Percutaneous Image-guided Needle Biopsy of Musculoskeletal Tumors: Technical Tips

Abstract

With recent advances in imaging technology, the frequency of detecting musculoskeletal lesions has also increased. Percutaneous image-guided needle biopsy is occasionally required for the diagnosis of such lesions. Moreover, in the era of personalized cancer care, chances in histopathological diagnosis and the importance of histopathological diagnosis by percutaneous needle biopsy are increasing. However, as percutaneous needle biopsy is not a common procedure for musculoskeletal lesions, careful planning and the application of adequate techniques such as hydrodissection and the trans-osseous approach are occasionally required. In this review, we have summarized the indications and techniques for percutaneous image-guided needle biopsy for musculoskeletal lesions, including lymphatic lesions.

Introduction

With recent advances in imaging technologies such as computed tomography (CT), magnetic resonance imaging (MRI), and 18-fluorodeoxyglucose positron emission tomography (PET), the frequency of detecting musculoskeletal lesions, such as bone tumor, muscle metastases, and lymphatic lesions, has also increasing. Some lesions can be diagnosed by imaging features and clinical history, but non-specific lesions are often difficult to diagnose using imaging examinations alone, therefore, histopathological diagnosis is required in such cases.

For the histopathological diagnosis of bone lesions, surgical biopsy offers a high diagnostic accuracy of 93.3%-100% [1, 2], but it is invasive and imposes a substantial burden on patients. Percutaneous needle biopsy is often preferred as an initial procedure to obtain a histopathological diagnosis [3, 4]. For soft tissue tumors, surgical biopsy is thought to be the standard method with a high accuracy of 93.5%-100% [2, 3, 5-7]. Nevertheless, percutaneous needle biopsy is also performed because of its low invasiveness [9-13], and opportunities for percutaneous needle biopsy of musculoskeletal lesions are increasing as minimally invasive medicine becomes more prevalent. However, to accomplish safe and effective procedures, biopsies must be performed under adequate image guidance. Moreover, recent advances in molecularly targeted therapy have increased the need for biopsy, while simultaneously increasing the amount of specimen collected [12]. To obtain a sufficient amount of specimen, understanding the features of each target and the imaging modalities used for biopsy is also important.

The purpose of this review was to summarize the outcomes of image-guided percutaneous needle biopsy for bone and soft tissue tumors and provide some techniques for achieving safe and effective biopsy procedures.

Literature search

A literature search was performed using PubMed using the following key words: (bone, percutaneous, “needle biopsy”), (soft tissue, percutaneous, “needle biopsy”), and (lymphoma, percutaneous, “needle biopsy”). The titles and abstracts of the articles obtained from the search were scrutinized to identify relevant studies. In this review, we have focused on studies evaluating percutaneous needle biopsy techniques. Some publications considered important were added during the manuscript preparation and revision process (Fig. 1).

Fig. 1.

Flowchart of the result from literature

Indications and contraindications

Techniques for biopsy of tumor specimens include surgical and needle biopsies. Generally, surgical biopsy is invasive, but it can yield a greater volume of specimen; the converse is true for needle biopsy [13, 14]. The decision to perform surgical or needle biopsy should be determined based on the tumor location, condition of the disease, performance status of the patient, and the amount of specimen needed to meet the purpose of the procedure [15].

The general indications for image-guided percutaneous needle biopsy for bone lesions are as follows: a) determination of benign or malignant status is difficult from nonspecific imaging, b) confirmation of metastatic tumor and/or acquisition of a tumor specimen for genetic mutation analysis in a patient with known malignancy, c) exclusion of malignancy in a bone fracture, d) confirmation of a diagnosis of multiple myeloma, and e) investigation of infection [13, 14].

In contrast, indications for percutaneous needle biopsy of soft tissue tumors are as follows: a) histopathological diagnosis of malignant lymphoma, b) confirmation of metastatic tumor and/or acquisition of tumor tissue for genetic mutation analysis in a patient with known malignancy, and c) diagnosis of an enlarging soft tissue tumor [13, 14].

