Diagnosing musculoskeletal tumours: How accurate is CT-guided core needle biopsy?

INTRODUCTION

Biopsy is a critical juncture in the diagnostic process for evaluating musculoskeletal tumours. The traditional diagnostic standard of open biopsy yields highly accurate diagnoses but associated with it is a significant rate of procedural complications. Imaging-guided needle biopsy is now being widely adopted as a competitive and minimally-invasive alternative with significantly lower complication rates. We assess its diagnostic outcomes at a tertiary referral centre in Melbourne, Australia.

METHOD

Data pertaining to biopsy and surgical histology were retrieved from the musculoskeletal tumour database at St Vincent's Hospital, Fitzroy following approval from the Human Research Ethics Committee (HREC 091/13). Data analyses were performed in STATA 12 to assess diagnostic parameters and related outcomes.

RESULTS

Bone tumours (n = 380) yielded accuracy of 80.8% with diagnostic error of 7.1% and undiagnostic rates of 12.1%. Soft-tissue tumours (n = 751) yielded accuracy of 83.2% with diagnostic error of 10.5% and undiagnostic rates of 6.3%. Biopsy of benign tumours (n = 648, accuracy = 85.3%, error = 5.9%, undiagnostic 8.8%) was more accurate than malignant tumours (n = 501, accuracy = 75.8%, error 14.0%, undiagnostic 7.4%). The overall procedural complication rate was 0.7%.

DISCUSSION

CT-guided core needle biopsy is a safe, accurate, and highly effective procedure that obviates the need for open and surgical biopsy in a significant number of cases. When combined with fusion imaging, CT guidance is an accurate method of targeting specific regions of interest.

Pigmented villonodular synovitis of the hip mimicking soft-tissue sarcoma: a case report

Pigmented villonodular synovitis is a rare and benign but potentially locally aggressive disease that should be considered in younger patients who present with monoarticular joint symptoms and pathology. We present a 30-year-old Sudanese woman with a huge mass arising from the right hip joint. A multimodality radiological approach to investigation and diagnosis is demonstrated and discussed. Histopathological examination of the resected specimen confirmed the diagnosis of pigmented villonodular synovitis with the mass consisting of a proliferation of fibrohistiocytic cells, abundant haemosiderin, foamy histiocytes, and occasional giant cells. The patient made a good recovery, with mobility aided by arm crutches and a hip abduction brace.

Scintigraphic findings in synovial sarcoma with structural correlation

Synovial sarcoma is a relatively rare malignant soft tissue tumour. It is highly aggressive, tends to occur in young adults and has a poor prognosis. The scintigraphic findings in 10 patients with histopathologically proven synovial sarcoma were reviewed. Most of the lesions occurred in the extremities and intense uptake of thallium was observed on 30-min and 4-h imaging in almost all cases. Thallium has an important role in the detection of possible metastatic disease and in monitoring response to therapy. The scintigraphic features of synovial sarcoma are presented and correlated with the radiographic findings.

Accurate localization of supernumerary mediastinal parathyroid adenomas by a combination of structural and functional imaging

Reoperation for refractory or recurrent hyperparathyroidism following parathyroidectomy carries the potential for increased morbidity and the possibility of failure to localize and remove the lesion intraoperatively. Reported herein are three cases demonstrating the combined use of sestamibi scintigraphy, CT and MR for accurate localization of mediastinal parathyroid adenomas.

Plasma amino-terminal pro-brain natriuretic peptide: a novel approach to the diagnosis of cardiac dysfunction

BACKGROUND

Heart failure is a common cause of hospitalization and death across the industrialized world. Improving the diagnosis and care of patients with heart failure is therefore likely to have a major impact on morbidity, mortality, and health care costs.

