PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES

PERCUTANEOUS CT-GUIDED PERCUTANEOUS CT-GUIDED BIOPSY OF THE BIOPSY OF THE

MUSCULO-SKELETAL MUSCULO-SKELETAL SYSTEM: SYSTEM:

RESULTS OF 1722 CASESRESULTS OF 1722 CASES

PERCUTANEOUS CT-GUIDED PERCUTANEOUS CT-GUIDED BIOPSY OF THE BIOPSY OF THE

MUSCULO-SKELETAL MUSCULO-SKELETAL SYSTEM: SYSTEM:

RESULTS OF 1722 CASESRESULTS OF 1722 CASES

E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia, E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia,

T. CalabrT. Calabrò,ò, A. Angelini, G. Rossi, U. Albisinni A. Angelini, G. Rossi, U. Albisinni

E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia, E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia,

T. CalabrT. Calabrò,ò, A. Angelini, G. Rossi, U. Albisinni A. Angelini, G. Rossi, U. Albisinni

Istituto Ortopedico Rizzoli- Istituto Ortopedico Rizzoli- University of Bologna, ItalyUniversity of Bologna, ItalyIstituto Ortopedico Rizzoli- Istituto Ortopedico Rizzoli- University of Bologna, ItalyUniversity of Bologna, Italy

Management of bone tumorsManagement of bone tumorsManagement of bone tumorsManagement of bone tumorsPlain filmsPlain filmsPlain filmsPlain films

Benign appearanceBenign appearance

Benign appearanceBenign appearance

AggressiveAggressive

appearanceappearance

AggressiveAggressive

appearanceappearance

CTCT(if flat bone)(if flat bone)

CTCT(if flat bone)(if flat bone)

StopStop(for many)(for many)


biopsybiopsy(if necessary)(if necessary)


MR ImagingMR ImagingMR ImagingMR Imaging

benignbenignbenignbenign malignantmalignantmalignantmalignant





CT/bone scan/ chest CT/bone scan/ chest xray or CTxray or CT

CT/bone scan/ chest CT/bone scan/ chest xray or CTxray or CT

biopsybiopsybiopsybiopsy

biopsy is a compromisebiopsy is a compromise biopsy is a compromisebiopsy is a compromise

need to have need to have significant tissuesignificant tissue

need to have need to have significant tissuesignificant tissue

need to avoid need to avoid contaminationcontamination

((**local / blood circul.local / blood circul.****))

need to avoid need to avoid contaminationcontamination

((**local / blood circul.local / blood circul.****))

* Schwartz, Ann Surg Oncol 1997**Zoubek, Eur J Pediatry 1996

Biopsy is the last step of the staging Biopsy is the last step of the staging Biopsy is the last step of the staging Biopsy is the last step of the staging

• • Fine needleFine needle

• • TrocarTrocar

• • IncisionalIncisional

• • FrozenFrozen

• • ExcisionalExcisional

• • Fine needleFine needle

• • TrocarTrocar

• • IncisionalIncisional

• • FrozenFrozen

• • ExcisionalExcisional

Types of biopsyTypes of biopsyTypes of biopsyTypes of biopsy

Role of CT with contrastRole of CT with contrastRole of CT with contrastRole of CT with contrast

SizeSizeSizeSize

SiteSiteSiteSite

MorphologyMorphologyMorphologyMorphology

Neurovascular bundlesNeurovascular bundlesNeurovascular bundlesNeurovascular bundles

Intra/extra compartmentalIntra/extra compartmental Intra/extra compartmentalIntra/extra compartmental

Operative criteriaOperative criteriaOperative criteriaOperative criteria

Choose the approachChoose the approachChoose the approachChoose the approach

Select the trocarSelect the trocarSelect the trocarSelect the trocar

Where to get the sampleWhere to get the sampleWhere to get the sampleWhere to get the sample

Operative criteria:Operative criteria:

Choose the approachChoose the approachOperative criteria:Operative criteria:

Choose the approachChoose the approach

On the line of ideal surgical incisionOn the line of ideal surgical incisionOn the line of ideal surgical incisionOn the line of ideal surgical incision


Select the trocarSelect the trocarOperative criteria:Operative criteria:

Select the trocarSelect the trocar

Big trocar, big sampleBig trocar, big sampleBig trocar, big sampleBig trocar, big sample


