Accuracy of biopsy techniques for limb and limb girdle soft tissue tumors

Sensitivity, Specificity, and Predictive Values of Tru-Cut® Biopsy in Grading Primary Localized Myxoid Liposarcomas of the Extremities

(1) Background: Histological diagnosis and tumor grading are major prognostic and predictive factors in soft tissue sarcomas (STS), as they dictate the treatment strategies with a direct impact on patient survival. This study aims to investigate the grading accuracy, sensitivity, and specificity of Tru-Cut^® biopsy (TCB) in primary localized myxoid liposarcomas (MLs) of the extremities and its impact on patient prognosis. (2) Methods: Patients with ML undergoing TCB and a subsequent tumor resection between 2007 and 2021 were evaluated. Concordance between the preoperative assessment and definitive histology was calculated with a weighted Cohen's kappa coefficient. Sensitivity, specificity, and diagnostic accuracy were calculated. (3) Results: Of 144 biopsies, the histological grade concordance rate was 63% (Kappa 0.2819). Neoadjuvant chemotherapy and/or radiotherapy impacted concordance with a downgrading effect in high-grade tumors. Among forty patients not treated in neoadjuvant settings, the sensitivity of TCB was 57%, the specificity was 100%, and the overall predictive values of positive and negative TCB were 100% and 50%, respectively. Misdiagnosis did not impact overall survival. (4) Conclusions: TCB may underestimate ML grading due to tumor heterogeneity. Neoadjuvant ChT and/or radiotherapy are associated with pathological downgrading; however, discordance in diagnosis does not modify patient prognosis because systemic treatment decision-making also includes other variables.

Role of Imaging in Initial Prognostication of Locally Advanced Soft Tissue Sarcomas

BACKGROUND

Although imaging is central in the initial staging of patients with soft tissue sarcomas (STS), it remains underused and few radiological features are currently used in practice for prognostication and to help guide the best therapeutic strategy. Yet, several prognostic qualitative and quantitative characteristics from magnetic resonance imaging (MRI) and positron emission tomography (PET) have been identified over these last decades.

OBJECTIVE

After an overview of the current validated prognostic features based on baseline imaging and their integration into prognostic tools, such as nomograms used by clinicians, the aim of this review is to summarize more complex and innovative MRI, PET, and radiomics features, and to highlight their role to predict indirectly (through histologic grade) or directly the patients' outcomes.

Pediatric and Young Adult Image-Guided Percutaneous Bone Biopsy-A New Standard of Care?

BACKGROUND

There are no consensus guidelines regarding the use of percutaneous needle biopsy for the diagnosis of soft tissue and bone tumors. The aim of this study was to understand the efficacy of image-guided percutaneous biopsy for pediatric patients with soft tissue and bony masses, the role of intraoperative image guidance, and diagnostic accuracy.

PATIENTS AND METHODS

A retrospective institutional chart review was performed on patients who underwent percutaneous biopsy of soft tissue or bone tumors between 2007 and 2017. Data collected included preoperative imaging, type of biopsy, demographics, insurance status, number of samples taken, and pathologic results.

RESULTS

One hundred forty-one children and young adults underwent 169 biopsies. Female patients received 48.2% of biopsies. The mean age was 14.3 ± 7.0 years. Core needle biopsies made up 89.4% of procedures, while 10.6% were fine needle aspirate. The mean number of samples per patient was 3.6 ± 2.5. All patients had imaging guidance, with computed tomography used in 44.7% of patients, 9.9% using fluoroscopy, 7.1% using ultrasound for guidance, and 53 (37.6%) patients had more than one modality. Diagnostic specimens were obtained in 97.9% of biopsies. The most common overall pathology was osteoid osteoma. The most common malignant tumors were osteosarcoma and Ewing's sarcoma.

CONCLUSION

Image-guided percutaneous biopsy is a safe and effective method of obtaining accurate tissue samples in children and young adults with soft tissue or bone masses.

LEVEL OF EVIDENCE

Level 4-Study of diagnostic test.

Soft-tissue sarcoma in adults: Imaging appearances, pitfalls and diagnostic algorithms

This article provides an overview of the current knowledge regarding diagnostic imaging of patients with soft-tissue sarcomas, which is a heterogeneous group of rare mesenchymal malignancies. After an initial contextualization, diagnostic flow-chart based on initial radiological findings of soft-tissue masses (with specific focus on adipocytic soft-tissue tumors [STTs], hemorragic STTs and retroperitoneal STTs) are provided considering relevant results from novel researches, guidelines, and experts' viewpoints, with the aim to help radiologists and clinicians in their practice. Particularly, the central place of sarcoma reference centers in the diagnostic and therapeutic management is highlighted, as well as the pivotal role that radiologists should play to correctly identify patients with soft-tissue sarcoma at the initial stage of the disease. Indications and methods for performing imaging-guided biopsies are also discussed, as well as clues to improve soft-tissue sarcoma grading with conventional and quantitative imaging.

Concordance of histopathological and radiological grading in soft tissue sarcomas

Aim: The grade of the tumor is essential for planning the treatment strategy in soft-tissue sarcomas (STS). The goal of this study is to determine magnetic resonance imaging features related to histopathological grade and aggressiveness of STS. Material and Method: This retrospective single-center study involved preoperative contrast-enhanced MRI examinations of 64 patients with STS. MRI findings evaluated were; heterogeneity, necrosis, hemorrhage, and relationship with surrounding tissue in T1-weighted (T1W), T2-weighted (T2W), and T1W post-contrast sequences of the lesion. Histological grade was determined with the Fédération Nationale des Centres de Lutte Contre Le Cancer (FNCLCC) grading system, and the aggressiveness of the lesion was measured with the Ki-67 index. Results: Sixty-four patients (mean age 45.5±21.6, M/F ratio 34/30) with STS were included. 33 (51.6%) patients graded as FNCLCC grade 3. On MRI examinations, the absence of necrosis was significantly associated with FNCLCC grade 1 and a low Ki-67 index (p

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication

BACKGROUND

These clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors.

METHODS

The Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the "Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014" and "Minds Manual for Clinical Practice Guideline Development 2017." Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters.

RESULTS

Twenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined.

CONCLUSION

We established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

Diagnostic delay in soft tissue tumors: a single-center study of a university cancer center with a focus on health services research

Background

Lumps and soft tissue tumors (STT) are frequent reasons for consulting a physician. Most STT are benign, and lumps are not always associated with a tumor. MRI is the most advanced imaging modality to assist a provisional diagnosis of STT. Only a small fraction of STT is malignant, these soft tissue sarcomas are known for their aggressive growth.

The study aims to analyze the influence of the MRI report on the speed of treatment of patients with suspected STT.

