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935
Review
Percutaneous Susan
Biopsy
V. Kattapuram1
and
Daniel
of Skeletal
of various
cuffing
and
trephine
Lesions
I. Rosenthal
Percutaneous needle biopsy of lesions aftecting the musculoskeletal system should be considered a routine radiologic procedure. Although relatively safe, the procedure requires expertise. An experienced radiologist and the cooperation of a skilled pathologist are essential. Consultation with the orthopedic surgeon is also important, especially when resection of the lesion is contemplated. Recent advances in imaging techniques and the availability
needles
have
made
it
easier to perform biopsies safely and accurately, even in difficult locations. The procedure obviates surgery in many instances and facilitates appropriate surgical planning in others. This review offers a pragmatic approach to percutaneous needle biopsy of skeletal lesions. It is hoped that more radiologists will be encouraged to undertake these valuable procedures.
Radiologists have become increasingly involved in interventional procedures of all types. Although biopsy of the skeletal system is not a new procedure, advances in imaging technology, particularly the introduction of CT-directed biopsy, have greatly extended the potential of this procedure. Almost no part of the skeleton is inaccessible by a percutaneous route, and, with the assistance of a skilled pathologist and cytologist, accurate diagnoses can be obtained from very small specimens. Biopsy of the musculoskeletal system is not a single procedure; rather, it consists of several procedures that differ greatly in technique depending on the type of lesion and its location. The choice of needle, potential complications, and probability of a successful outcome all depend on whether the lesion is blastic or lytic; whether it is located within bone,
bone marrow, or soft tissue; the amount of tissue that is likely to be needed by the pathologist; and the proximity of vital organs. Because of these complexities, close cooperation with the pathologist and orthopedic surgeon is needed. The orthopedic surgeon is important in selecting appropriate cases for needle biopsy, and in the choice of the needle path. The pathologist should be consulted concerning handling of the tissue and the quantity required. In general, larger specimens are needed for primary tumors than for metastatic lesions. In cases in which an adequate specimen is in doubt because of technical difficulties, rapid cytologic evaluation or frozen section diagnosis can be accomplished while the patient is still on the biopsy table. These techniques can help ensure that the procedure is not terminated before an adequate specimen is obtained. Potentially infected materials must be handled with sterile technique and cultured. The pathologist should always be informed of the radiologic differential diagnosis. In this article, we address some of the questions and difficulties encountered most often in percutaneous biopsies. It is our hope that this discussion will encourage more radiologists to undertake these procedures.
Needles A large number of needles have been devised for various applications [1 -1 0]. In general, these can be divided into largeand small-gauge cutting needles, aspiration needles, and trephine needles (Table 1). Aspiration needles
special
Received December 21 , 1990; accepted after revision April 29, 1991. Presented at the annual meeting of the American Roentgen Ray Society, Washington, Both authors: Department of Radiology, Massachusetts General Hospital and Harvard reprint requests to D. I.Rosenthal. AJR 157:935-942,
November
1991 0361 -803x/9i/i
Article
575-0935
© American
Roentgen
DC, May 1990, as an instructional course. Medical School, 1 5 Parkman St., ACC-5i 5, Boston,
Ray Society
MA 021 1 4. Address
936
KATTAPURAM
TABLE
1: Types of Needles
Skeletal
Lesions
Used for Percutaneous
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AJR:i57,
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Biopsy of I .
Aspiration Spinal
TT ,
Westcott
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--
-
Needle Type
Chiba
(Becton-Dickinson, Rutherford, (Cook Co., Bloomington, IN)
“-wJI_
NJ)
Cutting Tru-Cut (Baxter Health Care Corp., Deerfieid, Jamshidi (Kormed Co., Minneapolis, MN)
IL)
_
Trephine
Craig (Becton-Dickinson) Turkel (Turkel Instruments,
1991
Inc., Southfield,
MI) Fig. 1.-Photograph of Tru-Cut needle. Magnified view shows blunt tip (straight solid arrow), inner specimen groove and outer cutting sheath (curved arrow).
Ackermann (Slanco, Becton-Dickinson) Franseen (Cook Co.) Vim-Silverman
and fine-gauge cutting needles are used for radiologically guided biopsies of other organ systems, and will be familiar to most radiologists. Of the large-gauge cutting needles, the one in widest use and with which we have the greatest experience is the Tru-Cut needle (Baxter Health Care Corp., Deerfield, IL). This needle is available in two lengths, 1 1 .5 and 7.5 cm, but only one gauge. It is a disposable, side-cutting needle (Fig. 1). It is particularly useful for biopsy of primary soft-tissue neoplasms because it produces a large specimen, free from maceration. In our experience, it is also extremely valuable for lytic lesions of bone and bone marrow lesions. In the latter cases, a cortical window must be made first, since the Tru-Cut needle can bend easily if hard bone is encountered. The type of needle most closely associated with bone biopsy procedures is the trephine needle. These tend to be large-gauge [1 0-1 3] needles with a serrated or sawtooth cutting edge (trephine). In order to protect the soft tissues, the trephine is introduced with a coaxial technique through an outer protective sheath. The sheath in turn is introduced over a blunt obturator, which is intended to displace nerves and vessels, rather than cutting through them. In the case of the Craig needle, the obturator is introduced first, and the sheath is advanced over it by using a coaxial technique. The Turkel and Ackermann needles introduce the obturator and sheath simultaneously. An additional blunt obturator is usually provided for expressing the specimen from the trephine. Imaging The choice of imaging technology depends on anatomic location [1 1-1 8]. Fluoroscopy is faster, easier to use [1 1 12], and less costly than CT. However, CT introduces an additional element of safety because it can visualize the contiguous soft tissues, and can more readily place the needle within three dimensions [1 4-1 8]. Fluoroscopy in a single plane can be used when there is a dense bony cortex to limit the advance of the needle. For example, biopsy of destructive lesions of one cortex of an appendicular long bone can be performed safely with single-plane fluoruscopy because, after the needle traverses the destroyed area of bone, its further advance will ,
of tip (inset) (open arrow),
be halted by contact with the solid cortex on the other side. However, if the examiner cannot determine when the lesion has been contacted, as, for example, with an extremely lytic process; or if it is necessary to judge the depth of the needle by visual cues; or if the approach to the lesion must be oblique to the plane of visualization, as in a spinal biopsy, then it is necessary to use biplane or C-arm fluoroscopy. In general, we have found fluoroscopy to be preferable for biopsies of the extremities and the lumbar spine. We prefer CT for biopsies of the pelvis because of the difficulty of obtaining biplane images of the pelvis, and we consider CT essential for biopsies of the thoracic and cervical spine because of complex anatomy and adjacent vital structures. Before the biopsy procedure, a thorough radiologic evaluation should be performed. This is done to characterize and carefully locate the lesion with respect to surrounding anatomy. In addition, it is important to determine that the lesion is the best choice for biopsy. It is embarrassing (and potentially hazardous) to perform a biopsy of the cervical spine if a similar lesion is present in the pelvis! Preparation
and Technique
Before biopsy, patients should be evaluated for coagulopathy. In many cases a simple medical history will suffice. For lesions in the extremities in which it is possible to obtain hemostasis by pressure alone, clotting studies are usually unnecessary. For deeply situated lesions, particularly when use of a large-caliber needle is projected, we agree with Silverman et al. [1 9] regarding the appropriate protocol for selecting clotting studies. These will generally include a platelet count, prothrombin time (PT), and partial thromboplastin time (PiT). If there is any history of ingestion of nonsteroidal antimnflammatory drugs or a tendency to bruise easily, a study of bleeding time is added. Most biopsies are done on outpatients with the use of local anesthesia, and therefore premedication is not essential. It is sometimes preferable to use sedation in apprehensive patients. Figure 2 illustrates the approach to a destructive lesion of the left lateral aspect of the vertebral body and pedicie of Ti 0 under fluoroscopic guidance. Access to the vertebral body is achieved through the paraspinal soft tissues (Fig. 3). In the
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AJA:i57,
November
1991
BIOPSY
OF
SKELETAL
LESIONS
937
Fig. 2.-A and B, Posteroanterior (A) and lateral (B) fluoroscopic spot films show placement of a 20-gauge spinal needle used for local anesthesia. Note that in posteroantenor projection, tip of needle is lateral to medial edge of incompletely destroyed pedicle, indicating that needle is not within spinal canal. Lateral image shows that needle is in contact with posterolateral surface of vertebral body. C and D, Posteroanterior (C) and lateral (D) spot films show placement of a Turkel needle in tandem with spinal needle. Inner trephine has been advanced to its full length. Lateral film shows that trephine has not violated anterior cortex. Posteroanterior film shows that trephine tip is approximately midline.