Where to get the sample Where to get the sample Operative criteria:Operative criteria:

Where to get the sample Where to get the sample

Posterior approach for lesions of cervical spinePosterior approach for lesions of cervical spine

A

Anterior approach for lesions of cervical spineAnterior approach for lesions of cervical spineAnterior approach for lesions of cervical spineAnterior approach for lesions of cervical spine

B

Lateral approach for lesions of cervical spineLateral approach for lesions of cervical spineLateral approach for lesions of cervical spineLateral approach for lesions of cervical spine

Lesions of the thoracic spineLesions of the thoracic spineLesions of the thoracic spineLesions of the thoracic spine

Posterior approach for sacral lesionsPosterior approach for sacral lesionsPosterior approach for sacral lesionsPosterior approach for sacral lesions

CT-guided trocar biopsy in 1722 ptsCT-guided trocar biopsy in 1722 ptsRizzoli 1990-2008Rizzoli 1990-2008

CT-guided trocar biopsy in 1722 ptsCT-guided trocar biopsy in 1722 ptsRizzoli 1990-2008Rizzoli 1990-2008

Mean age 46 ( SD ± 20)Mean age 46 ( SD ± 20)Mean age 46 ( SD ± 20)Mean age 46 ( SD ± 20)

19 ( 3 %)

192 ( 30 %)

267 ( 41 %)

170 ( 26 %)

Site of procedure: Spine 648 (38%)Site of procedure: Spine 648 (38%)Site of procedure: Spine 648 (38%)Site of procedure: Spine 648 (38%)

Site of procedure: other skeletal sitesSite of procedure: other skeletal sitesSite of procedure: other skeletal sitesSite of procedure: other skeletal sites

449 (26%)

67 (4%)

125 (7%)

433 (25%)

Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008

Rizzoli results: 1990 – 2008Rizzoli results: 1990 – 2008Diagnostic AccuracyDiagnostic Accuracy

Rizzoli results: 1990 – 2008Rizzoli results: 1990 – 2008Diagnostic AccuracyDiagnostic Accuracy

D.A. D.A. 76.5 %76.5 %D.A. D.A. 76.5 %76.5 %

1317131713171317 358358358358 47474747

Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008Rizzoli results: 1990 - 2008

Common mistakes in biopsiesCommon mistakes in biopsiesCommon mistakes in biopsiesCommon mistakes in biopsies

• Surgical approachSurgical approach

• Site of the biopsySite of the biopsy

• Quality of the sampleQuality of the sample

• Tissue preservationTissue preservation

• Surgical approachSurgical approach

• Site of the biopsySite of the biopsy

• Quality of the sampleQuality of the sample

• Tissue preservationTissue preservation

Rizzoli results: 1990 – 2008Rizzoli results: 1990 – 2008Within 30 days 405 pts had another biopsyWithin 30 days 405 pts had another biopsy

Rizzoli results: 1990 – 2008Rizzoli results: 1990 – 2008Within 30 days 405 pts had another biopsyWithin 30 days 405 pts had another biopsy

Final accuracy: 95 %Final accuracy: 95 %Final accuracy: 95 %Final accuracy: 95 %

- Incisional biopsy- Incisional biopsy 45 45

- Percutaneous biopsy - Percutaneous biopsy 360360

- Incisional biopsy- Incisional biopsy 45 45

- Percutaneous biopsy - Percutaneous biopsy 360360

Diagnostic in 316 patientsDiagnostic in 316 patientsDiagnostic in 316 patientsDiagnostic in 316 patients

Incisional biopsy only inIncisional biopsy only inIncisional biopsy only inIncisional biopsy only in

- previous non diagnostic biopsies- previous non diagnostic biopsies

in “difficult” casesin “difficult” cases

- previous non diagnostic biopsies- previous non diagnostic biopsies

in “difficult” casesin “difficult” cases

• Mankin HJ, et al.Mankin HJ, et al.The hazards of biopsy, revisited: The hazards of biopsy, revisited: members of the musculoskeletal members of the musculoskeletal tumor society. tumor society. JBJS Am, JBJS Am, 19961996

• Mankin HJ, et al.Mankin HJ, et al.The hazards of biopsy, revisited: The hazards of biopsy, revisited: members of the musculoskeletal members of the musculoskeletal tumor society. tumor society. JBJS Am, JBJS Am, 19961996

• Wrong diagnoses 17.8 %

• Non representative biopsies 8.4 %

• Related complications 9.0 %

• Consequent changes in treatment and prognosis 10.0 %

• Wrong diagnoses 17.8 %

• Non representative biopsies 8.4 %

• Related complications 9.0 %

• Consequent changes in treatment and prognosis 10.0 %

Differencies between biopsies performed in specialized referral Centers and non specialized hospitals.

