DOI:10.2214/AJR.07.3138
AJR 2008; 190:W283-W289
© American Roentgen Ray Society
CT-Guided Biopsy of Bone: A Radiologist's Perspective
Leandro A. Espinosa1,
David A. Jamadar1,
Jon A. Jacobson1,
Michel O. DeMaeseneer2,
Farhad S. Ebrahim3,
Brian J. Sabb1,
Matthew T. Kretschmer1,
Janet S. Biermann4 and
Sung-Moon Kim1
1 Department of Radiology, University of Michigan Hospitals, 1500 E Medical
Center Dr., Ann Arbor, MI 48109.
2 Division of Radiologic Sciences, Wake Forest University, Winston-Salem,
NC.
3 Department of Radiology, University of Toledo Medical Center, Toledo,
OH.
4 Department of Orthopedic Surgery, University of Michigan Hospitals, Ann Arbor,
MI.
Received September 10, 2007;
accepted after revision November 16, 2007.
WEB
This is a Web exclusive article.
Address correspondence to D. A. Jamadar
(djamadar{at}med.umich.edu).
Abstract
OBJECTIVE. We present an overview of approaches for bone biopsy used
to minimize potential tumor seeding of adjacent soft-tissue structures and
compartments. We discuss a variety of approaches related to specific anatomic
parts and review pertinent anatomy.
CONCLUSION. We provide important guidelines and key examples that
will help readers perform percutaneous needle bone biopsy safely.
Keywords: bone biopsy • bone cancer • CT-guided biopsy • metastases • oncologic imaging
Introduction
Percutaneous needle bone biopsy is a safe and accurate method
[1–5]
for obtaining a tissue diagnosis. In general, superior results are obtained
with lesions in the extremities or pelvis compared with those in the spine
[6]. Percutaneous needle
biopsies have a very low complication rate (1.1%), whereas open biopsy has a
complication rate of up to 16%
[7]. A concerning complication
of percutaneous biopsy is the risk of seeding malignant cells along the needle
track, particularly if the lesion is a sarcoma, which would necessitate
resection of the needle track en bloc with the tumor at limb-sparing
reconstructive surgery [8].
Thus, choosing the appropriate needle path is critical for limb-salvage
procedures.
We discuss our general approach to percutaneous biopsy of bone and focus on
specific topographic approaches used for various anatomic areas of the
skeletal system. We describe our preferred biopsy route to complement
limb-sparing surgical resection in the event of malignant seeding along the
needle track. In addition, we describe other techniques, such as CT gantry
angling, periosteal sampling, and extrapleural saline infiltration for biopsy
of paraspinal lesions.
General Points
Thorough prebiopsy imaging review is essential, and further imaging may be
necessary. Close attention should be paid to evaluating the extent of the
lesion and whether skip lesions are present because these factors determine
the extent of resection and the feasibility of limb-salvage surgery. The
imaging findings should be correlated with patient symptoms and findings on
functional studies, such as PET and bone scanning, if indicated. In patients
with multiple lesions, the lesion that is most amenable to biopsy, allowing
the highest yield with the lowest risk of complications, is selected.
The presence of multiple lesions is also important because biopsy of a
potential metastasis has different considerations compared with biopsy of a
primary bone tumor. Fine-needle aspiration (FNA) can differentiate a
metastasis from a benign lesion; however, core biopsy is superior to FNA in
determining cell type and tumor grade, which is necessary for the diagnosis of
primary bone tumor. Primary bone tumors necessitate thoughtful percutaneous
track planning with limb-sparing resection and rehabilitation in mind, whereas
for metastases, the route is less important because seeding is of questionable
concern and the shortest and most direct route is usually used. As a general
rule, if the lesion is not metastatic—that is, if it is a primary bone
tumor or there is uncertainty about metastatic disease, we treat it as if
seeding of the biopsy track may occur and an appropriate percutaneous route is
used.
At the University of Michigan Hospitals, we use three different needles
(Fig. 1) of a variety that are
available for bone biopsy [9].
A 14-gauge coaxial bone biopsy system with an eccentric drill tip (Bonopty
bone biopsy system, C. R. Bard, Inc.) is used to obtain tissue from sclerotic
lesions and lesions with an intact cortex. The excentric bit allows a channel
to be drilled just wider than the external diameter of the cannula of the
coaxial system, so the cannula can be advanced and can act as a coaxial
introducer. Through this introducer, the bone biopsy component of this system
may be used, but also a soft-tissue "gun" or a fine-needle
aspirate may be obtained [10].
