PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES
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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)
StopStop(for many)(for many)
biopsybiopsy(if necessary)(if necessary)
biopsybiopsy(if necessary)(if necessary)
MR ImagingMR ImagingMR ImagingMR Imaging
benignbenignbenignbenign malignantmalignantmalignantmalignant
StopStop(for many)(for many)
StopStop(for many)(for many)
biopsybiopsy(if necessary)(if necessary)
biopsybiopsy(if necessary)(if necessary)
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
Operative criteria:Operative criteria:
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
Operative criteria:Operative criteria:
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