Cardiova~,c lntefvcnl Raditfl (1991) 14:69-72

CardioVascular andInterventional

Radiology

9 Springer-Verlag New York Inc. 1991

Percutaneous Skeletal Biopsy C. Ht, mberto Carrasco. Sidney Wallace, and William R. Richli l)cpurln'lcnl of l.)iagnoslic R,Miolog~, The University of ] c x a ' , M.I). Andcvxon Cancer Center. l'cxa:,. USA

Abstract. Percutaneous bone biopsy has become an accepted means for tissue diagnosis in indeterminate metastatic disease, whereas needle biopsy for the evaluation of primary skeletal neoplasms is controversial. Needle biopsies are also of value in the diagnosis of inflammatory lesions and eosinophilic granuloma. The diagnostic accuracy of this procedure ranges from 5{) to 94')2: in malignant disease, but is less favorable in benign disease, The low complication rate of about 0.2(':4 makes the percutaneous approach an attractive alternative to surgical biopsy. Key words: Needle biopsy--Skeletal neoplasms, diagnosis-- Metastases. diagnosis-- Eosinophilic granuloma, diagnosis

There are advantages of a closed needle biopsy over a surgical biopsy. Management pkmning is immediate allowing therapy Io be iniliatcd without waiting for an incision to heal. Trauma to normal as well as neoplastic tissues is minimized which possibly decreases the risk of tumor dissemination. The insult to the structural integrity of the involved bone is lessened. The risks, as well as the costs, of a surgical procedure and general anesthesia are avoided. Thus, the initial step in the diagnostic work-up of the patient with a suspected skeletal neoplasm is simplilied considerably. Moreover, failure to obtain a diagnostic specimen does not preclude a surgical biopsy,

Indications

Prior to any therapeutic intervention, most skeletal lesions require tissue diagnosis which may be achieved by means of an open (surgical) or closed (radiologic) needle biopsy. The use of needle biopsy in the diagnosis c~f skeletal neoplasms was initially reported in the early 1930s [I, 2]; since then. the technique has been extended to the diagnosis of osteomyetitis and, to a lesser extent, the evaluation of ntetabolic bone disease [3, 4]. Although the value of closed needle biopsy in skeletal metastases is unquestionable, its value in primary neoplasms is not as well accepted. "['he approach requires not only an interventional radioMgist interested in skeletal pathology but also a cytologist and a bone tumor pathologist experienced in interpreting small tissue samples whose diagnosis must be agreed to by the various specialists in charge of the patient's treatment.

Addrt, s~ reprint rcque'st.~ fo." C. H u m b c f t o Curra:.,co. M. l)., I)epurtn]enl of Diagnostic Radiology, Box 57, M.D. Ander-on Cancer Center, 1515 ltolcombe Blvd.. Houston, TX 77030, US,-\

The principal indication for skeletal needle biopsy is the diagnosis of metastatic disease which can usually be made with high confidence by its radiographic features alone. However, tissue diagnosis is indicated in I) apparent skeletal metastases that are in disagreement with the clinical stage of the disease; 2) a positive radionuclide bone scan that is not elucidated by other imaging modalities in a patient at risk for metastatic disease: 3) atypical radiographic presentation of metastatic disease, such as osteolylic lesions, in a patient with prostatic carcinoma; 4) skeletal metastases in patients with more than one primary neoplasm; 5) radiographically stable metastases, to determine the presence of viable cells thai will affect the decision.to continue therapy; and 6) the presence of skeletal metastases without an obvious site of origin, as a biopsy may simplify the search fbr the primary lesion [5]. At our institution, patients with suspected primary skeletal neoplasms are managed by a team of specialists comprising pathologists, surgeons, medical oncologists, and radiologists. Generally, tissue diagnosis of clinically and radiologically benign le-

