Kerry Ryan, George L. Carter, and Suzanne G. Demko
Procedures performed in oncology patients may serve both diagnosis and treatment. This chapter describes common procedures performed in medical oncology, along with special considerations and techniques to assist in performing them rapidly and confidently, and to keep the patient comfortable and well informed.
INFORMED CONSENT
Written informed consent, or a legally sufficient substitute, must be obtained before every procedure described here and filed in the patient’s medical record.
ANESTHESIA
All procedures are typically performed under local anesthesia. For certain patients and procedures, premedication with a narcotic (fentanyl) and a benzodiazepine (midazolam) should be considered. Lidocaine (1% mixed in a 3:1 or 5:1 ratio with NaHCO3 to prevent the usual lidocaine sting) or alternative anesthetic will ensure proper anesthetic effect.
INSTRUMENTS
Most medical facilities are equipped with sterile trays or self-contained disposable kits specific to each procedure. Additional instruments may be used at the operator’s discretion or preference.
PROCEDURES
Bone Marrow Aspiration and Biopsy
Indications
■Diagnosis
■Analysis of abnormal blood cell production
■Staging of hematologic and nonhematologic malignancies
Contraindications
■Only absolute contraindication is the presence of hemophilia, severe disseminated intravascular coagulopathy, or other severe bleeding disorder.
■Severe thrombocytopenia is not a contraindication. However, depending on the particular circumstances may transfuse for platelets <20,000.
■Skin infection at the proposed site of biopsy.
■Biopsy at previously radiated site may cause fibrosis; consider an alternative site.
■Avoid sternal aspirate in patients with thoracic aortic aneurysm or lytic bone disease of ribs or sternum.
■Heparin, low-molecular heparin, or warfarin should be discontinued before procedure and may be resumed after hemostasis is achieved.
Anatomy
■Sternal aspiration
•Patient is supine; head is not elevated.
•Landmarks: sternal angle of Louis and lateral borders of sternum in second intercostal space.
■Posterior superior iliac spine aspiration and biopsy (Fig. 42.1)
•Patient is prone or in lateral decubitus position.
■Anterior iliac crest aspiration and biopsy (for patients with history of radiation to pelvis or extremely obese patients)
•Patient is supine.
Procedure
■Sternal aspiration
•Identify landmarks, clean the area, and position a fenestrated drape using sterile technique.
•In the area to be aspirated, infiltrate the skin, subcutaneous tissues, and periosteum with 1% lidocaine for anesthesia. Using the infiltration needle, “sound” the surface of the bone to approximate the distance from skin to periosteum.
•Use a 16-gauge sternal aspiration needle with guard to prevent penetration of the posterior table of the sternum. Adjust needle guard based on the approximate distance from skin to periosteum.
•Make a 2 mm superficial skin incision with a surgical blade in the midsternum, medial at the second intercostal space.
•Introduce the aspiration needle with guard, using gentle, corkscrew-type pressure to advance the needle until fixed in bone. Remove obturator, attach a 10 to 12 mL syringe, and aspirate. The pain of this procedure cannot be prevented but lasts only a few seconds.
•Obtain 1 mL of aspirate. An amount >1 mL will be diluted by peripheral blood.
•Spicules of bone marrow will be present unless significant fibrosis is present or the marrow is packed with leukemia or other malignancy.
•If no specimen is obtained, replace the obturator and carefully advance the needle 2 to 3 mm to repeat aspiration.
•Prepare smears for evaluation.
■Posterior superior iliac spine aspiration and biopsy
•The technique described here is for the Jamshidi bone marrow needle. Other available needles, such as the HS Trapsystem Set, Goldenberg Snarecoil, and T-Lok bone marrow biopsy system, are variations of the Jamshidi with their own specific instructions. Also available is the On Control Bone Marrow Biopsy System that utilizes a battery-powered drill to insert the needle into the iliac bone.
•The patient may be prone, but the lateral decubitus position is more comfortable for the patient and better for identifying anatomic sites. These positions are suitable for all but the most obese patients. For extremely obese patients or for those who have had radiation to the pelvis, aspirate and biopsy may be taken from the anterior iliac crest.
•Once the site has been prepared and anesthetized, make a small incision at the site of insertion, and advance the needle into the bone cortex until it is fixed. Attempt to aspirate 0.2 to 0.5 mL of marrow contents. If unsuccessful, advance the needle slightly and try again. Failure to obtain aspirate, known as a “dry tap,” is often due to alterations within the marrow associated with myeloproliferative or leukemic disorders and less commonly due to faulty technique. In such a case, a touch preparation of the biopsy often provides sufficient cellular material for diagnostic evaluation.
