Percutaneous CT-guided sternal biopsy: factors affecting the diagnostic yield

Bone Biopsies: Practical Considerations and Technical Tips

Percutaneous image-guided needle biopsies are a safe and minimally invasive method of obtaining tissue of bone lesions. Radiologists are an integral part of a multidisciplinary team (MDT) approach to patient care in obtaining tissue for both pathologic diagnosis and advanced genetic/molecular testing. By utilizing image guidance, radiologists can target bone lesions with a very low complication rate. This review will discuss our approach to image-guided biopsies of bone lesions. Radiologists should be familiar with patient selection and imaging workup prior to performing biopsies, as well as the importance of coordinating the biopsy approach and sampling with the patient's clinical team. Management of bleeding and thrombotic risk in patients undergoing bone biopsies is also an important preprocedural consideration and will be discussed. The majority of bone biopsies are performed utilizing moderate sedation for patient analgesia and comfort, but close attention should be paid to patient comorbidities and potential interacting medications. Although computed tomography guidance remains the mainstay of image-guided biopsy, there are some circumstances in which ultrasound or fluoroscopic guidance may be beneficial. New advances in powered drill technology have made tissue sampling of bone lesions particularly sclerotic bone lesions both safer and faster with increased tissue yield. Finally, we will discuss image-guided biopsy of difficult anatomic regions that require special techniques to yield tissue safely.

Factors affecting the success of CT-guided core biopsy of musculoskeletal lesions with a 13-G needle

OBJECTIVE

To determine the value of CT-guided bone core biopsy and investigate factors that affect diagnostic yield and biopsy outcome.

MATERIALS AND METHODS

The single-centre retrospective analysis included 447 patients who had CT-guided core biopsy with a 13-G needle (Bonopty®) from January 2016 to December 2021. Histological results or ≥ 6 months of clinical and radiological follow-up served as outcome references. A successful biopsy was classified as "diagnostic" when a definitive diagnosis was made and "adequate" when only the malignant or benign nature of the tumour could be determined. Biopsies were "nondiagnostic" when the nature of the lesion could not be determined. The occult lesions were defined as not seen on CT but visible on other modalities.

RESULTS

In 275 (62%) females and 172 (38%) males, the overall success rate was 85% (383 biopsies), with 314 (70%) diagnostic biopsies and 69 (15%) adequate biopsies. There was no relationship between biopsy success and the localisation of the lesion, length of biopsy material, or number of biopsy attempts. The lesions' nature had a statistically significant effect on biopsy success with lytic and mixed lesions having the highest success rate. Occult lesions had the lowest success rate.

CONCLUSION

CT-guided bone core biopsy is an effective method in the workup of musculoskeletal diseases with the highest success rate in lytic and mixed lesions. No apparent relationship was found between biopsy success and biopsy length, number of attempts, or localisation of the lesion.

Diagnostic yield using electromagnetic navigation bronchoscopy for peripheral pulmonary nodules <2 cm

BACKGROUND

Although electromagnetic navigation bronchoscopy (ENB) is highly sensitive in the diagnosis of peripheral pulmonary nodules (PPNs), its diagnostic yield for subgroups of smaller PPNs is under evaluation.

OBJECTIVES

Diagnostic yield evaluation of biopsy using ENB for PPNs <2 cm.

DESIGN

The diagnostic yield, sensitivity, specificity, positive predictive value, and negative predictive value of the ENB-mediated biopsy for PPNs were evaluated.

METHODS

Patients who had PPNs with diameters <2 cm and underwent ENB-mediated biopsy between May 2015 and February 2020 were consecutively enrolled. The final diagnosis was made via pathological examination after surgery.

