Percutaneous image-guided needle biopsy of clavicle lesions: a retrospective study of diagnostic yield with description of safe biopsy routes in 55 cases

A Rare Case of Mid-clavicular Ewing Sarcoma Treated With Total Claviculectomy: A Case Report and Literature Review

Ewing sarcoma of the clavicle is an extremely rare tumor. The currently available evidence is limited to a small number of case reports. We present a case of a 13-year-old female patient referred to our tertiary care center with a progressively growing lump over the mid-clavicular, mystically diagnosed as a benign lipoma in a rural hospital. Radiological investigations and histopathological examination confirmed the diagnosis of metastatic Ewing sarcoma of the mid-clavicle. We outlined the management plan done for this patient followed by a description of the surgical technique of the total claviculectomy performed. Furthermore, we conducted a literature review on the available evidence on this topic and the functional outcomes of partial and total claviculectomy with or without reconstruction.

Ultrasound-Guided Percutaneous Bone Biopsy: Feasibility, Diagnostic Yield and Technical Notes

While nowadays, CT-guided bone biopsy represents the gold standard tool for histopathological and microbiological diagnosis of skeletal lesions, the role of US-guided bone biopsy has not yet been fully explored. US-guided biopsy offers several advantages, such as the absence of ionizing radiation, fast acquisition time, as well as good intra-lesional echo, and structural and vascular characterization. Despite that, a consensus in regard to its applications in bone neoplasms has not been established. Indeed CT-guided technique (or fluoroscopic ones) still represents the standard choice in clinical practice. This review article aims to review the literature data about US-guided bone biopsy, underlying clinical-radiological indications, advantages of the procedure and future perspectives. Bone lesions taking the best advantages of the US-guided biopsy are osteolytic, determining the erosion of the overlying bone cortex and/or with an extraosseous soft-tissue component. Indeed, osteolytic lesions with extra-skeletal soft-tissue involvement represent a clear indication for US-guided biopsy. Moreover, even lytic bone lesions with cortical thinning and/or cortical disruption, especially located in the extremities or pelvis, can be safely sampled with US guidance with very good diagnostic yield. US-guided bone biopsy is proven to be fast, effective and safe. Additionally, it offers real-time needle evaluation, an advantage when compared to CT-guided bone biopsy. In the current clinical settings, it seems relevant to select the exact eligibility criteria for this imaging guidance since the effectiveness can vary depending on the type of lesion and body site involved.

Clavicular Malignancies: A Borderline Surgical Management

Nearly 1% of all bone cancers are primary clavicular tumors and because of their rarity, treating clinicians are unfamiliar with their diagnosis, classification, treatment options, and prognosis. In terms of preserving function and avoiding complications, clavicle reconstruction seems logical; however, further studies are needed to support this measure. Reconstruction techniques are difficult taking into account the anatomical structures surrounding the clavicle. When chest wall defects are present, a multidisciplinary team, including an orthopedist and thoracic and plastic surgeons, is of paramount importance for optimal surgical management. Malignant clavicle tumors may include primary and secondary malignancies and neighboring tumors with clavicular invasion. Surgical resection of complex thoracic tumors invading the clavicles can result in larger defects, requiring chest wall reconstruction, which is a substantial challenge for surgeons. Correct diagnosis with proper preoperative planning is essential for limiting complications. Post-resection reconstruction of the partial or total claviculectomy is important for several reasons, including maintaining the biomechanics of the scapular girdle, protecting the vessels and nerves, reducing pain, and maintaining the anatomical appearance of the shoulder. The chest wall resection and reconstruction techniques can involve either partial or full chest wall thickness, influencing the choice of reconstructive technique and materials. In the present paper, we aimed to synthesize the anatomical and physiopathological aspects and the small number of therapeutic surgical options that are currently available for these patients.

Anatomical distribution, the incidence of malignancy and diagnostic workup in the pathological lesions of the clavicle: a review of 410 cases

BACKGROUND

The clavicle poses a diagnostic dilemma of the pathological lesions due to the wide range of pathologies seen at this site. This study aimed to identify and stratify various pathologies seen in the clavicle and to guide ways of investigation for diagnosis based on age, site and investigation findings.

MATERIALS AND METHODS

Four hundred and ten cases with clavicle lesions were identified in our database. Data were collected about the patient's medical history, previous investigation, inflammatory markers radiological investigations and biopsy. All patients were worked up and managed after discussion in a multidisciplinary team meeting (MDT).

RESULTS

Non-malignant lesions accounted for 79% of cases. Infection was the most common diagnosis (39%) and the commonest diagnosis in those less than 20 years of age. 73% of the lesions were found at the medial end of the clavicle. Malignant tumours were 21%, while primary benign bone tumours accounted for only 14%. 50% of the malignant lesions were due to metastatic disease. The risk of malignancy increases with advancing age. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were not sensitive as a diagnostic tool in cases of osteomyelitis confirmed by histology. Magnetic resonance imaging (MRI) was noted to have high sensitivity and specificity for identifying the nature of a lesion and diagnosis.