Methods

This was a retrospective, longitudinal, single-center study from 2011–2020. We included adult patients who had biopsies or resections of masses suspicious for STT in MRI exams. MRI reports were classified as benign (I), intermediate/unclear (II), or malignant (III). For these cohorts, time was statistically analyzed from MRI scan to first contact with the University cancer center (UCC) and surgery. Furthermore, distance in kilometers from the patients´ home to the UCC was examined and compared to age and suspected malignancy.

Results

Three hundred two patients (♀130; ♂172) were included. Histologic analyses revealed 286 tumors. The average age of the patients was 54.7(SD: 16.2) years. Malignant tumors were more often suspected in older patients (p = 0.0098). Patients with a benign diagnosed tumor in MRI contacted the UCC after an average of 31.3 (SD: 47.8) days. In contrast, patients with suspicion of a malignant tumor contacted the UCC significantly earlier, after 14.1 days (SD: 17.1); p = 0.0098. Likewise, the time between first contact and biopsy/resection was 32.8 days (SD: 35.7) for suspiciously benign tumors, and potentially malignant tumors were treated significantly faster 14.8 (SD: 16.0) days; (p = 0.028). Patients traveled on average 47.5 km (range: 0.5–483) to contact a specialized physician at the UCC. Suspected degree of malignancy or patient´s age had no statistical influence on traveled distance.

Discussion

The treatment speed depended to a great extent on the suspected malignancy of the STT in the MRI report. The provisional diagnoses from the radiologist highly influenced the time delay between MRI scan and first contact to the UCC and surgical treatment. No discrimination of age or distance to the UCC was observed in this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07891-w.

Accuracy of core needle biopsy for histologic diagnosis of soft tissue sarcoma

The biopsy technique of choice in soft tissue sarcoma (STS) diagnosis is controversial. We examined the diagnostic accuracy of percutaneous core needle biopsy (CNB) and compared it to open incisional biopsy. A retrospective study included 91 incisional biopsies and 102 CNBs. A pair-match investigation was conducted on 19 patient pairs, comparing sensitivity, specificity, and diagnostic accuracy. Furthermore, we investigated the role of molecular pathology in sarcoma diagnostics. In 81/91 (89%) patients with incisional biopsy, the entity was confirmed by definitive pathology, whereas this was the case in 89/102 (87%) CNB patients (p = 0.52). Grading remained unchanged in 46/55 (84%) of incisional and 54/62 (87%) of CNBs (p = 0.61). The pair matched analysis showed that the correct entity was determined in 96% of incisional and 97.6% of core needle biopsies. The time between the initial consultation and the interdisciplinary tumor board's treatment recommendation was shorter in core needle biopsies (8.37 vs. 15.63 days; p < 0.002). Incisional biopsies led to two wound infections and one hematoma, whereas wound infection occurred in one patient after CNB. CNB leads to faster diagnosis while reaching the same histological accuracy and is less burdensome for patients. Still, surgeons need to remain aware of the possibility of biopsy failure.

Natural speed of growth of untreated soft-tissue sarcomas: A dimension-based imaging analysis

PURPOSE

The interval from first symptoms to diagnosis, staging and referral to reference center can last months for soft-tissue sarcoma (STS) patients. Meanwhile, patients can undergo different imaging that capture the 'natural' tumor changes, before medical intervention. Aim was to depict these 'natural' dimensional variations and to correlate them with patients' outcome.

METHODS

Single-center retrospective study including all consecutive adults with newly-diagnosed STS, ≥2 pre-treatment imaging (CT-scan or MRI) on the tumor (Exam-0 and Exam-1), and managed in reference center between 2007 and 2018. Longest diameter (LD) and volume were calculated on both examinations to obtain the naïve dimensional growth before any intervention. SARCULATOR nomogram was applied on data at Exam-0 and Exam-1. Correlations with overall, metastatic and local relapse-free survivals (OS, MFS and LFS), and with pre-treatment pathological features were performed.

RESULTS

137 patients were included (median age: 65 years). Average naïve growth was +39.4% in LD and +503% in volume during an average Exam-0-to-Exam-1 interval of 130 days. The 10-year distant metastasis and OS predictions were different at Exam-0 and Exam-1 (P < 0.0001 for both). All the changes in radiological measurements significantly correlated with pre-treatment number of mitosis, grade and complex genomic (P-value range: <0.0001-0.0481). Multivariate Cox modeling identified the relative change in LD/month and absolute change in LD/month as independent predictors for OS and LFS, respectively (P = 0.0003 and 0.0001, respectively).

CONCLUSION

When available, the natural speed of growth on pre-treatment imaging should be evaluated to improve the estimation of pre-treatment histological grade and patients' OS and LFS.

Accuracy and Safety of Ultrasound-Guided Core Needle Biopsy of Soft Tissue Tumors in an Outpatient Setting: A Sarcoma Center Analysis of 392 Consecutive Patients

Simple Summary

In patients with unclear soft tissue lesions, treatment planning largely depends on histology. Core needle biopsy is the diagnostic standard in these cases. The aim of this retrospective study was to investigate accuracy and safety of ultrasound guided core needle biopsy at a tertiary referral center. We show that ultrasound guided biopsy was feasible as a one stop shop procedure in an outpatient setting in 87.6% of the cases. The rate of conclusive biopsies was 88.5%. After surgical resection, the dignity, tumor type and histopathological grading of the biopsy matched one of the resection specimens in 97.2%, 92.7% and 92.5% of the cases, respectively. Major complications occurred in 0.8% of the cases. With this study, we confirm that ultrasound guided core needle biopsy is safe, effective and can be performed at the first outpatient presentation to speed up the diagnostic and therapeutic cascade in sarcoma patients.

Abstract

Background: The aim of this study was to investigate diagnostic accuracy, safety and histologic results of ultrasound guided core needle biopsy (CNB) in patients with soft tissue lesions (STL) at a tertiary referral center. Methods: A retrospective analysis of all consecutive patients undergoing ultrasound guided CNB for STL at our sarcoma outpatient service between January 2015 and August 2020 was performed. Results: A total of 392 patients were identified. Main histologic entities were sarcomas, lipomas and desmoid tumors. Biopsy was performed in an outpatient setting in 87.6% of the cases. Conclusive biopsies were obtained in 88.5% of the cases. In patients who underwent surgical resection after CNB, the concordance of dignity, tumor entity and histopathological grading between biopsy and resection specimen were 97.2%, 92.7% and 92.5% respectively. The risk of inconclusive CNB was highest in intraabdominal or retroperitoneal tumors (19.5%) and lowest in lesions at the lower extremity (4.4%). Major complications after CNB occurred in three cases (0.8%). No case of biopsy tract seeding was observed during the study period. Conclusions: Ultrasound guided CNB for STL at first presentation in a dedicated surgical outpatient setting is a safe procedure and yields a high diagnostic accuracy.