A 16-gauge biopsy needle (Quick-Core, Cook) is used to sample a soft-tissue
mass external to bone, but it also works well through the 14-gauge Bonopty
coaxial system to biopsy a soft-tissue mass within bone. An 11-gauge needle
system (InterV Traplok, Medical Device Technologies, Inc.) provides a large
specimen core and is used for lesions containing cystic and necrotic
components, but in our experience, it is not as effective as the Bonopty
coaxial system for sclerotic lesions and where a normal (or thickened) cortex
of bone needs to be traversed. Also, once the biopsy sample has been taken
with the InterV Traplok system, if a second core is required, the entire
system must be repositioned.
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1 —Photograph shows three needle types for biopsy of bone
lesions. First type is Bonopty coaxial system (C. R. Bard, Inc.) (A).
Introducer (1) with trocar (below) traverses soft tissue. Trocar is removed to
allow drill bit (2) to replace it and traverse bone. Note cutting portion of
drill bit (straight arrow). Once in position, bit is removed to allow
bone biopsy needle (3) with trocar (below) to be positioned. Once positioned,
biopsy needle trocar is removed and biopsy sample is obtained. Second type is
Quick-Core biopsy "gun" (B) (Cook) for soft-tissue cores only.
Note illustrated needle is 9 cm long; a longer needle is required to fit
through Bonopty coaxial system. Third type of needle is 11-gauge InterV
Traplok system (C) (Medical Device Technologies, Inc.). Note detail of trap
device (curved arrow) to help retain biopsy tissue core within
needle.
|
|
In general, we perform all bone biopsies with the patient under conscious
sedation using local anesthesia; however, general anesthesia may be necessary
in children or uncooperative patients. Painful lesions, such as neurogenic
tumors, or lesions in the hand and foot may require a regional nerve block.
Liberal periosteal anesthetic infiltration is often helpful to minimize
pain.
If a soft-tissue mass is associated with a destructive bone lesion, the
biopsy may be taken from the soft-tissue component and, if possible, a biopsy
of an intraosseous part of the mass should also be obtained. The enhancing
regions of a soft-tissue mass as seen on contrast-enhanced CT or MRI should be
sampled, as should the center and periphery of the lesion. In addition, if a
mass is calcified or ossified, sampling the least mineralized portion often
shows the highest atypia. Biopsy samples from two or three different locations
in a single lesion, especially a large lesion, may be obtained.
An adequate biopsy sample is one that provides enough abnormal tissue for a
pathologist to comfortably make a diagnosis. We have found that with an
11-gauge needle, a single long core of abnormal tissue has been enough, and we
frequently divide this core into two pieces, one piece each for histology and
bacteriology. If the lesion is large, two or three cores obtained with a 14-
or 16-gauge needle have proved adequate, but five to eight or more cores may
be necessary if the cores are obtained with a small-gauge needle; we rarely
obtain such small cores of tissue. Two or three partial cores count as a
"single" core, and all fluid aspirated is sent routinely for
evaluation. With cystic lesions or lesions in which the majority of the lesion
is necrotic, we obtain multiple cores through both the superficial and deep
margins of the lesion. If blood is aspirated from the lesion, the clotted
blood should be sent for pathologic evaluation.
Differentiating infection from tumor is difficult because infection often
appears aggressive at imaging and may simulate malignancy. For this reason, we
suggest that at the time of biopsy the specimens be sent for both pathologic
and bacteriologic evaluations. In hemorrhagic lesions, postbiopsy embolization
of the needle track using a hemostatic agent, such as an absorbable collagen
hemostatic sponge (Helitene, Integra LifeSciences Corporation), may limit
bleeding.
The shortest path between skin and lesion that avoids neurovascular and
joint structures, lung, bowel, and other organs is optimal. For primary bone
lesions for which limb-sparing surgery is contemplated, every effort must be
made not to contaminate a disease-free compartment. If a sarcoma or a primary
tumor is suspected, seeding is a concern, and further specific principles are
followed: First, the needle path must be close to the incision for the
definitive limb-sparing surgery so that the needle path can be resected.
