Percutaneous skeletal biopsy

What Is the Optimal Method to Perform Bone Biopsy (Method, Location, Imaging Use) for Patients With Foot and Ankle Infections?

RECOMMENDATION

A bone biopsy should generally be performed in a percutaneous fashion, particularly in cases where surgical debridement is not considered necessary. If surgical debridement is considered necessary, then an open biopsy can be performed as part of the debridement. Percutaneous biopsy should be performed under sterile conditions by an interventional radiologist or other physician trained in image-guided techniques. The location of the biopsy will depend upon the clinical and radiographic evaluations, with a goal of maximizing the yield of the biopsy while minimizing the risk of injury to surrounding and/or overlying soft tissue structures.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Analysis of nondiagnostic results after image-guided needle biopsies of musculoskeletal lesions

BACKGROUND/RATIONALE

Image-guided needle biopsies are commonly used to diagnose musculoskeletal tumors, but nondiagnostic (ND) results can delay diagnosis and treatment. It is important to understand which factors or diagnoses predispose to a ND result so that appropriate patient education or a possible change in the clinical plan can be made. Currently it is unclear which factors or specific lesions are more likely to lead to a ND result after image-guided needle biopsy.

QUESTIONS/PURPOSES

We therefore identified specific factors and diagnoses most likely to yield ND results. We also asked whether an image-guided needle biopsy of bone and soft tissue lesions is an accurate and clinically useful tool.

METHODS

We retrospectively reviewed data from a prospectively collected database for a case-control study of 508 image-guided needle biopsies of patients with suspected musculoskeletal tumors between 2003 and 2008.

RESULTS

The interpretations of 453 of the 508 (89%) needle biopsies were accurate and clinically useful. Forty-five biopsies (9%) were ND and 10 (2%) were incorrect (IC). Bone lesions had a higher ND rate than soft tissue lesions (13% vs. 4%). The specific diagnosis with the highest ND rate was histiocytosis. Elbow and forearm locations had higher ND rates than average. Malignant tumors had a higher IC rate than benign tumors (5% vs. 0%); fibromyxoid sarcoma and rare subtypes of osteosarcoma had higher IC rates than other diagnoses. Repeat needle or open biopsies were performed in 71 (14%) patients. Bone lesions were more likely than soft tissue lesions to require repeat biopsies (18% vs. 9%).

CONCLUSIONS

A high rate of accuracy and clinical usefulness is possible with image-guided needle biopsies of musculoskeletal lesions. We believe these biopsies appropriate in selected circumstances but a key factor for appropriate use is an experienced musculoskeletal tumor team with frequent communication to correlate clinical, radiographic, and histologic information for each patient.

CT-guided needle biopsy for musculoskeletal lesions

INTRODUCTION

We determined the diagnostic accuracy rate of 207 cases that underwent CT-guided needle biopsy for musculoskeletal lesions during the past 10 years, and describe the efficacy and indications of this method.

MATERIALS AND METHODS

We retrospectively analyzed a consecutive series of 207 cases that presented to our oncology group and underwent CT-guided needle biopsy during the 10-year period between April 1998 and March 2008. Diagnostic accuracy was assessed statistically by anatomical location and final diagnosis. The biopsy site was the spine/sacrum in 70 cases, pelvis in 53, extremities in 51, rib/scapula in 20, and retroperitoneum in 13. Bone lesions were detected in 176 cases and soft tissue lesions in 31. The final diagnosis was metastatic tumor in 63 cases, primary bone tumor in 63, primary soft tissue tumor in 23, infection in 18, and hematopoietic malignancy in 16 and non-tumorous lesions in 24.

RESULTS

The diagnostic accuracy rate for all cases was 90%. No serious complications were seen. No statistically significant difference was found by anatomical site. According to the final diagnosis, benign tumors/malignant tumors (p < 0.005), primary bone tumor (p < 0.01), and infectious conditions (p < 0.001) showed significantly low diagnostic accuracy rates.

DISCUSSION

CT-guided needle biopsy is a safe method with high diagnostic accuracy for musculoskeletal lesions. However, in patients with a primary bone tumor, it should be indicated for the initial diagnosis. If a comprehensive assessment based on the imaging conflicts with the pathological findings, an open biopsy should be considered.

Percutaneous bone biopsy to distinguish osteomyelitis from charcot osteoarthropathy: two case reports

Level of Evidence: V, Expert Opinion

Clinical utility of percutaneous biopsies of musculoskeletal tumors

Percutaneous biopsies are frequently used for musculoskeletal lesions. We suspect published accuracy rates (80-97%) overestimate clinical utility. We retrospectively reviewed 120 consecutive percutaneous biopsies performed by interventional radiologists at our institution. Patients underwent core biopsy, fine-needle aspiration (FNA), or both. The biopsy interpretations were considered clinically useful if they allowed proper treatment to proceed and not useful if they were nondiagnostic or if surgical specimens disagreed with percutaneous specimen. Patients were categorized by biopsy type, tissue type, and tumor type. Ninety of 120 percutaneous biopsies were clinically useful, 27 were nondiagnostic, and three were incorrect; in these latter 30 patients we proceeded to open biopsy. Patients with both biopsies had clinically useful results (80.6%) more often than FNA or core alone(68.0% and 66.7%, respectively). Biopsies of bone lesions were clinically useful more often than those of soft tissue. Myxoid histology was associated with decreased clinical accuracy. Clinical utility was independent of tumor type. No single characteristic predicted increased probability of open biopsy. The clinical utility rate was acceptable, but below published accuracy rates. The combination of both biopsies was better than FNA alone. Myxoid findings rarely helped to guide definitive treatment. Treatment decision making requires balancing biopsy results with clinical data.