Adjunct diagnostic strategies in improving diagnostic yields in image-guided biopsies of musculoskeletal neoplasms-A cost-effectiveness analysis

BACKGROUND

Routine use of adjunct intraprocedural fresh frozen biopsy (FFP) or point-of-care (POC) cytology at the time of image-guided biopsy can improve diagnostic tissue yields for musculoskeletal neoplasms, but these are associated with increased costs.

OBJECTIVE

This study aimed to ascertain the most cost-effective adjunctive test for image-guided biopsies of musculoskeletal neoplasms.

METHODS

This expected value cost-effectiveness microsimulation compared the payoffs of cost (2020 United States dollars) and effectiveness (quality-adjusted life, in days) on each of the competing strategies. A literature review and institutional data were used to ascertain probabilities, diagnostic yields, utility values, and direct medical costs associated with each strategy. Payer and societal perspectives are presented. One- and two-way sensitivity analyses evaluated model uncertainties.

RESULTS

The total cost and effectiveness for each of the strategies were $1248.98, $1414.09, $1980.53, and 80.31, 79.74, 79.69 days for the use of FFP, permanent pathology only, and POC cytology, respectively. The use of FFP dominated the competing strategies. Sensitivity analyses revealed FFP as the most cost-effective across all clinically plausible values.

CONCLUSIONS

Adjunct FFP is most cost-effective in improving the diagnostic yield of image-guided biopsies for musculoskeletal neoplasms. These findings are robust to sensitivity analyses using clinically plausible probabilities.

Ki-67 immunoexpression and radiological assessment of necrosis improves accuracy of conventional and modified core biopsy systems in predicting the final grade assigned to adult-soft tissue sarcomas. An international collaborative study

Based on the French Federation Nationale des Centers de Lutte Contre le Cancer (FNCLCC) grading system, this study assesses the accuracy of conventional and modified core biopsy (CB) systems in predicting the final grade (low vs high) assigned to the resected specimen. Substituting Ki-67 immunoexpression for mitotic count, and radiological for histological assessment of necrosis, we used two modified FNCLCC CB grading systems: (1) Ki-67 immunoexpression alone, and (2) Ki-67 plus radiological assessment of necrosis. We graded 199 soft tissue sarcomas (STS) from nine centers, and compared the results for the conventional (obtained from local histopathology reports) and modified CB systems with the final FNCLCC grading of the corresponding resected specimens. Due to insufficient sample quality or lack of available radiologic data, five cases were not evaluated for Ki67 or radiological assessment of necrosis. The conventional FNCLCC CB grading system accurately identified 109 of the 130 high-grade cases (83.8%). The CB grading matched the final FNCLCC grading (low vs high) in 175 (87.9%) of the 199 resected tumors; overestimating the final grade in three cases and underestimating in 21 cases. Modified system 1 (Ki-67) accurately identified 117 of the 130 high-grade cases (90.0%). The CB grading matched the final FNCLCC grading (low vs high) in 175 (89.7%) of the 195 evaluated cases; overestimating seven and underestimating 13 cases. Modified system 2 (Ki-67 plus radiological necrosis) accurately identified 120 of the 130 high-grade cases (92.3%). This last matched the final FNCLCC grading (low vs high) in 177 (91.2%) of the 194 evaluated cases; overestimating seven and underestimating 10 cases. Modified system 2 obtained highest area under ROC curves, although not statistically significant. Underestimated CB grades did not correlate with histological subtypes, although many of the discrepant cases were myxoid tumors (myxofibrosarcomas or myxoid liposarcomas), leiomyosarcomas or undifferentiated pleomorphic/spindle cell sarcomas. Using modified FNCLCC CB grading systems to replace conventional mitotic count and histologic assessment of necrosis may improve the distinction between low and high-grade STS on CB. Our study confirms that classifying grade 1 as low grade and grades 2 and 3 as high grade improves correlation between CB and final grade by up to 21%, irrespective of CB system used. A higher than expected Ki-67 score in a low-grade sarcoma diagnosed on CB should raise concern that a higher-grade component may not have been sampled. Furthermore, correlation of all clinicopathological and radiological findings at multidisciplinary meetings is essential to assess the histological grade on CB as accurately as possible.

Soft tissue pathology for the radiologist: a tumor board primer with 2020 WHO classification update

Radiologists serve an important role in the diagnosis and staging of soft tissue tumors, often through participation in multidisciplinary tumor board teams. While an important function of the radiologist is to review pertinent imaging and assist in the differential diagnosis, a critical role is to ensure that there is concordance between the imaging and the pathologic diagnosis. This requires a basic understanding of the pathology of soft tissue tumors, particularly in the case of diagnostic dilemmas or incongruent imaging and histologic features. This work is intended to provide an overview of soft tissue pathology for the radiologist to optimize participation in multidisciplinary orthopedic oncology tumor boards, allowing for contribution to management decisions with expertise beyond image interpretation.

Core needle biopsy versus incisional biopsy for differentiation of soft-tissue sarcomas: A systematic review and meta-analysis

BACKGROUND

Controversies exist regarding the biopsy technique of choice for the accurate diagnosis of soft-tissue sarcoma (STS). The objective of this systematic review and meta-analysis was to compare the diagnostic accuracy of core needle biopsy (CNB) versus incisional biopsy (IB) in STS with reference to the final histopathological result.

METHODS

Studies regarding the diagnostic accuracy of CNB and IB in detecting STS were searched systematically in the MEDLINE and EMBASE databases. Estimates of sensitivity and specificity with associated 95% CIs for diagnostic accuracy were calculated. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2).

RESULTS

A total of 17 studies comprising 2680 patients who underwent 1582 CNBs and 241 IBs with subsequent tumor resection met the inclusion criteria. The sensitivity and specificity of CNB and IB to detect the dignity of lesions were 97% (95% CI, 95%-98%) and 99% (95% CI, 97%-99%), respectively, and 96% (95% CI, 92%-99%) and 100% (95% CI, 94%-100%), respectively. Estimates of the sensitivity and specificity of CNB and IB to detect the STS histotype were 88% (95% CI, 86%-90%) and 77% (95% CI, 72%-81%), respectively, and 93% (95% CI, 87%-97%) and 65% (95% CI, 49%-78%), respectively. Patients who underwent CNB had a significantly reduced risk of complications compared with patients who underwent IB (risk ratio, 0.14; 95% CI, 0.03-0.56 [P ≤ .01). Quality assessment of studies revealed a high risk of bias.