Second, the needle should not traverse an uninvolved compartment, joint, or
neurovascular bundle. This is particularly relevant if these structures are
needed for reconstruction. Third, avoiding the physes will allow the option of
physis-sparing surgery in the skeletally immature. The biopsy should be
considered part of the surgical therapy, and a team approach with the surgical
oncology team is critical for a positive outcome. We recommend that the biopsy
route should always be discussed with the surgeon treating the patient before
biopsy of a suspected primary bone tumor
[8,
11].
The Upper Limb
The Shoulder
The deltoid and pectoral muscles are typically used for reconstruction at
the shoulder. Because the deltoid muscle is innervated by the axillary nerve
from posterior to anterior, en bloc resection of a posterior needle track may
denervate and leave functionless the more anterior muscle (Fig.
2A,
2B). A proximal humeral lesion
should be approached through the anterior third of the deltoid
(Fig. 3). The deltopectoral
groove is to be avoided because this approach may compromise the use of
pectoral muscle for reconstruction and may contaminate the main neurovascular
bundle of the upper limb.
View larger version (54K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —Shoulder illustrations. Axial (A) and coronal
(B) shoulder illustrations show zones permissible for biopsy
(green) including anterior deltoid (Y). Areas outlined in blue should
be avoided, such as posterior deltoid (N). Note deltopectoral groove
(straight arrows), neurovascular structures (curved arrow,
A), and cephalic vein (blue, B).
|
|
View larger version (73K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —Shoulder illustrations. Axial (A) and coronal
(B) shoulder illustrations show zones permissible for biopsy
(green) including anterior deltoid (Y). Areas outlined in blue should
be avoided, such as posterior deltoid (N). Note deltopectoral groove
(straight arrows), neurovascular structures (curved arrow,
A), and cephalic vein (blue, B).
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3 —63-year-old man with grade I chondroblastoma. Axial CT
section of left shoulder shows 11-gauge biopsy needle (arrows) with
tip within sclerotic lesion in humeral head (H). Anterior approach through
anterior portion of deltoid muscle (D) was used.
|
|
The Forearm
The interosseous membrane between the radius and ulna forms a natural
barrier to the spread of tumor. When sampling lesions through the extensor
compartment, the flexor compartment should not be traversed and vice versa
(Figs. 4 and
5). It is optimal to biopsy the
ulna at its subcutaneous border; if this approach is not possible,
contamination of the extensor carpi ulnaris or flexor carpi ulnaris is
associated with the least morbidity after resection.
View larger version (59K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4 —Illustration of forearm in axial plane. Interosseous membrane
(arrows) separates extensor (E) and flexor (F) compartments. Special
care should be taken not to violate interosseous membrane, thus avoiding
contamination of multiple compartments. R = radius, U = ulna.
|
|
View larger version (75K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5 —20-year-old woman with enchondroma of radius. Axial CT image
through forearm shows 11-gauge needle (arrow) with tip in radius
(asterisk). Care is taken not to traverse interosseous membrane.
|
|
The Pelvis and Lower Limb
The Pelvis
For primary lesions of bone, if at all possible, avoid traversing the
gluteal muscles posteriorly and the rectus femoris muscle anteriorly
(Fig. 6). Resection of the
gluteal muscles is associated with a poor outcome after limb-sparing surgery
because these muscles provide a significant proportion of functionality after
surgery. An anterior or posterior approach through the ilium avoids the
gluteal musculature (Fig. 7).
If the lesion is a suspected metastasis, stabilization with hardware rather
than resection may be used; therefore, the shortest path may be chosen
(Fig. 8).
View larger version (59K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6 —Illustrations of pelvis at level of iliac bone
(right) and inferior pubic ramus (left). Gluteus muscle
group (G) and rectus femoris muscle (arrowhead) must be avoided.
