PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia, T. Calabrò, A. Angelini, G. Rossi, U. Albisinni E. Rimondi, P. Ruggieri, G. Bosco, G. Ussia, T. Calabrò, A. Angelini, G. Rossi, U. Albisinni Istituto Ortopedico Rizzoli- University of Bologna, Italy

Management of bone tumors Plain films Benign appearance AggressiveappearanceAggressiveappearance CT (if flat bone) CT Stop (for many) Stop biopsy (if necessary) biopsy MR Imaging benignbenignmalignantmalignant Stop (for many) Stop biopsy (if necessary) biopsy CT/bone scan/ chest xray or CT biopsybiopsy

biopsy is a compromise biopsy is a compromise need to have significant tissue significant tissue need to have significant tissue significant tissue need to avoid contamination (*local / blood circul.**) need to avoid contamination (*local / blood circul.**) * Schwartz, Ann Surg Oncol 1997 **Zoubek, Eur J Pediatry 1996 Biopsy is the last step of the staging

Fine needle Fine needle Trocar Trocar Incisional Incisional Frozen Frozen Excisional Excisional Fine needle Fine needle Trocar Trocar Incisional Incisional Frozen Frozen Excisional Excisional Types of biopsy

Role of CT with contrast Size Size Site Site Morphology Morphology Neurovascular bundles Neurovascular bundles Intra/extra compartmental Intra/extra compartmental

Operative criteria Choose the approach Choose the approach Select the trocar Select the trocar Where to get the sample Where to get the sample

Operative criteria: Choose the approach On the line of ideal surgical incision

Operative criteria: Select the trocar Big trocar, big sample

Operative criteria: Where to get the sample

Posterior approach for lesions of cervical spine

A Anterior approach for lesions of cervical spine

B Lateral approach for lesions of cervical spine

Lesions of the thoracic spine

Posterior approach for sacral lesions

CT-guided trocar biopsy in 1722 pts Rizzoli Mean age 46 ( SD ± 20)

19 ( 3 %) 192 ( 30 %) 267 ( 41 %) 170 ( 26 %) Site of procedure: Spine 648 (38%)

Site of procedure: other skeletal sites 449 (26%) 67 (4%) 125 (7%) 433 (25%)

Rizzoli results:

Rizzoli results: 1990 – 2008 Diagnostic Accuracy Rizzoli results: 1990 – 2008 Diagnostic Accuracy D.A %

Rizzoli results:

Common mistakes in biopsies Surgical approach Surgical approach Site of the biopsy Site of the biopsy Quality of the sample Quality of the sample Tissue preservation Tissue preservation Surgical approach Surgical approach Site of the biopsy Site of the biopsy Quality of the sample Quality of the sample Tissue preservation Tissue preservation

Rizzoli results: 1990 – 2008 Within 30 days 405 pts had another biopsy Rizzoli results: 1990 – 2008 Within 30 days 405 pts had another biopsy Final accuracy: 95 % - Incisional biopsy 45 - Incisional biopsy 45 - Percutaneous biopsy Percutaneous biopsy Incisional biopsy 45 - Incisional biopsy 45 - Percutaneous biopsy Percutaneous biopsy 360 Diagnostic in 316 patients

Incisional biopsy only in - previous non diagnostic biopsies - previous non diagnostic biopsies in “difficult” cases in “difficult” cases - previous non diagnostic biopsies - previous non diagnostic biopsies in “difficult” cases in “difficult” cases

Mankin HJ, et al. Mankin HJ, et al. The hazards of biopsy, revisited: members of the musculoskeletal tumor society. JBJS Am, 1996 Mankin HJ, et al. Mankin HJ, et al. The hazards of biopsy, revisited: members of the musculoskeletal tumor society. JBJS Am, 1996 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. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. Mankin HJ, et al. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. JBJS Am, 1982 Mankin HJ, et al. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. Mankin HJ, et al. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. JBJS Am, 1982

Harvard medical school series: Treated between 1999 and 2000 Treated between 1999 and 2000 CT-guided core needle biopsy has an overall accuracy of 71% CT-guided core needle biopsy has an overall accuracy of 71% 359 patients with a MS tumor 359 patients with a MS tumor Hau et al, Skeletal radiol 2002

CT-guided core needle biopsy is better than fine needle aspiration biopsy for diagnosis CT-guided core needle biopsy is better than fine needle aspiration biopsy for diagnosis Hau et al, Skeletal radiol 2002 It is the logical and safe choice for diagnostic studies of patients with MS lesions. It is the logical and safe choice for diagnostic studies of patients with MS lesions. Harvard medical school series:

St Vincent’s series: Treated between 1998 and 2001 Treated between 1998 and 2001 CT-guided core needle biopsy has an accuracy of 80.3% CT-guided core needle biopsy has an accuracy of 80.3% 127 patients with a MS tumor 127 patients with a MS tumor Altuntas et al, ANZ J Surg 2005

CT-guided core needle biopsy is safe and effective for the diagnosis of MS lesions. CT-guided core needle biopsy is safe and effective for the diagnosis of MS lesions. biopsy should be conducted in the institution performing the definitive treatment biopsy should be conducted in the institution performing the definitive treatment Altuntas et al, ANZ J Surg 2005 St Vincent’s series:

430 pts with spine lesions 430 pts with spine lesions Treated from 1990 to 2005 Treated from 1990 to diagnostic biopsy 401 diagnostic biopsy Total accurancy of 93.3 % Total accurancy of 93.3 % 430 pts with spine lesions 430 pts with spine lesions Treated from 1990 to 2005 Treated from 1990 to diagnostic biopsy 401 diagnostic biopsy Total accurancy of 93.3 % Total accurancy of 93.3 % Rimondi et al, Eur Spine J 2008 Rizzoli series of the spine:

Rimondi et al, Eur Spine J 2008 Rizzoli series of the spine: Percutaneous CT-guided biopsy is considered the procedure of choice in spine lesions Percutaneous CT-guided biopsy is considered the procedure of choice in spine lesions If biopsy was not diagnostic, another trocar biopsy should be repeated If biopsy was not diagnostic, another trocar biopsy should be repeated

75-97 % histologic congruity between diagnosis at biopsy and definitive surgery % histologic congruity between diagnosis at biopsy and definitive surgery Quantity – Quality of the tissue Knowledge of the case Quantity – Quality of the tissue Knowledge of the case Surgical Pathologist

Surgical Pathologist must: Know the case Know the case Talk to surgeon and radiologist Talk to surgeon and radiologist Examine imaging studies Examine imaging studies Know the case Know the case Talk to surgeon and radiologist Talk to surgeon and radiologist Examine imaging studies Examine imaging studies

Conclusion Why CT-guided biopsy? Percutaneous CT-guided biopsy is: Percutaneous CT-guided biopsy is: - safe - speed - cheap Percutaneous CT-guided biopsy is: Percutaneous CT-guided biopsy is: - safe - speed - cheap

ConclusionsConclusions Percutaneous CT-guided biopsy is a useful technique that should be recommended for most of the bony lesions Percutaneous CT-guided biopsy is a useful technique that should be recommended for most of the bony lesions Careful selection of patients with previous accurate imaging Careful selection of patients with previous accurate imaging Ultrasound-guided biopsy with tru-cut is usually preferable for soft tissues Ultrasound-guided biopsy with tru-cut is usually preferable for soft tissues

ORTHOPEDICORTHOPEDIC PATHOLOGISTPATHOLOGIST RADIOLOGISTRADIOLOGIST A TEAM APPROACH APPROACH Gold standard ONCOLOGISTONCOLOGIST