CONCLUSIONS

CNB has high accuracy in diagnosing the dignity of lesions and STS histotype in patients with suspected STS with fewer complications compared with IB. Therefore, CNB should be regarded as the primary biopsy technique.

Risk Factors for Diagnostic Failure of Ultrasound-Guided Core Needle Biopsy of Soft-Tissue Tumors Based on World Health Organization Classification Category and Biologic Potential

OBJECTIVE. The purpose of this study is to evaluate the diagnostic outcome of ultrasound (US)-guided core needle biopsy (CNB) of soft-tissue tumors and to assess the factors associated with significant diagnostic failure. MATERIALS AND METHODS. We performed a retrospective analysis of biopsy specimens obtained from patients with soft-tissue tumors of the extremities and superficial trunk who underwent both US-guided CNB and surgical resection. In accordance with the World Health Organization classification, biopsy results and findings from final histologic analysis of the surgically resected specimen (hereafter known as final histologic findings) were categorized in terms of biologic potential as benign, intermediate (locally aggressive), intermediate (rarely metastasizing), or malignant. Biopsy results were considered to show a significant diagnostic failure if they resulted in incorrect classification of biologic potential compared with final histologic findings, if results were indeterminate, or if nondiagnostic specimens were obtained. World Health Organization classification categories and the biologic potential of the tumors according to final histologic findings were assessed to identify any relationship with diagnostic failure of CNB, as were other tumor- and patient-related factors. RESULTS. Significant diagnostic failure was seen for 40 of 303 biopsies (13.20%). Multivariate analysis showed a significant association between diagnostic failure and adipocytic tumors (odds ratio [OR], 9.686; p = 0.037) or vascular tumors (OR, 40.115; p = 0.005); intermediate (rarely metastasizing) biologic potential (OR, 12.279; p = 0.001), or malignant biologic potential (OR, 5.668; p < 0.001); and discordance between radiologic and final histologic findings or indeterminacy of biologic potential (OR, 2.500; p = 0.034). CONCLUSION. The World Health Organization classification categories (adipocytic or vascular), biologic potential (intermediate [rarely metastasizing] or malignant), and discordance between radiologic and final histologic findings or indeterminacy of biologic potential were found to be independent risk factors for significant diagnostic failure of CNB of soft-tissue tumors.

One-bloc percutaneous large biopsy of soft-tissue tumours: feasibility study and possible indications

AIM

To report the early results of the Intact lesion excision system (LES) regarding feasibility, tolerance and efficiency in obtaining soft-tissue tumour samples under ultrasound guidance.

MATERIALS AND METHODS

The feasibility and tolerance of Intact LES procedures under ultrasound guidance were studied prospectively in 15 patients. The procedure was performed on an outpatient basis under local anaesthesia by a single interventional radiologist with 6 years of experience and lasted around 30 min.

RESULTS

The feasibility of the Intact LES for soft-tissue masses was good except when lesions were hard and calcified. Tolerance was good, with median pain experienced during the procedure evaluated at 4.5/10 (SD 2.2) and median post-procedural pain at day 1 evaluated at 1.8/10 (SD 2.5). No major complications were observed; however, for vascularised lesions, one case of acute wound bleeding and two post-procedural haematomas led to delayed pain.

CONCLUSION

Percutaneous biopsy of suspected soft-tissue sarcoma using the LES device under ultrasound guidance is well tolerated and feasible. After a first non-contributing core biopsy, and especially, in the case of lipomatous lesions, it is a valuable option to consider, as is surgical incision biopsy.

A meta-analysis supports core needle biopsy by radiologists for better histological diagnosis in soft tissue and bone sarcomas

BACKGROUND

Although surgical biopsy has historically been considered to be the standard diagnostic biopsy for soft tissue and bone sarcomas, recent literature suggests that percutaneous core needle biopsy yields similar results. Therefore, an evaluation of the exact diagnostic accuracy and associated influential variables of core needle biopsy that is based on a large data set would be useful.

METHODS

We searched MEDLINE, Web of Science, and EMBASE to identify core needle biopsy studies for predicting final histological subtypes of musculoskeletal lesions. The diagnostic accuracies of core needle biopsy and of surgical biopsy were assessed and compared by using random-effect meta-analyses. The factors relevant to diagnostic accuracy were evaluated by meta-regression and subgroup analyses.

RESULTS

We selected 32 studies comprising 7209 musculoskeletal lesions. The pooled proportion estimate for the diagnostic accuracy of core needle biopsy was 0.84 (95% confidential interval, CI: 0.81-0.87), which indicated an approximate 84% concordance between core needle biopsy results and final histological diagnoses. The findings of meta-regression and subgroup analyses suggested that radiologists were better core needle biopsy operators than surgeons. An additional meta-analysis for direct comparison between core needle biopsy and surgical biopsy demonstrated that diagnostic accuracy was significantly lower for core needle biopsy than for surgical (pooled odds ratio: 0.39, 95% CI: 0.20-0.76).

CONCLUSION

Our results suggested that core needle biopsy should be performed by expert radiologists and that surgical biopsy should be performed if diagnosis following core needle biopsy does not match the clinical presentation and radiographic findings.

Safety and Accuracy of Core Needle Biopsy for Soft Tissue Masses in an Ambulatory Setting

BACKGROUND

Percutaneous needle biopsy has been found to be a safe and accurate method for the initial investigation of soft tissue masses. The notion exists that needle biopsies should be performed in specialized sarcoma centers, which can place a financial burden on patients without a sarcoma center near their place of residence. There is no consensus in the current literature regarding the diagnostic accuracy and clinical utility of clinic-based percutaneous core needle biopsy performed by community orthopedic surgeons with fellowship training in musculoskeletal oncology.

QUESTIONS/PURPOSES

Our primary goal was to determine if office-based core needle biopsy of soft tissue masses could safely yield accurate diagnoses when performed by a community orthopedic surgeon with fellowship training in musculoskeletal oncology.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 105 patients who underwent percutaneous core needle biopsy of soft tissue masses in a community clinic. All procedures were performed by one fellowship-trained musculoskeletal oncologist. Accuracy of the initial clinic-based needle biopsy was determined through comparison to the results of pathological analysis of the surgically excised masses. Final data analysis included 69 patients who underwent both clinic-based biopsy and subsequent surgical excision of their masses.

RESULTS

We found clinic-based biopsies to be 87.0% accurate for exact diagnosis and 94.2% accurate in determining whether the mass was benign or malignant (p < 0.0001). Minor complications related to the clinic-based biopsy occurred in 5.80% of cases, with no documentation of major complications.

CONCLUSIONS

Our results provide evidence that office-based percutaneous biopsy can be administered safely and yield accurate, clinically useful results when performed by a fellowship-trained musculoskeletal oncologist.