Fig. 3.-A, CT scan of extrapleural approach to a high thoracic vertebra. Distance from midline is measured and marked on patient’s skin. Needle should be angled steeply (in this case approximately 30#{176} from vertical). B, CT scan of paraspinal approach to a lumbar vertebra. A more horizontal approach is used (in this case approximately 45#{176} from vertical).
lumbar spine the skin puncture site is typically 1 0-i 2 cm lateral to the midline and the angle of approach is approximately 45#{176} from the sagittal plane. It is desirable for the needle to be perpendicular to the posterolateral surface of the vertebral body at the point of contact. Higher levels require more medial skin punctures and a steeper angle of approach
(Fig. 3A). In the midthoracic spine, in order to avoid the pleura, the angle typically may be only 20-30#{176}from the sagittal plane and the puncture site 6-8 cm from the midline. CT may be helpful in these cases to determine the optimum approach. The approach to a ‘esion of a cervical vertebral body is often anterior (this is discussed separately).
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938
KATTAPURAM
For a lumbar or thoracic biopsy, the patient may be positioned either prone or lateral decubitus. The skin entry point is selected so that it is not necessary to angle the needle in a cranial or caudal direction. The skin is anesthetized with Xylocaine, and a spinal needle is advanced along the projected course. The position is checked frequently with biplane fluoroscopic images. The target is the posterolateral corner of the vertebral body. On the anteroposterior projection, the tip of the needle should always project lateral to the medial cortex of the adjacent pedicle to guarantee that the needle is outside the spinal canal (Fig. 2A). On the lateral view, the needle should encounter bone at approximately the posterior border of the vertebral body (Fig. 2B). Thus, with fluoroscopic guidance it is necessary to estimate the relative distances that the needle can be safely advanced anteriorly and toward the midline and adjust the angle of approach to reach this final destination. With each centimeter’s advance of the needle, 0.5-i .0 ml of Xylocaine is injected. Once the needle encounters the target, an incision is made in the skin adjacent to the needle and the trephine assembly is introduced. It is advanced in tandem with the needle used for anesthesia, and we make sure that it follows an identical route. When the obturator encounters the posterolateral vertebral corner, as determined by feel, the sheath is advanced over the obturator until it strikes bone, and the cannula is removed. Using one hand to maintain the position of the sheath, we introduce the trephine through the sheath and advance it into the bone with a rotating movement. It is best to rotate the needle in only one direction to take advantage of its beveled teeth and to avoid maceration of the specimen. The amount of pressure necessary to advance the needle may vary. In the lumbar spine, firm manual pressure is almost always sufficient. Biopsy of dense cortical bone in the extremities may require considerable force and the assistance of a large hand drill [20]. If the force necessary to advance the needle becomes excessive or if the advance of the needle suddenly stops, the trephine should be withdrawn and examined. Occasionally, dense bone may bend the teeth of the trephine, closing its orifice. More often, the needle becomes impacted with dense bone. Expressing the specimen to clear the needle at this point will allow the biopsy to be resumed. The trephine is advanced until its maximal length extends beyond the sheath or until the radiologist no longer considers it safe to proceed. The vertebral biopsy needles have been designed so that the maximal extent of the trephine will not transgress the anterior cortex of a typical lumbar vertebrae. The radiologist should not assume this to be the case, however. There is no substitute for exact knowledge of the location of the needle tip. Thoracic and cervical vertebrae are smaller and must be treated individually. The position of the trephine should be documented before the specimen is removed. The needle can usually be removed without loss of the specimen. It is seldom necessary to use suction, as the firm bony tissue will usually be wedged into the trephine. In fact, it is often difficult to express the specimen from the trephine, even with the assistance of the obturator. It is suggested that
AND
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the trephine be placed within a sterile tube or covered loosely with a gauze pad before any force is applied to the obturator, as the specimen may suddenly be extruded. We have had the unfortunate experience of seeing a bony specimen rapidly ejected from a trephine needle and bounce off a flat surface or shallow dish. For this reason, it is recommended that the trephine be placed within a tube before this maneuver is attempted. Special
Circumstances
Most patients can tolerate this procedure easily. Local anesthesia with Xylocaine is virtually always effective as long as the entire needle path is anesthetized down to the surface of the bone. Patients with severely destroyed bones often appear to lose sensation and tolerate the procedure better than those with small lesions. If radicular pain is encountered in the course of advancing the needle, the needle is pulled back slightly and redirected. However, displacement of the lesion by the needle tip may in turn displace a nerve root that is not immediately contiguous with the needle, thus producing radicular symptoms. If we are convinced that the needle is not adjacent to a spinal nerve root, we sometimes proceed despite radicular symptoms. Occasionally, owing to hypervascular lesions or even the normal vascularity of the marrow, copious bleeding may occur through the sheath after the trephine is removed. Replacing the obturator in the sheath will tamponade the bleeding. We usually wait 3-5 mm before obtaining a second sample or removing the needle. Usually, two or three samples of bone are obtained, depending on the size of the initial sample. The procedure as thus described can be made more difficult by several factors. There may not be a convenient needle path to reach the lesion, although sometimes relatively maccessible lesions can be approached by creative positioning of the patient (Fig. 4). A more common concern is the presence of adjacent vital structures, which must be avoided. Biopsy of lesions in the chest wall potentially can cause a pneumothorax. CT is helpful in planning a needle path and in determining a safe depth (Fig. 5). Proximity to the spinal canal also warrants the use of CT guidance, which we routinely employ for biopsy of the postenor elements. Biopsy of a cervical vertebral body requires a somewhat different technique. The bulky posterior elements and articular masses prevent a posterior approach. In the lower cervical spine, a lateral approach may be used; however, in the upper cervical spine the position of the carotid sheath dictates an anterior approach. The needle is advanced between the pharynx and the carotid sheath. It is sometimes helpful to retract the great vessels laterally. This is usually easily accomplished with one hand while the needle is advanced with the other. It is done more readily if the neck is not extended excessively. In most cases we prefer to do a fine-needle aspiration biopsy of cervical vertebrae; however, it is possible to use the same large-caliber cutting and trephine needles in the cervical spine as are used elsewhere (Fig. 6). A difficulty that is unique to the skeletal system is the need to penetrate hard, round, bony surfaces. In bones such as
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AJR:i57,
November
1991
BIOPSY
OF
SKELETAL
LESIONS
939
Fig. 4.-A, Anteroposterior plain film of hip shows a lytic lesion in medial femoral head. Appearance might suggest that this lesion is easily accessible, if femoral vessels can be avoided. B, CT scan obtained with patient prone reveals that lesion is almost entirely covered by acetabulum, severely limiting ability to reach it by needle. C, CT scan obtained with leg in marked internal rotation was used to guide placement of a Tru-Cut needle. Biopsy results indicated eosinophilic granuloma.
