Surgeon led biopsy of musculoskeletal tumours Robert U. AshfordStanley W. McCarthy S. Fiona BonarRichard A. Scolyer Rooshdiya Z. KarimPaul D. Stalley NSW Bone & Soft Tissue Sarcoma Service

“Poorly performed biopsies compromise limb salvage surgery and patient survival” Mankin JBJS 1982

Biopsy of Musculoskeletal Tumours Tertiary Centre is best & core biopsy preferred Fraught with complications –Mankin (1982 & 1986) : –23% error rate –17% complication rate –5% amputation rate because of biopsy Our experience –Pollock & Stalley 2004 –38% of biopsies performed elsewhere hindered Rx –17% amputation rate

Biopsy of Suspicious Lesions CT guided biopsy for all ? –127 Biopsies –20% non-correlation rate (25 patients) –10 Non-diagnostic CT Bx (6/10 malignant) –1 Major error: CT Bx – Schwannoma ; Excision - synovial sarcoma Altuntas et al (2004): ANZ J Surg

Sydney to Venice km

Distance Sydney to Albury 560km Bega 420km Bourke 775km Broken Hill 1159km Coffs Harbour 572kmDubbo 407km Grafton 618km Wagga 470km London to Venice1139 km London to Geneva740 km New York to Washington328 km Toronto to New York831 km

RPAH Protocol 1. MDT Sarcoma Clinic Assessment 2. Completion of imaging 3. Biopsy 1.Surgeon (Consultant / Fellow) 2.GA 3.Core Biopsy (Trucut) 4.Frozen Section with surgeon present 5.Repeat Biopsy Core or open if 4 not representative

Study Retrospective review of all biopsies performed at RPAH under the care of the senior author for 2 years (July 2003 – June 2005) Comparison of core, core proceed to open and open biopsies Analysis of accuracy and non-diagnostic rates Comparison with CT core biopsies from literature

Biopsy Technique Biopsy MethodNumberPercentage Trucut Core9334.3% Core proceed to open114.1% CT Core248.9% Open (Incisional, Curetting) % Excisional5821.4% Reamings93.3% Total271100%

Bone Tumours MalignantBenign Osteosarcoma24GCT7 Chondrosarcoma9Infection4 MFH7ABC3 Lymphoma8Haemangioma3 Myeloma7EG2 Ewing’s2Ganglion Cyst2 Chordoma1CMF1 Synovial Sarcoma1Paget’s1 NHL1Osteoid Osteoma1 Metastases11 Total71Total24

Soft Tissue Tumours MalignantBenign MFH8Desmoid Fibromatosis3 Leiomyosarcoma4Fibroma3 Synovial Sarcoma3Schwannoma2 Liposarcoma1Myxoma2 Fibromyxoid sarcoma1Synovial Chondromatosis 1 Fibrosarcoma1Neuroma1 Myofibrosarcoma1Haemangiopericytoma1 Rhabdomyosarcoma1 Total20Total13

Results 104 protocol biopsies No non-diagnostic biopsies 11/104 (10.6%) necessary to proceed to open biopsy –27% of ultimately benign lesions –23% of soft tissue lesions

Accuracy N DiagnosticErrorsAccuracy Bone Lesions Core % C / O330100% CT % Soft Tissue Lesions Core % C/O % CT330100%

One Error 62 Female with thigh mass Non-diagnostic imaging F/S diagnosis: lymphoid tissue favour Hodgkin’s Disease Final diagnosis: B cell lymphoma No alteration in surgical management

Discussion Tertiary centre is best Core biopsy is often appropriate Adding frozen section eradicates risk of non-diagnostic biopsy Open biopsy if core non-diagnostic A good pathologist is obligatory

Before doing a biopsy …….. think