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sions that require surgical excision is made by intraoperative biopsy. Cartilagenous tumors cannot be graded by small samples obtained surgically or through a needle biopsy: when they are mdiologically pathognomonic and clinically suspect they are completely excised for histologic grading. The procedure is considered curative if the grade of" thc neoplasm is low and it is considered an adequate biopsy if the grade is high [6]. Skcletal biopsy is best. done tit the treating institution so that if patient referral is contemplated, this must be done prior to biopsy [7]. The use of needle biopsy lot" evaluation of primary skeletal neoplasms is somewhat controversial. Most pathoh)gists require larger quantities of tissue than those obtained by needle biopsy for histologic interpretation of samples from skeletal tumors. It is also believed that because most primary skeletal neoplasms are treated surgically, biopsy is best accomplished intraoperatively at the time of definitive trealmenl. However, some primary skeletal neoplasms are treated with preoperative chemotherapy and thus require tissue diagnosis prior to excision. Although a needle biopsy is not adequate for definitive subclassification of a sarcoma, it provides the information necessary to initiate treatment. The specimens obtained tire small, yet large enough to demonstrate the histologid pattern of the neoplasm. Needle biopsies are also of value in thc diagnosis of inflammatory lesions, including osteomyelitis. In patients with eosinophilic granuloma, needle biopsy is used in corLiLmction with intralcsional injection of methylprednisolone which is associated with healing in nearly all patients [8].

Contraindicalions

There are no absolute contraindications for skeletul needle biopsies. A relative contra-indication is any uncorrectable bleeding diathesis. As with any other procedure, the risks of the biopsy must be weighed against those of initiating therapy without a specifiC: diagnosis [91.

Technical Considerations

Conventional radiography is usually adequate for localization of the tumor and selection of the approach route. Computed tomography and magnetic resonance imaging best demonstrate the extent of a lesion, especially when it is not adequately demonstrated by conventional radiography. Although ultrasonography accurately defines the extraosseous component of tumors, it is seldom used in biopsy of

C.H. Carrasco

el

al.: Perculancoux Skclclal l{iop,,y

the skeleton. Radionuclide bone scanning may aid in the localization of lesions not yet apparent by' the other imaging modalities [10l. ]'he skeleton is appropriately imaged by fluoroscopy which we consider the modality of choice for needle biopsy: guidance under computed tomography is usually not ;t practical consideration.

Instruments

The need of a specimen l\~r cytologic or histologic examination as well as the location of ll|e lesion arm the integrity of the overlying cortical bone determine the choice of instruments. Most needlcs used in closed biopsies possess tt stylet or a troc;_tr. Thinwalled needles ranging in caliber from 18 to 23 gauge suffice lot collection of material for cytologic examination. The needles with the more acute bevel angles and the l=ranzen trephine types yield the best samples I 1I]. Culling needles, such ;.Is [he "fravenol Tru-Cut, are used to obtain tissue samples for histology. This needle yiclds samples measuring up to approximatcly 2 • 31) mm usually devoid of crushing artifacts. Cortical perlk)ration requires a drill [12] or a large caliber trephine ncedle such as the Ackcrmann needle, As histologic samples obtained with these trephine needles Frequently have crushing artilhcts that hinder their interpretation, several instruments that avoid these artifacts have been described [13, 141.

Technique

The anatomic relationships of lhe lesion must be carefully considered to avoid damage to adjacent vascular, neural, and visceral structures, lntroth,clion of the needle along the long axis of the lesion allows acquisition of the greatest quantity of tissue, especially in thin or flat bones where a perpendicular approach risks damaging underlying structures. If resection is contemplated, the biopsy tract should be agreed upon with the treating surgeon. Needle insertion should be through the shortest path fi'om the skin to the target and parallel to the axis of the x-ray beam. This can usually be accomplished with a fluoroscopy unit capable of imaging in wu'ious angles or by positioning lhe patient so as to maintain the skin site and the target fluoroscopically superimposed. Needle biopsy is usually performed using local anesthesia except in children, who almost always require general anesthesia. After slerily cleansing and draping the skin site, a local anesthetic is generously infiltrated along Ihe planned tract under fluo-