Fig. 5.-CT scan is used to guide depth of rib biopsy. With fluoroscopic guidance, it would have been difficult to be certain that needle did not transgress pleura.
Fig. 6.-Cervical spine biopsy with CT guidance was done by using a large-caliber (Tru-Cut) needle introduced anteriorly. In this case there was easy access to lesion through thyroid gland, so that retraction of vessels was not necessary. Lesion was shown to be metastatic carcinoma. Primary lesion had not been determined at this time.
the clavicle and ischium, despite careful immobilization, it may be very difficult to obtain adequate “purchase” of the needle tip, which may skid along the surface to an undesirable position. This is a problem particularly when the cortical surface is intact and the intended target is endosteal or intramedullary. In such instances, the use of a hand drill is helpful [20]. The drill bit is introduced within a sheath, which is necessary to protect the surrounding soft tissues, and an assistant steadies the sheath while the examiner operates the drill. If it is necessary to include cortical bone in the sample, the drill may be adapted to the Luer-Lok fitting of the trephine [21]. Despite the somewhat frightening appearance of the hand drill assembly, patients seem to have less discomfort when this technique is used, perhaps because of the marked decrease in the time necessary to obtain the sample. We have found that a 2.8-mm drill bit creates a hole that is adequate to admit a Tru-Cut needle into the marrow for
purposes of biopsy. With the sheath in place, relocating the hole repeatedly for additional marrow samples is straightforward (Fig. 7). Certain lesions may present particular difficulties. Lesions with dense ossification present several problems. It may be extremely difficult to penetrate densely ossified tissue with a trephine needle. Although the drill can be helpful, instances are still encountered in which it is almost impossible to advance the trephine because of plugging and bending of the needle. The presence of a large amount of ossified tissue may result in a macerated specimen that is difficult for the pathologist to interpret. In general, densely mineralized areas of lesions tend to represent the most differentiated portions, and therefore, when it is possible, a less mineralized area should always be selected as the target for biopsy (Fig. 8). Certain types of diseases are relatively more difficult for the pathologist to interpret. This is especially true of primary
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940
A
KATTAPURAM
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1991
C
Fig. 7.-A, Solitary focal area of increased uptake is seen on radionuclide scan in patient with breast cancer. B, Hand drill within a protective sheath was used to penetrate intact cortex. Radiograph shows sheath still in place after drill was removed and spinal needle was introduced for biopsy of marrow, which indicated metastatic breast cancer. C, At conclusion of procedure, drill hole is readily visible on a spot film. The only radiographic manifestation of lesion is a faint zone of sclerosis (arrows).
Fig. 8.-CT guidance is used for biopsy of nonmineralized soft-tissue component of this osteosarcoma. In this case, soft-tissue component was thought to represent highest-grade tissue. If it is possible to avoid cortical biopsy, risk of pathologic fracture is reduced.
Fig. 9.-Anteroposterior fluoroscopic film shows biopsy of angioma of posterior with large-caliber (Turkel) needle.
tumors, in which the histology may vary from one portion to the other. Cartilage tumors are notoriously difficult. In such instances, as large a sample as possible should be obtained, and the radiologist must be alert to any discrepancies between the interpretation of the biopsy specimen and the probable diagnosis based on the imaging studies. Lymphomas also present difficulties because the pathologist may need to study the nodal architecture, which is something that cannot be easily accomplished with a needle biopsy. In our institution, lymphoma classification requires the study of cell surface markers, and for this reason, specimens of suspected Iymphoma are always delivered fresh in saline rather than fixed in preservative. Finally, hypervascular lesions present a relative, but not absolute, contraindication to biopsy with a large-caliber needle. Despite this, we have successfully performed biopsies on many hypervascular osteosarcomas, renal cell cancer metastases, and angiomas of the skeleton without problems (Fig. 9).
Results
spot ilium
of the Procedure
Table 2 lists some of the accuracies reported over the years of bone biopsy procedures [2, 6, 8-i 0, i 7, i 8, 22-45]. Some of the early work was done without any radiographic guidance, and the results were fairly poor. The trend has been generally improving, with peak accuracy approaching 90%. Accuracy depends partly on the types of cases involved. The highest accuracy is generally achieved in the diagnosis of metastatic tumor, and the worst is in primary tumors. This is fortunate because metastatic lesions are usually the most common indication for bone biopsy. In our institution, the initial occurrence of metastasis is often documented by biopsy, even if more than one site is demonstrated. Other reasons for a biopsy of metastatic disease include uncertainty about diagnosis (e.g., pathologic fracture) and unknown primary tumor. Nondiagnostic specimens may be obtained for a variety of reasons other than faulty technique. Densely osteoblastic
AJR:157,
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BIOPSY
1991
TABLE 2: Accuracies of Musculoskeletal Spine) Reported Since 1931
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Source,
Year
Coley et al. [2], 1931 Snyder and Coley [26], 1945 Valls et al. [22], 1948 Mazet and Cozen [23], 1952 Frankel [29], 1954 Ottolenghi [24], 1955 Ackermann [6], 1956 Kendall [30], 1960 Ackermann [25], 1963 Cramer [32], 1964 Qttolenghi [31 ], 1 964 Ottolenghi [27], 1969 Hajdu and Melamed [33], 1971 ; [34], 1973 Gladstein and Grantham [35], 1974 Armstrong et al. [37], 1 978 De Santos et al. [39], 1979 Adler and Rosenberger [38], 1979 Murphyet al, [40], 1981 Ayala and Zornosa [42], 1983 Tehranzadeh et al. [43], 1983 Haaga et al. [1 0], 1983 Hewes et al. [41], 1983 Bernardino [44], 1984 Laredo and Bard [28], 1 986 Bender and Berquist [1 7], 1 986 Kattapuram et al. [45], 1991
OF
SKELETAL
Biopsy (Including
Accuracy
(%)
94 68 80 72 59 95 11 67 16 71 79 73-92 81 97 68 93 88 94 79 72 78 85-94 94 78 90 91
Note-The numbers given for accuracy are those quoted by the authors. It was not possible to verify that the strict definition of accuracy ([true positive plus true negative]/total) was used in all cases.
lesions are not only physically difficult to sample, but also frequently yield macerated specimens. It may be difficult to obtain diagnostic cellular material from lesions that are mostly cystic or necrotic. For highly vascular lesions, and lesions that are in particularly dangerous locations, the examiner may limit the number of needle passes that would otherwise be done.
