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F N BonMusculoskeletal Tumor

Fathurachman

Oncology Section

Dept. of Orthopaedic & Traumatology

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Prologue

Musculoskeletal tumor

Multi-discipline approach

Systematic steps

FNAB: alternative method

Major role on Dx & Tx

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FNAB, Technical

Development FNAB on tumors that had a classic

radiographic appearance

Role: a confirmatory test FNAB: for previously undiagnosed

orthopaedic masses and tumors

FNAB is most successfully

Confirming the clinicoradiographicdiagnosis

In a patient whose tumor has classicpresentation

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FNAB, Technical

Development 20- to 40-year-old age

group

A distal femoral orproximal tibial lytic,eccentric, geographic,subchondralepiphyseal lesion

Almost certainly has aGCT

FNAB is excellent atconfirming thediagnosis of GCT ofbone

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FNAB, Technical

Development FNAB is an integral component of an

overall team approach

Team includes:Orthopaedic oncologistMedical oncologist

Radiologists

Pathologists The pathologists must be skillful in

the cytopathologic interpretation oforthopaedic tumor aspirates

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FNAB, Technical

Development Multiple advantages compared to

open biopsy

It is quick, inexpensive, andminimally invasive

Performed on the day of the initialoffice visit

To establish the diagnosis ofosteosarcomas at less than onefourth the cost of open biopsy

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FNAB, Technical

Development Without any anesthesia

Minimal to no discomfort

Well tolerated by patients

23- or 25-gauge needle

Diagnostic aspiration biopsiesobviate the need for open

biopsies

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FNAB, Technical

Development This allows surgery to proceed

expeditiously

Confirmed preoperative diagnosis

Avoids the need to wait for the pathologists to

process the frozen section intraoperatively

Alternatively, should an osteo-sarcoma be

diagnosed at FNAB

Then the appropriate systemic evaluation andchemotherapy can be initiated quickly

Without having to schedule and perform an open

procedure

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FNAB, Technical

Development FNAB is successful in the diagnosis

of bone malignancies

Highly accurate in diagnosingosteosarcoma, myeloma, andEwing's sarcoma as well as otherbony sarcomas

FNAB can correctly identify bonysarcomas in 93% of cases

Histogenetic subtyping can beachieved in approximately 82% of

these same cases

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FNAB, Technical

Development Negative for malignancy" or that

"contains no malignant cells" doesnot absolutelyconfirm the absenceof malignancy

It simply means that: no identifiablemalignant cells were aspiratedandexpelled onto the glass slide

Due to non-representative sampling

To the needle having missed thelesion altogether

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FNAB, Technical

Development To the absence of a malignant entity

Therefore, a "negative" FNAB: onecomponent of an overall diagnostic picture

Deeper lesions: imaging guided FNAB canavoid a false-negative finding due to theneedle missing the lesion

If the cytologic findings and interpretations

are not consistent with the clinical andradiographic findings and a malignancy issuspected, then open biopsy or coreneedle biopsy is indicated

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Materials

Performed in the outpatient setting

Inpatients as well

A mobile cart containing:The appropriate stains

Glass slides

Syringes

Syringe holder

Double-headed microscope

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Before Procedure

The attending pathologist, surgeon

and musculoskeletal radiologist

typically review:Plain radiographs

CT scans

MRI scans

Bone scans

Other appropriate clinical,

laboratory, and radiographic data

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Procedure

Prepared with povidone iodine

No local anesthetic

A 25-gauge needle on a 20-ccsyringe containing 5 cc of air isadvanced through the skin into thetumor

The plunger on the syringe is thenwithdrawn fully, creating anadditional 15 cc of vacated potentialair space within the syringe and a

vacuum at the needle tip

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Procedure

The needle is then rapidly and

sequentially advanced andwithdrawnwithin the tumor mass inmultiple directionsto provide arepresentative sample from multiple

areas within the tumor

Ideally, this procedure is performedthrough one puncture sitewithin thetumor wall

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Procedure

Once the aspiration passes within thetumor have been completed, the negativepressure is released and the plunger

returns to the 5-cc position in the syringewith 5 cc of air remaining in the syringe

The needle is then withdrawn from thepatient

An assistant maintains pressure on thearea for a minimum of 5 minutes to preventtumor bleeding and local tumor spread

The aspirated specimen typically fills onlythe hub of the needle

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Procedure

Rarely, with a bloody specimen, asmall amount of bloody tissuesufficient to reach to the channel ofthe syringe is obtained

The sample of aspirated material isexpressed onto glass slides utilizingthe retained 5 cc of air in the syringeto expel the specimen

The material is then smeared with asecond glass slide

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Procedure

And one smear is air dried andstained:

Diff-Quik (Fisher ScientificBiomedical Sciences, Inc,Swedesboro, NJ)

The other slide is immediately

immersed in 95% ethanol forsubsequent staining by thePapanicolaou method

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Interpretation

Knowledge of

normal bone &

marrow cells

On smear:

Megakaryocyte

Osteoblast

Osteoclast

Chondroblast Osteoid matrix

Chondroid matrix

Normal bone &

cartilage

Primary &secondary tumor

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Interpretation

Secondary tumor: foreign

structure

Matrix (+):Primary tumor

Reactive lesion

Benign

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Interpretation

Soft tissue malignancy

Difficult

Overlapping feature of cells &

tissue

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Interpretation

Lowhagen & Skoog, Karolinska Hosp.,

Sweden:

1. Soft tissue origin, not a reactive lesion,inflammation, degenerative,

metastatic, lymphoma

2. Soft tissue tumor, benign or malignant?

3. Malignant tumor, low or high grade?

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From: Lunardhi, J.H., in : Fine needle aspiration cytology in

musculoskeletal pathology, Proceeding of Scientific Meeting &

Workshop of Indonesian Musculoskeletal Pathology, Surabaya,

22-23 March 2003

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Further Analysis

Sophisticated analysis

Immunocytochemical

Electron microscope

Chromosome analysis

Molecular analysis

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Summary

Accurate diagnostic information

Help clinician to decide

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