Current concepts in the biopsy of musculoskeletal tumors

Abstract

In the management of bone and soft tissue tumors, accurate diagnosis, using a combination of clinical, radiographic, and histological data, is critical to optimize outcome. On occasion, diagnosis can be made by careful history, physical examination, and images alone. However, the ultimate diagnosis usually depends on histologic analysis by an experienced pathologist. Biopsy is a very important and complex surgery in the staging process. It must be done carefully, so as not to adversely affect the outcome. Technical considerations include proper location and orientation of the biopsy incision and meticulous hemostasis. It is necessary to obtain tissue for a histological diagnosis without spreading the tumor and so compromise the treatment. Furthermore, the surgeon does not open compartmental barriers, anatomic planes, joint space, and tissue area around neurovascular bundles. Nevertheless, avoid producing a hematoma. Biopsy should be carefully planned according to the site and definitive surgery and should be performed by an orthopedic surgeon with an experience in musculoskeletal oncology who will perform the definitive surgery. Improperly done, it can complicate patient care and sometimes even eliminate treatment options. Different biopsy techniques are suitable: fine-needle aspiration, core-needle biopsy, and incisional biopsy. The choice of biopsy depends on the size, the location of the lesion, and the experience of the pathologist.

Figure 1

Sagittal MRI T2 (a), coronal MRI T1 (b), and axial MRI fat sat (c) scans of the right foot show heterogeneous intratumoral hypointensive signal on T1 and hyperintensive signal on T2. Incisional biopsy is made by (d) a small longitudinal incision between the second and third metatarsals; then (e) once the tumor capsule is found, (f) the tissue sampling is done with cold knife. Diagnosis: soft tissue chondroma.

Figure 2

Sagittal MRI T1 (a), coronal MRI STIR (b), and axial MRI T2 (c) scans of the right thigh show heterogeneous intratumoral hypointensive signal on T1 and hyperintensive signal on T2 in the diaphysis of the femur. An 8-gauge core-needle bone biopsy inserted under CT guide (d) into marrow of the right femur (e). Diagnosis: Lymphoma.

Figure 3

Coronal MRI STIR (a), sagittal MRI T2 (b), and axial MRI T1 (c) scans of the left thigh show homogeneous intratumoral hypointensive signal on T1 and hyperintensive signal on T2. A 14-gauge ultrasound-guided soft tissue percutaneous biopsy (d) of the left tight. Diagnosis: schwannoma.