Contraindications for biopsy for bone tumors and soft tissue tumors are as follows: a) uncorrected coagulopathy, b) inability to obtain a safe access route, and c) inability to obtain patient consent [13, 14]. In particular, to avoid bleeding complications, patients with uncorrected coagulopathy should not undergo percutaneous needle biopsy. Usually, Prothrombin Time-International Normalized Ratio <1.5 and platelet count >50,000 are recommended for safe coagulopathy at the time of interventional procedures [16, 17]. Anticoagulant or antiplatelet drugs may be discontinued before the procedure, as shown in several guidelines [18, 19]. The decision to perform bridging to short-acting parenteral agents such as heparin depends on the patients’ clinical status, the pharmacologic characteristics of the medication used, and procedural bleeding risks. For example, bridging should be considered for patients who are treated with warfarin for atrial fibrillation, mechanical heart valves, or drug-eluting stents following percutaneous coronary intervention [19]. However, when performing biopsy for tumors in superficial areas, the criteria might be loosened slightly, as the puncture site can be compressed [20].

Techniques

Bone biopsy

Image-guided biopsy is usually performed under local anesthesia [13]. Bone biopsy is performed using several modalities, including CT, fluoroscopy, ultrasonography (US), and MRI. CT is the most frequently used modality during bone biopsy due to its ability to clearly visualize bone structures and surrounding organs [21-24]. Generally, CT is the first-choice modality during bone lesion biopsy [13, 14]. Fluoroscopy is another option for image guidance, with clear visualization of bone structures [14, 22-24]. However, the needle should be carefully inserted as the depth is unclear on 2-dimensional images, and the surrounding organs are occasionally invisible. Cone-beam CT may help decrease the risk of complications when performing biopsies using fluoroscopy [25]. US is also used as image guidance for biopsy for several organs, offering the advantages of real-time image acquisition, high availability, and no radiation exposure. Biopsy for osteolytic lesions can be performed under US guidance [22, 23, 26], but osteoblastic lesions are difficult to detect on US. MRI- and PET-CT-guided biopsy have also been reported to offer clear visibility of the target tumor and high diagnostic accuracy, but the availability of these modalities is limited [27, 28].

The diagnostic accuracy of percutaneous biopsy for bone lesions based on previous studies is 77%-94% [23, 26, 29-32]. Percutaneous biopsy can be performed for both osteolytic and osteoblastic lesions. However, diagnostic accuracy is reportedly higher for osteolytic lesions because of the difficulty in detecting the target area containing tumor cells in radiologically visible sclerotic areas and maceration or degradation by crush artefacts during penetration of sclerotic bone tissue [30-33]. Moreover, samples with tumor cells comprising >20% are recommended for successful genetic mutation analysis [15]. The pre-analysis step of decalcification for specimens from osteoblastic bone lesions causes degeneration of nucleic acids and DNA, resulting in a lower success rate for molecular analysis [34, 35]. Biopsy should, thus, be performed for osteolytic parts when both osteolytic and osteoblastic lesions are accessible.

Osteolytic lesions can be biopsied with a commonly used 18- or 20-gauge biopsy needle (Fig. 2). Core-needle biopsy with aspiration has recently become available and reportedly allows obtaining greater amounts of specimens [36]. When osteolytic lesions exist in normal bone tissue, bone tissue can be passed through a 14-gauge bone biopsy needle. After placing the needle into the osteolytic lesion across the bone tissue, an 18-gauge biopsy needle can be inserted into the lesion through the bone biopsy needle (Fig. 3).

Fig. 2.

A 54-year-old man was referred to our hospital for investigation of a sacral tumor found after a consultation for lower back pain. (a) A 55-mm osteolytic tumor (arrow) has developed on the left side of the sacrum. (b) Biopsy is performed in a prone position under CT fluoroscopic guidance. The tumor is punctured by an 18-gauge semi-automatic biopsy needle (arrow) and biopsy is performed. The tumor is diagnosed as metastasis from lung adenocarcinoma.

