CT-Guided Biopsy of Bone and Soft-Tissue Lesions: Role of On-Site Immediate Cytologic Evaluation

Application of Indocyanine Green Fluorescence Imaging in Assisting Biopsy of Musculoskeletal Tumors

(1) Background: Biopsies are the gold standard for the diagnosis of musculoskeletal tumors. In this study, we aimed to explore whether indocyanine green near-infrared fluorescence imaging can assist in the biopsy of bone and soft tissue tumors and improve the success rate of biopsy. (2) Method: We recruited patients with clinically considered bone and soft tissue tumors and planned biopsies. In the test group, indocyanine green (0.3 mg/kg) was injected. After identifying the lesion, a near-infrared fluorescence camera system was used to verify the ex vivo specimens of the biopsy in real time. If the biopsy specimens were not developed, we assumed that we failed to acquire lesions, so the needle track and needle position were adjusted for the supplementary biopsy, and then real-time imaging was performed again. Finally, we conducted a pathological examination. In the control group, normal biopsy was performed. (3) Results: The total diagnosis rate of musculoskeletal tumors in the test group was 94.92% (56/59) and that in the control group was 82.36% (42/51). In the test group, 14 cases were not developed, as seen from real-time fluorescence in the core biopsy, and then underwent the supplementary biopsy after changing the puncture direction and the location of the needle channel immediately, of which 7 cases showed new fluorescence. (4) Conclusions: Using the near-infrared fluorescence real-time development technique to assist the biopsy of musculoskeletal tumors may improve the accuracy of core biopsy and help to avoid missed diagnoses, especially for some selected tumors.

Prediction of Complication Risk in Computed Tomography-guided Thoracic Biopsy: A Prescription for Improving Procedure Safety

PURPOSE

Computed tomography-guided transthoracic biopsy (CTTB) is a minimally invasive procedure with a high diagnostic yield for a variety of thoracic diseases. We comprehensively assessed a large CTTB cohort to predict procedural and patient factors associated with the risk of complications.

MATERIALS AND METHODS

The medical record and computed tomography images of 1430 patients who underwent CTTB were reviewed individually to obtain clinical information and technical procedure factors. Statistical analyses included descriptive and summary statistics, univariate analysis with the Fisher test, and multivariate logistic regression.

RESULTS

The most common type of complication was pneumothorax (17.4%), followed by bleeding (5.9%). Only 26 patients (1.8%) developed a major complication. Lung lesions carried a higher risk of complications than nonlung lesions. For lung lesions, the nondependent position of the lesion, vertical needle approach, trespassing aerated lung, and involvement of a trainee increased the risk of complication, whereas the use of the coaxial technique was a protective factor. The time with the needle in the lung, the number of biopsy samples, and the distance crossing the aerated lung were identified as additional risk factors in multivariate analysis. For nonlung lesions, trespassing the pleural space was the single best predictor of complications. A logistic regression-based model achieved an area under the receiver operating characteristic curve of 0.975, 0.699, and 0.722 for the prediction of major, minor, and no complications, respectively.

CONCLUSIONS

Technical procedural factors that can be modified by the operator are highly predictive of the risk of complications in CTTB.

Tumors of the Spine: When Can Biopsy Be Avoided?

Regarding osseous tumors of the spine, characteristic morphology is encountered in hemangioma of the vertebral body, osteoid osteoma (OO), osteochondroma, Paget's disease, and bone islands. In these cases, radiologic imaging can make a specific diagnosis and thereby avoid biopsy, especially when the radiologist has chosen the correct imaging modality to establish the diagnosis, such as thin-slice computed tomography in suspected OO. A benign lesion is suggested by a high amount of fat within the lesion, the lack of uptake of the contrast agent, and a homogeneous aspect without solid parts in a cystic tumor. Suspicion of malignancy should be raised in spinal lesions with a heterogeneous disordered matrix, distinct signal decrease in T1-weighted magnetic resonance imaging, blurred border, perilesional edema, cortex erosion, and a large soft tissue component. Biopsy is mandatory in presumed malignancy, such as any Lodwick grade II or III osteolytic lesion in the vertebral column. The radiologist plays a crucial role in determining the clinical pathway by choosing the imaging approach wisely, by narrowing the differential diagnosis list, and, when characteristic morphology is encountered, by avoiding unnecessary biopsies.