LEVEL OF EVIDENCE

Diagnostic study, level IV.

MR image analysis of pedal osteomyelitis: distribution, patterns of spread, and frequency of associated ulceration and septic arthritis

PURPOSE

To evaluate the anatomic distribution of pedal osteomyelitis and septic arthritis in a large patient group with advanced pedal infection and to compare ulcer location with the distribution of osteomyelitis and septic arthritis.

MATERIALS AND METHODS

Contrast material-enhanced magnetic resonance (MR) imaging findings were reviewed for 161 feet in 51 women and 107 men (82% of whom had diabetes mellitus) who were suspected of having osteomyelitis and who underwent tissue diagnosis. Location of skin ulceration and presence of osteomyelitis (indicated by means of low T1-weighted signal intensity, high T2-weighted signal intensity, and contrast enhancement) and septic arthritis (indicated by synovial enhancement and adjacent cellulitis) were evaluated by two musculoskeletal radiologists.

RESULTS

In the forefoot, osteomyelitis occurred most frequently at the fifth metatarsal (n = 24), first metatarsal (n = 21), and first distal phalanx (n = 15). In the hindfoot, the calcaneus (n = 21) was involved most frequently. Osteomyelitis was directly adjacent to skin ulcers or surgical defects in all cases but one. Spread of osteomyelitis to adjacent bones in the forefoot occurred in 26 (16%) bones. Evidence of septic arthritis on MR images was present in 53 (33%) feet and involved most frequently the fifth (n = 13) and first (n = 8) metatarsophalangeal joints.

CONCLUSION

Pedal osteomyelitis results almost exclusively from contiguous infections and occurs most frequently around the fifth and first metatarsophalangeal joints. One-third of patients with advanced pedal infection show evidence of septic arthritis on MR images.

Sonographically guided core needle biopsy of bone and soft tissue tumors

OBJECTIVE

To determine the value of sonographically guided core needle biopsies of musculoskeletal tumors as a reliable alternative to fluoroscopy and computed tomography.

METHODS

A prospective study was performed in 74 patients referred for image-guided needle biopsy of primary or recurrent musculoskeletal neoplasms and suspected solitary metastasis. Imaging studies performed before biopsy established the feasibility of sonographic guidance in 65 lesions, of which 38 were soft tissue tumors and 27 were bone lesions with extraosseous masses. The lesions were located mainly in the appendicular skeleton. Tissue samples were obtained with a 14-gauge cutting needle coupled to an automated biopsy device under local anesthesia and sonographic guidance. Statistical analysis was based on 48 biopsies confirmed by successful clinical treatment (10 cases) or surgical resection (38 cases).

RESULTS

An accurate diagnosis was obtained in 47 (97%) of 48 biopsies; sensitivity was 96%, and specificity was 100%. The method did not yield sufficient tissue to establish a diagnosis in 1 case. Considering all 65 biopsies, high-quality specimens were obtained in 96%. The procedure was carried out expeditiously, and there were no complications.

CONCLUSIONS

Sonographically guided core needle biopsy is accurate and safe, obviating open biopsy in most soft tissue masses and bone tumors with extraosseous masses in the appendicular skeleton. In such patients, the sonographically guided procedure is the most prompt and effective method for obtaining tissue samples.

The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society

In 1982, members of the Musculoskeletal Tumor Society, representing sixteen centers for the treatment of bone and soft-tissue cancer, compiled data regarding the hazards associated with 329 biopsies of primary malignant musculoskeletal sarcomas. The investigation showed troubling rates of error in diagnosis and technique, which resulted in complications and also adversely affected the care of the patients. These data were quite different when the biopsy had been carried out in a treatment center rather than in a referring institution. On the basis of these observations, the Society made a series of recommendations about the technical aspects of the biopsy and stated that, whenever possible, the procedure should be done in a treatment center rather than in a referring institution. In 1992, the Musculoskeletal Tumor Society decided to perform a similar study to determine whether the rates of complications, errors, and deleterious effects related to biopsy had changed. Twenty-five surgeons from twenty-one institutions submitted the cases of 597 patients. The results were essentially the same as those in the earlier study. The rate of diagnostic error for the total series (in which cases from referring institutions and treatment centers were combined) was 17.8 percent. There was no significant difference in the rate of patients for whom a problem with the biopsy forced the surgeon to carry out a different and often more complex operation or to use adjunctive irradiation or chemotherapy (19.3 percent in the current study, compared with 18 percent in the previous one). There was also no significant differences in the percentage of patients who had a change in the outcome, such as the need for a more complex resection that resulted in disability, loss of function, local recurrence, or death, attributable to problems related to the biopsy (10.1 percent in the current study, compared with 8.5 percent in the 1982 study). Eighteen patients in the current study had an unnecessary amputation as a result of the biopsy, compared with fifteen in the previous study. Errors, complications, and changes in the course and outcome were two to twelve times greater (p < 0.001) when the biopsy was done in a referring institution instead of in a treatment center.