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University of California San Francisco, CA 94117
We read with interest the article by Morrison et al. [1] in the June 2001 issue of the American Journal of Roentgenology. The title of this article, "Preoperative CT-Guided Hookwire Needle Localization of Musculoskeletal Lesions," leads the reader to expect information on the advantages and disadvantages of CT-guided hookwire needle localization of musculoskeletal lesions before surgery. However, the discussion focuses mainly on percutaneous, guided biopsy and, to a lesser extent, on surgical biopsy. The indications, principles, and techniques of these two procedures are completely different from those of hookwire needle localization. CT-guided hookwire placement is widely used for preoperative localization of breast microcalcifications and nonpalpable breast nodules, as well as of pulmonary nodules that are too small for percutaneous needle biopsy [2]. The technique has also been used for preoperative localization of deep osteoid osteomas, hepatic lesions, infratemporal fossa foreign bodies, and, more recently, deep intramuscular hemangiomas [3].
The hookwire technique for preoperative localization is used for lesions that are deep, small, or located in an organ whose shape and position may change with the position of the patient. Hookwire localization is intended to help the surgeon find the lesion during surgery, thus allowing minimally invasive treatment. This goal was not relevant in the five cases reported by Morrison et al. [1]. Because the ribs are superficial, the rib lesions could have been localized with precision simply by placing a skin marker. The focus of fixed popliteal soft-tissue calcification caused by recurrent osteosarcoma could have been easily removed by reopening the first incision.
It should be kept in mind that hookwire placement carries risks. In addition to possible dislodgement of the hookwire, other more serious problems can occur, such as transection of the wire during surgery with retention of the hook, or migration of the wire within the soft tissues of the thigh with breakage at the hooked end. The most severe complication is pneumothorax [4], which can occur as a result of wire migration into the chest wall during placement of the needle in the lesion. The advantages and disadvantages of hookwire localization must be carefully weighed against each other to determine whether the procedure is in the best interest of each individual patient.
References
Thomas Jefferson University Hospital Philadelphia, PA
19107
Wilford Hall Medical Center San Antonio, TX 78236
We appreciate the concerns expressed by Guermazi et al. regarding the needle localization technique discussed in our article, "Preoperative CT-Guided Hookwire Needle Localization of Musculoskeletal Lesions" [1]. However, we strongly dispute the assertion that rib lesions can be reliably localized with a skin marker. The oblique course of the ribs, mobility of the skin, and variability based on arm position, as well as the movement of the ribs during the breathing cycle, can cause tremendous difficulty for surgeons attempting to localize a rib lesion based on a skin mark. This difficulty is accentuated in obese patients and those with lesions beneath the scapula. In our opinion, preoperative radiologic localization of rib lesions using skin marking should be approached with caution, because it will lead to increased risk of resection of an incorrect rib.
We also dispute the claim that the recurrent osteosarcoma depicted "could have been easily removed by reopening the first incision." In this case, the lesion was within a region of scar tissue directly adjacent to the neurovascular bundle in the popliteal fossa. It was the opinion of the subspecialty orthopedic oncology surgeon that needle localization would allow the safest approach to the lesion and reduce risk of morbidity for the patient.
Regarding the risk of complications, one basic concept that should be emphasized is that preoperative needle localization should not be considered a procedure any less involved than a percutaneous biopsy. The potential for needle migration was one issue raised by Guermazi et al. We acknowledge this as a possible complication, but one that can be mitigated by careful planning and execution of the procedure. As with any biopsy, the needle entry site and tract to the lesion should be planned to avoid important structures. In the case of rib lesions, the needle tip should be positioned such that it is abutting the bone to prevent migration. When localizing lesions in bone with this technique, migration should theoretically be much less likely than it was in previously reported cases in which the needle was placed in loose soft tissues such as the breast or lung [2, 3]. In those rare situations in which the needle tip must be positioned within or next to a lesion in the soft tissues of the musculoskeletal system, planning is necessary to ensure that the needle course would not endanger any sensitive structures if it were to be advanced un-intentionally. After placement, the wire protuding from the skin can be bent with a hemostat so that it lies flush against the skin and cannot advance further. In our experience, no migration of the needle has occurred after placement.
Surgical complications such as wire transection or loss are minimized by effective communication with the referring surgeon. The surgeon should be made aware of the type of needle used, the length, and the precise location of the needle course, tip, and hook relative to adjacent structures. We routinely print a sheet of images of the procedure, including that of the final needle placement, which we send to the operating room along with the patient. Surgeons ordering this procedure are generally experienced at using hookwire localization of other organ systems; however, the radiologist performing the localization should discuss the technique with the surgeon to ensure that he or she is familiar with the procedure.
Keeping these potential limitations in mind, we reiterate that needle localization of musculoskeletal lesions is a useful and safe technique; however, it should be primarily reserved for situations in which the alternatives, percutaneous biopsy or nonguided open surgical biopsy, would place the patient at even greater risk.
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