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Alshumrani Y, Droukas D, Carney BJ, Willim R, Brook A, Wu JS. CT guided versus non-image guided bone marrow aspiration and biopsy: Comparison of indications, specimen quality and cost. Clin Imaging 2024; 113:110236. [PMID: 39106655 DOI: 10.1016/j.clinimag.2024.110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/09/2024]
Abstract
PURPOSE To compare the indications, specimen quality, and cost of CT versus non-image guided bone marrow aspirate and biopsy (BMAB). METHODS All CT and non-image guided BMAB performed from January 2013-July 2022 were studied. Body-mass-index (BMI), skin-to-bone distance, aspirate, and core specimen quality, and core sample length were documented. Indications for CT guided BMAB were recorded. Categorical variables were compared using chi-squared test and continuous variables using Mann-Whitney test. Analysis of per-biopsy factors used linear mixed-effect models to adjust for clustering. Cost of CT and non-image guided BMAB was taken from patient billing data. RESULTS There were 301 CT and 6535 non-image guided BMABs studied. All CT guided BMAB were studied. A subset of 317 non-image guided BMAB was selected randomly from the top ten CT BMAB referrers. BMI (kg/m2) and skin-to-bone distance (cm) was higher in the CT versus the non-image guided group; 34.4 v 26.8, p < 0.0001; 4.8 v 2.5, p < 0.0001, respectively. Aspirate and core sample quality were not different between groups, p = 0.21 and p = 0.12, respectively. CT guided core marrow samples were longer, p < 0.0001. The most common CT BMAB referral indications were large body habitus (47.7 %), failed attempt (18.8 %) and not stated (17.4 %). Cost of a CT guided BMAB with conscious sedation was $3945 USD versus $310 USD for non-image guided. CONCLUSION CT guided BMAB are commonly performed in patients with large body habitus and failed attempt. However, the cost is 12.7 fold higher with no increase in specimen quality. These findings can help referrers be cost conscious.
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Affiliation(s)
- Yousef Alshumrani
- Department of Internal Medicine - Division of Radiology, King Khalid University, 7887 Alfara street, Abha 62529, Saudi Arabia; Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America
| | - Daniel Droukas
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Brian J Carney
- Department of Medicine, Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Robert Willim
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
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Gyftopoulos S, Cardoso MDS, Wu JS, Subhas N, Chang CY. Bone Marrow Biopsies: Is CT, Fluoroscopy, or no Imaging Guidance the Most Cost-Effective Strategy? Acad Radiol 2024; 31:2880-2886. [PMID: 38290886 DOI: 10.1016/j.acra.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
RATIONALE AND OBJECTIVES To determine the most cost-effective strategy for pelvic bone marrow biopsies. MATERIALS AND METHODS A decision analytic model from the health care system perspective for patients with high clinical concern for multiple myeloma (MM) was used to evaluate the incremental cost-effectiveness of three bone marrow core biopsy techniques: computed tomography (CT) guided, and fluoroscopy guided, no-imaging (landmark-based). Model input data on utilities, costs, and probabilities were obtained from comprehensive literature review and expert opinion. Costs were estimated in 2023 U.S. dollars. Primary effectiveness outcome was quality adjusted life years (QALY). Willingness to pay threshold was $100,000 per QALY gained. RESULTS No-imaging based biopsy was the most cost-effective strategy as it had the highest net monetary benefit ($4218) and lowest overall cost ($92.17). Fluoroscopy guided was excluded secondary to extended dominance. CT guided biopsies were less preferred as it had an incremental cost-effectiveness ratio ($334,043) greater than the willingness to pay threshold. Probabilistic sensitivity analysis found non-imaging based biopsy to be the most cost-effective in 100% of simulations and at all willingness to pay thresholds up to $200,000. CONCLUSION No-imaging based biopsy appears to be the most cost-effective strategy for bone marrow core biopsy in patients suspected of MM. CLINICAL RELEVANCE No imaging guidance is the preferred strategy, although image-guidance may be required for challenging anatomy. CT image interpretation may be helpful for planning biopsies. Establishing a non-imaging guided biopsy service with greater patient anxiety and pain support may be warranted.