[Radiotherapy of primary breast sarcomas: Retrospective study]

PURPOSE

Primary breast sarcomas are heterogeneous tumours derived from non-epithelial mammary gland structures. Although they represent a rare entity, their incidence may increase in the coming years owing to conservative approach considered in the treatment of breast cancer. The aim of this work was to highlight the effect of postoperative irradiation in the treatment of these tumours.

MATERIALS AND METHODS

This is a retrospective study conducted at the Mohammed-VI centre for cancer treatment between 2004 and 2011. Survival rates were calculated by the Kaplan-Meier method.

RESULTS

Fifteen cases were collected. The median age was 41.9years. Phyllode sarcoma accounted for 66% of this series. Surgical treatment was performed in 93% of the patients with negative margins in 33.33% of the cases. Neoadjuvant chemotherapy was indicated in 46% of the patients with locally advanced tumours and 66% of the patients received postoperative radiotherapy for positive or close margins. Five years overall survival and relapse free survival was not significantly different with the use of adjuvant radiotherapy.

CONCLUSION

Due to the rarity of this entity and the absence of randomized trials, evidence based management is still lacking. However, a multidisciplinary approach is to be required including surgical excision followed by radiotherapy, depending on the tumour characteristics.

Diagnosis and treatment of soft-tissue sarcomas of the extremities and trunk

The relatively low incidence and often atypical clinical presentation of soft-tissue sarcomas (STS) impedes early and adequate diagnosis. Patients may report on recently enlarged soft-tissue swellings, infrequently complain of painful lesions, or even have no symptoms at all.

A thorough diagnostic work-up is essential in order to distinguish between benign soft-tissue tumours and STSs. Patient history, clinical features and radiological findings all help in assessing the underlying pathology. ‘Worrying’ features such as recent increase in size, deep location relative to the fascia, a tumour exceeding 4 cm in size, and invasive growth patterns seen on imaging should prompt verification by biopsy.

Even though acquisition of biopsy material may be incomplete, one should bear in mind some essential rules. Regardless of the biopsy technique applied, the most direct route to the lump in question should be identified, contamination of adjacent structures should be avoided and a sufficient amount of tissue acquired.

Treatment of STS is best planned by a multidisciplinary team, involving experts from various medical specialities. The benchmark therapy consists of en bloc resection of the tumour, covered by a safety margin of healthy tissue. Depending on tumour histology, grade, local extent and anatomical stage, radiotherapy, chemotherapy and isolated hyperthermic limb perfusion may be employed.

Due to the complexity of treatment, any soft-tissue swelling suspected of malignancy is best referred directly to a sarcoma centre, where therapeutic management is carefully planned by an experienced multidisciplinary team.

Cite this article: EFORT Open Rev 2017;2:421-431. DOI: 10.1302/2058-5241.2.170005

Risk assessment in solitary fibrous tumors: validation and refinement of a risk stratification model

Solitary fibrous tumors are an uncommon sarcoma type characterized by NAB2-STAT6 gene fusion. While solitary fibrous tumors metastasize in 5-25% of cases, it has historically been challenging to determine which specific tumor and patient characteristics predict aggressive behavior. We previously reported on a novel risk stratification scheme for solitary fibrous tumors incorporating patient age, tumor size, and mitotic activity to predict risk of metastasis. Herein we validate this risk stratification scheme in an independent, lower-risk population of 79 patients with primary non-meningeal solitary fibrous tumors, and propose incorporating tumor necrosis as a fourth variable to further improve the risk score. Fifty-seven percent of cases were considered low risk, 29% intermediate risk, and 14% high risk for metastasis. Of 50 patients with sufficient clinical follow-up data, no metastases developed in the low-risk patients (n=23), while there was a 7% 10-year metastatic risk in the intermediate risk group (n=17), and a 49% 5-year metastatic risk for the high-risk patients (n=10). When tumor necrosis was added as a fourth variable to the model, predictive power was enhanced. Under the revised stratification, the proportion of tumors identified as low risk increased to 66%, with no metastasis at 10 years, intermediate risk cases comprised 24% with 10% risk of metastasis at 10 years, and high risk comprised 10% of cases with 73% risk of metastasis at 5 years. In Kaplan-Meier analysis, this fourth-variable stratification provided significant discrimination between the risk groups (P=0.0005). These findings confirmed the clinical utility of our previously published risk stratification model and support the inclusion of necrosis as a fourth variable in the model.

Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications

Soft tissue sarcomas are a rare and multifaceted group of solid tumours. Neoadjuvant chemotherapy is increasingly used to limit loss of function after wide surgical excision with the ultimate aim of improving patient survival. Recently, advances in the identification of effective treatment strategies and improvements in patient risk stratification have been reached. A randomized trial demonstrated that neoadjuvant epirubicin and ifosfamide improves survival of patients affected by five high-risk soft tissue sarcoma histologies of trunk and extremities, including undifferentiated pleomorphic sarcoma, myxoid liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumours, and leiomyosarcoma. Selection of patients for these treatments is expected to be improved by the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system, as it tailors T-stage categories on primary tumour site and considers a prognostic nomogram for retroperitoneal sarcoma, which also includes soft tissue sarcoma histology and other patient and tumour features not directly included in the TNM staging. Within this framework, this article will present neoadjuvant treatment strategies for high-risk soft tissue sarcoma, emphasizing the most recent advances and discussing the need for further research to improve the effectiveness of neoadjuvant treatments.

Association of core needle biopsy tract resection with local recurrence in extremity soft tissue sarcoma

OBJECTIVE

Due to minimal tissue violation in percutaneous core needle biopsy (CNB), in contrast to open biopsy, the risk of tumor seeding and subsequent local recurrence (LR) along the biopsy tract remains unclear in extremity soft tissue sarcoma (STS). This study sought to examine the association of CNB tract resection on LR in a large STS institutional database.

MATERIALS AND METHODS

After a retrospective review of the 116 patients who underwent CNB prior to surgery for previously untreated non-metastatic extremity STS, 36 patients who did not have CNB tracts resected (CNB-NR) were matched with 36 who had CNB tracts resected (CNB-R) for the factors that are known to affect LR.

RESULTS

Two patients (6%) developed LR in the CNB-R group, whereas three patients (8%) developed LR in the CNB-NR group (P = 0.643). On Kaplan-Meier analysis, there was no significant difference in LR-free survival between the two groups (94.3% ± 3.9 for the CNB-R group vs. 93.8% ± 4.3 for the CNB-NR group, P = 0.747).