Same results than in 1982 study!

Differencies between biopsies performed in specialized referral Centers and non specialized hospitals.

Same results than in 1982 study!

• Mankin HJ, et al.Mankin HJ, et al. The hazards of biopsy in patients with The hazards of biopsy in patients with malignant primary bone and soft tissue tumors.malignant primary bone and soft tissue tumors.

JBJS Am,JBJS Am, 1982 1982

• Mankin HJ, et al.Mankin HJ, et al. The hazards of biopsy in patients with The hazards of biopsy in patients with malignant primary bone and soft tissue tumors.malignant primary bone and soft tissue tumors.

JBJS Am,JBJS Am, 1982 1982

Harvard medical school series:Harvard medical school series:Harvard medical school series:Harvard medical school series:

Treated between 1999 and 2000Treated between 1999 and 2000Treated between 1999 and 2000Treated between 1999 and 2000CT-guided core needle biopsy has CT-guided core needle biopsy has an overall accuracy of 71%an overall accuracy of 71%

CT-guided core needle biopsy has CT-guided core needle biopsy has an overall accuracy of 71%an overall accuracy of 71%

359 patients with a MS tumor359 patients with a MS tumor359 patients with a MS tumor359 patients with a MS tumor

Hau et al, Skeletal radiol 2002 Hau et al, Skeletal radiol 2002

CT-guided core needle biopsy is CT-guided core needle biopsy is better than fine needle aspiration better than fine needle aspiration biopsy for diagnosisbiopsy for diagnosis

CT-guided core needle biopsy is CT-guided core needle biopsy is better than fine needle aspiration better than fine needle aspiration biopsy for diagnosisbiopsy for diagnosis

Hau et al, Skeletal radiol 2002 Hau et al, Skeletal radiol 2002

It is the logical and safe choice for It is the logical and safe choice for diagnostic studies of patients with diagnostic studies of patients with MS lesions.MS lesions.

It is the logical and safe choice for It is the logical and safe choice for diagnostic studies of patients with diagnostic studies of patients with MS lesions.MS lesions.

Harvard medical school series:Harvard medical school series:Harvard medical school series:Harvard medical school series:

St Vincent’s series:St Vincent’s series:St Vincent’s series:St Vincent’s series:

Treated between 1998 and 2001Treated between 1998 and 2001Treated between 1998 and 2001Treated between 1998 and 2001CT-guided core needle biopsy CT-guided core needle biopsy has an accuracy of 80.3%has an accuracy of 80.3%

CT-guided core needle biopsy CT-guided core needle biopsy has an accuracy of 80.3%has an accuracy of 80.3%

127 patients with a MS tumor127 patients with a MS tumor127 patients with a MS tumor127 patients with a MS tumor

Altuntas et al, ANZ J Surg 2005 Altuntas et al, ANZ J Surg 2005

CT-guided core needle biopsy is CT-guided core needle biopsy is safe and effective for the diagnosis safe and effective for the diagnosis of MS lesions.of MS lesions.

CT-guided core needle biopsy is CT-guided core needle biopsy is safe and effective for the diagnosis safe and effective for the diagnosis of MS lesions.of MS lesions.

biopsy should be conducted in the biopsy should be conducted in the institution performing the institution performing the definitive treatmentdefinitive treatment

biopsy should be conducted in the biopsy should be conducted in the institution performing the institution performing the definitive treatmentdefinitive treatment

Altuntas et al, ANZ J Surg 2005 Altuntas et al, ANZ J Surg 2005

St Vincent’s series:St Vincent’s series:St Vincent’s series:St Vincent’s series:

430 pts with spine lesions430 pts with spine lesions Treated from 1990 to 2005Treated from 1990 to 2005 401 diagnostic biopsy 401 diagnostic biopsy Total accurancy of 93.3 %Total accurancy of 93.3 %