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Affiliation(s)
- Soterios Gyftopoulos
- Department of Radiology, NYU Langone Health, New York, New York, USA (S.G., M.D.S.C.); Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA (S.G.)
| | | | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Hospital, Boston, Massachusetts, USA (J.S.W.)
| | - Naveen Subhas
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA (N.S.)
| | - Connie Y Chang
- Department of Radiology, Massachusetts General Hospital, Yawkey 6E, 55 Fruit Street, Boston, Massachusetts 02114, USA (C.Y.C.).
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Spinnato P, Colangeli M, Rinaldi R, Ponti F. Percutaneous CT-Guided Bone Biopsies: Indications, Feasibility and Diagnostic Yield in the Different Skeletal Sites-From the Skull to the Toe. Diagnostics (Basel) 2023; 13:2350. [PMID: 37510093 PMCID: PMC10378450 DOI: 10.3390/diagnostics13142350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/13/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
CT-guided bone biopsies are currently the diagnostic tool of choice for histopathological (and microbiological) diagnoses of skeletal lesions. Several research works have well-demonstrated their safety and feasibility in almost all skeletal regions. This comprehensive review article aims at summarizing the general concepts in regard to bone biopsy procedures, current clinical indications, the feasibility and the diagnostic yield in different skeletal sites, particularly in the most delicate and difficult-to-reach ones. The choice of the correct imaging guidance and factors affecting the diagnostic rate, as well as possible complications, will also be discussed. Since the diagnostic yield, technical difficulties, and complications risk of a CT-guided bone biopsy significantly vary depending on the different skeletal sites, subdivided analyses of different anatomical sites are provided. The information included in the current review article may be useful for clinicians assisting patients with possible bone neoplasms, as well as radiologists involved in the imaging diagnoses of skeletal lesions and/or in performing bone biopsies.
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Affiliation(s)
- Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Colangeli
- Orthopaedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Raffaella Rinaldi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federico Ponti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Foureau DM, Paul BA, Guo F, Lipford EH, Fesenkova K, Tjaden E, Drummond K, Bhutani M, Atrash S, Ndiaye A, Varga C, Voorhees PM, Usmani SZ. Standardizing Clinical Workflow for Assessing Minimal Residual Disease by Flow Cytometry in Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e41-e50. [PMID: 36443182 PMCID: PMC10448729 DOI: 10.1016/j.clml.2022.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Minimal residual disease (MRD) status is an established prognostic biomarker for patients with multiple myeloma. Commonly used MRD testing techniques such as next generation sequencing or next generation flow cytometry can detect as little as one or two multiple myeloma plasma cells in 106 normal bone marrow cells. Early pull of bone marrow aspirates (BMA), necessary to achieve such level of sensitivity, can be difficult to secure in routine clinical practice due to the competing need for early pull samples for clinical response assessment, therefore introducing the risk of analytical interference during MRD testing. METHODS To overcome this challenge, we standardized our workflow for collecting specimens by using a technical first pull after needle repositioning for MRD testing. To capture a comprehensive picture of MRD assay performance and specimen adequacy, we tested for MRD on 556 technical first pull bone marrow aspirates by next generation flow cytometry. Among the specimens, several key multiple myeloma treatment milestones were represented: end of induction therapy, two to three months post-autologous stem cell transplant, early and late stages of maintenance therapy. RESULTS By using the technical first pull bone marrow aspirate, we achieved an analytical assay input of 10 million nucleated cells for 97.5% of specimens. Our analytical sensitivity reached 10-6; (i.e., 10 multiple myeloma plasma cells in 10 × 106 bone marrow cells). Twenty-four percent of specimens were significantly hemodiluted. Low assay input or hemodilution quantifiably lowered the assay sensitivity. CONCLUSION Specimen adequacy is, therefore, an important metric to incorporate into MRD status reporting.
