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PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES

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

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PERCUTANEOUS CT-GUIDED BIOPSY OF THE MUSCULO-SKELETAL SYSTEM: RESULTS OF 1722 CASES

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  1. 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 Istituto Ortopedico Rizzoli- Universityof Bologna, Italy

  2. Management ofbonetumors Plain films Benign appearance Aggressive appearance Stop (for many) CT (if flat bone) MR Imaging benign malignant biopsy (if necessary) Stop (for many) biopsy (if necessary) CT/bone scan/ chest xray or CT biopsy

  3. Biopsyis the last stepof the staging biopsyis a compromise need to have significant tissue needtoavoid contamination (*local / bloodcircul.**) * Schwartz, AnnSurgOncol 1997 **Zoubek, Eur J Pediatry 1996

  4. Typesofbiopsy • Fine needle • Trocar • Incisional • Frozen • Excisional

  5. Roleof CT withcontrast • Size • Site • Morphology • Intra/extra compartmental • Neurovascular bundles

  6. Operative criteria • Choose the approach • Select the trocar • Where to get the sample

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

  8. Operative criteria:Select the trocar Big trocar, big sample

  9. Operative criteria:Wheretoget the sample

  10. Posterior approach for lesions of cervical spine

  11. Anterior approach for lesions of cervical spine A

  12. Lateral approach for lesions of cervical spine B

  13. Lesions of the thoracic spine

  14. Posterior approach for sacral lesions

  15. CT-guided trocar biopsy in 1722 ptsRizzoli 1990-2008 Mean age 46 ( SD ± 20)

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

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

  18. Rizzoli results: 1990 - 2008

  19. Rizzoli results: 1990 – 2008 Diagnostic Accuracy D.A. 76.5 % 1317 358 47

  20. Rizzoli results: 1990 - 2008

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

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

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

  24. Mankin HJ, et al.The hazardsofbiopsy in patientswithmalignantprimarybone and soft tissuetumors. • JBJS Am, 1982 • Mankin HJ, et al. • The hazardsofbiopsy, revisited: membersof the musculoskeletaltumor society. • JBJS Am, 1996 • Wrong diagnoses 17.8 % • Non representativebiopsies 8.4 % • Relatedcomplications 9.0 % • Consequentchanges in treatment and prognosis 10.0 % Differenciesbetweenbiopsiesperformed in specializedreferralCentersand non specializedhospitals. Sameresultsthan in 1982 study!

  25. Harvard medicalschoolseries: • 359 patients with a MS tumor • Treated between 1999 and 2000 • CT-guided core needle biopsy has an overall accuracy of 71% Hauetal, Skeletalradiol2002

  26. Harvard medical school series: • CT-guided core needle biopsy is better than fine needle aspiration biopsy for diagnosis • It is the logical and safe choice for diagnostic studies of patients with MS lesions. Hauetal, Skeletalradiol2002

  27. St Vincent’s series: • 127 patients with a MS tumor • Treated between 1998 and 2001 • CT-guided core needle biopsy has an accuracy of 80.3% Altuntasetal, ANZ J Surg2005

  28. St Vincent’s series: • 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 Altuntasetal, ANZ J Surg2005

  29. Rizzoli seriesof the spine: • 430 pts with spine lesions • Treated from 1990 to 2005 • 401 diagnostic biopsy • Total accurancy of 93.3 % Rimondi etal, Eur Spine J 2008

  30. Rizzoli seriesof the spine: • Percutaneous CT-guided biopsy is considered the procedure of choice in spine lesions • If biopsy was not diagnostic, another trocar biopsy should be repeated Rimondi etal, Eur Spine J 2008

  31. 75-97 % histologic congruity between diagnosis at biopsy and definitive surgery SurgicalPathologist Quantity – Quality of the tissue Knowledge of the case

  32. SurgicalPathologistmust: • Know the case • Talk to surgeon and radiologist • Examine imaging studies

  33. ConclusionWhyCT-guidedbiopsy? • Percutaneous CT-guided biopsy is: - safe - speed - cheap

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

  35. Gold standard PATHOLOGIST ORTHOPEDIC A TEAM APPROACH RADIOLOGIST ONCOLOGIST

  36. eugenio.rimondi@ior.it

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