CONCLUSION

Our data suggest any influence of a CNB tract resection on LR, within the limitations of this study, is likely to be of minor clinical importance in extremity STS. Although it would be prudent to resect the CNB tract in most cases, not resecting the CNB tract is a feasible option if identification or removal of the CNB tract proves difficult.

Preoperative Radiation Therapy Followed by Reexcision May Improve Local Control and Progression-Free Survival in Unplanned Excisions of Soft Tissue Sarcomas of the Extremity and Chest-Wall

Background. The management for unplanned excision (UE) of soft tissue sarcomas (STS) has not been established. In this study, we compare outcomes of UE versus planned excision (PE) and determine an optimal treatment for UE in STS. Methods. From 2000 to 2014 a review was performed on all patients treated with localized STS. Clinical outcomes including local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) were evaluated using the Kaplan-Meier estimate. Univariate (UVA) and multivariate (MVA) analyses were performed to determine prognostic variables. For MVA, Cox proportional hazards model was used. Results. 245 patients were included in the analysis. 14% underwent UE. Median follow-up was 2.8 years. The LR rate was 8.6%. The LR rate in UE was 35% versus 4.2% in PE patients (p < 0.0001). 2-year PFS in UE versus PE patients was 4.2 years and 9.3 years, respectively (p = 0.08). Preoperative radiation (RT) (p = 0.01) and use of any RT for UE (p = 0.003) led to improved PFS. On MVA, preoperative RT (p = 0.04) and performance status (p = 0.01) led to improved PFS. Conclusions. UEs led to decreased LC and PFS versus PE in patients with STS. The use of preoperative RT followed by reexcision improved LC and PFS in patients who had UE of their STS.

Federation Nationale des Centers de Lutte Contre le Cancer grading of soft tissue sarcomas on needle core biopsies using surrogate markers

Needle core biopsy (NCB) of soft tissue sarcomas (STSs) presents problems for French Federation Nationale des Centers de Lutte Contre le Cancer (FNCLCC) histological grading because small sample size hinders determination of necrosis and mitotic activity. We graded 53 STSs on NCB using a modified FNCLCC grading system that substitutes Ki-67 immunoexpression for mitotic count and uses a radiological assessment of necrosis, and compared the results with those obtained by conventional FNCLCC grading of the corresponding untreated, surgically resected specimen. Forty-eight of the 53 tumors were classified as malignant on NCB (concordance = 91%). The modified FNCLCC grade correctly separated high-grade (grades II and III) from low-grade sarcomas in 70% of cases and predicted the traditional FNCLCC grade given to the resected specimen in 49% of cases. Ki-67 scores of 2 or 3 were observed in 5 tumors classified as low-grade neoplasms on NCB but upgraded to a high-grade dedifferentiated liposarcoma on resection. Underestimated NCB grades were commonly encountered with lipomatous tumors due to sampling error, whereas Ki-67 or radiologic necrosis scores higher than the corresponding histological scores were responsible for the vast majority of overestimated NCB grades. Our FNCLCC grading scheme replacing conventional mitosis counting and histologic assessment of necrosis with surrogate markers is useful in separating high- and low-grade STSs on NCB for STS treatment planning. High Ki-67 rate should raise suspicion of a higher-grade component, particularly with fatty tumors.

The introduction of early patient rehabilitation in surgery of soft tissue sarcoma and its impact on post-operative outcome

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are implemented in multiple fields of surgery, but not yet in soft-tissue sarcoma (STS) surgery. We wondered whether its introduction into STS surgery might have impacted postoperative outcome.

METHODS

Two hundred and fifty seven adult patients with primary limb or trunk wall STS received ERAS from 2008 to 2012 as a part of the intra-operative management. We evaluated, in retrospect, the intra-operative management, post-operative outcomes, functional and oncological results of these patients and compared them with 459 prior patients treated under a standard recovery after surgery (SRAS) program from 1989 to 2007.

RESULTS

The most visible change from SRAS to ERAS in the perioperative management was decrease of wound drainage (72% vs. 15%, p < 0.001) and increase of wound bandaging (16% vs. 66%; p < 0.001), underlining the appliance of the ERAS protocol. Post-operatively, hospital stay dropped from nine (0-74) to three (0-22) days (p < 0.001) without affecting major morbidity (8% vs. 5%, NS) or readmission to the hospital (5% vs. 4%, NS). Functional outcome improved (p = 0.009) but whether this change was due to ERAS remains to be proved because complementary treatments changed over time. Tumour control remained unaffected, with an estimated risk of local recurrence at 5 years of 12% in both groups.

CONCLUSION

Introducing a rapid recovery program was associated with a shorter hospitalization stay without compromising surgical or oncological outcomes. The program appears to be safe and reliable to use in patients undergoing STS surgery.

Predictors of diagnostic success in image-guided pediatric soft-tissue biopsies

BACKGROUND

Image-guided percutaneous core needle biopsy (PCNB) of soft-tissue lesions is a minimally invasive technique that can provide a definitive diagnosis for treatment. Anatomical and age considerations in children require judicious use of safe percutaneous biopsy techniques. There are, however, limited data on the determinants of diagnostic yield in soft-tissue lesions in this population.

OBJECTIVES

To assess lesion-related and technical factors that affect diagnostic yield and safety in PCNB of pediatric soft-tissue lesions.

MATERIALS AND METHODS

This was a retrospective cohort study of 205 PCNB performed from January 2000 to July 2014. Diagnostic yield and its associations with technical and lesion-related factors were evaluated using bivariate analysis.

RESULTS

The mean patient age was 11.1 ± 6.9 years (interquartile range [IQR]: 4.3-16 years). Ultrasound guidance alone was used in 91% of cases. The mean number of passes was 7.5 ± 3.2 (IQR: 5-9 passes) per case. The overall diagnostic yield was 75% and the overall accuracy was 88%. Performing fewer than four passes was associated with a nondiagnostic biopsy (P = 0.001). There were no lesion or other technical factors that predicted a diagnostic biopsy. There were two complications (1%) over 14 years.

CONCLUSION

Image-guided PCNB is a safe and effective means for the diagnosis of pediatric soft-tissue abnormalities. Aside from performing at least four passes, our data show no technical or lesion-related factors that increase diagnostic yield in pediatric PCNB of soft-tissue lesions.

Follow-up of recurrences of limb soft tissue sarcomas in patients with localized disease: performance of ultrasound

OBJECTIVES

To evaluate diagnostic performance of ultrasound in the detection of local recurrences in patients with localized soft tissue sarcomas of the limb.