Radiology-pathology correlation for bone and soft tissue tumors or tumor-like masses: single institutional experience after implementation of a weekly conference

OBJECTIVES

To determine the frequency of non-diagnostic and discordant results from bone and soft tissue biopsies performed at our institution over a 3-year period and to investigate whether implementation of a weekly musculoskeletal radiology-pathology correlation conference decreased the time to appropriate patient management in cases of discordance.

METHODS

Consecutive image-guided core needle biopsy results obtained over a 12 month period of time were reviewed in a retrospective fashion. Following implementation of the correlation conference, subsequent consecutive image-guided core needle biopsy results obtained over a 26 month period of time were reviewed in a prospective fashion. For non-diagnostic and discordant cases, the time in days from date of availability of the biopsy result to date of documentation of a specific follow-up action plan was recorded.

RESULTS

Diagnostic yield was 96.5% and 94.9% for the retrospective and prospective periods, respectively. There were four discordant results in the retrospective cohort (1.7%) and seven discordant results in the prospective cohort (2.1%). Following implementation of the weekly correlation conference, there was significant decrease (p < 0.05) in median time from a discordant biopsy result to follow-up action plan. There were no unnecessary surgeries, litigation, or other unfavorable consequences in either cohort.

CONCLUSION

Image-guided core needle biopsies of bone and soft tissue provide high diagnostic yield, often with specific diagnoses. The statistically significant decrease in number of days to follow-up action plan for discordant results suggests radiology-pathology review has a positive impact on patient care. Subjective benefits from communication and educational standpoints are also noteworthy.

Role of cytotechnologists in rapid onsite adequacy assessment of cytology materials for diagnostic workup and specimen allocation for ancillary testing using a standardized protocol

INTRODUCTION

Data on the performance of cytotechnologists in assessing specimen adequacy of needle core biopsies (NCB) is scant and their role in specimen triaging for ancillary studies have not been well established.

MATERIALS AND METHODS

We retrospectively analyzed rapid onsite evaluation (ROSE) performed exclusively by cytotechnologists on 248 NCB and fine-needle aspiration (FNA) specimens. Overall adequacy and accuracy rates were determined by comparing to final diagnosis. We also reviewed the process of specimen allocation for ancillary testing to determine whether specimens were appropriately triaged at the time of ROSE.

RESULTS

Of the 248 cases, 222 (89.5%) were touch imprint and 26 (10.5%) were FNA smears. The overall adequacy rate was 73.4% (182 of 248). Concordance for "adequate" interpretation by ROSE with unequivocal malignant or benign diagnoses on final interpretation was 95.6%. The sensitivity, specificity, and accuracy of ROSE for a final "positive for malignancy" were 89.2% (95% CI 83.04% to 93.69%), 43.24% (95% CI 31.77% to 55.28%), and 73.87% (95% CI 67.57% to 55.28%), respectively. Cases with "positive for malignancy" on final diagnosis were "adequate" by ROSE in 89.1% (132 of 148) and "inadequate" in 10.8% (16 of 148), P < 0.0001. Ancillary tests were performed in 168 of 248 (67.7%); the majority were immunohistochemical stains for determining tumor subtype. Predictive biomarkers were performed successfully in 100% of metastatic breast cancers.

CONCLUSIONS

Cytotechnologists performed at a high level of competency in providing ROSE and allocating specimens for ancillary testing, which were performed successfully in the majority of cases. Implementation of a standardized protocol for tissue management/prioritization is of paramount importance to maximize tissue preservation and minimize wastage.

Initial experience with dual-energy computed tomography-guided bone biopsies of bone lesions that are occult on monoenergetic CT

OBJECTIVE

Our purpose was to determine whether dual-energy CT (DECT), specifically the bone marrow setting of the virtual noncalcium (VNCa) algorithm, could be used to identify and accurately biopsy suspected bone malignancies that were visible on magnetic resonance imaging (MRI), nuclear bone scintigraphy, or positron-emission tomography/computed tomography (PET/CT), but occult on monoenergetic computed tomography (CT) by virtue of being either isodense or nearly isodense to surrounding normal bone.

MATERIALS AND METHODS

We present 4 cases in which DECT was used to detect various malignant bone lesions and was successfully used to direct percutaneous DECT-guided bone biopsies.

RESULTS

Two of the lesions were solid tumor metastases (breast and prostate carcinoma), whereas two others were hematological malignancies (leukemia and lymphoma). This technique enabled us to confidently and accurately direct the biopsy needle into the target lesion.