Ideal approach is directly into iliac bone (arrows), either anterior
or posterior.
|
|
View larger version (90K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7 —74-year-old man with osteoblastic osteosarcoma. Axial CT
image of pelvis with patient prone shows 14-gauge needle (black
arrow) with tip within lesion (white arrow). Posterior approach
through iliac bone, thus avoiding gluteal muscles (G), was used.
|
|
View larger version (89K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8 —70-year-old man with metastatic lung cancer. Axial CT scan
through pelvis shows lytic metastasis in left anterior iliac bone
(asterisk); 18-gauge needle (arrow) (Quick-Core, Cook) is
seen traversing lytic lesion.
|
|
The Thigh
An anterior approach through the rectus femoris muscle should be avoided
(Fig. 9). Resection of these
extensor muscles—in particular, the rectus femoris muscle—provides
suboptimal results during limb-sparing surgery. If a lesion is closely apposed
to the femoral vessels, a medial approach is preferred because a medial
incision facilitates vessel exploration. The lateral approach is often more
ergonomically feasible and avoids the medial neurovascular structures,
especially if the vastus lateralis muscle is involved without vascular
involvement (Fig. 10A,
10B). In the distal thigh, the
suprapatellar recess may extend for a varying distance proximally and should
be avoided along with the remainder of the knee joint. For a medial approach,
we may either elevate the leg to be biopsied or flex and externally rotate the
contralateral hip to provide easy access to the medial thigh.
View larger version (49K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9 —Illustration of axial thigh. Rectus femoris muscle (RF) and
hamstrings (HAM) are to be avoided. Medial or lateral approach through vastus
medius (VM) and vastus lateralis (VL) is preferred. F = femur.
|
|
View larger version (147K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10A —58-year-old man with metastatic adenocarcinoma. Coronal
T2-weighted MR image shows marrow replacement in distal femur (F), soft-tissue
signal abnormality (arrows) surrounding medial distal femur, and
adjacent intramedullary low signal (arrowheads).
|
|
The Leg
The interosseous membrane between the tibia and fibula is a natural barrier
to tumor spread. Because the anterior medial tibia is subcutaneous, both
compartments may be avoided (Figs.
11 and
12).
View larger version (90K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12 —52-year-old woman with enchondroma. Axial CT scan of left leg
shows 14-gauge core biopsy needle (arrows) traversing tibia (T)
through anteromedial approach. Note marrow replacement of tibia.
|
|
Difficult Anatomic Regions
The Hand and Foot
The complex anatomy of the hand and foot necessitates discussion with a
surgeon in planning a biopsy route. Patients undergoing biopsy of these
sensitive areas may benefit from a regional nerve block. We try to avoid
traversing the sole of the foot or the palm of the hand
(Fig. 13) because these areas
are more sensitive to pain. Initial needle stabilization in a structure with
little subcutaneous tissue at CT-guided biopsy may be challenging
(Fig. 14) and often requires
sterile towels around the needle for support.
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 13 —34-year-old woman with right first metatarsal osteoma. Axial
CT scan of right foot shows 11-gauge biopsy needle (arrow) sampling
osteoma (asterisk) in medial aspect of first metatarsal (T).
|
|
View larger version (80K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 14 —20-year-old woman with enchondroma of radius. Axial CT scan
of right forearm shows biopsy needle (arrows). Because of little
surrounding tissue in distal extremity to stabilize needle during
imaging-guided placement, sterile towel (T) was rolled and used to support
needle.
|
|
The Ribs
The diagnostic yield from a rib biopsy is higher if there is an associated
soft-tissue mass (Fig. 15).
The convex superficial surface, small size, and adjacent lung make these
biopsies challenging. A tangential approach rather than one perpendicular to
the pleura is favored to minimize risk of pneumothorax.
The Spine
Typically, vertebral body lesions are biopsied using an approach through
the pedicles (Fig. 16).
However, if the epicenter of the lesion is not accessible through the
pedicles, a costovertebral approach may be considered
(Fig. 17). Injection of saline
into the soft tissues may be used to displace tissue away from the spine and
displace the adjacent lung away from the needle path (Fig.
18A,
18B).
View larger version (118K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 17 —61-year-old woman with nodular sclerosing Hodgkin's disease
treated with radiation. Axial image of spine shows 16-gauge core biopsy needle
(arrow) through lytic vertebral lesion (arrowhead) using
costovertebral approach.
|
|
View larger version (99K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 18A —56-year-old woman with metastatic lung cancer. Axial image of
spine shows 22-gauge spinal needle (arrow) in posterior paraspinal
soft tissues (arrowhead), through which saline was injected to
displace lung away from biopsy needle path.
|
|
Periosteal Sampling
Infrequently, the anatomy or the density of a bone may make obtaining a
bone sample difficult. If periosteal bone apposition is present, a sample
obtained here may yield a diagnosis (Fig.
19).