METHODS

An analysis of patients treated for soft tissue sarcomas between 2005 and April 2014 was performed. Sixty-eight patients (men/women, 36:32; age range, 18-84 years) were evaluated. Sensitivity, specificity with 95% confidence intervals (CIs), positive predictive value (PPV), pre-test probability (the prevalence), negative predictive value (NPV), likelihood ratio for positive results (LH+), accuracy and post-test probability (post-P) of ultrasound were reported on a per patient basis using surgical findings and clinical follow-up as reference standard. Effects of independent variables (US equipment, age and sex, body mass index, radiologist) were considered. Comparison with MR was also performed.

RESULTS

The overall sensitivity and specificity were 0.88 (0.60-0.94) and 0.94 (0.86-0.98). PPV, pre-test probability, NPV, LH+, accuracy and post-P: 0.83/0.25/0.96/14.9/0.92/0.83. There were two false negative cases both graded as G3 and deeply located and three false positive US cases. Diagnostic accuracy was not dependent by US machine (p = 0.08), age and sex (p = 0.16), body mass index (p = 0.07) and radiologists (p = 0.07).

CONCLUSIONS

Diagnostic accuracy of ultrasound was relatively high. Negative US results excluded the presence of a local recurrence with acceptable accuracy.

KEY POINTS

• US accuracy is relatively high in sarcoma follow-up. • Negative US results exclude the presence of local recurrence with acceptable accuracy. • US may miss a small proportion of lesions. • False positive US cases are rare.

Comparative effectiveness research for sarcoma

Modern multidisciplinary management of sarcoma represents several opportunities for comparative effectiveness research. Focusing on the outcomes of survival, quality of life and cost-effectiveness of care, the current state of the art is summarized. Specialized/regional care for sarcoma and the utility of tumor boards or multispecialty discussion is discussed. Issues related to treatment efficacy and sequencing in relation to chemotherapy, radiation, and surgery as well as margin reporting and surveillance are also discussed. Finally, future avenues of comparative effectiveness research for sarcoma are highlighted throughout the chapter.

Modern surgical techniques for management of soft tissue sarcomas involving the spine: outcomes and complications

Several types of soft tissue sarcomas may locally extend to the spine. The best therapeutic strategy for such lesions strongly depends on the histological diagnosis. In this article the authors provide an up-to-date review of current guidelines regarding the management of soft tissue sarcomas involving the spine. Special attention is given to outcomes and complications of modern surgical series in order to highlight current challenges in the management of such lesions.

[Value of core needle biopsy in preoperative diagnostics of soft tissue tumors: possibilities and limitations]

The differential diagnosis of soft tissue swellings encompasses a variety of benign, intermediate, low-grade malignant and high-grade neoplastic lesions in addition to tumor-like reactive processes. As treatment of these heterogeneous conditions varies greatly from conservative observation and simple local excision up to extensive radical surgical resection, treatment decisions are based mainly on a precise preoperative histological diagnosis on limited biopsy material. Even for clinically unequivocal sarcomas, the importance of the preoperative histological diagnosis has been increasingly emphasized as different therapeutic regimens have been established for different sarcoma types and the indications for preoperative treatment is influenced by the tumor grade and by the entity itself. Other factors positively influencing the increasing use of core needle biopsy for preoperative tumor diagnosis in soft tissue pathology are the availability of modern high-resolution imaging modalities as well as the establishment of several new second generation immunohistochemical markers and the discovery of entity-specific translocations detected by fluorescence in situ hybridization (FISH) in several sarcoma subtypes. In this review it will be shown that a targeted approach for processing core needle biopsies oriented towards the characteristic topographical, demographic, cytomorphological and architectural features of soft tissue lesions facilitates a precise diagnosis of soft tissue neoplasms in most cases. However, profound knowledge of the different aspects of soft tissue tumor diagnostics and familiarity with the frequent as well as the less common and rare tumor entities and variants is a prerequisite for appropriate interpretation of core needle biopsy findings and for selecting a limited but well-suited marker panel. The utilization of modern immunohistochemistry and/or FISH methods is highly useful for establishing the diagnosis of rare and unusual neoplasms in core needle biopsies.

Grading of soft tissue sarcomas: from histological to molecular assessment

Several histological grading systems for soft tissue sarcomas have been described since the early 1980s. Their main objective is to select patients for adjuvant chemotherapy. Two histological grading systems are used in daily practice, the National Cancer Institute (NCI) and the French Federation of Cancer Centers Sarcoma Group (FNCLCC) systems. They have been devised by combining histological parameters: number of mitoses per high-power field, the presence of necrosis, cellular and nuclear morphology and the degree of cellularity for the NCI grading; and tumour differentiation, mitotic index and extent of necrosis for the French system. Histological grading is far more appropriate to assess the risk of metastasis. However, several limitations prevent its use: grade cannot be applied to all histological types, its reproducibility is not perfect, a three-grade system generates an intermediate grade with undetermined prognosis, and finally the core needle biopsy, now widely used for the diagnosis of soft tissue sarcoma, is not the best sample to assess the grade. The development of molecular grading in addition to histological grading probably represents the next step. Molecular signatures based on quantitative evaluation of chromosomal complexity such as CINSARC (complexity index in sarcomas) appear as a strong independent predictive factor for metastasis in several types of sarcoma, and even in several other types of cancer. When they can be instituted in daily practice on formalin fixed, paraffin embedded material, molecular signatures will not only provide information on risk of metastasis, but also better understanding of cancer development, response or resistance to evaluated drugs, and potential targets for future treatments.

Sampling modality influences the predictive value of grading in adult soft tissue extremity sarcomas

CONTEXT

Histologic grade is one of the best predictors of outcome in adult soft tissue sarcomas. Current grading systems were validated on resection specimens; however, there has been a trend toward the use of biopsies to diagnosis these tumors.

OBJECTIVES

To determine whether the grade of an extremity soft tissue sarcoma determined on tissue obtained by either core needle biopsy or incisional biopsy is predictive of metastasis- or disease-free survival, and whether either sampling modality is superior.

DESIGN

One hundred three core needle biopsies and 107 incisional biopsies of nonmetastatic spindle cell sarcomas of the extremities were retrieved from the archives. All cases had a minimum 2-year follow-up. Patient data and outcome and tumor characteristics were recorded. Tumors were reviewed and evaluated using the French Federation of Cancer Centers Sarcoma Group grading system. Kaplan-Meier survival curves were generated to correlate tumor grade with metastasis- and disease-free survival for both groups.

RESULTS

Patient and tumor characteristics were similar between groups except that more tumors were grade 3 and superficial in the incisional biopsy group. Grade determined on core needle biopsy was not predictive of either metastasis-free survival (P = .59) or disease-free survival (P = .50). In contrast, grade determined on incisional biopsy was predictive of both metastasis-free survival (P < .001) and disease-free survival (P = .001).