RESULTS

A total of 82 lesions from 65 patients were analyzed. The median tumor size was 11 mm. All lesions were subjected to ENB-mediated biopsy, of which 29 and 53 were classified as malignant and benign, respectively. Subsequent segmentectomy, lobectomy, or wedge resection, following pathological examinations were performed on 64 nodules from 57 patients. The overall sensitivity, specificity, positive predictive value, and negative predictive value for nodules <2 cm were 53.3%, 91.7%, 92.3%, and 51.2%, respectively. The receiver operating curve showed an area under the curve of 0.721 (p < 0.001). Additionally, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.5%, 100%, 100%, and 42.9%, respectively, for nodules with diameters equal to or larger than 1 cm; and 30.8%, 86.7%, 66.7%, and 59.1%, respectively, for nodules less than 1 cm. In the subgroup analysis, neither the lobar location nor the distance of the PPNs to the pleura affected the accuracy of the ENB diagnosis. However, the spiculated sign had a negative impact on the accuracy of the ENB biopsy (p = 0.010).

CONCLUSION

ENB has good specificity and positive predictive value for diagnosing PPNs <2 cm; however, the spiculated sign may negatively affect ENB diagnostic accuracy. In addition, the diagnostic reliability may only be limited to PPNs equal to or larger than 1 cm.

Partial sternectomy with reconstruction of a giant cell tumor of the sternum, a case report, Saudi, Arabia

BACKGROUND

Giant cell tumor (GCT) is a relatively common and locally aggressive benign bone tumor that rarely affects the sternum.

CASE PRESENTATION

We report a case of giant cell tumor of the sternum in a 28-year-old Saudi with painful swelling at the lower part of the sternum. Subtotal sternectomy and reconstruction with a neosternum using two layers of proline mesh, a methyl methacrylate prosthesis, and bilateral pectoralis muscle advancement flaps were performed.

CONCLUSIONS

Giant cell tumor of the sternum is a rare diagnosis. Surgical resection with negative margins is the ideal management. To avoid defects or instability of the chest wall, reconstruction of the chest wall with neosternum should be considered.

Percutaneous CT-Guided Bone Biopsies: Indications, Feasibility and Diagnostic Yield in the Different Skeletal Sites-From the Skull to the Toe

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.

A Retrospective Analysis of Sternal Lesions Detected on Breast MRI in Patients Without History of Cancer

OBJECTIVE

To determine the imaging characteristics and stability over time of sternal lesions identified on breast MRI in patients without history of cancer.

METHODS

An IRB-approved retrospective analysis of all breast MRIs performed at our institution from September 1, 2017 to December 1, 2021 that included one of several key words related to the sternum. Studies with history of non-dermatologic malignancy including breast cancer, absence of a true sternal lesion, or presence of symptoms during the examination were excluded. Imaging was reviewed for size, distribution, signal characteristics, and presence of contrast enhancement, perilesional edema, periosteal edema, or intralesional fat. Available comparison imaging, clinical history, and follow-up recommendations were reviewed. Descriptive statistics were used to summarize lesion data.

RESULTS

Of 60 lesions included from 60 patients, 40 lesions with more than two years of comparison imaging were either stable or decreased in size and none demonstrated change in signal characteristics. The majority of these presumed benign lesions demonstrated hypointense signal on T1-weighted sequences (21/40, 52.5%), hyperintense signal on fluid-sensitive sequences (33/40, 82.5%), contrast enhancement (32/40, 80.0%), and absence of clear intralesional fat (29/40, 72.5%). One patient who did not have comparison imaging was diagnosed with malignancy (multiple myeloma) eight months following their MRI. This lesion demonstrated uniquely diffuse and heterogeneous enhancement but did not undergo biopsy.

CONCLUSION

Sternal lesions in women without history of non-dermatologic malignancy have a very low likelihood of malignancy. Common imaging characteristics of the presumed benign lesions can inform imaging recommendations when incidental sternal lesions are discovered.

Percutaneous image-guided sternal biopsy: a cross-institutional retrospective review of diagnostic yield and safety in 50 cases

OBJECTIVE

Image-guided sternal biopsy may be technically daunting given the immediately subjacent critical structures. There is a paucity of literature describing technique, safety, and efficacy. This study aims to quantify the diagnostic yield and safety of image-guided sternal biopsies. Secondary aims include (1) describing the preferred approach/technique and (2) identifying imaging features and disease entities associated with higher and lower diagnostic yields.