Fig. 10.-A, Lateral plain film of femur shows a destructive lesion extending posteriorly Into thigh. B, Under CT guidance, a Tru-Cut needle was Introduced Into lesion from a posterior approach. Histology revealed osteosarcoma. Although the posterior approach was most direct, and easiest for the radiologist, later consultation with the surgeon Indicated that the preferred approach to this Isslon was anterior. Thus, the needle track could not be excised, potentially compromising the outcome.
LESIONS
94i
Complications Potential complications vary greatly depending on the anatomic location and the type of needle used. The reported prevalence has varied between zero and i 0% [8, i 3, 1 7, 18, 24, 35, 37, 40, 43, 46-55]. Some complications (pain, bleeding, infection, spread of disease) are generic. Others, such as pneumothorax, neurologic damage, and pathologic fracture, are site specific. In our opinion, the risk of significant complication (excluding mild to moderate discomfort and nondiagnostic tissue) should be much less than I We have encountered several problems that deserve emphasis. Nonsteroidal antimnflammatory drugs can markedly prolong the bleeding time [56]. In the case of aspirin, this effect can persist for a week or even longer after use is discontinued and may be seen in patients with normal platelet counts, PT, and PU. We have seen significant bleeding when this hazard was overlooked. Tumor implantation in the needle track is really quite rare, but it can occur [8, 47]. For this reason it is important that when biopsy of a primary tumor is done, the biopsy be done in such a way that the needle track can be resected along with the specimen. The shortest needle path to the lesion is not always the most desirable. If the lesion is a suspected recurrence, it is usually desirable to place the needle near the original incision, since this area will be resected along with the recurrent lesion. Sometimes the surgical technique may not be intuitively obvious from the appearance of the lesion (Fig. 1 0), and in order to avoid contamination of additional compartments by the needle track, consultation with the surgeon regarding the proposed surgery is advisable. Finally, we have observed a minor complication in a number of instances that proved to be quite alarming. It is possible to anesthetize major motor nerves, leading to paresis or paralysis. The depth and extent of anesthesia can be slowly progressive as the anesthetic diffuses beyond the original injection site, and thus may simulate damage from the biopsy procedure. It is important to remain calm in such circum%.
KATTAPURAM
942
stances, hr.
as uneventful
recovery
should
occur
within
3 or 4
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REFERENCES 1 . Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 1930;92: 169-1 81 2. Coley BL, Sharp GS, Ellis EB. Diagnosis of bone tumors by aspiration. Am JSurg 1931;i3:215-224 3. Hoffman WJ. Punch biopsy in tumor diagnosis. Surg Gynecol Obstet 1933:56:829 4. Martin HE, Ellis EB. Aspiration biopsy. Surg Gynecol Obstet 1934;59:578589 5. Turkel H, Bethell FH. Biopsy of bone marrow performed by a new and simple instrument. J Lab Clin Med 1943:28: 1246-1 251 6. Ackermann W. Vertebral trephine biopsy. Ann Surg 1956:143:373-385 7. Craig FS. Vertebral body biopsy. J Bone Joint Surg [Am] 1956;38-A:93102 8. De Santos LA, Lukeman JM, Wallace S, Murray JA, Ayala AG. Percutaneous needle biopsy of bone in cancer patient. AJR 1978;130:641-649 9. Zornosa J, ed. Percutaneous needle biopsy. Baltimore: Williams & Wilkins, 1981 10. Haaga JR. Lipuma JP, Bryan PJ, Balsara VJ, Cohen AM. Clinical comparison of small and large caliber cutting needles for biopsy. Radiology 1983:146:665-667 ii. Lalli AF. Roentgen-guided aspiration biopsiesofskeletallesions. CanAssoc RadiolJ 1970:21:71-73 12. Lalli AF. The direct fluoroscopically guided approach to renal, thoracic and skeletal lesions. Curr Prob Radiol 1972;2:30-41 1 3. Collins JD, Bassett L, Main GD, Kagan C. Percutaneous biopsy following bone scans. Radiology 1979:132:439-442 14. Haaga JR. New techniques for CT-guided biopsies. AJR 1979;i33:633641 1 5. Hardy DC, Murphy WA, Gilula LA. Computed tomography in planning percutaneous bone biopsy. Radiology 1980;134:447-450 1 6. Zornosa J, Bernardino ME, Ordonez NG, Thomas JL, Cohen MA. Percutaneous needle biopsy of soft tissue tumors guided by ultrasound and computed tomography. Skeletal Radiol 1982;9:33-36 i 7. Bender CE, Berquist TH. Imaging assisted percutaneous biopsy of the thoracic spine. Mayo Clln Proc 1986:61:942-950 1 8. Kattapuram SV, Rosenthal DI. Percutaneous biopsy of the cervical spine using CT guidance. AiR 1987;149:539-541 i 9. Silverman 5G. Mueller PR, Pfister AC. Hemostatic evaluation before abdominal interventions: an overview and proposal. AJR 1990:154:233-238 20. Cohen MA, Zornosa J, Finkelstein JB. Percutaneous needle biopsy of long bonelesionsfacilitated by the use ofa hand drill. Radiology 1981:139:750751 21 . Kattapuram SV, Rosenthal DI, Phillips WJ. Trephine biopsy of the skeleton with the aid of a hand drill. Radiology 1984;i52:231 22. VaIls J, Ottolenghi CE, Schajowicz F. Aspiration biopsy in diagnosis of lesions of vertebral bodies. JAMA 1948:136:376-382 23. Mazet R, Cozen L. The diagnostic value of vertebral body needle biopsy. Ann Surg 1952:135:245-252 24. Ottolenghi CE. Diagnosis of orthopaedic lesions by aspiration biopsy: results of 1061 punctures. J Bone Joint Surg [Am] 1955;37-A:443-464 25. Ackerman W. Application of the trephine for bone biopsy: results of 635 cases. JAMA 1963;184:1l-17 26. Snyder RE, Coley BL. Further studies on the diagnosis of bone tumors by aspiration biopsy. Surg Gynecol Obstet 1945;80:5i7-522 27. Ottolenghi CE. Aspiration biopsy of the spine: technique for the thoracic spine and results of twenty-eight biopsies in the region and overall results of 1050 biopsies of other spinal segments. J Bone Joint Surg [Am] 1969;51-A: 1531-1544
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28. 29. 30. 31.
32. 33. 34. 35. 36. 37.
38. 39.
40.
41. 42.