•Biopsy can be performed directly after aspiration without repositioning to a different site on the posterior iliac crest. Advance the needle using a twisting motion, without the obturator in place, to obtain the recommended 1.5 to 2 cm biopsy specimen. To ensure successful specimen collection, rotate the needle briskly in one direction and then the other; then gently rock the needle in four directions by exerting pressure perpendicular to the shaft with the needle capped. Gently remove the needle while rotating it in a corkscrew manner. Remove the specimen from the needle by pushing it up through the hub with a stylet, taking care to avoid needlestick injuries. Jamshidi needle kits include a small, clear plastic guide to facilitate this process.
FIGURE 42.1 Biopsy site in the posterior superior iliac spine. The needle should be directed toward the anterior superior iliac spine.
Aftercare
■Place a pressure dressing over the site and apply direct external pressure for 5 to 10 minutes to avoid prolonged bleeding and hematoma formation.
■The pressure dressing should remain in place for 24 hours.
■The patient may shower after the pressure dressing is removed, but should avoid immersion in water for 1 week after the procedure to avoid infection.
Complications
Infection and hematoma are the most common complications of bone marrow biopsy and aspiration. Careful technique during and after the procedure can minimize these effects.
Lumbar Puncture
Indications
■Analysis of cerebrospinal fluid (CSF), including pressure measurement, for diagnosis and to assess adequacy of treatment
■Administration of intrathecal chemotherapy
Contraindications
■Increased intracranial pressure.
■Coagulopathy or thrombocytopenia. There are no significant data regarding the optimum platelet count at which a lumbar puncture (LP) can be performed. American National Red Cross transfusion guidelines suggested a minimum of 40,000.
■Infection near the planned site of LP.
■Heparin, low-molecular heparin, or warfarin should be discontinued before procedure and may be resumed after hemostasis is achieved.
Anatomy
■Avoid interspaces above L3 (Fig. 42.2), as the conus medullaris rarely ends below L3 (L1–L2 in adults, L2–L3 in children).
■The L4 spinous process or L4–L5 interspace lies in the center of the supracristal plane (a line drawn between the posterior and superior iliac crests).
■There are eight layers from the skin to the subarachnoid space: skin, supraspinous ligament, interspinous ligament, ligamentum flava, epidural space, dura, subarachnoid membrane, and subarachnoid space.
FIGURE 42.2 Anatomy of the lumbar spine. Ideal needle insertion is between L3 and L4 interspace, which can be found where the line joining the superior iliac crests intersects the spinous process of L4. Positioning of the patient for lumbar puncture: in lateral decubitus or sitting position. (From Zuber TJ, Mayeaux EF. Atlas of Primary Care Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:13.)
Procedure
■Describe the procedure to the patient, with assurances that you will explain what you are about to do before you do it.
■Patient should be in a lateral decubitus or sitting position. The lateral decubitus position is preferable for obtaining opening pressures. The seated position may be used if the patient is obese or has difficulty remaining in the lateral decubitus position. Either seated or lying on one side, the patient should curl into a fetal position with the spine flexed to widen the gap between spinous processes (Fig. 42.2).
■Identify anatomic landmarks and the interspace to be used for the procedure.
■Using sterile technique, prepare the area and one interspace above or below it with povidone–iodine solution. Drape the patient, establishing a sterile field.
■Using 1% lidocaine/bicarb mixture, anesthetize the skin and deeper tissues, carefully avoiding epidural or spinal anesthesia.
■Insert the spinal needle through the skin into the spinous ligament, keeping the needle parallel to the bed or table. Immediately angle the needle 30° to 45° cephalad. The bevel of the spinal needle should be positioned facing the patient’s flank, allowing the needle to spread rather than cut the dural sac. Advance the needle through the eight layers in small increments. With practice, an experienced operator can identify the “pop” as the needle penetrates the dura into the subarachnoid space. Even so, it is wise to remove the stylet to check for CSF before each advance of the needle.
■When the presence of CSF is confirmed, attach a manometer to measure opening pressure. Collect 8 to 15 mL of CSF. If special studies are required, 40 mL of CSF may be safely removed. Four sample tubes should be sent as follows: tube 1, cultures; tube 2, chemistries (especially glucose and protein); tube 3, cell count and differential; tube 4, cytopathology or other special studies (flow cytometry, cytogenetics, etc.).
