A review of excised biopsy tract histology for primary bone tumours: Is excision necessary? Price A, Maxwell C, Beardsall J, Jeys L

Background Biopsy tracts are excised at the point of definitive surgery. Theoretical risk of malignant seeding of the biopsy tract. Cases of malignant seeding of the needle biopsy tracts in other malignancies. Insufficient evidence to suggest that biopsy tracts pose a risk to local recurrence Case reports and small studies are conflicting.

Aims 1.To investigate how frequently biopsy tract excision is carried out at ROH. 2.To establish the incidence of seeding of biopsy tracts in our patients. 3.Evaluate whether certain tumour types are more likely to seed a biopsy tract. 4.Determine whether the excision of biopsy tracts reduces the rate of local recurrence.

Methods A retrospective analysis of 278 patients with primary bone tumours 1/1/08-31/12/09 Minimum 3 years follow up. Histology reports for all patients were reviewed. The database was used to find: Diagnosis Age at diagnosis Type and date of biopsy Type and date of surgical procedure Local recurrence, metastases and death. Statistical analysis was carried out using Statsview (Berkley, California).

278 Primary bone tumours between Surgery recorded at ROH 109 Biopsy tract excised 108 Negative biopsy tract histology 1 Positive biopsy tract histology 94 Biopsy tract not excised 75 No surgery recorded at ROH 278 Primary bone tumours between Surgery recorded at ROH 109 Biopsy tract excised 108 Negative biopsy tract histology 1 Positive biopsy tract histology 94 Biopsy tract not commented upon in pathology report 75 No surgery recorded at ROH Patient selection

203 patients at ROH Mean age at diagnosis was 33yrs (range 3-90yrs). 88% underwent needle biopsy as the method of biopsy. Wide range of definitive surgical procedures. 109 had a biopsy tract excision 94 did not have a tract excision mentioned – 45 amputations - ?tract excised – The remainder could not be identified at the time of surgery? – Average time from biopsy to procedure for these patients 4mths

109 patients with excised biopsy tract The primary diagnosis varied considerably 108 patients had no evidence of seeding. 1 patient had histological evidence of seeding within the biopsy tract: “..along the needle track, a 3mm solid nodule of high grade sarcoma similar to the high grade component of the intraosseous tumour. This nodule most likely represents an implant.”

One case of malignant infiltration 72yr old with dedifferentiated chondrosarcoma of the distal femur. Needle biopsy 20 days prior to EPR and excision of the biopsy tract. Large local recurrence within 5 months of diagnosis. The patient died 10 months later with metastatic disease.

Local recurrence rates The group who did not have a biopsy tract excision had less LR than the excised group 9 vs. 19%, p=0.04 This probably reflects a higher rate of amputation in the non biopsy group. Not excising the tract does not necessarily increase the risk of local recurrence.

Time to local recurrence

Survival

Discussion Our study shows that biopsy tract excision was not commented upon in 46% cases, of those 48% underwent amputation. 49 patients (24%) had no biopsy tract excised at definitive surgery, as it may be that the tract was difficult to locate. Local recurrence rate was lower in patients who did not undergo biopsy excision, however, this is most likely to be due to the large number of amputations carried out in this group. Survival and time to LR recurrence remained the same in both groups. We have since become aware of three previous incidences of biopsy tract seeding in patients at the ROH between These were all in chrondrosarcomas.

Conclusion Removal of biopsy tract remains the gold standard. Association between local recurrence and biopsy tracts is difficult to confirm. The biopsy tract may be at higher risk in tumours such as chondrosarcomas which do not receive chemotherapy. Take home message Overall the rate of seeding in our cohort is low. This reassures us that the patient is unlikely to be compromised if identification or removal of the biopsy tract proves difficult.

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