CONCLUSION

The authors demonstrate that the DECT VNCa bone marrow algorithm may be helpful in identifying isodense bone lesions of various histologies and may be used to guide percutaneous bone biopsies. This technique may help to maximize diagnostic yield, minimize the number of passes into the region of concern, and prevent patients from undergoing repeat biopsy.

An improved biopsy technique for rabbits with VX2 bone tumors

The present study aimed to investigate the efficacy of an improved biopsy method for reducing local exudation and metastasis. After resecting the VX2 tumor in cancer-bearing VX2 rabbits, a tumor cell suspension was prepared. Tumor cells were transplanted into the tibias of 20 rabbits in order to establish a bone tumor model. These adult rabbits underwent a puncture procedure after 2 weeks. All the left tibias were punctured using the improved biopsy method (the experimental group), where bolt closures were implanted into puncture holes through the metallic casing following biopsy. All the right tibias were punctured using a traditional biopsy technique (the control group). Color Doppler ultrasonography was used to assess the exudation of each puncture hole after 1 h. After 7 days, a pathological study was performed on the soft tissue near each puncture hole. The success rate of the bone model was 100% for the 20 rabbits. The exudation rate in the experimental group was lower than that in the control group (25 vs. 80%, respectively; χ2=12.13; P<0.05). The tumor-spreading rate in the experimental group was lower than that in the control group (35 vs. 85%, respectively; χ2=10.41; P<0.05). Overall, it was shown that the improved biopsy method can prevent local bleeding and tumor metastasis.

PET-Based Percutaneous Needle Biopsy

PET can be used to guide percutaneous needle biopsy to the most metabolic lesion, improving diagnostic yield. PET biopsy guidance can be performed using visual or software coregistration, electromagnetic needle tracking, cone-beam computed tomography (CT), and intraprocedural PET/CT guidance. PET/CT-guided biopsies allow the sampling of lesions that may not be clearly visible on anatomic imaging, or of lesions that are morphologically normal. PET can identify suspicious locations within complex tumors that are most likely to contain important diagnostic and prognostic information.

Percutaneous CT-guided needle biopsies of musculoskeletal tumors: a 5-year analysis of non-diagnostic biopsies

OBJECTIVE

To study non-diagnostic CT-guided musculoskeletal biopsies and take steps to minimize them. Specifically we asked: (1) What malignant diagnoses have a higher non-diagnostic rate? (2) What factors of a non-diagnostic biopsy may warrant more aggressive pursuit? (3) Do intra-procedural frozen pathology (FP) or point-of-care (POC) cytology reduce the non-diagnostic biopsy rate?

MATERIALS AND METHODS

This study was IRB-approved and HIPAA-compliant. We retrospectively reviewed 963 consecutive CT-guided musculoskeletal biopsies. We categorized pathology results as malignant, benign, or non-diagnostic and recorded use of FP or POC cytology. Initial biopsy indication, final diagnosis, method of obtaining the final diagnosis of non-diagnostic biopsies, age of the patient, and years of biopsy attending experience were recorded. Groups were compared using Pearson's χ(2) test or Fisher's exact test.

RESULTS

In all, 140 of 963 (15%) biopsies were non-diagnostic. Lymphoma resulted in more non-diagnostic biopsies (P < 0.0001). While 67% of non-diagnostic biopsies yielded benign diagnoses, 33% yielded malignant diagnoses. Patients whose percutaneous biopsy was indicated due to the clinical context without malignancy history almost always generated benign results (96%). Whereas 56% of biopsies whose indication was an imaging finding of a treatable lesion were malignant, 20% of biopsies whose indication was a history of malignancy were malignant. There was no statistically significant difference in the nondiagnostic biopsy rates of pediatric versus adult patients (P = 0.8) and of biopsy attendings with fewer versus more years of experience (P = 0.5). The non-diagnostic rates of biopsies with FP (8%), POC cytology (25%), or neither (24%) were significantly different (P < 0.0001).

CONCLUSION

Lymphoma is the malignant diagnosis most likely to result in a non-diagnostic biopsy. If the clinical and radiologic suspicion for malignancy is high, repeat biopsy is warranted. If the clinical context suggests a benign lesion, a non-diagnostic biopsy may be considered reassuring. Frozen pathology may decrease the non-diagnostic biopsy rate.