Laredo diology Frankel
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1991
JD, Bard M. Thoracic spine: percutaneous trephine biopsy. Ra1986:160:485-489 CJ. Aspiration biopsy of the spine. J Bone Joint Surg [Am] 1954:36-
A:69-74 Kendall PH. Needle biopsy of the vertebral bodies. Ann Phys Med 1960:5:236-242 Ottolenghi CE, Schajowicz F, DeSchant FA. Aspiration biopsy of the cervical spine: technique and results in thirty-four cases. J Bone Joint Surg [Am] 1964;46-A:715-733 Cramer LE, Khun C III, Stein AH Jr. Needle biopsy of bone. Surg Gynecol Obstet 1964;1 18: 1253-1 256 Hajdu SI, Melamed MR. Needle biopsy of primary malignant bone tumors. Surg Gynecol Obstet 1971;i33:829-832 Hajdu SI, Melamed MR. The diagnostic value of aspiration smears. Am J Clin Pathol 1973;59:350-356 Gladstein MO, Grantham SA. Closed skeletal biopsy. Clin Orthop 1974;103:75-79 Hajdu SI. Aspiration biopsy of primary malignant bone tumors. Radiat Ther Oncol 1975:10:73-81 Armstrong P, Chalmers AH, Green G, Irving FD. Needle aspiration/biopsy of the spine in suspected disc space infection. Br J Radiol 1978;51 :333337 Adler 0, Rosenberger A. Fine needle aspiration biopsy of osteolytic metastatic lesions. AJR 1979;133:15-18 De Santos LA, Murray JA, Ayala AG. The value of percutaneous needle biopsy in the management of primary bone tumors. Cancer 1979;43:735744 Murphy WA, Destouet JM, Gilula LA. Percutaneous skeletal biopsy 1981: a procedure for radiologists-results, review and recommendations. Radiology 1981;139:545-549 Hewes AC, Vigorita VJ, Freiberger RH. Percutaneous bone biopsy. The importance of aspirated osseous blood. Radiology 1983:148:69-72 Ayala AG, Zomosa J. Primary bone tumors: pathologic study of 222
biopsies. Radiology 1983;149:675-679 43. Tehranzadeh J, Freiberger RH, Ghelman A. Closed skeletal needle biopsy. AJR 1983:140:113-115 44. Bernardino ME. Percutaneous biopsy. AJR 1984;i42:41-45 45. Kattapuram SV, Khurana JS, Rosenthal DI. Percutaneous needle biopsy of the spine. Spine 1992 (in press) 46. Hanafee WN, Tobin PL. Closed bone biopsy by a radiologist. Radiology 1969;92:605-606 47. Engzeu V, Esposti PL, Rubio C, Sigukdson A, Zajicek J. Investigation of tumor spread in connection with aspiration biopsy. Acta Radiol [Oncol] 1971:10:385-398 48. Debnam JW, Staple 1W. Trephine bone biopsy by radiologists. Radiology 1975;1 16:607-609 49. Debnarn JW, Staple 7W. Needle biopsy of bone. Radiol Clin North Am 1975:13:157-164 50. McLaughlin RE, Miller WA, Miller CW. Quadriparesis after needle aspiration of the cervical spine: report of a case. J Bone Joint Surg [Am] 1976:58A:1i67-1168 51 . Stahl DC, Jacobs B. Diagnosis of obscure lesions of the skeleton: evaluation of biopsy methods. JAMA 1967;20i :229-23i 52. Aarngopal V, Geller M. latrogenic Klebsiella meningitis following closed needle biopsy of the lumbar spine: report of a case and review of literature. Wis MedJ 1977:76:41-42 53. Moore TM, Meyers MH, Patzakis MJ, et al. Closed biopsy of musculo54.
55. 56.
skeletal lesions. J Bone Joint Surg [Am] 1979;61-A:375-380 Southwick WO, Robinson RD. Surgical approaches to the vertebral bodies in the cervical and lumbar regions. J Bone Joint Surg [Am] 1957:39A:631 -644 Nagel DA, Albright JA, Keggi KJ, Southwick WO. Closer look at spinal lesions: open biopsy of vertebral lesions. JAMA 1965;1 91 :103-106 Lind S. Prolonged bleeding time. Am J Med 1984;77:305-312
935
Review
Percutaneous Susan
Biopsy
V. Kattapuram1
and
Daniel
of Skeletal
of various
cuffing
and
trephine
Lesions
I. Rosenthal
Percutaneous needle biopsy of lesions aftecting the musculoskeletal system should be considered a routine radiologic procedure. Although relatively safe, the procedure requires expertise. An experienced radiologist and the cooperation of a skilled pathologist are essential. Consultation with the orthopedic surgeon is also important, especially when resection of the lesion is contemplated. Recent advances in imaging techniques and the availability
needles
have
made
it
easier to perform biopsies safely and accurately, even in difficult locations. The procedure obviates surgery in many instances and facilitates appropriate surgical planning in others. This review offers a pragmatic approach to percutaneous needle biopsy of skeletal lesions. It is hoped that more radiologists will be encouraged to undertake these valuable procedures.
Radiologists have become increasingly involved in interventional procedures of all types. Although biopsy of the skeletal system is not a new procedure, advances in imaging technology, particularly the introduction of CT-directed biopsy, have greatly extended the potential of this procedure. Almost no part of the skeleton is inaccessible by a percutaneous route, and, with the assistance of a skilled pathologist and cytologist, accurate diagnoses can be obtained from very small specimens. Biopsy of the musculoskeletal system is not a single procedure; rather, it consists of several procedures that differ greatly in technique depending on the type of lesion and its location. The choice of needle, potential complications, and probability of a successful outcome all depend on whether the lesion is blastic or lytic; whether it is located within bone,
bone marrow, or soft tissue; the amount of tissue that is likely to be needed by the pathologist; and the proximity of vital organs. Because of these complexities, close cooperation with the pathologist and orthopedic surgeon is needed. The orthopedic surgeon is important in selecting appropriate cases for needle biopsy, and in the choice of the needle path. The pathologist should be consulted concerning handling of the tissue and the quantity required. In general, larger specimens are needed for primary tumors than for metastatic lesions. In cases in which an adequate specimen is in doubt because of technical difficulties, rapid cytologic evaluation or frozen section diagnosis can be accomplished while the patient is still on the biopsy table. These techniques can help ensure that the procedure is not terminated before an adequate specimen is obtained. Potentially infected materials must be handled with sterile technique and cultured. The pathologist should always be informed of the radiologic differential diagnosis. In this article, we address some of the questions and difficulties encountered most often in percutaneous biopsies. It is our hope that this discussion will encourage more radiologists to undertake these procedures.
Needles A large number of needles have been devised for various applications [1 -1 0]. In general, these can be divided into largeand small-gauge cutting needles, aspiration needles, and trephine needles (Table 1). Aspiration needles
special
Received December 21 , 1990; accepted after revision April 29, 1991. Presented at the annual meeting of the American Roentgen Ray Society, Washington, Both authors: Department of Radiology, Massachusetts General Hospital and Harvard reprint requests to D. I.Rosenthal. AJR 157:935-942,
November
1991 0361 -803x/9i/i
Article
575-0935
© American
Roentgen
DC, May 1990, as an instructional course. Medical School, 1 5 Parkman St., ACC-5i 5, Boston,
Ray Society
MA 021 1 4. Address
936
KATTAPURAM
TABLE
1: Types of Needles
Skeletal
Lesions
Used for Percutaneous
AND
ROSENTHAL
AJR:i57,
November
Biopsy of I .