View larger version (65K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 19 —45-year-old man with parosteal osteosarcoma. Axial image of
left arm shows 11-gauge biopsy needle (arrow) sampling periosteal
bone apposition (arrowhead) adjacent to humerus (H) via preferred
anterior transdeltoid approach.
|
|
Gantry Angling
This technique is useful when trying to avoid traversing a compartment, as
in the pelvis. The axial plane may not include both the optimal entry point of
the needle and the target. By angling the gantry, the entry point and the
target may be on a single image or, more commonly, on a smaller number of
images, facilitating more accurate needle alignment and a less complicated
biopsy (Fig. 20A,
20B,
20C,
20D).
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 20B —52-year-old man with grade II chondrosarcoma. Sequential
axial CT section through pelvis with gantry angled shows needle
(arrow) entering anteriorly at iliac bone (I), path oblique to CT
scan plane.
|
|
View larger version (107K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 20C —52-year-old man with grade II chondrosarcoma. Sequential
axial CT section through pelvis with gantry angled shows needle
(arrow) oblique to CT scan plane with distal tip at tumor
(arrowhead).
|
|
View larger version (108K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 20D —52-year-old man with grade II chondrosarcoma. Sequential
axial CT section through pelvis with gantry angled shows needle
(arrow) oblique to CT scan plane with distal tip having traversed
tumor (arrowhead).
|
|
Conclusion
In conclusion, by communicating with the surgical team and following some
basic principles, we can obtain adequate samples of tissue and minimize the
surgical implications of seeding the needle track in the biopsy of primary
tumors of bone.
References
- Altuntas AO, Slavin J, Smith PJ, et al. Accuracy of computed
tomography guided core needle biopsy of musculoskeletal tumours.
ANZ J Surg 2005;75
: 187–191[CrossRef][Medline]
- Jelinek JS, Murphey MD, Welker JA, et al. Diagnosis of primary bone
tumors with image-guided percutaneous biopsy: experience with 110 tumors.
Radiology 2002;223
: 731–737[Abstract/Free Full Text]
- Leffler SG, Chew FS. CT-guided percutaneous biopsy of sclerotic
bone lesions: diagnostic yield and accuracy. AJR1999; 172:1389
–1392[Abstract/Free Full Text]
- Ashford RU, McCarthy SW, Scolyer RA, Bonar SF, Karim RZ, Stalley
PD. Surgical biopsy with intraoperative frozen section: an accurate and
cost-effective method for diagnosis of musculoskeletal sarcomas. J
Bone Joint Surg Br 2006; 88:1207
–1211[CrossRef][Medline]
- Fraser-Hill MA, Renfrew DL, Hilsenrath PE. Percutaneous needle
biopsy of musculoskeletal lesions. Part 2. Cost-effectiveness.
AJR 1992; 158:813
–818[Abstract/Free Full Text]
- Hau A, Kim I, Kattapuram S, et al. Accuracy of CT-guided biopsies
in 359 patients with musculoskeletal lesions. Skeletal
Radiol 2002; 31:349
–353[CrossRef][Medline]
- Welker JA, Henshaw RM, Jelinek J, Shmookler BM, Malawer MM. The
percutaneous needle biopsy is safe and recommended in the diagnosis of
musculoskeletal masses: outcomes analysis of 155 patients at a sarcoma
referral center. Cancer 2000;89
:2677
–2686[CrossRef][Medline]
- Anderson MW, Temple HT, Dussault RG, Kaplan PA. Compartmental
anatomy: relevance to staging and biopsy of musculoskeletal tumors.
AJR 1999; 173:1663
–1671[Abstract]
- Roberts CC, Morrison WB, Leslie KO, Carrino JA, Lozevski JL, Liu
PT. Assessment of bone biopsy needles for sample size, specimen quality and
ease of use. Skeletal Radiol 2005;34
: 329–335[CrossRef][Medline]
- Logan PM, Connell DG, O'Connell JX, Munk PL, Janzen DL.
Image-guided percutaneous biopsy of musculoskeletal tumors: an algorithm for
selection of specific biopsy techniques. AJR1996; 166:137
–141[Abstract/Free Full Text]
- van der Bijl AE, Taminiau AH, Hermans J, Beerman H, Hogendoorn PC.
Accuracy of the Jamshidi trocar biopsy in the diagnosis of bone tumors.
Clin Orthop Relat Res 1997;334
: 233–243[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