Optimal handling of bone tumor specimens

The diagnosis of bone tumors is challenging and depends on optimal processing of specimens as well as integration of radiographic and clinical information. The correct diagnosis will often require ancillary techniques such as immunohistochemistry, flow cytometry and molecular or cytogenetic analysis. From a pathologist's standpoint, optimal processing of specimens is paramount and often requires some foreknowledge of anticipated diagnosis in order to triage a specimen properly. The type of specimen, small vs. large, will often dictate the type of information that should be reported by the pathologist. Small specimens, including core biopsies and small incisional biopsies, are often obtained for primary diagnosis and as such, require a different approach to management. In addition to assuring the adequacy of the specimen for diagnosis, the pathologist will often need to triage these materials for appropriate ancillary studies. Large specimens, including amputations and large resections, pose a different set of technical problems for handling and processing. In this setting, information such as grading, staging, and marginal status become more crucial and the subsequent processing of the specimen should be handled in a very standardized manner to facilitate optimal pathologic reporting. This chapter offers a concise but detailed review for handling both types of bone tumor specimens.

Imprint cytopathology of core needle biopsies: a "first responder" role for cytotechnologists

INTRODUCTION

Imprint cytopathology (IC) of image-guided core needle biopsies (CNBs) is used to ensure adequate sampling. In our institution, cytotechnologists (CyTs) are the "first responders" for on-site adequacy assessment (OSAA) of image-guided CNBs. We report our experience with this expanded and relatively unexplored role for CyT.

MATERIALS AND METHODS

We reviewed all image-guided CNBs performed over a 12-month period that required OSAA. OSAA was provided primarily by CyT. Interpretation between all IC specimens and tissue diagnoses (concordance) and between adequate IC specimens and tissue diagnoses (accuracy) were analyzed. Performance was compared using the Fisher exact test. We retrospectively reviewed discrepant cases to deduce the reasons for discordance.

RESULTS

We evaluated 255 CNBs: 179 computed tomography-guided, 74 ultrasonography-guided, 2 endoscopy-guided. Lung (39%) followed by liver (16%) and lymph node (11%) were the most frequent sites of OSAA IC. Overall adequacy and accuracy rates were 80.8% and 87.9%, respectively, with a concordance rate of 81.2%. The performance for CyT alone, CyT/cytopathology fellow, and CyT/cytopathologist were comparable (P > 0.05). Review of discordant cases showed agreement with 91% of OSAA IC cases originally interpreted as inadequate, but with only 19% interpreted as adequate.

CONCLUSIONS

OSAA IC of CNBs expands the CyT's role in an effort to ensure adequate sampling. CyT performance was high in recognition of adequate versus inadequate IC slides when compared with the tissue. Reasons for discrepancy included sampling error and overinterpretation of atypia as being sufficient evidence of adequacy. Organ-specific cytologic criteria to assess adequacy are required to reduce interpretation error.

Diagnostic benefits and cost-effectiveness of on-site imprint cytology adequacy evaluation of core needle biopsies of bone lesions

BACKGROUND

Core needle biopsy (CNB) is a well-established, successful technique for the diagnosis of various organ system lesions. To increase diagnostic yield, on-site cytologic evaluation of adequacy (OCA) is routinely performed at many institutions. Numerous studies evaluating the impact of OCA on CNB have been published. However, little has been said regarding accuracy of OCA for bone lesions.

METHODS

To evaluate this, we reviewed our experience during a two-year period, and compared OCA results with the final diagnosis of the corresponding CNB. For the study, diagnoses were divided into three categories: malignant, benign, and nonspecific/nondiagnostic findings.

RESULTS

Sixty-one cases were included. During OCA, 25 cases were diagnosed as malignant, three cases as benign, and 33 as nonspecific/nondiagnostic. On histologic evaluation, 29 cases were malignant, 16 were benign, and 16 were classified as nonspecific/nondiagnostic. Concordance with final CNB diagnosis was seen in 100% of malignant, 67% of benign, and 45% of nonspecific/nondiagnostic on-site cytology evaluations. The overall diagnostic success rate of OCA for malignancy was 86% (25/29). The success rate of OCA for benign lesions was only 13%. Fifty-four percent of cases were diagnosed as nonspecific/nondiagnostic on-site. This category included four false negative cases.

CONCLUSIONS

We conclude that for lesions with a suspicion of malignancy, OCA is a valuable adjuvant diagnostic tool. However, for cases with a benign or nonspecific clinical impression, OCA has a limited diagnostic role. Careful selection of cases in which OCA is beneficial is necessary to maintain accuracy and to limit procedure costs.

