Fine needle aspiration for the diagnosis and treatment of musculoskleletal tumours

World Health Organization Reporting System for Soft Tissue Cytopathology: Risk of malignancy and reproducibility of categories among observers

INTRODUCTION

In 2024, the World Health Organization (WHO) is scheduled to publish the WHO Reporting System for Soft Tissue Cytopathology (WHORSSTC). This system establishes categories with well-defined definitions, criteria, and estimated risks of malignancy (ROMs) for soft tissue tumors. The estimates of ROM are based on a relatively small number of published studies. Interobserver reproducibility is not addressed in the reporting system even though reproducibility of a reporting system is highly important.

METHODS

A manual search of one authors personal consultation files and teaching set (L.J.L.) was conducted for all cytologic specimens of soft tissue tumors accessioned between January 1, 1985 and December 31, 2022. Only cases with documented surgical pathology follow-up were included in the study. Slides from each case were evaluated independently by three cytopathologists with each case assigned to one of the WHORSSTC categories. A ROM for each of the WHORSSTC categories was calculated. Interobserver agreement was evaluated by the kappa and weighted kappa statistics.

RESULTS

Risk for malignancy by category were: Category 1: 0%, Category 2: 28%, Category 3: 57%, Category 4: 47%, Category 5: 63%, and Category 6: 88%. Kappa statistics for agreement between raters varied from 0.2183 to 0.3465 and weighted kappa varied from 0.3778 to 0.5217.

CONCLUSIONS

The WHORSSTC showed a progression of malignancy risk from the category "benign" (28%) to the category "malignant" (88%). Interobserver agreement was only fair.

Extensive Lateral Cervical Desmoid Tumor Dependent on the Levator Scapulae Muscle Involving the Vertebral Artery Treated by Surgical Resection and Intraoperative Navigation: A Case Report and Review of the Literature

Desmoid tumors are rare, benign, but locally aggressive fibromatoses that pose significant therapeutic challenges, particularly when located in the head and neck region. This report details the case of an extensive cervical desmoid tumor dependent on the levator scapulae muscle and involving the vertebral artery managed through surgical resection and intraoperative navigation. A 45-year-old male presented with a slowly growing cervical mass. Imaging revealed an 83x68x40 mm mass in the right lateral paravertebral space, dependent on the levator scapulae muscle and involving the vertebral artery. Biopsy confirmed a low-grade fusocellular myofibroblastic neoplasm consistent with a desmoid tumor. Given the poor prognosis associated with the symptomatic mass, surgical resection was performed using Brainlab intraoperative navigation (Brainlab, Munich, Germany). The procedure was successful, with preservation of vital structures and no evidence of recurrence postoperatively. Desmoid tumors in the head and neck region, though rare, require precise diagnostic and therapeutic approaches due to their aggressive nature and proximity to critical anatomical structures. The use of intraoperative navigation, in this case, facilitated accurate tumor resection, minimizing damage to surrounding tissues. Pathological analysis revealed a CTNNB1 gene mutation, specifically the S45P variant, which is associated with an increased risk of recurrence. This case highlights the importance of a multidisciplinary approach, incorporating advanced surgical techniques and genetic analysis, in the management of complex desmoid tumors. Intraoperative navigation proved invaluable in achieving successful surgical outcomes, underscoring its potential utility in similar cases. Continued follow-up is essential, given the potential for recurrence associated with desmoid tumors.

Surgical excision of complex lipoma from the foot: A case report

Malignant soft tissue tumors of the foot and ankle are rare but diagnostic imaging and/or interventional biopsy are vital to establish the nature and grading of a suspicious tumor prior to definitive surgical intervention. The purpose of the study is to provide an account on how a symptomatic mass of the plantar aspect of the foot warranted a referral to a sarcoma center, highlighting the importance of having access to diagnostic imaging and a pathway to refer suspected cases to specialist centers. A single patient with a symptomatic soft tissue tumor of the plantar foot was referred from our service to the regional sarcoma center who considered to be benign, and therefore, open surgical resection was performed by our team. Histopathological analysis identified the excised mass as a lipoma. At 2 years, postoperatively there was no recurrence, and the patient presented with an asymptomatic foot. United Kingdom (UK) guidelines suggest that all soft tissue masses of suspicious nature, greater than 50 mm, deep seated irrespective of size, or fast growing lesions should be referred to a sarcoma unit prior to surgical management. European guidance identifies a threshold of 15 mm for a mass in the foot. Patients presenting with red flag symptoms irrespective of size of mass should be referred to a sarcoma center. Advanced imaging and multidisciplinary input to enable appropriate surgical planning is recommended for suspicious soft tissue tumors that present to the foot and ankle surgeon.

Fine-needle aspiration biopsy for the diagnosis of bone and soft tissue lesions: a systematic review and meta-analysis

INTRODUCTION

The workup of musculoskeletal (MSK) lesions utilizes a range of diagnostic tests including incisional biopsy, core needle biopsy, and fine-needle aspiration (FNA). FNA is the most cost-effective and least invasive biopsy method, but variation in its reported diagnostic performance has constrained its use for MSK lesions. Herein, we undertake a meta-analysis to clarify the diagnostic performance of FNA for bone and soft tissue lesions.

MATERIALS AND METHODS

A systematic search was run in MEDLINE, EMBASE, and CINAHL. Included studies were aggregated for pooled estimates of adequacy, accuracy, and sensitivity/specificity for all MSK lesions as well as bone and soft tissue independently. Analysis of heterogeneity and risk of bias were assessed across studies. Covariate subgroup analyses were attempted to investigate potential influences on diagnostic accuracy.

RESULTS

Twenty-five articles met inclusion criteria, representing 4604 FNAs. Adequacy was 92.3% (range: 59.2%-98.0%, S = 9.4%), and sensitivity/specificity for the nature (malignant or benign) of the lesion was 95.6% (95% CI: 94.5%-96.5%) and 96.9% (95% CI: 95.9%-97.7%). FNA was 75.8% accurate (range: 42.5%-99.3%, S = 17.3%) for definitive diagnosis. FNA provides higher accuracy for benign versus malignant nature in bone lesions but achieves a definitive diagnosis more frequently in soft tissue lesions.

CONCLUSIONS

The results of this meta-analysis support the expanded use of FNA in the diagnostic workup of bone and soft tissue lesions, particularly in light of a sensitivity and specificity comparable to incisional and core needle biopsy.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.