C.H. ('arrasco ct al.: Percutaneou,; Skeletal Biop%' roscopic observation. Adequate anesthesia results in a relatively painless biopsy. Most skeletal diseases for which biopsy is indicated arise in the medulh.uy cavity, from where they may destroy the cortex and becorne extraosseous. When the cortex has been destroyed, samples arc easily obtained using a 22-gauge spinal-typc needle R)r cytologic and a cutting needle ["or histohygic analysis, respectively. Entirely intraosscous lesions require perforation of the cortex to gain access to the underlying tumor, a procedure that is greatly facilitated by the use of a drill. In blastic processes, tissue should be acquired from the least ,.lense area of the lesion 115], in neoplastic diseases, compact bone, becausc of its hypocellularity, is of little diagnostic value and special efforts to obtain a core of it are not warranted. Initially, a sample of the lesion is obtained for immediate cytologic asse.,,smcnt which determines whether additional samples are needed for histology, electron microscopy, or other special studies.

Special Biopsy Tectmique Needle biopsy of spinal lesions is performed with minimal risk under local anesthesia and usually on an outpatient basis. Techniques for a transpharyngeal approach to the upper cervical vertebral bodies using general anesthesia have been described [161. However, using computed tomography, the ce,'vical spine is easily approachable transcutaneously [171. The approach varies according to the location of the lesion and its relationship to vital structures in the neck. A biopsy of the bodies of the lower cervical segments, including the first thoracic vertebra, can be obtained using fluoroscopy through a lateral approach t16]. Vertebral bodS' biopsy in the thoracic spine is complicated somewhat by the proximity of the pleura and lung parenchyma, both of which can usually be avoided with adequate patient positioning. The patient is initially positioned in the lateral decubitus contralateral to the side of the greatest vertebral body involvement. Once the pleural reflection is fluoroscopically identified, the patient is turned toward the prone oblique, at approximately a 35 ~ angle [181, until the reflection is projected in front of the vertebral body. Thus, a window bordered by the heads of the ribs is made available for the insertion of the biopsy instrument; the pleural reflection lies anteriorly, a plane through the articular processes and the spinal canal lie posteriorly. Angulation of the fluoroscopy unit along the rib axis helps avoid these structures during needle insertion. Biopsy of the vertebral bodies in the lumbar

71 and lower thoracic segments is l:acilitatcd by the presence of a relatively large paraspinal musculalure and it is performed in a fashion similar to thal described previously. Biopsies of the sacral lesions are usually obtained through a direct posterior approach.

Complications There are few complications associated with needle biopsy of the skeleton. Pain is the most frequent side effect and is usually secondary to inadequate local anesthesia. Negative pressure and nmnipulations within a medullary canal thai is not completely damaged by disease may cause severe pain. A 1981 review of the literature reported a complication rate of 0.2% [19l. Severe neurologic damage and paraplegia have been among the most serious complications reported [7, 20-22t. Pneumothorax may occur in biopsies of the bony thorax. Hemorrhage may occur in patients with coagulopathies or when large vessels are lacerated by the biopsy instrument. Tuberculous sinus tracts secondary to biopsy of tuberculous spondylitis have been reported [23]. Contamination of the biopsy tract by tumor is rare.

ResMts In most of the larger series reported, the diagnostic accuracy of percutaneous skeletal biopsies has been around 80%, ranging from 50 to 949,~ 16, 15, 19, 2433]. At our institution, the overall accuracy of needle biopsy in primary skeletal lesions from 1976 to 1987 was 73% 1331. Needle biopsy had an accuracy of 87% m primary malignant neoplasms and 83% in benign tumors. The diagnostic yield of the procedure in non-neoplastic and miscellaneous lesions was 62%. The accuracy in osteosarcoma was 89% and in Ewing's sarcoma it was 94%. Giant cell tumors were adequately diagnosed in 91c2; of the cases. Nondiagnostic biopsies usually occur in biastic tumors and cystic lesions. In suspected infectious diseases of the skeleton, particularly in tuberculous spondylitis, the incidence of positive bacterial cultures has generally been low compared with the incidence of positive diagnosis made based on the histopathologic features of the biopsy specimen [32.34, 35J. In summary, percutaneous needle biopsy of the skclcton is a safe, accurate, economical, and relatively painless method of obtaining tissue for histologic, cytologic, or bacteriologic diagnosis of skeletal lesions. The procedure can be repeated when needed with minimal morbidity and does not pre-

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elude a subsequent surgical biopsy. It should be emphasized that the diagnostic accuracy of the procedure depends largely on the experience of the c.vtoand histopathologist.