CONCLUSIONS

Biopsy, particularly core needle biopsy, represents a convenient diagnostic tool, particularly in the context of neoadjuvant therapy. However, based on these results incisional biopsy is recommended if grading is to be used to predict prognosis in spindle cell soft tissue sarcomas of the extremities.

[Significance of sonographically guided percutaneous needle biopsy in the diagnostics of soft tissue tumors]

BACKGROUND

The role of percutaneous needle biopsy in the diagnostics of soft tissue tumors is controversially discussed. The specificity of this method has been examined in this study based on the collective of patients treated in our university hospital. Secondly, the influence of the specialization of the treating surgeon has been evaluated.

PATIENTS AND METHODS

This study included 96 patients who underwent percutaneous needle biopsy and, if necessary, surgical resection. The specificity, logistic requirements and possible complications of percutaneous biopsy were evaluated. Special attention was paid to the influence of specialization of the treating surgical team on the specificity of the method.

RESULTS

The results of the biopsy were able to define the entity of the lesion correctly in 69.7 %, the dignity in 75.0 % and the grading in 72.0 % of the cases. In the group treated by a specialized team, the specificity of the method was 84.6 % concerning the entity of the lesion, 84.6 % concerning the dignity and 80 % concerning the grading. With regard to the entity the specificity was significantly increased (p < 0.05).

CONCLUSION

The findings show that percutaneous needle biopsy represents a logistically simple and efficient diagnostic method for soft tissue tumors which is rarely associated with complications. Subsequent treatment should be performed in a specialized centre.

Tail-end troubles: imaging of soft-tissue buttock tumours

Primary soft-tissue buttock tumours are relatively common entities, although they are infrequently reported in the literature. The buttock can be a difficult anatomical site to treat soft-tissue tumours due to the proximity of the sciatic nerve and the propensity of tumours at this site to extend into the pelvis and perineum. Therefore, the radiologist plays an important role in the multidisciplinary assessment of these lesions. Cross-sectional imaging, principally magnetic resonance imaging, is used to determine the exact location and extension of the tumour. Furthermore, certain tumours have characteristic imaging appearances that can help to establish a suitably ordered differential diagnosis. From our prospectively maintained database at The Royal Marsden Hospital, including 225 cases that were treated at the Sarcoma Unit over a 30 year period, we present examples of benign and malignant primary soft-tissue buttock tumours and describe the pertinent imaging characteristics, with emphasis on computed tomography and magnetic resonance imaging findings.

Identification of the biopsy track in musculoskeletal tumour surgery: a novel technique using India ink

Local recurrence along the biopsy track is a known complication of percutaneous needle biopsy of malignant musculoskeletal tumours. In order to completely excise the track with the tumour its identification is essential, but this becomes increasingly difficult over time. In an initial prospective study, 22 of 45 patients (48.8%) identified over a three-month period, treated by resection of a musculoskeletal tumour, had an unidentifiable biopsy site at operation, with identification statistically more difficult after 50 days. We therefore introduced the practice of marking the biopsy site with India ink. In all 55 patients undergoing this procedure, the biopsy track was identified pre-operatively (100%); this difference was statistically significant. We recommend this technique as a safe, easy and accurate means of ensuring adequate excision of the biopsy track.

Tru-cut biopsy as the initial method of tissue diagnosis in bone tumors with soft tissue extension

BACKGROUND

Tru-cut biopsy in suspected bone tumors can be performed even in less specialized centers. Tru-cut biopsy has been proved as safe with more than 90% accuracy. However, its usefulness was not widely studied in general hospitals where Tru-cut biopsy is performed by orthopedic surgeons. This study was conducted to find out the accuracy and adequacy of Tru-cut biopsy performed by an orthopedic surgeon not trained in musculoskeletal oncology, in a general hospital.

MATERIALS AND METHODS

A study was conducted through a prospectively collected database using a uniform protocol. All patients who had a malignant appearing bone lesion with a palpable soft tissue mass were included in the current study. Fifty such consecutive cases underwent Tru-Cut biopsy by orthopedic residents or registrars who were aware of the principles of Tru-cut biopsy and the recommendations of Musculoskeletal Tumor Society. When an open biopsy or a resection of the tumor was subsequently performed, the histological diagnosis was compared for accuracy with the diagnosis of needle biopsy. We evaluated adequacy of sample obtained and accuracy of diagnosis in terms of sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

Seventy seven cases were initially enrolled. Out of which 18 were excluded and 59 patients were biopsied. Out of which 50 were analysed. Only 4 out of 50 biopsied specimens were inadequate resulting in an adequacy rate of 92%. Among 46 cases, which were analyzed for diagnostic accuracy, 84.78% had true-positive result, 8.69% had true negative, and 6.52% had false-negative report. The sensitivity and specificity of Tru-cut biopsy in our series was 92.85% and 100%, respectively, with positive predictive value of 100% and negative predictive value of 57.14%.

CONCLUSIONS

Tru-cut biopsy can be recommended as an initial method of tissue diagnosis in musculoskeletal tumors with soft tissue extension.

Biópsia percutânea por agulha grossa de tumores de partes moles guiada por tomografia computadorizada: resultados e correlação com análise da peça cirúrgica

OBJETIVO: Avaliar a eficácia da biópsia percutânea por agulha grossa (BPAG) de tumores de partes moles guiada por tomografia computadorizada (TC), em relação ao sucesso na obtenção de amostra para análise, e comparar o diagnóstico da BPAG com o resultado anatomopatológico da peça cirúrgica, quando disponível. MATERIAIS E MÉTODOS: Foram revisados os prontuários e laudos diagnósticos de 262 pacientes com tumores de partes moles submetidos a BPAG guiada por TC em um centro de referência oncológico entre 2003 e 2009. RESULTADOS: Das 262 biópsias realizadas, foi possível a obtenção de amostra adequada em 215 (82,1%). Os tumores mais prevalentes foram os sarcomas (38,6%), carcinomas metastáticos (28,8%), tumores mesenquimais benignos (20,5%) e linfomas (9,3%). Foi possível realizar graduação histológica em 92,8% dos pacientes com sarcoma, sendo a maioria (77,9%) classificada como alto grau. Do total de pacientes, 116 (44,3%) realizaram cirurgia para exérese e confirmação diagnóstica. A BPAG mostrou acurácia de 94,6% na identificação de sarcomas, com sensibilidade de 96,4% e especificidade de 89,5%. A graduação histológica teve concordância significativa entre a BPAG e a peça cirúrgica (p < 0,001; kappa = 0,75). CONCLUSÃO: A BPAG guiada por TC demonstrou elevada acurácia diagnóstica na avaliação de tumores de partes moles e na graduação histológica dos sarcomas, permitindo um adequado planejamento terapêutico.