CONCLUSION

We have identified age as a positive predictor of a malignant cause in pathological lesions of the clavicle. MRI should be considered in all these cases. CRP and ESR have poor predictive values in diagnosing infection in the clavicle. Patients presenting with clavicle lesions should be discussed in a specialist MDT and undergo a systemic diagnostic workup, still in some cases, diagnosis can be speculated based on the patient's age, location of the lesion within the clavicle and the features seen on the MRI scan.

LEVEL OF EVIDENCE

IV.

Acromioclavicular Joint: What to Look for

Acromioclavicular joint (ACJ) pathology is a common source of shoulder girdle pain, frequently coexisting with and sharing overlapping clinical features of rotator cuff and glenohumeral articular lesions. ACJ trauma and osteoarthritis dominate clinical presentation; however, an array of pathologies can affect the joint. MR imaging of the ACJ is a powerful secondary diagnostic tool in early diagnosis of ACJ pathology and in accurate assessment of ACJ injuries, helping to resolve clinically challenging cases and allowing for individualized treatment planning. Knowledge of ACJ anatomy, biomechanics, and pathology is fundamental to interpreting and providing a clinically relevant ACJ MR imaging report.

Distal Clavicle Osteochondroma Causing Supraspinatus Tendinopathy

Shoulder pain is a very common symptom especially in young and active population. Rotator cuff tendinopathies are believed to be the most common cause of shoulder pain up to 86%. Tumors around the shoulder area can cause pain or joint stiffness when expanding in the subacromial space. We present a rare case of a distal clavicle osteochondroma. It is a benign tumor which in this area causes supraspinatus tendinopathy and every physician should suspect this kind of diseases during the diagnostic approach of a shoulder pain. In this case, early diagnosis and appropriate treatment with excision of the lesion gave us a very good outcome with fully relief of the symptoms.

Bone tumours of the clavicle: Histopathological, anatomical and epidemiological analysis of 113 cases

Backround

This retrospective study aimed to determine the frequency of bone tumours of the clavicle and their histopathological, anatomical and epidemiological characteristics in a large case series.

Methods

The records of 327 lesions of the clavicle collected from 1976 to 2018 in our bone tumour registry and institute of pathology were reviewed. Following data were evaluated: age, gender, side, radiological assessment, tumour location within the clavicle, and histopathological findings.

Results

Bone tumours were detected in 113 patients with a mean age of 40 years. The lateral third of the clavicle was most frequently involved. Analysis revealed 22 benign, 31 intermediate, and 60 malignant tumours. Eosinophilic granuloma was the most commonly found neoplasm (18.6%), followed by bone metastases (15.0%), Plasma cell myeloma (8.8%), Ewing sarcoma (8.8%), and Osteosarcoma (8.0%). 53% of the tumours were malignant. Mean age was 51 years in the malignant tumour group and 28 years in patients with a benign/intermediate lesion (p < 0.001).

Conclusions

The high incidence of malignant bone tumours of the clavicle found in this study highlight the importance of biopsy to prevent delay in diagnosis and treatment of these lesions, especially in patients with increased age. We believe that the results of this study are of clinical importance and may aid the physician in the management of these rare lesions.

Primary Osteomyelitis of the Clavicle in Children

Osteomyelitis of the clavicle is a rare entity with a broad differential diagnosis and high potential for complications if not diagnosed promptly and treated appropriately. The threshold for surgical intervention should be low to prevent osteonecrosis and bony resorption. In addition, although rare, life-threatening complications have been reported. This report describes primary osteomyelitis of the clavicle that was diagnosed in a 22-month-old girl on her third clinical evaluation after 4 days of symptoms. She presented to a children's tertiary care emergency department with fever and acute pain and swelling of her right shoulder and arm. The diagnosis was confirmed through clinical, laboratory, and imaging studies including ultrasound; these revealed subperiosteal abscess formation, which may have developed in part as the result of a delayed diagnosis from the 2 prior emergency department visits. The patient was treated initially with intravenous antibiotics and underwent therapeutic as well as diagnostic needle-guided tissue aspiration under ultrasound guidance. This ruled out malignancy but was not curative, and the subperiosteal abscess recurred within 24 hours, prompting formal operative irrigation and debridement. The patient was seen for 12-month follow-up and has had no complications or evidence of recurrence. This case emphasizes the need for a high index of suspicion to prevent diagnostic delays as well as the importance of a low threshold for surgical debridement to minimize the potential for complications that could prolong the treatment course. [Orthopedics. 2016; 39(4):e760-e763.].