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17. Kattapuram ,SV. Ro,~enthal I)l (19;S7! P,.:lc,taneous biopsy of 1he cervical spin,: thing CT guidance. AJR 149:539-541 18. l.,aredo J-D, F;ard M (1986) Thoracic ,,pine: PCl'cnl;dllC'OiJ\ trephine biopsy. Radiology 160:485-4N9 19. Murphy WA. I.)eslouct JM. (;ilula I,A 11981) Perculancou,; skeletal biopsy 1981: A proo.'dure I\)r r:tdioh)gisls--rcsuhs, review, and rccomlnendations. Radiology 119:545-549 2(1. McLallghlin RI':, Miller WR, Miller CW 119761Quadripare~,is after needle aspiration of the ,..'ervical -,pine: Report of a case. J R~}ne Joint Surg [Am[ 56:1167-1168 21. Slam I)C..lacobs B t196,7) Diagnosis of obscure lesion:, of the skeleton: I".vah~al,tn of biop.,y melhods. J A M A 201:229231 22. Ranlgopal V, Geller M r l a h o g e n i c Klebxiella ineningitis following closed needle biopsy of the h,nlbar ,,pine: Report of a case and review of literature. Wis Mcd J 76:41-42 23. Armstrong P, Chatmers AH, Green G, Irving JD (1978~ Needie aspiration/biopsy of the spine in suspected disc space infection. Br d Radiol 51:333-337 24 Deete~ TJ (1'.;72] The drill biopsy o | bone lesions. Clin R a diet 23:536-540 25. Pepe RC, Lalli AF (1976) Pcrcutarmous a,,piralion bone biopsy by fluoroscopic guidance. ("level ('lin Q 43:77--K~ 2(~. T h o m n m s e n P, I-q-edeliken P 1197~ Fine needle aspiration biopsy of bone lesions: Clinical value. Acla Or(hop S t a n d 47:137-143 27. DcSanlo:, I,A. t,ukcman JM, Wallace S, Murray JA. A,vala A (1978) Percutaneous needle biopsy o1 bone in the cancer palienl. A JR 130:641-649 28. Tilhnan MM. Meyern M t l . Palzakis M J, Terry R. Ilarvcy JP (19791 Closed biops~ of musculoskeletal lesions..I Bone Joint Sure [Aml 61:375.-379 29. Slormby N, Akcrman M 11973) Cytodiagnosix of bone lesions by means of fine needle aspiration biopsy. Acla Cylol 1"7:166-172 311. l)ebnam JW, Staple TW (1975)Trephine bone biopsy, by radiologisls: Rcsuhs of 73 procedures. Radiology IH~:607609 31. A k e r m a n M, Berg NO. Pernson BM (19761 Fine needle aspiration biop,sy in the r of lender-like lesions oF b,,',lle. Acta Orlhop Scand 47:129-136 32. "l'ehranzadeh J. t:reibeJgcr RH, G h e l m a n B (19831 Closed skeletal needle biop-,y: Review of 1211 eases. A JR I-1t1:113115 33. :\yala AG, Raymond KA. Re JY. (:arr:Jsco CH. Fanning CV. Murray .I,\ (1989) Needle biopsy of primary bone lesions: M.D. Anderson experience. Ik0.hol Anne 24:219-25l 34. :\mbro-,e GB. Alpert M, Neer (7S { I9M~I Ver!ebrai body hiop',y. J:\M,'~ 197:6t9-622 35. Griftiths HED, Jones DM {1971) Vertebral osleonlyelilis: A diagnoslic problem. J Bone Join( Surg IBrl 53:383-39l