Fig. 3.

An 80-year-old woman with a history of breast cancer treated surgically 10 years earlier and gastric cancer treated by endoscopic submucosal dissection 3 years earlier complained of back pain. (a) A 26-mm osteolytic tumor (arrow) has developed on the right side of the 11^th thoracic vertebral body. (b) A 14-gauge bone biopsy needle (arrow) is inserted into the tumor through the bone tissue through the left pedicle of the vertebral arch. (c) An 18-gauge semi-automatic biopsy needle (arrowhead) is inserted through the bone biopsy needle (arrow) and biopsy is performed. The tumor is diagnosed as myeloma.

A bone biopsy needle is used at the time of biopsy for osteoblastic lesions. An 11-14-gauge bone biopsy needle is advanced into the lesion and retrieved while aspirating with a syringe. When the needle is advanced through a relatively hard tissue, the needle tends to deviate from the side opposite the needle bevel as the force is applied from the hard tissue [37]. Thus, when advancing the needle into the bone, the direction of the needle should be carefully checked and rotated as necessary (Fig. 4). A screw drill reportedly helps improve the diagnostic accuracy to 73%-92% for osteoblastic lesions [38, 39].

Fig. 4.

A 66-year-old man with cancer of the duodenal papilla developed an osteoblastic lesion in the 4^th thoracic vertebral body. (a) A 34-mm osteoblastic lesion is present on the dorsal side of the 4^th thoracic vertebral body. (b) A 14-gauge bone biopsy needle (arrow) is inserted into the osteoblastic lesion. (c) The needle is advanced into the deep side of the lesion while rotating it (arrow). The obtained specimen is revealed to represent bone metastasis from a duodenal papilla cancer.

The sample number was reported to be 2-10 in previous reports [22, 26, 29, 30, 33, 35, 40-42]. However, needle size and sample number have not been shown to be significant factors for technical success in a meta-analysis [42]. In contrast, the radiologist operator was identified as a significant factor of technical success [42]. Careful planning with profound knowledge about images and considerable experience in interventional radiology procedures may contribute to good outcomes in biopsy.

The puncture route should be determined running shorter normal bone tissue, with avoiding major vessels or nerves [13, 14]. Although needle tract seeding during puncture procedures for malignant tumors is rare, with a reported incidence of less than 0.01% [43, 44], selecting the route in which later resection could be allowed is also important.

Soft tissue tumor biopsy

Soft tissue tumors can develop in various areas. As in biopsy for bone tumors, percutaneous biopsy for soft tissue tumors is also performed mainly under CT or US guidance under local anesthesia [7-11]. Biopsy is generally performed under US guidance for tumors in a superficial area and under CT guidance for tumors in a deep area [7, 13]. However, the modality should be determined by considering the location of each tumor and the surrounding organs.

The diagnostic yield of core-needle biopsy for soft tissue tumors, including lymphatic lesions, has been reported to be 76%-97% [7-10, 29, 45]. In particular, surgical biopsy for soft tissue tumors located in deep areas, such as the retroperitoneal or mediastinal regions, is invasive and places a substantial burden on the patient. Percutaneous needle biopsy is superior to surgical biopsy in terms of reduced invasiveness and earlier results from histopathological diagnosis; therefore, core-needle biopsy should be considered as the first choice for patients who require early diagnosis or with low performance status [7]. Several studies reported that no significant difference was found between diagnostic accuracy and needle size, although a larger number of specimens were obtained using a thick needle [46-48]. Nevertheless, the number of specimens obtained by core-needle biopsy is less than that obtained by surgical biopsy; therefore, the risk of false-negative results must also be considered. In particular, in the diagnosis of Hodgkin lymphoma, obtaining specimens containing many tumor cells is important, as Reed-Sternberg cells need to be confirmed for diagnosis. Thus, the biopsy technique should be determined according to the condition of the patient and the suspected disease type.

