Computed tomography–guided percutaneous biopsy for vertebral neoplasms: a department's experience and hybrid biopsy technique to improve yield

Augmenting CT-Guided Bone Biopsies Using 18F-FDG PET/CT Guidance

Computer tomography (CT)-guided percutaneous core biopsies are currently the gold standard in diagnostic procedures for patients with bone lesions of unknown kind. CT-guided biopsies can lead to misdiagnosis or repetition of biopsies in case of small or heterogeneous lesions. We hypothesize that molecular image guidance could be used to optimize the biopsy strategy, by supporting the detection of heterogeneous lesions or lesions without radiographic substrate. To evaluate this hypothesis, we investigated if and how the addition of 2-deoxy-2-18F-fluoro-D-glucose-positron emission tomography (18F-FDG-PET)/CT could augment routine CT-guided bone biopsies. To this end, 106 patients who underwent a CT-guided bone biopsy between April 2019 and April 2020, obtained from either a vertebral or peripheral bone, were included. Patients were divided into 2 groups: 36 patients received an 18F-FDG-PET/CT scan prior to their CT-guided bone biopsy (PET group), while 70 patients only had a morphological CT scan (CT group). Histopathology was used to categorize biopsies into five subgroups (inconclusive, benign, malignant or infectious disease, or normal tissue). In the PET group, the number of conclusive biopsies was significantly higher compared to the CT group (N = 33/36 (92%) versus N = 53/70 (76%); p < 0.05). Furthermore, the number of first-try biopsies was lower in the PET group compared to the CT group (1.9 vs. 2.54, p = 0.051). In conclusion, 18F-FDG-PET/CT imaging significantly increased the success rate of first-try CT-guided bone biopsies by showing less inconclusive biopsies and misdiagnosis.

Image-Guided Percutaneous Needle Biopsy for Benign and Malignant Bone Tumors: Systematic Review and Meta-Analysis

PURPOSE

To compare the diagnostic yield and accuracy of both image-guided core-needle biopsy (CNB) and fine-needle biopsy and evaluate the benefit of performing fine-needle biopsy in addition to CNB in patients with suspected benign and malignant bone tumors.

MATERIALS AND METHODS

A systematic search was performed on March 10, 2021, to determine whether fine-needle aspiration (FNA) plays any role when performed alone or in combination with CNB. The included studies were aggregated for the pooled estimates of diagnostic yield and histologic accuracy of image-guided percutaneous needle biopsy of bone tumors. Twenty-nine studies published between 1996 and 2021 were included.

RESULTS

When all patients with bone tumors were included, the rates of diagnostic yield and accuracy of FNA and CNB were 88.5% and 82.5% and 91.4% and 92.7%, respectively; the rates of both the methods combined were 96.5% and 94.1%, respectively; and for the lytic subgroup, the rates of diagnostic yield and accuracy of CNB and both the methods combined were 94.3% and 100% and 98.9% and 90.4%, respectively. A P value of <.05 was considered statistically significant.

CONCLUSION

The present meta-analysis showed that core biopsy alone outperformed fine-needle biopsy alone in all categories of benign and malignant tumors. Additionally, the diagnostic yield was improved when FNA was used in addition to CNB for lytic bone lesions.

Management of Chordoma of the Sacrum and Mobile Spine

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Chordomas account for 1% to 4% of primary tumors of the spine and sacrum.

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En bloc resection is the preferred surgical treatment for the management of chordomas.

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Proton beam radiation is increasingly being used as a postoperative radiation modality for the treatment of chordomas.

Clinical application of a modified percutaneous vertebroplasty instrument in vertebral body biopsy in adults

Background

Percutaneous vertebroplasty (PVP) has been widely used to treat vertebral pathological fractures in recent decades, and the modified PVP instrument is very suitable for percutaneous biopsy of diseases promoting vertebral bone destruction. The purpose of this study was to evaluate the relevance of the clinical application of the modified PVP instrument in computed tomography-guided (CT-guided) biopsies of the vertebral body.

Methods

Retrospective analysis of clinical data obtained by percutaneous biopsy using a modified PVP outer shell of a bone filler device (OSBF) from 161 patients presenting vertebral body destruction was conducted. The rate of correctly performed biopsy diagnosis was evaluated from three aspects: imaging performance, histological type, and vertebral segment.

