Biopsy principles in orthopedics
[[Biopsy|Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]]]C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[3]
Synonyms and keywords: Bone biopsy, Soft tissue biopsy, Biopsy in musculoskeletal system
Overview
Biopsy
Indications
- Aggressive bone or soft tissue lesions.
- Soft tissue lesions more than 5cms.
- Soft tissue lesions deep to fascia.
- Soft tissue lesions overlying bone or neurovascular structures.
- When diagnosis is unclear despite patient being symptomatic.
- Solitary bone lesions in a patient with history of carcinoma.
Contraindications
- Asymptomatic latent bone lesions.
- Symptomatic benign active bone lesions confirmed on imaging studies.
- Asymptomatic soft tissue lesion which are completely benign on MRI such as lipoma and hemangioma.
Prerequisites for a Biopsy
- CBC, platelets and coagulation studies.
- Cross-sectional imaging to evaluate local anatomy such CT scan and MRI.
- Treatment center carrying out biopsy must be capable of proper diagnosis and treatment.
- The surgeon who performs biopsy should preferably be the one who is later going to do the final excision.
Technique
- Open
- Closed
Open Technique
Types
Incisional biopsy
- A small surgical incision carefully placed to access tumor without contamination of critical structures.
Excisional biopsy
- it is done for small, superficial soft tissue masses.
Incision
- Longitudinal incision in the extremities is taken.
- It should allow for extension of the incision for definitive management
Approach
- Never expose neurovascular structures.
- During the biopsy, all tissue exposed is considered contaminated with tumor.
- Meticulous hemostasis to be carried out.
- Post-surgery hematomas are considered contaminated with tumor.
- Always deflate the tourniquet prior to wound closure.
Biopsy
- Perform through the involved compartment of the tumor.
- For bone lesions with a soft tissue mass, perform the biopsy using the soft tissue mass.
Closure
- If drain is kept, remove the drain out of the skin in line with surgical incision.
- This helps in excising the drain site with definitive surgical extensive incision.
Closed Technique
Types
Fine Needle Aspiration (FNA)
- It provides cytologic specimen.
- It is the most commonly used for carcinoma.
- It is usually not preferred for sarcoma.
Core biopsy (Tru-cut Biopsy)
- It allows for tumor structural examination.
- It allows evaluation of both the cytologic and stromal elements of the tumor.
- It is frequently used for sarcomas.
Sequence of Diagnostic Studies
The various investigations must be performed in the following order:
Staging
Enneking (MSTS) Staging System
- The Enneking surgical staging system (also known as the MSTS system) for benign musculoskeletal tumors based on radiographic characteristics of the tumor host margin.[3]
- It is widely accepted and routinely used classification.
Stages | Description |
---|---|
1 | Latent: Well demarcated borders |
2 | Active: Indistinct borders |
3 | Aggressive: Indistinct borders |
- The Enneking surgical staging system (also known as the MSTS system) for malignant musculoskeletal tumors based on histological and radiographic characteristics of the tumor host margin.[3][4]
Stages | Grade | Site | Metastasis |
---|---|---|---|
IA | G1: Low grade | T1: Intracompartmental | M0: No metastasis |
IB | G1: Low grade | T2: Extracompartmental | M0: No metastasis |
IIA | G2: High grade | T1: Intracompartmental | M0: No metastasis |
IIB | G2: High grade | T2: Extracompartmental | M0: No metastasis |
III | G1 or G2 | T1 or T2 | M1: Regional or distant metastasis |
References
- ↑ Peabody, Terrance (2014). Orthopaedic oncology : primary and metastatic tumors of the skeletal system. Cham: Springer. ISBN 9783319073224.
- ↑ Czerniak, Bogdan (2016). Dorfman and Czerniak's bone tumors. Philadelphia, PA: Elsevier/Saunders. ISBN 9780323023962.
- ↑ 3.0 3.1 Jawad MU, Scully SP (2010). "In brief: classifications in brief: enneking classification: benign and malignant tumors of the musculoskeletal system". Clin Orthop Relat Res. 468 (7): 2000–2. doi:10.1007/s11999-010-1315-7. PMC 2882012. PMID 20333492.
- ↑ Peabody, Terrance (2014). Orthopaedic oncology : primary and metastatic tumors of the skeletal system. Cham: Springer. ISBN 9783319073224.