How should musculoskeletal biopsies be performed?

[Giant cell tumor of bone-an update]

In the past few years, numerous new insights have been gained in the field of giant cell tumor of bone (GCTB). On the one hand, the detection of the highly characteristic histone mutation in the H3F3A gene in GCTB is becoming increasingly important in diagnostics in differentiating GCTB from other giant cell-rich lesions of bone as well as for defining rare variants of GCTB without osteoclastic giant cells. On the other hand, the effects of the H3F3A mutation were shown to have an impact on the epigenetic profile of tumor-driving stromal cells, providing new insights into tumorigenesis of GCTB.

Bone biopsy devices - a patent review

INTRODUCTION

Bone biopsies have great value for the diagnosis of, amongst others, hematologic diseases. Although the bone biopsy procedure is mostly performed minimally invasive with the use of a slender cannula, the patient may still experience discomfort, especially when the procedure has to be repeated due to an unsuccessful biopsy.

AREAS COVERED

This review presents a comprehensive overview of bone biopsy devices presented in the patent literature. The patents were obtained using a classification search combined with keywords in the Espacenet patent database and were subsequently verified using pre-set eligibility criteria. This resulted in 62 unique patents included in this review.

EXPERT OPINION

The included patents were categorized based on the used strategies for the three steps that can be identified during a bone biopsy (1) biopsy sampling, (2) biopsy severing and (3) biopsy harvesting. Most patents described strategies for multiple steps. Insight into the used strategies and the comprehensive overview may serve as a source of inspiration for the design of novel bone biopsy devices.

Malignant Bone and Soft Tissue Lesions of the Foot

Malignant tumors of the foot are rare pathologies that can involve the skin, soft tissue, or bone. Due to their rarity, they are often misdiagnosed, resulting in inadequate excision and poor outcomes. A correct approach with a careful examination and radiological study, followed by a properly performed biopsy, is thus mandatory to avoid these pitfalls. The present article reviews the most common malignant bone and soft tissue lesions of the foot region, discussing their clinicopathological presentation, imaging features, and current concepts in treatment.

Transarticular epithelioid hemangioma of the ankle-a case of a rare vascular neoplasm

Epithelioid hemangioma of the bone is a rare kind of vascular neoplasm posing a diagnostic challenge because of its ability to mimic malignant tumors. We report a case of a fast-growing, talofibular joint-involving epithelioid hemangioma, which was suspectedly initiated by vascular damage due to trauma and arthroscopy. The ankle mass appeared as a lytic lesion on the CT images and as a T1 hypo-, T2 mildly hyperintense, lobulated structure on the MRI scans. The contrast enhancement pattern was typical to vascular neoplasms. Histologically the lesion consisted of well-formed vessels lined with epithelioid cells with a slightly atypical nuclear morphology, inflammation with a significant number of eosinophils, and low mitotic rate. Immunohistochemistry analysis showed the presence of vascular markers but no rearrangements characteristic of soft tissue sarcomas were registered by the next-generation sequencing. The surgical treatment was curative. The report presents current imaging methods and summarizes the imaging findings of transarticular spreading tumors. The paper also highlights that for the differential diagnosis of vascular tumors showing signs of aggressivity, the pathological analysis is inevitable. Correct diagnosis of the epithelioid hemangioma is essential, as the treatment of more malignant entities is substantially different. An added value of the report is that to the best of our knowledge, a transarticular spreading epithelioid hemangioma of the ankle has never been described before.

The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience

Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety.