Results

The results of 149 biopsy cases were consistent with the final clinical diagnosis. From those cases, 92 were diagnosed as vertebral body metastasis, 45 cases presented primary spinal tumors and tumor-like changes, 7 cases presented vertebral body infections, and 5 cases displayed normal bones or fractures. From the remaining 12 patients, whose biopsy results were inconsistent with the final clinical diagnosis, 4 presented vertebral metastases, 4 displayed primary vertebral tumors, and 4 presented vertebral infections. The diagnostic rate of the modified PVP OSBF biopsy was 92.5%. The rate of correct biopsy diagnosis for vertebral metastases was 95.8%. The rate of correct diagnosis of primary vertebral tumors and tumor-like biopsy was 91.8%, and the rate of correct diagnosis for vertebral infectious diseases was 63.6%.

Conclusion

The modified PVP OSBF allows obtaining more lesion tissue, in multiple directions and multiple angles, during the biopsy of vertebral bones presenting destructive lesions. The technique displays appropriate safety and high diagnostic accuracy and presents a desirable reference value for the preoperative diagnosis of diseases that yield vertebral bone destruction, especially for vertebral tumor lesions.

Percutaneous CT Guided Vertebral Biopsy: Anatomy and Technical Considerations

In this review article, the authors discuss the anatomy and technical aspects of CT-guided biopsy of vertebral lesions. CT guidance is highly useful for vertebral biopsies, as the anatomy of the spine is complex and varies widely across the levels. Prebiopsy imaging should be reviewed and later correlated with the final histopathological diagnosis. The majority of the spine biopsies are performed under local anesthesia, except those in critical locations and pediatric age groups. The biopsy sample is sent for histopathological analysis and/or microbiological analysis depending on the indications. It is preferable to use a coaxial system for biopsies, so multiple cores can be obtained with a single needle puncture, thus minimizing the negative yield and complications. Complications after image-guided percutaneous biopsy are rare and can be managed easily.

Comparative analysis of CT guided vertebral biopsy by a conventional bone biopsy needle versus bone biopsy needle with acquisition cradle

BACKGROUND

We aimed to compare the rate of diagnostically successful vertebral biopsies using conventional bone biopsy needles versus those performed with bone biopsy needles with an acquisition cradle.

METHODS

We retrospectively analyzed the data of patients who underwent CT-guided vertebral biopsy between December 2017 to December 2019 at our institute. From December 2017 to November 2018, the procedure was performed on 185 patients using an 11G conventional bone biopsy needle, Jamshidi needleTM "(group 1)". From December 2018 to December 2019, the procedure was performed on 242 patients using an 11G T-handle Jamshidi needle with an acquisition cradle "(group 2)". We reviewed their histopathological reports for both groups of patients to determine the rate of diagnostically successful biopsies. We also compared the crush artifact amongst the unsuccessful biopsy samples acquired by the two types of biopsy needles.

RESULTS

427 patients (270 male and 157 female patients; mean age, 46.4 years; age range, 25-67 years) who underwent CT-guided vertebral biopsy from December 2017 to December 2019 were included in our study. In group 1, diagnostic success was achieved in 136 out of 185 biopsies (73.5%); whereas in group 2, diagnostic success was achieved in 219 out of 242 biopsies (90.50%), p < 0.0001. Out of the diagnostically unsuccessful biopsies in Group 1, 36 out of 49 (73.5%) were due to crush artifact; whereas crush artifact accounted for only 3 out of 23 (13.0%) diagnostically unsuccessful biopsies in group 2, p < 0.0001. Other causes of unsuccessful biopsies (hemorrhagic contents or presence of normal osseous tissue and fibrin only) were statistically insignificant.

CONCLUSION

The use of a T-handle Jamshidi needle with an acquisition cradle appears beneficial compared to the conventional Jamshidi needle in terms of the significantly higher rate of diagnostic success and a lower rate of crush artifact.

Diagnostic yield, accuracy, and complication rate of CT-guided biopsy for spinal lesions: a systematic review and meta-analysis

BACKGROUND

CT-guided biopsy is a commonly used diagnostic procedure for spinal lesions. This meta-analysis aims to investigate its diagnostic performance and complications, as well as factors influencing outcomes.

METHODS

A systematic review of the literature was performed to identify studies reporting outcomes of CT-guided biopsies for spinal lesions. Diagnostic yield (ie, the rate of procedures resulting in a specific pathological diagnosis) and diagnostic accuracy (ie, the rate of procedures resulting in the correct diagnosis) were the primary outcomes of interest. Complications following biopsy procedures were also included.