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Affiliation(s)
- David M Foureau
- Immune Monitoring Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, NC.
| | - Barry A Paul
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Fei Guo
- Immune Monitoring Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Edward H Lipford
- Department of Hematologic Pathology, Atrium Health, Charlotte, NC
| | - Kateryna Fesenkova
- Immune Monitoring Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Elise Tjaden
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Kendra Drummond
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Shebli Atrash
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Ami Ndiaye
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Cindy Varga
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Saad Z Usmani
- Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY.
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Khdhir M, Jabbour Y, Azzi C, El-Alam R, Muallem N, Moukaddam H. Complications associated with improper palpation-guided iliac bone marrow biopsy tracts identified on follow-up imaging. Skeletal Radiol 2022; 51:2155-2166. [PMID: 35612650 DOI: 10.1007/s00256-022-04078-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone marrow biopsy complications are rare. Our aim is to study the association of improper palpation-guided iliac biopsy tract with complications. MATERIALS AND METHODS This is a retrospective study of adult patients who underwent iliac bone marrow biopsy without image guidance at our hospital from January 2019 to January 2021, and have cross-sectional radiologic imaging of the pelvis within 30 days following the procedure. Electronic health records were reviewed for clinical data. Two radiologists reviewed images of the pelvis for assessment of biopsy tract and complications. RESULTS A total of 443 procedures were included in 309 patients, mean age 53.4 ± 18.1 years, 112 females (36.2%). In addition, 332 tracts were proper (75%), 97 improper (22%), and 14 unidentified (3%). All 11 complications occurred in procedures with improper tracts; nine bleeding, one fracture, and one facet joint injury. Improper tract was significantly associated with complications (p < .001). There was no statistically significant association between platelet count, international normalized ratio, antiplatelet use and anticoagulant use, and presence of complications (p > .05). Body mass index and subcutaneous fat thickness overlying posterior superior iliac spine were not associated with improper tract (p > .05). Procedures performed by providers with ≤ 12 months' experience were significantly associated with improper tract (p < .001) and hence associated with complications (p = .007). CONCLUSION Improper tracts were common in palpation-guided iliac bone marrow biopsy and significantly associated with complications. No complications were encountered in proper tract procedures. Procedures performed by providers with ≤ 12 months' experience were significantly associated with improper tract and complications.
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Affiliation(s)
- Mihran Khdhir
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon.
| | - Yara Jabbour
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon
| | - Caline Azzi
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon
| | - Raquelle El-Alam
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon
| | - Nadim Muallem
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon
| | - Hicham Moukaddam
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020, PO Box 11-0236, Beirut, Lebanon
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Omission of Planning CT Reduces Patient Radiation Exposure during CT-Guided Bone Marrow Biopsy and Aspiration. Tomography 2021; 7:747-751. [PMID: 34842812 PMCID: PMC8628954 DOI: 10.3390/tomography7040062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study is to evaluate the impact of eliminating a preprocedural planning computed tomography during CT-guided bone marrow biopsy on the technical aspects of the procedure, including patient dose, sample quality, procedure time, and CT fluoroscopy usage. Retrospective analysis of 109 patients between 1 June 2018 and 1 January 2021 was performed. Patients were grouped based on whether they received a planning CT scan. Relative radiation exposure was measured using dose-length product (DLP). Secondary metrics included number of CT fluoroscopic acquisitions until target localization, total number of CT fluoroscopic acquisitions, biopsy diagnostic yield, and procedure time. A total of 43 bone marrow biopsies with planning CT scans (Group 1) and 66 bone marrow biopsies without planning CT scans (Group 2) were performed. The average total DLP for Group 1 and Group 2 was 268.73 mGy*cm and 50.92 mGy*cm, respectively. The mean radiation dose reduction between the groups was 81% (p < 0.0001). Significantly more CT fluoroscopy acquisitions were needed for needle localization in Group 2 than Group 1 (p < 0.0001). Total number of CT fluoroscopy acquisitions was four for Group 1 and eight for Group 2 (p = 0.0002). There was no significant difference between the groups in procedure time or diagnostic yield. Patients without a planning CT scan received more fluoroscopic CT acquisitions but overall were exposed to significantly less radiation without an increase in procedure time.
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