Fluid-fluid Levels in Musculoskeletal Tumor Imaging

Fluid-fluid levels result from the separation of two fluids of differing densities within a cavernous space with the boundary between the two layers running in a horizontal plane at 90 degrees to the direction of gravity. Magnetic resonance imaging is the most sensitive imaging modality to identify fluid-fluid levels. Although the most common bone lesions containing fluid-fluid levels are aneurysmal bone cyst and telangiectatic osteosarcoma, fluid-fluid levels can be observed in a wide variety of bone and soft tissue lesions. Therefore, fluid-fluid levels cannot be considered diagnostic of any particular type of tumor and the diagnosis should be made on the basis of other clinical, radiological and pathological findings. This article summarizes the pathophysiology and imaging characteristics of fluid-fluid levels and discusses the differential diagnosis of tumors with this imaging sign.

Imaging Features of Primary Tumors of the Hand

Musculoskeletal tumors of the hand are a rare entity and are divided into skeletal and soft tissue tumors. Either category comprises benign and malignant or even intermediate tumors. Basic radiology allows an optimal resolution of bone and related soft tissue areas, ultrasound and more sophisticated radiologic tools such as scintigraphy, CT and MRI allow a more accurate evaluation of tumor extent. Enchondroma is the most common benign tumor affecting bone, whereas chondrosarcoma is the most commonly represented malignant neoplasm localized to hand bones. In the soft tissues, ganglions are the most common benign tumors and epithelioid sarcoma is the most frequently represented malignant tumor targeting hand soft tissues. The knowledge regarding diagnostic and therapeutic management of these tumors is often deriving from small case series, retrospective studies or even case reports. Evidences from prospective studies or controlled trials are limited and for this lack of clear and supported evidences, data from the medical literature on the topic are controversial, in terms of demographics, clinical presentation, diagnosis, prognosis and therapy. The correct recognition of the specific subtype and extension of the tumor through first line and second line radiology is essential for the surgeon, in order to effectively direct the therapeutic decisions.

Imaging of Soft Tissue Tumors

Differentiation of malignant from benign soft tissue tumors is challenging with imaging alone, including that by magnetic resonance imaging and computed tomography. However, the accuracy of this differentiation has increased owing to the development of novel imaging technology. Detailed patient history and physical examination remain essential for differentiation between benign and malignant soft tissue tumors. Moreover, measurement only of tumor size based on Response Evaluation Criteria In Solid Tumors criteria is insufficient for the evaluation of response to chemotherapy or radiotherapy. Change in metabolic activity measured by ¹⁸F-fluorodeoxyglucose positron emission tomography or dynamic contrast enhanced-derived quantitative endpoints can more accurately evaluate treatment response compared to change in tumor size. Magnetic resonance imaging can accurately evaluate essential factors in surgical planning such as vascular or bone invasion and "tail sign". Thus, imaging plays a critical role in the diagnosis and treatment of soft tissue tumors.

Percutaneous Imaging-Guided versus Open Musculoskeletal Biopsy: Concepts and Controversies

Bone and soft tissue tumors are a largely heterogeneous group of tumors. Biopsy of musculoskeletal (MSK) tumors is sometimes a challenging procedure. Although the open biopsy is still considered the gold standard for the biopsy of MSK lesions, core needle biopsy can replace it in most cases, with similar accuracy and a low complication rate. The biopsy should be performed in a tertiary sarcoma center where the multidisciplinary team consists of at minimum a tumor surgeon, an MSK pathologist, and an MSK radiologist who can assess all steps of the procedure. Several factors can influence the success of the biopsy including the lesion characteristics, the equipment, and the method used for the procedure. This review highlights some of the important aspects regarding the biopsy of the MSK tumors, with special attention to imaging a guided core needle biopsy and highlighting some of the recent advancements and controversies in the field.

Imaging Analyses of Bone Tumors

Despite the evolution in imaging, especially the introduction of advanced imaging technologies, radiographs still are the key for the initial assessment of a bone tumor. Important aspects to be considered in radiographs are the location, shape and size or volume, margins, periosteal reaction, and internal mineralization of the tumor's matrix; careful evaluation of these may provide for accurate diagnosis in >80% of cases. Computed tomography and magnetic resonance imaging are often diagnostic for lesions with typical findings such as the nidus of osteoid osteoma and bone destruction such as in Ewing sarcoma and lymphoma that may be difficult to detect with radiographs; they may also be used for surgical planning. Magnetic resonance imaging accurately determines the intraosseous extent and articular and vascular involvement by the tumor. This article summarizes the diagnostic accuracy of imaging analyses in bone tumors and emphasizes the specific radiographic findings for optimal radiographic diagnosis of the patients with these tumors.