RESULTS

Thirty-nine studies with 3917 patients undergoing 4181 procedures were included. Diagnostic yield per procedure was 91% (95% CI 88% to 94%) among 3598 procedures. The most common reason for non-diagnostic biopsies was inadequacy of sample. No difference in diagnostic yield between different locations and between lytic, sclerotic, and mixed lesions was found. Diagnostic yield did not differ between procedures using ≤13G and ≥14G needles. Diagnostic accuracy per procedure was 86% (95% CI 82% to 89%) among 3054 procedures. Diagnostic accuracy among 2426 procedures that yielded a diagnosis was 94% (95% CI 92% to 96%). Complication rate was 1% (95% CI 0.4% to 1.9%) among 3357 procedures. Transient pain and minor hematoma were the most common complications encountered.

CONCLUSION

In our meta-analysis of 39 studies reporting diagnostic performance and complications of CT-guided biopsy, we found a diagnostic yield of 91% and diagnostic accuracy of 86% with a complication rate of 1%. Diagnostic yield did not differ between different locations, between lytic, sclerotic and mixed lesions, and between wide- and thin-bore needles.

Ewing's Sarcoma of the Vertebral Body in an Adolescent: A Rare Case Report and Literature Review

We report the case of a 14-year-old girl who presented with a one-month history of back pain and bilateral lower limb weakness preceded by constitutional symptoms. She neither had a family history of malignancy nor a previous history of trauma. A series of imaging procedures revealed an aggressive lesion of the T12 vertebra with a large soft-tissue component and intraspinal extension leading to spinal cord compression causing cord edema. She underwent urgent posterior instrumentation and fixation of T9 to T12 vertebrae due to worsening neurological deficits. Adjuvant and neoadjuvant chemotherapy with palliative spinal stabilisation were also performed. Features of the lesion were highly consistent with ES on immunohistochemical study and fluorescence in situ hybridization (FISH) analysis for the EWSR1 gene. Postoperatively, both of her lower limbs improved in power and she benefited from regular physiotherapy.

Review article: the current status of CT-guided needle biopsy of the spine

CT-guided percutaneous needle biopsy of the spine is a well-described technique for determining the nature of indeterminate vertebral lesions or establishing a diagnosis of spinal infection, the high diagnostic accuracy and the safety of the procedure having been extensively documented. The purpose of the current article is to review the literature to date on CT-guided spinal biopsy. Specifically, indications for spinal biopsy, techniques for optimising yield, detail of the approaches for various spinal levels which is dependent upon both the region within the spinal column and lesion location within the vertebra (body vs. neural arch), determinants of biopsy outcome and complications are covered. It is hoped that the review will be of particular benefit to junior radiologists who are required to perform this procedure.

PET/CT-guided versus CT-guided percutaneous core biopsies in the diagnosis of bone tumors and tumor-like lesions: which is the better choice?

OBJECTIVE

The present study aimed to evaluate the diagnostic performance and safety of PET/CT-guided percutaneous core bone biopsy and to compare the PET/CT-guided method to conventional CT-guided percutaneous core biopsies to diagnose Chinese patients with bone tumors and tumor-like lesions.

METHODS

Data for 97 patients with bone tumors and tumor-like lesions diagnosed by percutaneous core bone biopsy from February 2013 to November 2018 were retrospectively analyzed. The study included 42 cases in the PET/CT group and 55 cases in the CT alone group. The diagnostic performance, cost and complications associated with the intervention were compared between the two groups. All patients were eventually confirmed to have bone tumors and tumor-like lesions according to surgical pathology findings.

RESULTS

There were no significant differences in patient characteristics (P > 0.05). For the patients in the PET/CT group, the overall diagnostic yield of the initial biopsies and the diagnostic accuracy derived from the surgically proven cases were both 97.62%, which was significantly higher than the values in the CT group during the same period (P < 0.05). No major biopsy-related complications (e.g., serious bleeding or tumor dissemination) occurred before, during, or after the intervention. Therefore, no significant difference was observed between the two groups with regard to the complication rate (P > 0.05).

CONCLUSION

Compared with CT-guided percutaneous bone biopsy, PET/CT-guided percutaneous bone biopsy is an effective and safe alternative with high diagnostic performance in the evaluation of hypermetabolic bone lesions to diagnose bone tumors and tumor-like lesions.

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.