Aspiration Spinal
TT ,
Westcott
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--
-
Needle Type
Chiba
(Becton-Dickinson, Rutherford, (Cook Co., Bloomington, IN)
“-wJI_
NJ)
Cutting Tru-Cut (Baxter Health Care Corp., Deerfieid, Jamshidi (Kormed Co., Minneapolis, MN)
IL)
_
Trephine
Craig (Becton-Dickinson) Turkel (Turkel Instruments,
1991
Inc., Southfield,
MI) Fig. 1.-Photograph of Tru-Cut needle. Magnified view shows blunt tip (straight solid arrow), inner specimen groove and outer cutting sheath (curved arrow).
Ackermann (Slanco, Becton-Dickinson) Franseen (Cook Co.) Vim-Silverman
and fine-gauge cutting needles are used for radiologically guided biopsies of other organ systems, and will be familiar to most radiologists. Of the large-gauge cutting needles, the one in widest use and with which we have the greatest experience is the Tru-Cut needle (Baxter Health Care Corp., Deerfield, IL). This needle is available in two lengths, 1 1 .5 and 7.5 cm, but only one gauge. It is a disposable, side-cutting needle (Fig. 1). It is particularly useful for biopsy of primary soft-tissue neoplasms because it produces a large specimen, free from maceration. In our experience, it is also extremely valuable for lytic lesions of bone and bone marrow lesions. In the latter cases, a cortical window must be made first, since the Tru-Cut needle can bend easily if hard bone is encountered. The type of needle most closely associated with bone biopsy procedures is the trephine needle. These tend to be large-gauge [1 0-1 3] needles with a serrated or sawtooth cutting edge (trephine). In order to protect the soft tissues, the trephine is introduced with a coaxial technique through an outer protective sheath. The sheath in turn is introduced over a blunt obturator, which is intended to displace nerves and vessels, rather than cutting through them. In the case of the Craig needle, the obturator is introduced first, and the sheath is advanced over it by using a coaxial technique. The Turkel and Ackermann needles introduce the obturator and sheath simultaneously. An additional blunt obturator is usually provided for expressing the specimen from the trephine. Imaging The choice of imaging technology depends on anatomic location [1 1-1 8]. Fluoroscopy is faster, easier to use [1 1 12], and less costly than CT. However, CT introduces an additional element of safety because it can visualize the contiguous soft tissues, and can more readily place the needle within three dimensions [1 4-1 8]. Fluoroscopy in a single plane can be used when there is a dense bony cortex to limit the advance of the needle. For example, biopsy of destructive lesions of one cortex of an appendicular long bone can be performed safely with single-plane fluoruscopy because, after the needle traverses the destroyed area of bone, its further advance will ,
of tip (inset) (open arrow),
be halted by contact with the solid cortex on the other side. However, if the examiner cannot determine when the lesion has been contacted, as, for example, with an extremely lytic process; or if it is necessary to judge the depth of the needle by visual cues; or if the approach to the lesion must be oblique to the plane of visualization, as in a spinal biopsy, then it is necessary to use biplane or C-arm fluoroscopy. In general, we have found fluoroscopy to be preferable for biopsies of the extremities and the lumbar spine. We prefer CT for biopsies of the pelvis because of the difficulty of obtaining biplane images of the pelvis, and we consider CT essential for biopsies of the thoracic and cervical spine because of complex anatomy and adjacent vital structures. Before the biopsy procedure, a thorough radiologic evaluation should be performed. This is done to characterize and carefully locate the lesion with respect to surrounding anatomy. In addition, it is important to determine that the lesion is the best choice for biopsy. It is embarrassing (and potentially hazardous) to perform a biopsy of the cervical spine if a similar lesion is present in the pelvis! Preparation
and Technique
Before biopsy, patients should be evaluated for coagulopathy. In many cases a simple medical history will suffice. For lesions in the extremities in which it is possible to obtain hemostasis by pressure alone, clotting studies are usually unnecessary. For deeply situated lesions, particularly when use of a large-caliber needle is projected, we agree with Silverman et al. [1 9] regarding the appropriate protocol for selecting clotting studies. These will generally include a platelet count, prothrombin time (PT), and partial thromboplastin time (PiT). If there is any history of ingestion of nonsteroidal antimnflammatory drugs or a tendency to bruise easily, a study of bleeding time is added. Most biopsies are done on outpatients with the use of local anesthesia, and therefore premedication is not essential. It is sometimes preferable to use sedation in apprehensive patients. Figure 2 illustrates the approach to a destructive lesion of the left lateral aspect of the vertebral body and pedicie of Ti 0 under fluoroscopic guidance. Access to the vertebral body is achieved through the paraspinal soft tissues (Fig. 3). In the
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AJA:i57,
November
1991
BIOPSY
OF
SKELETAL
LESIONS
937
Fig. 2.-A and B, Posteroanterior (A) and lateral (B) fluoroscopic spot films show placement of a 20-gauge spinal needle used for local anesthesia. Note that in posteroantenor projection, tip of needle is lateral to medial edge of incompletely destroyed pedicle, indicating that needle is not within spinal canal. Lateral image shows that needle is in contact with posterolateral surface of vertebral body. C and D, Posteroanterior (C) and lateral (D) spot films show placement of a Turkel needle in tandem with spinal needle. Inner trephine has been advanced to its full length. Lateral film shows that trephine has not violated anterior cortex. Posteroanterior film shows that trephine tip is approximately midline.
Fig. 3.-A, CT scan of extrapleural approach to a high thoracic vertebra. Distance from midline is measured and marked on patient’s skin. Needle should be angled steeply (in this case approximately 30#{176} from vertical). B, CT scan of paraspinal approach to a lumbar vertebra. A more horizontal approach is used (in this case approximately 45#{176} from vertical).
lumbar spine the skin puncture site is typically 1 0-i 2 cm lateral to the midline and the angle of approach is approximately 45#{176} from the sagittal plane. It is desirable for the needle to be perpendicular to the posterolateral surface of the vertebral body at the point of contact. Higher levels require more medial skin punctures and a steeper angle of approach
(Fig. 3A). In the midthoracic spine, in order to avoid the pleura, the angle typically may be only 20-30#{176}from the sagittal plane and the puncture site 6-8 cm from the midline. CT may be helpful in these cases to determine the optimum approach. The approach to a ‘esion of a cervical vertebral body is often anterior (this is discussed separately).