METHODS AND RESULTS

To determine the relation between cardiac function and plasma levels of amino-terminal brain natriuretic peptide precursor (NT-proBNP), plasma NT-proBNP levels and ventricular function (by radionucleotide ventriculography) were measured in healthy patients, patients with renal failure, patients with recent myocardial infarction, and patients investigated for cardiorespiratory symptoms. Plasma NT-proBNP levels were greater in healthy women (median, 1.5 fmol/mL; range, 1.0 to 13.8 fmol/mL; n = 34) than healthy men (median, 1.0 fmol/mL; range, 1.0 to 3.3 fmol/mL; n = 33; P = .012). NT-proBNP levels were elevated in subjects with renal failure (geometric mean, 314 fmol/mL; range, 18 to 5,800 fmol/mL) and were related to left ventricular ejection fraction (LVEF) (r = -0.86; P < .0001; n = 19). NT-proBNP levels were also related to LVEF in patients with recent myocardial infarction (r = -0.62; P = .0003; n = 29) and those investigated for cardiorespiratory symptoms (r = -0.56; P < .0001; n = 129). Applying an upper limit of normal of 5 fmol/mL for men and 15 fmol/mL for women (specificity, 100%), elevated plasma NT-proBNP levels had 100% sensitivity for the detection of LVEF less than 45% after myocardial infarction and 97% sensitivity for the detection of LVEF less than 45% in patients investigated for cardiorespiratory symptoms. NT-proBNP levels were also elevated in 87% of the patients with normal systolic function (LVEF > or = 45%) after myocardial infarction and in 87% of the patients investigated for cardiorespiratory symptoms with heart failure and normal systolic function (LVEF > or = 45%).

CONCLUSIONS

Plasma NT-proBNP level is a sensitive indicator of cardiac dysfunction, both in the presence and absence of systolic dysfunction, and may prove to be a useful tool for the identification and management of cardiac dysfunction in the general community.

Abdominal pain

Appendicitis, a common surgical problem, occurs in the elderly and at times can be difficult to diagnose particularly if multiple disorders are present. This case demonstrates some of these issues.

The plantaris tendon as a tendo-osseous graft. Part II. Clinical studies

To minimize adhesions following tendon repair, early post-operative movement is recommended. This has proved difficult with tendon grafting because of weakness of the repair sites, particularly distally, and because of slow revascularization. A potential solution is the use of a composite tendon-bone graft in which a bone block is attached to the end of the tendon. The tendon is threaded through a hole in the distal phalanx from the dorsal to the palmar side and impacted like a cork to create an immediate strong fixation. The tendon itself is then tunnelled through the pulley system and the proximal repair is carried out with a multiple weave technique which can withstand immediate active movement. The ideal tendon-bone complex is the plantaris attached to a segment of calcaneus. A preliminary report with two case studies is presented.

The plantaris tendon as a tendo-osseous graft. Part I. An anatomical study

Comparative studies have shown that bone-bone union develops faster than a junction between grafted tendon and bone, and would thus allow earlier post-operative movement, limiting adhesion formation. In this context the nature of the insertion of the plantaris tendon into the calcaneus is reviewed as a possible source of composite bone-tendon grafts. It is proposed that the composite plantaris tendon with its bony block attachment is inserted through a hole in the distal phalanx of the finger creating an immediate firm distal fixation. From cadaver dissections it was found that in at least 80% of cases the insertion of the plantaris tendon was directly into the calcaneus, independent of the tendo Achilles, and was therefore suitable for use as the proposed tendon graft.

The non coping elderly patient

Non coping elderly patients require considerable support from their general practitioners. They can provide the ongoing medical care and co-ordinate the assistance of many agencies to help patients cope at home until alternative placement can be arranged to ease the situation for patients, their relatives and doctors.

Suicide and related deaths in Victorian doctors

A cohort of University of Melbourne medical graduates (1950-1959 graduates inclusive) was followed up until December 31, 1986. Vital status at the end of the study period was ascertained and, for those who had died, cause of death was determined. The cohort consisted of 1453 members (1279 men and 174 women). One hundred and twenty-six of the group had died (115 men and 11 women) and 68 (4.7%; 57 men and 11 women) were lost to follow-up. The major causes of death were cardiovascular disease and malignant neoplasms. The standardised mortality ratios (SMRs) for all-cause mortality were low (59 for the male doctors and 84 for the female doctors) indicating that male doctors experience a "force of mortality" 59% that of the general population and female doctors 84%. For the male doctors, the SMR for suicide was 113 (95% confidence interval [CI], 54-207) (10 of 115 deaths in male doctors) about double the SMR for mortality from all causes. For the female doctors, the SMR for suicide was 501 (95% CI, 103-1500) (3 of 11 deaths in female doctors). For deaths resulting from all accidents the SMR was low for the males (29) and higher for the females (126). The SMR for mental disorders for the male doctors was marginally raised (132). This study reveals some indication of a problem in doctors in regard to deaths by suicide, other violent deaths and mental disorders. A larger study involving a control group of equivalent social class is required to confirm the findings of this study.