Rare aneurysmal bone cysts: multifocal, extraosseous, and surface variants

Multifocal, extraosseous, and surface aneurysmal bone cysts are rare variants of the primary lesions. The clinicopathological features are similar, and the optimal treatment is surgical. Although local recurrences may occur, the prognosis is excellent. This review article introduces the readers to a rare diagnosis which they may have been previously unfamiliar with, presents the clinicopathological and imaging features of these rare aneurysmal bone cyst variants, and discusses their diagnosis and treatment. The clinicians who treat patients with aneurysmal bone cysts should be familiar with these uncommon entities and their differential diagnosis.

Benign peripheral nerve tumors

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach.

Schwannoma of the foot: report of four cases and literature review

Schwannoma is a soft tissue tumor that rarely presents in the foot. Patients are usually asymptomatic, but in some cases symptoms typically result from the mass effect and direct involvement of the nerve and surrounding tissue. We report on four consecutive cases. The first patient was a 57-years-old female that referred symptoms similar to the Morton’s neuroma with a mass arising from the medial plantar nerve. The second patient was treated for a schwannoma in the plantar area. The third case was a female with a schwannoma arising from the sural nerve and the fourth patient had a tumor arising from the medial plantar nerve. All patients underwent surgical excision and histological evaluation. No signs of neurological deficit or recurrence were observed at final follow-up. Purpose of the study was to define clinical features, optimal management and outcome of schwannomas of the foot, through an accurate review of the literature. (www.actabiomedica.it)

[Histological diagnosis of bone tumors: Guidelines of the French committee of bone pathologists reference network on bone tumors (RESOS)]

The management of patients having a bone lesion requires in many cases the realization of a histological sample in order to obtain a diagnosis. However, with the technological evolution, CT-guided biopsies are performed more frequently, often in outpatient clinics. Interpretation of these biopsies constitutes new challenges for the pathologists within the wide spectrum of bone entities. The purpose of the document is to propose guidelines based on the experience of the French committee of bone pathologists of the reference network on bone tumors (RESOS) regarding the indications and limitations of the diagnosis on restricted material.

Giant cell tumor of bone revisited

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic malignant bone tumor. It accounts for 4–10% of all bone tumors and typically affects the meta-epiphyseal region of long bones of young adults. The most common site involved is the distal femur, followed by the distal radius, sacrum, and proximal humerus. Clinical symptoms are nonspecific and may include local pain, swelling, and limited range of motion of the adjacent joint. Radiographs and contrast-enhanced magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosis. Surgical treatment with curettage is the optimal treatment for local tumor control. A favorable clinical outcome is expected when the tumor is excised to tumor-free margins, however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Local adjuvants have been used for improved curettage, in addition to systematic agents such as denosumab, bisphosphonates, or interferon alpha. This article aims to discuss the clinicopathological features, diagnosis, and treatments for GCT of bone.

Practical Guidelines for Ultrasound-Guided Core Needle Biopsy of Soft-Tissue Lesions: Transformation from Beginner to Specialist

Ultrasound-guided core needle biopsy (US-CNB) is an important step in the diagnosis of musculoskeletal soft-tissue lesions. To maximize efficacy and minimize the complications of US-CNB, it is critical to collaborate with a multidisciplinary team and to understand the particular considerations of US-CNB for these lesions. The purpose of this article is to provide a systematic review and step-by-step tips for using US-CNB to diagnose musculoskeletal soft-tissue lesions.