse events from BM biopsy was 0.12%; hemorrhage was the most frequent and serious event, with 3 fatal cases reported [3]. Subsequently, in 2004, hemorrhage was again revealed to be both the most common and most serious event, occurring in 9 out of a total of 15 adverse events [9]. The survey confirmed that a diagnosis of MPN is a risk factor for hemorrhage, even in the absence of aspirin therapy.

We and others have showed that myeloproliferative neoplasm (MPN), quantitative or qualitative platelet abnormalities, aspirin therapy, coagulopathy, and obesity are associated with development of RPH following BM trephine biopsy (Table 1).

Table 1.

Clinical characteristics, risk factors and outcome in patients with RPH after BM biopsy.

Author [reference number]	Number of cases	Underlying disease(s)	Obesity	Thrombocytopenia (count ×109/L in parantheses)	Possible platelet dysfunction (aspirin therapy in parantheses)	Coagulopathy (anticoagulation or DIC)	Outcome
A Wahid 2007 [10]	1	PRV	Yes		Yes		Alive: 1
Bain 2003 [2]	14	ET: 5			Yes (3 on aspirin)		Fatal: 1
		PRV: 2			Yes
		CML: 1	Yes		Yes
		BC: 1			Yes	Yes (DIC)
		MD: 2	Yes in 1	Yes (25 and 68)	Yes
		Carcinoma: 1		Yes (50)	Yes	Yes (DIC)
		Anemia of chronic disease: 1				Yes (anticoagulation)
		Unknown: 1
Bain 2004 [6]	10	ET: 2	Yes in 1		Yes (1 on aspirin)	Yes (1 on anticoagulation)	Fatal: 3
		MPD: 2		Yes in 1 (96)	Yes (1 on aspirin)
		MDS: 1			Yes
		MF: 1		Yes (23)	Yes
		WM: 1			Yes
		Following BMT for refractory AML: 1		Yes (38)	Yes
		Anemia of chronic disease: 1		Yes (17)		Yes (anticoagulation)
		Megaloblastic anemia: 1
Bain 2005 [5]	1	MPD: 5	Yes in 1		Yes (3 on aspirin)	Yes (1 on anticoagulation)	Alive: 11
		MDS: 1	Yes in 1		Yes
		AML: 2		Yes (39 and 86)	Yes
		ITP: 1		Yes (6)	Yes
		vWD: 1			Yes
		Not stated: 1
Bain 2006 [7]	9	MPD: 3			Yes (1 on aspirin)		Alive: 9
		AML: 1			Yes
		MDS: 1			Yes
		Multiple Myeloma: 1			Yes
		Not stated: 3
Chamisa 2007 [11]	1	Thrombocytopaenia		Yes (62)	Yes		Fatal: 1
Feeney 2006 [4]	1	Abdominal aortic aneurysm, chronic renal failure			Yes (aspirin)		Alive: 1
Gupta 1992 [12]	1	Multiple myeloma		Yes (49)	Yes		Fatal: 1
Luoni 1994 [1]	1	PRV			Yes		Alive: 1
Rodrigo 2004 [9]	6	PRV: 2			Yes		Alive: 6
		CML: 1			Yes
		Lymphoma & osteoporosis: 1	Yes
		Renal osteodystrophy & osteoporosis: 1			Yes
		Paget’s disease: 1			Yes (aspirin)
Salem 2003 [3]	2	ITP		Yes(45)	Yes		Alive: 2
		Pancytopenia & SLE		Yes (22)	Yes

Adapted with adjustments from Reference [2]. SLE – systemic lupus erythematosus; PRV – polycythemia rubra vera; ET – essential thrombocythemia; BC – blast crisis; MDS – myelodysplastic syndrome; MF – myelofibrosis; BMT – bone marrow transplant; MPD – myeloproliferative disease; AML – acute myeloid leukemia; ITP – immune thrombocytopenia; vWD – von Willebrand’s Disease; WM – Waldenstrom’s Macroglobulinemia.

Surgery has been shown to successfully evacuate hematoma causing severe respiratory distress [10]; however, the advent of interventional radiology may be beneficial in avoiding risks associated with surgery. Selective arterial embolization was shown to be an effective endovascular approach in providing a fast and minimally invasive treatment [11,12].

Conclusions

BM biopsy may occasionally cause life-threatening RPH, which may not be immediately apparent; therefore, it must be done carefully following standard guidelines, with longer periods of observation for persistent pain, and stopping all anti-platelets or anticoagulant therapy prior to the procedure. BM biopsy should only be performed when there is a clear clinical indication, and by appropriately trained personnel.