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938
KATTAPURAM
For a lumbar or thoracic biopsy, the patient may be positioned either prone or lateral decubitus. The skin entry point is selected so that it is not necessary to angle the needle in a cranial or caudal direction. The skin is anesthetized with Xylocaine, and a spinal needle is advanced along the projected course. The position is checked frequently with biplane fluoroscopic images. The target is the posterolateral corner of the vertebral body. On the anteroposterior projection, the tip of the needle should always project lateral to the medial cortex of the adjacent pedicle to guarantee that the needle is outside the spinal canal (Fig. 2A). On the lateral view, the needle should encounter bone at approximately the posterior border of the vertebral body (Fig. 2B). Thus, with fluoroscopic guidance it is necessary to estimate the relative distances that the needle can be safely advanced anteriorly and toward the midline and adjust the angle of approach to reach this final destination. With each centimeter’s advance of the needle, 0.5-i .0 ml of Xylocaine is injected. Once the needle encounters the target, an incision is made in the skin adjacent to the needle and the trephine assembly is introduced. It is advanced in tandem with the needle used for anesthesia, and we make sure that it follows an identical route. When the obturator encounters the posterolateral vertebral corner, as determined by feel, the sheath is advanced over the obturator until it strikes bone, and the cannula is removed. Using one hand to maintain the position of the sheath, we introduce the trephine through the sheath and advance it into the bone with a rotating movement. It is best to rotate the needle in only one direction to take advantage of its beveled teeth and to avoid maceration of the specimen. The amount of pressure necessary to advance the needle may vary. In the lumbar spine, firm manual pressure is almost always sufficient. Biopsy of dense cortical bone in the extremities may require considerable force and the assistance of a large hand drill [20]. If the force necessary to advance the needle becomes excessive or if the advance of the needle suddenly stops, the trephine should be withdrawn and examined. Occasionally, dense bone may bend the teeth of the trephine, closing its orifice. More often, the needle becomes impacted with dense bone. Expressing the specimen to clear the needle at this point will allow the biopsy to be resumed. The trephine is advanced until its maximal length extends beyond the sheath or until the radiologist no longer considers it safe to proceed. The vertebral biopsy needles have been designed so that the maximal extent of the trephine will not transgress the anterior cortex of a typical lumbar vertebrae. The radiologist should not assume this to be the case, however. There is no substitute for exact knowledge of the location of the needle tip. Thoracic and cervical vertebrae are smaller and must be treated individually. The position of the trephine should be documented before the specimen is removed. The needle can usually be removed without loss of the specimen. It is seldom necessary to use suction, as the firm bony tissue will usually be wedged into the trephine. In fact, it is often difficult to express the specimen from the trephine, even with the assistance of the obturator. It is suggested that
AND
ROSENTHAL
AJR:i57,
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1991
the trephine be placed within a sterile tube or covered loosely with a gauze pad before any force is applied to the obturator, as the specimen may suddenly be extruded. We have had the unfortunate experience of seeing a bony specimen rapidly ejected from a trephine needle and bounce off a flat surface or shallow dish. For this reason, it is recommended that the trephine be placed within a tube before this maneuver is attempted. Special
Circumstances
Most patients can tolerate this procedure easily. Local anesthesia with Xylocaine is virtually always effective as long as the entire needle path is anesthetized down to the surface of the bone. Patients with severely destroyed bones often appear to lose sensation and tolerate the procedure better than those with small lesions. If radicular pain is encountered in the course of advancing the needle, the needle is pulled back slightly and redirected. However, displacement of the lesion by the needle tip may in turn displace a nerve root that is not immediately contiguous with the needle, thus producing radicular symptoms. If we are convinced that the needle is not adjacent to a spinal nerve root, we sometimes proceed despite radicular symptoms. Occasionally, owing to hypervascular lesions or even the normal vascularity of the marrow, copious bleeding may occur through the sheath after the trephine is removed. Replacing the obturator in the sheath will tamponade the bleeding. We usually wait 3-5 mm before obtaining a second sample or removing the needle. Usually, two or three samples of bone are obtained, depending on the size of the initial sample. The procedure as thus described can be made more difficult by several factors. There may not be a convenient needle path to reach the lesion, although sometimes relatively maccessible lesions can be approached by creative positioning of the patient (Fig. 4). A more common concern is the presence of adjacent vital structures, which must be avoided. Biopsy of lesions in the chest wall potentially can cause a pneumothorax. CT is helpful in planning a needle path and in determining a safe depth (Fig. 5). Proximity to the spinal canal also warrants the use of CT guidance, which we routinely employ for biopsy of the postenor elements. Biopsy of a cervical vertebral body requires a somewhat different technique. The bulky posterior elements and articular masses prevent a posterior approach. In the lower cervical spine, a lateral approach may be used; however, in the upper cervical spine the position of the carotid sheath dictates an anterior approach. The needle is advanced between the pharynx and the carotid sheath. It is sometimes helpful to retract the great vessels laterally. This is usually easily accomplished with one hand while the needle is advanced with the other. It is done more readily if the neck is not extended excessively. In most cases we prefer to do a fine-needle aspiration biopsy of cervical vertebrae; however, it is possible to use the same large-caliber cutting and trephine needles in the cervical spine as are used elsewhere (Fig. 6). A difficulty that is unique to the skeletal system is the need to penetrate hard, round, bony surfaces. In bones such as
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AJR:i57,
November
1991
BIOPSY
OF
SKELETAL
LESIONS
939
Fig. 4.-A, Anteroposterior plain film of hip shows a lytic lesion in medial femoral head. Appearance might suggest that this lesion is easily accessible, if femoral vessels can be avoided. B, CT scan obtained with patient prone reveals that lesion is almost entirely covered by acetabulum, severely limiting ability to reach it by needle. C, CT scan obtained with leg in marked internal rotation was used to guide placement of a Tru-Cut needle. Biopsy results indicated eosinophilic granuloma.
Fig. 5.-CT scan is used to guide depth of rib biopsy. With fluoroscopic guidance, it would have been difficult to be certain that needle did not transgress pleura.
Fig. 6.-Cervical spine biopsy with CT guidance was done by using a large-caliber (Tru-Cut) needle introduced anteriorly. In this case there was easy access to lesion through thyroid gland, so that retraction of vessels was not necessary. Lesion was shown to be metastatic carcinoma. Primary lesion had not been determined at this time.
the clavicle and ischium, despite careful immobilization, it may be very difficult to obtain adequate “purchase” of the needle tip, which may skid along the surface to an undesirable position. This is a problem particularly when the cortical surface is intact and the intended target is endosteal or intramedullary. In such instances, the use of a hand drill is helpful [20]. The drill bit is introduced within a sheath, which is necessary to protect the surrounding soft tissues, and an assistant steadies the sheath while the examiner operates the drill. If it is necessary to include cortical bone in the sample, the drill may be adapted to the Luer-Lok fitting of the trephine [21]. Despite the somewhat frightening appearance of the hand drill assembly, patients seem to have less discomfort when this technique is used, perhaps because of the marked decrease in the time necessary to obtain the sample. We have found that a 2.8-mm drill bit creates a hole that is adequate to admit a Tru-Cut needle into the marrow for
purposes of biopsy. With the sheath in place, relocating the hole repeatedly for additional marrow samples is straightforward (Fig. 7). Certain lesions may present particular difficulties. Lesions with dense ossification present several problems. It may be extremely difficult to penetrate densely ossified tissue with a trephine needle. Although the drill can be helpful, instances are still encountered in which it is almost impossible to advance the trephine because of plugging and bending of the needle. The presence of a large amount of ossified tissue may result in a macerated specimen that is difficult for the pathologist to interpret. In general, densely mineralized areas of lesions tend to represent the most differentiated portions, and therefore, when it is possible, a less mineralized area should always be selected as the target for biopsy (Fig. 8). Certain types of diseases are relatively more difficult for the pathologist to interpret. This is especially true of primary
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940
A
KATTAPURAM
AND
ROSENTHAL
AJR:i57,
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November
1991
C
Fig. 7.-A, Solitary focal area of increased uptake is seen on radionuclide scan in patient with breast cancer. B, Hand drill within a protective sheath was used to penetrate intact cortex. Radiograph shows sheath still in place after drill was removed and spinal needle was introduced for biopsy of marrow, which indicated metastatic breast cancer. C, At conclusion of procedure, drill hole is readily visible on a spot film. The only radiographic manifestation of lesion is a faint zone of sclerosis (arrows).