MATERIALS AND METHODS

A retrospective review of 50 image-guided sternal biopsies performed at two quaternary care centers from 2000 to 2019 was performed. Recorded lesion-related variables included as follows: location, density, extraosseous extension, and size. Recorded variables from electronic medical records included as follows: patient demographics, histologic or microbiological diagnosis, and complications. Recorded technique-related variables included as follows: needle obliquity, type, and gauge; biopsy core number and length; and modality.

RESULTS

Of the 50 biopsies, 88.0% resulted in a definitive histologic diagnosis. Six biopsies were non-diagnostic. The majority of biopsies were performed under computed tomography (88.0%), followed by ultrasound (12.0%). Tumor was the most common biopsy indication (90.0%), followed by infection (10.0%). Of the diagnostic biopsies indicated for tumor, 88.9% were malignant. Seventy-four percent of the lesions were predominantly lytic. Fifty percent of lesions had extraosseous extension. Lesion locations were as follows: manubrium (48.0%), sternal body (48.0%), and sternomanubrial joint (4.0%). No minor or major, acute, or delayed procedure-related complications were encountered.

CONCLUSION

Image-guided sternal biopsy is an efficacious and safe method of obtaining a definitive histologic diagnosis regardless of lesion-specific features or location.

Pearls and Pitfalls for Soft-Tissue and Bone Biopsies: A Cross-Institutional Review

Management of soft-tissue and bone neoplasms depends on a definitive histologic diagnosis. Percutaneous image-guided biopsy of bone and soft-tissue tumors is a cost-effective and accurate method to obtain a histopathologic diagnosis. Biopsy requests must be approached thoughtfully to avoid numerous potential pitfalls. Hasty biopsy planning places the patient at increased risk for misdiagnosis, delayed therapy, repeated invasive procedures, and substantial morbidity. Biopsy planning begins with a thorough review of the relevant clinical history and pertinent imaging. The biopsy route must be planned in concert with the referring orthopedic oncologist to preserve limb-sparing options. Carefully selecting the most appropriate imaging modality to guide the biopsy increases the chances of reaching a definitive diagnosis. It is also critical to identify and target with expertise the part of the lesion that is most likely to yield an accurate diagnosis. Percutaneous biopsy is a safe procedure, and familiarity with preprocedural laboratory testing parameters, anticoagulation guidelines, and commonly used sedation medications minimizes the risk of complications while ensuring patient comfort. Nondiagnostic biopsy results are not infrequent and may still have value in guiding patient treatment. Awareness of the imaging manifestations of tumor recurrence is also important. The aim of this article is to provide a comprehensive review of pertinent preprocedural, periprocedural, and postprocedural considerations for bone and soft-tissue musculoskeletal biopsies.The online slide presentation from the RSNA Annual Meeting is available for this article.^©RSNA, 2020.

Initial experience with dual-energy computed tomography-guided bone biopsies of bone lesions that are occult on monoenergetic CT

OBJECTIVE

Our purpose was to determine whether dual-energy CT (DECT), specifically the bone marrow setting of the virtual noncalcium (VNCa) algorithm, could be used to identify and accurately biopsy suspected bone malignancies that were visible on magnetic resonance imaging (MRI), nuclear bone scintigraphy, or positron-emission tomography/computed tomography (PET/CT), but occult on monoenergetic computed tomography (CT) by virtue of being either isodense or nearly isodense to surrounding normal bone.

MATERIALS AND METHODS

We present 4 cases in which DECT was used to detect various malignant bone lesions and was successfully used to direct percutaneous DECT-guided bone biopsies.

RESULTS

Two of the lesions were solid tumor metastases (breast and prostate carcinoma), whereas two others were hematological malignancies (leukemia and lymphoma). This technique enabled us to confidently and accurately direct the biopsy needle into the target lesion.

CONCLUSION

The authors demonstrate that the DECT VNCa bone marrow algorithm may be helpful in identifying isodense bone lesions of various histologies and may be used to guide percutaneous bone biopsies. This technique may help to maximize diagnostic yield, minimize the number of passes into the region of concern, and prevent patients from undergoing repeat biopsy.