Bone and Soft-Tissue Biopsies: What You Need to Know

Percutaneous, image-guided musculoskeletal biopsy, due to its minimal invasive nature, when compared with open surgical biopsy, is a safe and effective technique which is widely used in many institutions as the primary method to acquire tissue and bone samples. Indications include histopathologic and molecular assessment of a musculoskeletal lesion, exclusion of malignancy in a bone/vertebral fracture, examination of bone marrow, and infection investigation. Preprocedural workup should include both imaging (for lesion assessment and staging) and laboratory (including coagulation tests and platelet count) studies. In selected cases, antibiotic prophylaxis should be administered before the biopsy. Core needle biopsy of musculoskeletal lesions has a diagnostic accuracy that ranges from 66 to 98% with higher diagnostic yield for lytic, large-size, malignant lesions and when multiple and long specimens are obtained. Reported complication rates range between 0 and 10% and usually do not exceed 5%, with a suggested threshold of 2%. The purpose of this review article is to illustrate the technical aspects, the indications, and the methodology of percutaneous image-guided bone biopsy that will assist the interventional radiologist to perform these minimal invasive techniques.

Solid bone tumors of the spine: Diagnostic performance of apparent diffusion coefficient measured using diffusion-weighted MRI using histology as a reference standard

PURPOSE

To assess the diagnostic performance of mean apparent diffusion coefficient (mADC) in differentiating benign from malignant bone spine tumors, using histology as a reference standard. Conventional magnetic resonance imaging (MRI) sequences have good reliability in evaluating spinal bone tumors, although some features of benign and malignant cancers may overlap, making the differential diagnosis challenging.

MATERIALS AND METHODS

In all, 116 patients (62 males, 54 females; mean age 59.5 ± 14.1) with biopsy-proven spinal bone tumors were studied. Field strength/sequences: 1.5T MR system; T₁ -weighted turbo spin-echo (repetition time / echo time [TR/TE], 500/13 msec; number of excitations [NEX], 2; slice thickness, 4 mm), T₂ -weighted turbo spin-echo (TR/TE, 4100/102 msec; NEX, 2; slice thickness, 4 mm), short tau inversion recovery (TR/TE, 4800/89 msec; NEX, 2; slice thickness, 4 mm, IT, 140 msec), axial spin-echo echo-planar diffusion-weighted imaging (DWI) (TR/TE 5200/72 msec; slice thickness 5 mm; field of view, 300; interslice gap, 1.5 mm; NEX, 6; echo-planar imaging factor, 96; no parallel imaging) with b-values of 0 and 1000 s/mm², and 3D fat-suppressed T₁ -weighted gradient-recalled-echo (TR/TE, 500/13 msec; slice thickness, 4 mm) after administration of 0.2 ml/kg body weight gadolinum-diethylenetriamine pentaacetic acid. Two readers manually drew regions of interest on the solid portion of the lesion (hyperintense on T₂ -weighted images, hypointense on T₁ -weighted images, and enhanced after gadolinium administration on fat-suppressed T₁ -weighted images) to calculate mADC. Histology was used as the reference standard. Tumors were classified into malignant primary tumors (MPT), bone metastases (BM), or benign primary tumors (BPT). Statistical tests: Nonnormality of distribution was tested with the Shapiro-Wilk test. The Kruskal-Wallis and Mann-Whitney U-test with Bonferroni correction were used. Sensitivity and specificity of the mADC values for BM, MPT, and BPT were calculated. Approximate receiver operating characteristic curves were created. Interobserver reproducibility was evaluated using the intraclass correlation coefficient (ICC).

RESULTS

The mADC values of MPT (n = 35), BM (n = 65), and BPT (n = 16) were 1.00 ± 0.32 (0.59-2.10) × 10^-3 mm² /s, 1.02 ± 0.25 (0.73-1.96) × 10^-3 mm² /s, 1.31 ± 0.36 (0.83-2.14) × 10^-3 mm² /s, respectively. The mADC was significantly different between BPT and all malignant lesions (BM+MPT) (P < 0.001), BM and BPT (P = 0.008), and MPT and BPT (P = 0.008). No difference was found between BM and MPT (P = 0.999). An mADC threshold of 0.952 × 10^-3 mm² /s yielded 81.3% sensitivity, 55.0% specificity. Accuracy was 76% (95% confidence interval [CI] = 63.9%-88.1%). Interobserver reproducibility was almost perfect (ICC = 0.916; 95% CI = 0.879-0.942).

CONCLUSION

DWI with mADC quantification is a reproducible tool to differentiate benign from malignant solid tumors with 76% accuracy. The mADC values of BPT were statistically higher than that of malignant tumors. However, the large overlap between cases may make mADC not helpful in a specific patient.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1034-1042.