The tactics and technique of musculoskeletal biopsy

Abstract

The treatment of musculoskeletal neoplasms and infection is usually based on an initial diagnostic biopsy.Prior to biopsy, a hypothesis should be formed about the most likely diagnosis and a differential diagnosis. These deliberations should consider whether the lesion is a primary benign or malignant tumour, a metastasis, a haematological problem or an infection.A tactical plan should be developed which evaluates the necessity, the risk, the approach and finally defines the technique of biopsy most likely to achieve a representative result in the clinical case.In developing this technical approach, the pitfalls should be anticipated, i.e. inadequate sampling, difficulty of pathological interpretation and contamination.The tactical approach should be developed in conjunction with a multi-disciplinary team together with appropriate pre-biopsy imaging. Cite this article: EFORT Open Rev 2017;2:51-57. DOI: 10.1302/2058-5241.2.160065.

Keywords: biopsy techniques; complications; imaging; multi-disciplinary approach; musculoskeletal; tumours.

Fig. 1

Microphotographs of haematoxylin and eosin (H&E)-stained histological section of a core biopsy of a classical bone lymphoma: low power view (left side, 50× magnification) shows the characteristic shearing artefact with streaks of disrupted tumour cell nuclei, obliterating the nuclear detail and often preventing diagnosis in most segments of the biopsy tissue (left side). Focal preservation of the characteristic cellular and nuclear detail with clear cytoplasm and polylobated nuclei with somewhat coarser chromatin at high power magnification (right side, 400× magnification) leads to the correct diagnosis of diffuse large cell lymphoma.

Fig. 2

The spring-loaded CareFusion® Core Biopsy device with the cannula for co-axial procedures.

Fig. 3

CareFusion® T-handle Jamshidi® bone biopsy set.

Fig. 4

The cannulated power drill system for larger core bone biopsies with rongeurs that can be inserted through the drill holes after removal, especially in cystic lesions.

Fig. 5

Fine rongeur, that can be inserted through the cannulated drill or even through the 8G Jamshidi needle shown in Fig. 2.

Fig. 6

a) Mass involving the sacrum. Dilated neurogenic bladder. Two non-diagnostic posterior core biopsies, one non-diagnostic open posterior biopsy. b) Nine months following the first non-diagnostic needle and open posterior attempts the diagnostic transforaminal (S2) CT-guided rongeur biopsy was performed by the author. Ewing sarcoma: top: posterior entry of the rongeur; bottom: rongeur within the pre-sacral lesion.

Fig. 7

Metastasis of cholangiocarcinoma (left). The metastasis was successfully inactivated by radiofrequency. The needle was removed after cooling. A new metastasis and biopsy proven contamination of the biopsy path is shown on the right.