Fig. 8.-CT guidance is used for biopsy of nonmineralized soft-tissue component of this osteosarcoma. In this case, soft-tissue component was thought to represent highest-grade tissue. If it is possible to avoid cortical biopsy, risk of pathologic fracture is reduced.
Fig. 9.-Anteroposterior fluoroscopic film shows biopsy of angioma of posterior with large-caliber (Turkel) needle.
tumors, in which the histology may vary from one portion to the other. Cartilage tumors are notoriously difficult. In such instances, as large a sample as possible should be obtained, and the radiologist must be alert to any discrepancies between the interpretation of the biopsy specimen and the probable diagnosis based on the imaging studies. Lymphomas also present difficulties because the pathologist may need to study the nodal architecture, which is something that cannot be easily accomplished with a needle biopsy. In our institution, lymphoma classification requires the study of cell surface markers, and for this reason, specimens of suspected Iymphoma are always delivered fresh in saline rather than fixed in preservative. Finally, hypervascular lesions present a relative, but not absolute, contraindication to biopsy with a large-caliber needle. Despite this, we have successfully performed biopsies on many hypervascular osteosarcomas, renal cell cancer metastases, and angiomas of the skeleton without problems (Fig. 9).
Results
spot ilium
of the Procedure
Table 2 lists some of the accuracies reported over the years of bone biopsy procedures [2, 6, 8-i 0, i 7, i 8, 22-45]. Some of the early work was done without any radiographic guidance, and the results were fairly poor. The trend has been generally improving, with peak accuracy approaching 90%. Accuracy depends partly on the types of cases involved. The highest accuracy is generally achieved in the diagnosis of metastatic tumor, and the worst is in primary tumors. This is fortunate because metastatic lesions are usually the most common indication for bone biopsy. In our institution, the initial occurrence of metastasis is often documented by biopsy, even if more than one site is demonstrated. Other reasons for a biopsy of metastatic disease include uncertainty about diagnosis (e.g., pathologic fracture) and unknown primary tumor. Nondiagnostic specimens may be obtained for a variety of reasons other than faulty technique. Densely osteoblastic
AJR:157,
November
BIOPSY
1991
TABLE 2: Accuracies of Musculoskeletal Spine) Reported Since 1931
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Source,
Year
Coley et al. [2], 1931 Snyder and Coley [26], 1945 Valls et al. [22], 1948 Mazet and Cozen [23], 1952 Frankel [29], 1954 Ottolenghi [24], 1955 Ackermann [6], 1956 Kendall [30], 1960 Ackermann [25], 1963 Cramer [32], 1964 Qttolenghi [31 ], 1 964 Ottolenghi [27], 1969 Hajdu and Melamed [33], 1971 ; [34], 1973 Gladstein and Grantham [35], 1974 Armstrong et al. [37], 1 978 De Santos et al. [39], 1979 Adler and Rosenberger [38], 1979 Murphyet al, [40], 1981 Ayala and Zornosa [42], 1983 Tehranzadeh et al. [43], 1983 Haaga et al. [1 0], 1983 Hewes et al. [41], 1983 Bernardino [44], 1984 Laredo and Bard [28], 1 986 Bender and Berquist [1 7], 1 986 Kattapuram et al. [45], 1991
OF
SKELETAL
Biopsy (Including
Accuracy
(%)
94 68 80 72 59 95 11 67 16 71 79 73-92 81 97 68 93 88 94 79 72 78 85-94 94 78 90 91
Note-The numbers given for accuracy are those quoted by the authors. It was not possible to verify that the strict definition of accuracy ([true positive plus true negative]/total) was used in all cases.
lesions are not only physically difficult to sample, but also frequently yield macerated specimens. It may be difficult to obtain diagnostic cellular material from lesions that are mostly cystic or necrotic. For highly vascular lesions, and lesions that are in particularly dangerous locations, the examiner may limit the number of needle passes that would otherwise be done.
Fig. 10.-A, Lateral plain film of femur shows a destructive lesion extending posteriorly Into thigh. B, Under CT guidance, a Tru-Cut needle was Introduced Into lesion from a posterior approach. Histology revealed osteosarcoma. Although the posterior approach was most direct, and easiest for the radiologist, later consultation with the surgeon Indicated that the preferred approach to this Isslon was anterior. Thus, the needle track could not be excised, potentially compromising the outcome.
LESIONS
94i
Complications Potential complications vary greatly depending on the anatomic location and the type of needle used. The reported prevalence has varied between zero and i 0% [8, i 3, 1 7, 18, 24, 35, 37, 40, 43, 46-55]. Some complications (pain, bleeding, infection, spread of disease) are generic. Others, such as pneumothorax, neurologic damage, and pathologic fracture, are site specific. In our opinion, the risk of significant complication (excluding mild to moderate discomfort and nondiagnostic tissue) should be much less than I We have encountered several problems that deserve emphasis. Nonsteroidal antimnflammatory drugs can markedly prolong the bleeding time [56]. In the case of aspirin, this effect can persist for a week or even longer after use is discontinued and may be seen in patients with normal platelet counts, PT, and PU. We have seen significant bleeding when this hazard was overlooked. Tumor implantation in the needle track is really quite rare, but it can occur [8, 47]. For this reason it is important that when biopsy of a primary tumor is done, the biopsy be done in such a way that the needle track can be resected along with the specimen. The shortest needle path to the lesion is not always the most desirable. If the lesion is a suspected recurrence, it is usually desirable to place the needle near the original incision, since this area will be resected along with the recurrent lesion. Sometimes the surgical technique may not be intuitively obvious from the appearance of the lesion (Fig. 1 0), and in order to avoid contamination of additional compartments by the needle track, consultation with the surgeon regarding the proposed surgery is advisable. Finally, we have observed a minor complication in a number of instances that proved to be quite alarming. It is possible to anesthetize major motor nerves, leading to paresis or paralysis. The depth and extent of anesthesia can be slowly progressive as the anesthetic diffuses beyond the original injection site, and thus may simulate damage from the biopsy procedure. It is important to remain calm in such circum%.
KATTAPURAM
942
stances, hr.
as uneventful
recovery
should
occur
within
3 or 4
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