■Replace the stylet, withdraw the needle, observe the site for CSF leak or hemorrhage, and bandage appropriately.
■Ease the patient into a recumbent position and maintain for 60 minutes.
Complications
■Spinal headache occurs in approximately 20% of patients after LP. Incidence appears to be related to needle size and CSF leak and not to postprocedure positioning. There is no evidence that increased fluid intake prevents spinal headache. It is characterized by pounding pain in the occipital region when the patient is upright. Incidence is highest in female patients, younger patients (peaks 20–40), and patients with a history of headache prior to LP. Patients should be encouraged to remain recumbent if possible, drink plenty of fluids, and take over-the-counter analgesics. For severe, persistent spinal headache (up to 1 week is possible), stronger medication, caffeine, or an analgesic patch may be indicated. Data indicate that a Sprotte (“pencil-tipped”) needle reduces the risk of post-LP headache.
■Nerve root trauma is possible but rare. A low interspace entry site reduces the risk of this complication.
■Cerebellar or medullar herniation occurs rarely in patients with increased intracranial pressure. If recognized early, this process can be reversed.
■Infection, including meningitis.
■Bleeding: A small number of red blood cells in the CSF is common. In approximately 1% to 2% of patients, serious bleeding can result in neurologic compromise from spinal hematoma. Risk is highest in patients with thrombocytopenia or serious bleeding disorders, or patients given anticoagulants immediately before or after LP.
Paracentesis
Indications
■To confirm diagnosis or assess diagnostic markers
■As treatment for ascites resulting from tumor metastasis or obstruction
Contraindications
■The complication rate for this procedure is about 1%.
■The potential benefit of therapeutic paracentesis outweighs the risk of coagulopathy.
Anatomy
■Identify the area of greatest abdominal dullness by percussion, or mark the area of ascites via ultrasound. Take care to avoid abdominal vasculature and viscera.
Procedure
■Place the patient in a comfortable supine position at the edge of a bed or table.
■Identify the area of the abdomen to be accessed (Fig. 42.3).
■Prepare the area with povidone–iodine solution and establish a sterile field by draping the patient.
■Anesthetize the area with a 1% lidocaine/bicarb mixture.
■For diagnostic paracentesis, insert a 22- to 25-gauge needle attached to a sterile syringe into the skin, then pull the skin laterally and advance the needle into the abdomen. Release the tension on the skin and withdraw an appropriate amount of fluid for testing. This skin-retraction method creates a Z-track into the peritoneal cavity, which minimizes the risk of ascitic leak after the procedure (Fig. 42.4).
■For therapeutic paracentesis, use the Z-track method with a multiple-port flexible catheter over a guide needle. When the catheter is in place, the ascites may be evacuated into multiple containers. Make sure that the patient remains hemodynamically stable while removing large amounts of ascites.
■When the procedure is completed, withdraw the needle or catheter and, if there is no bleeding or ascitic leakage, place a pressure bandage over the site.
■Following therapeutic paracentesis, the patient should remain supine until all vital signs are stable. Offer the patient assistance getting down from the bed or table.
■If necessary, standard medical procedures should be used to reverse orthostasis. The patient should be hemodynamically stable before being allowed to leave the operating area.
FIGURE 42.3 Sites for diagnostic paracentesis. (From Zuber TJ, Mayeaux EF. Atlas of Primary Care Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:46.)
FIGURE 42.4 Z-track technique for inserting needle into peritoneal cavity. (From Zuber TJ, Mayeaux EF. Atlas of Primary Care Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:47.)
COMPLICATIONS
■Hemorrhage, ascitic leak, infection, and perforated abdominal viscus have been reported. Properly siting paracentesis virtually eliminates these complications.
Thoracentesis
Indications
■Diagnostic or therapeutic removal of pleural fluid
Contraindications
There are no absolute contraindications to diagnostic thoracentesis. Relative contraindications include the following:
■Coagulopathy.
■Bullous emphysema (increased risk of pneumothorax).
■Cardiovascular disease.
■Patients on mechanical ventilation with PEEP have no greater risk of developing a pneumothorax than nonventilated patients. However, mechanically ventilated patients are at greater risk of developing tension physiology or persistent air leak if a pneumothorax does occur.
■Patients unable to cooperate.
■Cellulitis, if thoracentesis would require penetrating the inflamed tissue.
Imaging
If chest radiographs suggest loculation of fluid, decubitus films and possibly computed tomography or ultrasound may be required before thoracentesis is attempted.
Anatomy
■Carefully ascertain the location of the diaphragm to avoid accidental injury to abdominal organs and viscera.