Image-guided needle biopsy for soft tissue tumors located in superficial areas can be performed under US guidance. Muscular metastasis is also an appropriate target for US-guided biopsy (Fig. 5).

Fig. 5.

A 66-year-old man who had been receiving chemotherapy for squamous cell lung carcinoma developed a tumor on the back. (a) A 37-mm tumor (arrow) showing enhancement by contrast media is detected in the left longissimus thoracis muscle. (b) The tumor (arrow) is evident on ultrasonography. (c) Biopsy is performed using an 18-gauge semi-automatic biopsy needle (arrowhead) under US guidance. Metastasis from squamous cell lung carcinoma is diagnosed, but genetic mutation analysis reveals no specific mutation.

Several techniques facilitate the biopsy of difficult lesions. When the tumor is located in the anterior mediastinum just behind the sternum, the tumor can be easily punctured using a trans-osseous approach (Fig. 6). The puncture route can also be secured by hydrodissection, which makes space by pushing organs in the way with lidocaine or saline injection while performing biopsy for mediastinal tumors, although lung parenchyma appears along the puncture route (Fig. 7). Hydrodissection is also helpful when performing biopsies for tumors located near the intestine (Fig. 8).

Fig. 6.

A 43-year-old woman who underwent breast cancer resection 8 years earlier developed mediastinal tumor. (a) CT reveals a 36-mm mediastinal tumor (arrow) posterior to the sternum. (b) A trans-osseous route is selected to avoid the penetration into the aortic arc by the needle. The sternum is penetrated using a 14-gauge bone biopsy needle (arrow). (c) An 18-gauge semi-automatic biopsy needle (arrowhead) is inserted thorough the bone biopsy needle (arrow) and safely inserted into the tumor. The tumor is diagnosed as breast cancer metastasis.

Fig. 7.

A 70-year-old woman was referred to our hospital for the investigation of an incidentally detected mediastinal tumor increasing in size. (a) A 27-mm mediastina tumor (arrow) anterior to the ascending aorta (b) To avoid puncturing, the needle is inserted towards the ascending aorta and passing the lung parenchyma, hydrodissection is intended. A 23-gauge needle (arrow) is inserted near the pleura, and saline is injected into the gap between the parietal and visceral pleura. (c) The needle (arrow) is inserted towards the mediastinum while injecting the saline (asterisk) under CT fluoroscopic guidance. (d) An 18-gauge semi-automatic biopsy needle (arrow) is inserted through the injected saline without puncturing the lung parenchyma. Biopsy is safely performed, and the tumor is diagnosed as thymoma.

Fig. 8.

A 64-year-old man was referred to our hospital for investigation of an incidentally detected retroperitoneal tumor. (a) A 38-mm tumor (arrow) exists in the left psoas muscle, left external iliac artery, and vein. (b) A 23-gauge needle (arrow) is inserted into the left side of the descending colon and saline (asterisk) is injected. (c) Saline (asterisk) is used to push the descending colon to the right side. An 18-gauge semi-automatic biopsy needle (arrow) is inserted through the saline and biopsy is performed. The tumor is diagnosed as dedifferentiated liposarcoma.

Conclusion

The importance of tissue sampling continues to increase in this era of personalized cancer care. Although biopsy for musculoskeletal and lymphatic lesions is not a common procedure, careful pre-procedural planning and using an adequate technique can contribute to the acquisition of adequate tissue samples with relatively low invasiveness for patients.

Conflict of interest

The authors declare that they have no conflict of interest.

Disclaimer

Yoshitaka Inaba is one of the Senior Editors of Interventional Radiology and on the journal's Editorial Board. Takaaki Hasegawa is one of the Associate Editors of Interventional Radiology and on the journal's Editorial Board. They were not involved in the editorial evaluation or decision to accept this article for publication at all.