Risk-benefit analysis of sampling methods for fine-needle aspiration cytology: a mathematical modeling approach

The effectiveness of fine-needle aspiration (FNA) increases with the number of needle passes, but needle passes are also associated with increased risk of adverse events. The trade-off between needle passes and adequacy has not been well characterized. Clinical studies are limited because of their inherent variability and limited sample size. We developed mathematical models to compare the performance of a variety of sampling protocols under a wide range of conditions. Specifically, we compared the performance of sampling methods using a fixed number of needle passes with sampling methods using a rapid onsite evaluation (ROSE) with a variable number of needle passes. Variable sampling with ROSE generally required fewer needle passes than fixed sample size policies to achieve a desired adequacy rate. Variable sampling policies using ROSE achieve greater per-case adequacy with fewer needle passes than sampling policies using a fixed number of passes if assessor accuracy is high.

Percutaneous CT-guided vertebral bone biopsy in children

BACKGROUND

Few published series are dedicated solely to CT-guided vertebral bone biopsy in children.

OBJECTIVE

The objective of our study was to review the diagnostic yield of CT-guided vertebral bone biopsy in children.

MATERIALS AND METHODS

A retrospective review of 26 consecutive CT-guided vertebral bone biopsies during a 7-year period in 24 children (16 girls and 8 boys), mean age 8.8 years (range 1-16 years) was performed at our institution. Procedures were reviewed for diagnostic accuracy, biopsy location, complications and final diagnosis.

RESULTS

Twenty-five of 26 biopsies (96%) were technically successful. Twenty-one of 26 biopsies were diagnostic (81%); 2/26 (8%) were false-negative removing non-lesional tissue, 2/26 (8%) were nondiagnostic, and 1/26 (4%) was technically unsuccessful. The diagnoses were as follows: 12/26 biopsies (46%) were osteomyelitis, 3/26 (11%) biopsies were Langerhans cell histiocytosis, 3/26 biopsies (11%) were normal bone, 2/26 (8%) biopsies were malignant tumors, and 1/26 (4%) biopsies was osteoblastoma. There was one self-limited, procedure-related complication: a small right-sided pneumothorax occurred in the setting of attempting to create a protective extrapleural biopsy window.

CONCLUSION

Percutaneous CT-guided vertebral bone biopsy can be performed safely in children with a high degree of diagnostic accuracy.

The influence of rapid onsite evaluation on the adequacy rate of fine-needle aspiration cytology: a systematic review and meta-analysis

Rapid onsite evaluation (ROSE) has the potential to improve the adequacy rates of fine-needle aspiration (FNA) cytology. Studies have obtained variable results on the influence of ROSE. We conducted a systematic review and meta-analysis of studies on the influence of ROSE on FNA adequacy. We synthesized evidence across all anatomic locations. We only included studies that contained a control arm and compared cohorts with ROSE against cohorts without ROSE at a single location. We screened 2,179 studies and identified 25 studies that met our inclusion criteria. On average, ROSE improves the adequacy rate by 12%, but there was considerable variability across studies. The adequacy rate with ROSE depends on the non-ROSE adequacy rate. Sixty-five percent of the variability in the adequacy rate with ROSE was found to occur because of differences in the adequacy rate without ROSE. Studies with high non-ROSE adequacy rates showed low improvement after ROSE was implemented. Studies must account for the effect of the non-ROSE adequacy rate to determine the effect of ROSE on FNA adequacy rates.

The comparative effectiveness of fine-needle aspiration cytology sampling policies: a simulation study

Sample adequacy is an important aspect of overall fine-needle aspiration cytology (FNAC) performance. FNAC effectiveness is augmented by an increasing number of needle passes, but increased needle passes are associated with higher costs and greater risk of adverse events. The objective of this study was to compare the impact of several different sampling policies on FNAC effectiveness and adverse event rates using discrete event simulation. We compared 8 different sampling policies in 12 different sampling environments. All sampling policies were effective when the per-pass accuracy is high (>80%). Rapid on-site evaluation (ROSE) improves FNAC effectiveness when the per-pass adequacy rate is low. ROSE is unlikely to be cost-effective in sampling environments in which the per-pass adequacy is high. Alternative ROSE assessors (eg, cytotechnologists) may be a cost-effective alternative to pathologists when the per-pass adequacy rate is moderate (60%-80%) or when the number of needle passes is limited.