AJR 2001; 176:1531-1533
© American Roentgen Ray Society
Preoperative CT-Guided Hookwire Needle Localization of Musculoskeletal Lesions
William B. Morrison1,
Timothy G. Sanders2,
Theodore W. Parsons3 and
Brian J. Penrod4
1
Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th
St., Philadelphia, PA 19107.
2
Department of Radiology, Wilford Hall Medical Center, 2200 Bergquist Dr.,
Lackland AFB, San Antonio, TX 78236.
3
Department of Orthopedic Surgery, Wilford Hall Medical Center, Lackland AFB,
San Antonio, TX 78236.
4
Department of Radiology, Brooke Army Medical Center, Ft. Sam Houston, San
Antonio TX, 78216.
Received August 9, 2000;
accepted after revision November 10, 2000.
Address correspondence to W. B. Morrison.
Introduction
Use of hookwire needles for preoperative localization of breast lesions and
pulmonary nodules
[1,2,3,4,5,6]
is advantageous because the needle can be precisely positioned via imaging
guidance; the hook keeps the needle in position so that the patient can be
transported to the surgical suite for excision of the suspicious area. This
technique can also be applied to lesions of the musculoskeletal system.
Preoperative wire localization of osteoid osteoma has been described
[7,8].
Although these lesions are now often ablated percutaneously by the radiologist
[9], there are other potential
indications for this technique. In rare instances, a bone or soft-tissue
lesion is difficult to biopsy safely via a percutaneous procedure and is
problematic for open surgical biopsy because of its small size, a location
precariously close to vessels and nerves, adjacent scar tissue, or distorted
anatomy. In these situations, CT-guided hookwire needle localization of the
lesion before surgical biopsy may be the best option for the patient.
Materials and Methods
Over the course of 3 years, five patients underwent preoperative hookwire
needle localization of musculoskeletal lesions—three sclerotic rib foci,
one paraspinal soft-tissue lesion, and one popliteal fossa soft-tissue lesion.
All procedures were performed using a helical CT scanner (HiSpeed Advantage;
General Electric Medical Systems, Milwaukee, WI). Through consultation with
the surgeon, we determined the optimal skin entry region for the surgical
approach in each patient. Initially, patients were scanned with 5-mm sections
through the area of suspected lesion so that we could plan the site, depth,
and angulation of needle entry. The skin was marked with a surgical marker and
cleansed with povidone-iodine. The length of the hookwire needle (Hawkins II
Flexstrand BLN; Medical Device Technologies, Gainesville, FL) to be used was
determined by the depth required to reach the lesion, with an additional 5-10
cm external to the skin margin. The needle tip was placed at the desired site
next to or within the lesion using CT guidance. When the tip was optimally
positioned, the hookwire was deployed by pulling back the outer sheath
(Fig. 1); follow-up
thin-section CT confirmed final placement and served as a surgical guide. The
wire end external to the skin was coiled loosely and packed in sterile fashion
with gauze and tape. The patient was then transferred to the surgical suite
for excision of the lesion.
Results
Surgical excision of the lesion was performed in all patients without
complication. Pathologic findings for the five patients were the following:
metastatic carcinoid tumor in the rib (Fig.
2A,2B),
fibrous dysplasia in the rib, healthy rib bone with a presumed diagnosis of
bone island (no further follow-up data is available), liposarcoma in the
paraspinal tissue, and recurrent osteosarcoma in the popliteal fossa (Fig.
3A,3B).
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Fig. 2A. —45-year-old man with history of thymic carcinoid tumor who
presented with rib pain associated with solitary sclerotic bone lesion. After
hookwire needle localization and resection, histologic diagnosis of metastatic
carcinoid tumor was made. 99mTc-methylene diphosphonate bone scan
shows focal uptake (arrow) in one rib. No other sites of abnormal
uptake were observed.
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Fig. 2B. —45-year-old man with history of thymic carcinoid tumor who
presented with rib pain associated with solitary sclerotic bone lesion. After
hookwire needle localization and resection, histologic diagnosis of metastatic
carcinoid tumor was made. CT scan through ribs shows small sclerotic lesion
(open arrow) with intact overlying cortex and no soft-tissue mass.
Hookwire needle tip (solid arrow) has been positioned adjacent to
lesion.
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Fig. 3A. —18-year-old woman with history of distal femoral osteosarcoma
and limb-sparing surgery using femoral allograft. Routine follow-up
radiography showed focus of calcification in popliteal soft tissues suggestive
of recurrence. Lesion hardness would have made percutaneous biopsy difficult,
and standard open surgical biopsy would have been complicated by scarring and
proximity to neurovascular structures. After CT-guided placement of hookwire
needle at anterior margin of lesion (away from popiteal vessels), safe
surgical excision was performed. Diagnosis of recurrent osteosarcoma was
confirmed histologically. Lateral radiograph of knee shows postoperative
changes of distal femoral resection and allograft placement. Note small focus
of calcification (arrow) in adjacent popliteal soft tissues.
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Fig. 3B. —18-year-old woman with history of distal femoral osteosarcoma
and limb-sparing surgery using femoral allograft. Routine follow-up
radiography showed focus of calcification in popliteal soft tissues suggestive
of recurrence. Lesion hardness would have made percutaneous biopsy difficult,
and standard open surgical biopsy would have been complicated by scarring and
proximity to neurovascular structures. After CT-guided placement of hookwire
needle at anterior margin of lesion (away from popiteal vessels), safe
surgical excision was performed. Diagnosis of recurrent osteosarcoma was
confirmed histologically. CT scan shows calcified lesion abutting popliteal
vessels posteriorly (short arrows). Note precise placement of
hookwire needle tip (long arrow) at anterior margin of calcified
lesion.
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Discussion
Most musculoskeletal lesions can be safely accessed percutaneously with an
imaging-guided biopsy needle. However, in some rare cases, this technique can
be extremely difficult or carry a risk that is excessive when compared with
the chances of success. These situations include small lesions in small,
curved bones, such as rib lesions; lesions with overlying sclerotic bone or
thick cortex with no soft-tissue extension or access for a drill; hard lesions
in soft tissue, such as calcifications, which would be pushed away by the
biopsy needle; and lesions with a high risk for bleeding, such as a vascular
lesion in noncompressible tissues. Other lesions set for open surgical biopsy
may carry greater risk or less chance for success because of their small size
or contiguity with major blood vessels or nerves. Some surgeons may prefer an
open surgical approach to percutaneous biopsy. In these situations, hookwire
needle localization of the lesion using principles and techniques used for
years to locate breast lesions before surgery can potentially decrease
operative morbidity and increase the rate of success in obtaining a diagnostic
sample. However, caution must be exercised in regard to forceful placement of
the thin hookwire needle into hard structures, such as bone, if fracture of
the wire is to be avoided.
Our report has limitations that should be acknowledged. First, the small
number of patients precludes an in-depth analysis of the efficacy of and
specific indications for use of this technique. Also, we did not compare this
technique with more standard biopsy techniques.
In summary, CT-guided percutaneous hookwire needle localization of
musculoskeletal lesions is a simple procedure that may be effective in
facilitating surgical localization and biopsy and warrants further study.
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Introduction
Materials and Methods