■Place the patient in a seated position facing a table, arms resting on a raised pillow. Have the patient lean forward 10° to 15° to create intercostal spaces.
■Perform thoracentesis through the seventh or eighth intercostal space, along the posterior axillary line. With guidance from fluoroscopy, sonography, or computed tomography, the procedure may be performed below the fifth rib anteriorly, the seventh rib laterally, or the ninth rib posteriorly. Without radiographic guidance, underlying organs may be injured.
■The extent of pleural effusion is indicated by decreased tactile fremitus and dullness to percussion. Begin percussion at the top of the chest and move downward, listening for a change in sound. When a change is noted, compare to the percussive sound in the same interspace and location on the opposite side. This will denote the upper extent of pleural effusion.
Procedure
■Position the patient and clean the site with antiseptic. Initially, infiltrate the epidermis using a 25-gauge needle and 1% or 2% lidocaine. Next, with a syringe attached to a 22-guage needle advance toward the rib and then “walk” over the superior edge of the rib (Fig. 42.5). This decreases the risk of injury to the neurovascular bundle. Aspirate frequently to ensure that no vessel has been pierced and to determine the distance from the skin to the pleural fluid. When pleural fluid is aspirated, remove the anesthesia needle and note the depth of penetration.
■A small incision may be needed to pass a larger gauge thoracentesis needle into the pleural space. Generally, a 16- to 19-gauge needle with intracath is inserted just far enough to obtain pleural fluid. Fluid that is bloody or different in appearance from the fluid obtained with the anesthesia needle may be an indication of vessel injury. In this case, the procedure must be stopped. If there is no apparent change in the pleural fluid aspirated, advance the flexible intracath and withdraw the needle to avoid puncturing the lung as the fluid is drained. Using a flexible intracath with a three-way stopcock allows for removal of a large volume of fluid with less risk of pneumothorax. If only a small sample of pleural fluid is needed, a 22-gauge needle connected to an airtight three-way stopcock is sufficient. Attach tubing to the three-way stopcock and drain fluid manually or by vacutainer. Withdrawing more than 1,000 mL per procedure requires careful monitoring of the patient’s hemodynamic status. As the needle is withdrawn, have the patient hum or do the Valsalva maneuver to increase intrathoracic pressure and lower the risk of pneumothorax.
■After the procedure, obtain a chest radiograph to determine the amount of remaining fluid, to assess lung parenchyma, and to check for pneumothorax. Small pneumothoraces do not require treatment; pneumothoraces involving >50% lung collapse do.
FIGURE 42.5 Thoracentesis. (A) Z-track technique for anesthetizing to prevent injury to neurovascular bundle. (B) Advancement of soft plastic catheter through the needle into pleural space. (From Zuber TJ, Mayeaux EF. Atlas of Primary Care Procedures.Philadelphia, PA: Lippincott Williams & Wilkins; 1994:26-27.)
Complications
■Pneumothorax
■Air embolism (rare)
■Infection
■Pain at the puncture site
■Bleeding
■Splenic or liver puncture
REVIEW QUESTIONS
1.A 34-year-old male presents to your oncology office with a newly diagnosed stage Burkitt cell lymphoma. He is complaining of headaches and his wife states he has unstable gait and fallen a number of times at home. What should your next step be?
A.Perform an emergent LP to rule out leptomeningeal disease.
B.Prescribe the patient pain medication for his headache.
C.Perform a MRI or CT of his brain before proceeding to a LP.
2.A 56-year-old male with stage IV diffuse large B-cell lymphoma presents for his staging workup following six cycles of R-CHOP. You are planning on doing a bone marrow on him today to complete his restaging. Two months ago he has had a deep venous thrombosis and is now on enoxaparin 100 mg/kg subcutaneously twice daily. He took his morning dose, 2 hours ago. Do you proceed with the bone marrow today?
A.Yes
B.No
3.A 64-year-old female presents with metastatic ovarian cancer and is short of breath. She is found to have a large right-sided pleural effusion and you decide to perform a thoracentesis. What intercostal spaces should you perform a thoracentesis through?
A.Ninth or tenth intercostal space
B.Seventh or eighth intercostal space
C.Sixth or seventh intercostal space
D.Fifth or fourth intercostal space
Suggested Readings
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3.Humphries JE. Dry tap bone marrow aspiration: clinical significance. Am J Hematol. 1990;35(4):247-250.
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12.Zuber, TJ, Mayeaux, EF. Atlas of Primary Care Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:26, 27.