Monday, April 1, 2013

The pain of new BMBs, and the pain of GI issues...

Hello folks.  I hope this finds you on the end of a happy holiday week, whether or you celebrate Easter, Passover, the Great Pumpkin or something else altogether.

Two topics for today's post.

First, fellow traveler Suzierose, who I am obligated to point out for context's sake is not a particular fan on BB or MIRT or UAMS' approach, wrote me with the following question / observation which I think is a good one for all patients to consider:

Hey Nick!

suzierose here.

Gotta a question for you. 

You mentioned how painful the last BMA was for you, mine was too.  And it remained sore for awhile.  So I am wondering if they withdrew more aspirate in a SINGLE draw then they generally do for a BMA. We both know it is the aspirate that hurts like hell.

The reason I think this is because while reading about MFC I learned that one reason it has not been used as a standard is due to the discrepancy in enumeration of plasma cells from 2 samples.  As you know, there are typically hot spots in the BM.  So if they take 2 aspirates it is likely that creates the discrepancy, in PC count, as the 2nd sample (typically the one used for cytometry) is more 'dilute'.  Which would account for the enumeration difference when they stain the first PC sample and then use the second PC sample for  flow cytometry.

In contrast, if they take one large volume aspirate the concentation of cells will likely be the same & minimize any such discrepancy.

So, the next time you speak to Barlogie, could you ask this question:

Did they withdraw one large aspirate sample as opposed to 2 in order to do the MFC?

I suspect this is what results in our extreme discomfort.  I know one thing, my last BMA was way more painful and it lasted for awhile. Unlike the other BMA's where it was painful during the aspirate but it dissipated quickly.

Just wondering.


While we may disagree on a few things, Suzierose is exceptionally knowledgeable about this disease and this raises a number of interesting points.

First, by way of background, MFC in the above refers to multi-flow cytometry which is an advanced methods of analyzing bone marrow as might be used, for example, in Arkansas' test for residual disease, which I just had done.  PC count is plasma cell count -- plasma cells are one of the bases of the immune system and it is these that run amok with Myeloma.

So to answer, a couple of comments:

* My understanding is they do take more bone marrow out per bunch to accommodate the additional tests.  BB used to do two punches per test -- one for the normal cytometry / BMB and one for special gene array tests.  In UAMS' protocol, gene arrays are useful for diagnosis, establishing a detailed picture of baseline physiology, measuring the impact of initial treatment, and measuring the outcome of treatment (though once one is in remission, definitionally the gene arrays look normal).   Because I've been in remission, and because I'd just as soon reduce the number of holes in my backside, I generally avoid gene arrays.  As I was opting out of this most recent one, the BM nurse told me that they do it all with one punch and just take more material now.  I still declined it, but they only did one punch for the MRD test (MFC) as well.  The single sample was, I believe, about 3cm so that's a pretty big hole in the bone.  This certainly could cause the extra pain.  In my case, I believe the Zometa also had something to do with it -- the woman said she really had to put a lot of elbow grease into smashing the tool into my hip.  Sounds painful just typing about it!

* I don't have my labs in front of my but there is overlap in the results of the test -- they can get a PC count from the biopsy, or from the aspirate, and in this case I think there was insufficient cellularity in my biopsy to perform the test.

The second topic, which I'll tackle tomorrow since work calls, is the lousy GI distress in which I found myself.  Since I recently had a negative PET, I'm not concerned about stomach or colon cancer -- and I'm not concerned about infection, either.  But I am worried that all this treatment has caused IBS or worse yet something like Crohn's disease.  So I'm afraid an endoscopy is in my near future.  More on this tomorrow.

With that in mind, sweet dreams.  : \


  1. It sounds like the discrepancy in the BM testing may indeed be based on size and depth, and the realization that MM cells can disperse throughout the bone marrow and not be equally available for pickup may also have some effect on the results. I think a more effective mode for determining cellular involvement with MM is needed and perhaps it could be one that is less painful as well. Intending you are finding out that it is just an irritable bowel that can be set right with probiotics...

  2. Nick: I'm a patient at MIRT. I've had more than a dozen bone marrow biopsy's (BMB) there. I've experienced very little if any post procedural pain. I always take the fentanyl citrate "lollipop" before my procedure and ask for the full package of pain killers just before the procedure.

    Do you get both painkillers before your procedure?

    The BMB technicians say my bones are "average" hardness. I gather your bones are much harder than mine. I'm sorry to hear it.

    Pete N