430 pts with spine lesions430 pts with spine lesions Treated from 1990 to 2005Treated from 1990 to 2005 401 diagnostic biopsy 401 diagnostic biopsy Total accurancy of 93.3 %Total accurancy of 93.3 %

Rimondi et al, Eur Spine J 2008Rimondi et al, Eur Spine J 2008

Rizzoli series of the spine:Rizzoli series of the spine:Rizzoli series of the spine:Rizzoli series of the spine:

Rimondi et al, Eur Spine J 2008Rimondi et al, Eur Spine J 2008

Rizzoli series of the spine:Rizzoli series of the spine:Rizzoli series of the spine:Rizzoli series of the spine:

Percutaneous CT-guided biopsy is Percutaneous CT-guided biopsy is considered the procedure of choice considered the procedure of choice in spine lesionsin spine lesions

Percutaneous CT-guided biopsy is Percutaneous CT-guided biopsy is considered the procedure of choice considered the procedure of choice in spine lesionsin spine lesions

If biopsy was not diagnostic, another If biopsy was not diagnostic, another trocar biopsy should be repeatedtrocar biopsy should be repeated

If biopsy was not diagnostic, another If biopsy was not diagnostic, another trocar biopsy should be repeatedtrocar biopsy should be repeated

75-97 % histologic congruity between 75-97 % histologic congruity between diagnosis at diagnosis at biopsybiopsy

and and definitive definitive surgerysurgery

75-97 % histologic congruity between 75-97 % histologic congruity between diagnosis at diagnosis at biopsybiopsy

and and definitive definitive surgerysurgery

Quantity – Quality of the tissueQuantity – Quality of the tissueKnowledge of the caseKnowledge of the caseQuantity – Quality of the tissueQuantity – Quality of the tissueKnowledge of the caseKnowledge of the case

Surgical PathologistSurgical PathologistSurgical PathologistSurgical Pathologist

Surgical Pathologist must:Surgical Pathologist must:Surgical Pathologist must:Surgical Pathologist must:

Know the caseKnow the case

Talk to surgeon and radiologistTalk to surgeon and radiologist

Examine imaging studiesExamine imaging studies

Know the caseKnow the case

Talk to surgeon and radiologistTalk to surgeon and radiologist

Examine imaging studiesExamine imaging studies

ConclusionConclusionWhy CT-guided biopsy?Why CT-guided biopsy?

ConclusionConclusionWhy CT-guided biopsy?Why CT-guided biopsy?

Percutaneous CT-guided biopsy is:Percutaneous CT-guided biopsy is:

- safe- safe

- speed- speed

- cheap- cheap

Percutaneous CT-guided biopsy is:Percutaneous CT-guided biopsy is:

- safe- safe

- speed- speed

- cheap- cheap

ConclusionsConclusionsConclusionsConclusionsPercutaneous CT-guided biopsy is a useful Percutaneous CT-guided biopsy is a useful

technique that should be recommended for technique that should be recommended for most of the bony lesionsmost of the bony lesions

Percutaneous CT-guided biopsy is a useful Percutaneous CT-guided biopsy is a useful technique that should be recommended for technique that should be recommended for most of the bony lesionsmost of the bony lesions

Careful selection of patients with previous Careful selection of patients with previous accurate imagingaccurate imaging

Careful selection of patients with previous Careful selection of patients with previous accurate imagingaccurate imaging

Ultrasound-guided biopsy with tru-cut is Ultrasound-guided biopsy with tru-cut is usually preferable for soft tissuesusually preferable for soft tissues

Ultrasound-guided biopsy with tru-cut is Ultrasound-guided biopsy with tru-cut is usually preferable for soft tissuesusually preferable for soft tissues

ORTHOPEDICORTHOPEDICORTHOPEDICORTHOPEDIC PATHOLOGISTPATHOLOGISTPATHOLOGISTPATHOLOGIST

RADIOLOGISTRADIOLOGISTRADIOLOGISTRADIOLOGISTA TEAM A TEAM

APPROACHAPPROACHA TEAM A TEAM

APPROACHAPPROACH

Gold standardGold standardGold standardGold standard

ONCOLOGISTONCOLOGISTONCOLOGISTONCOLOGIST

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PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES