Biopsy of Bone Tumours

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Principles:

  1. Should know probable diagnosis and stage of tumour before biopsy as it is the last step in the staging of the patient
  2. Performed by the surgeon who will perform the definitive surgery (? biopsy -> frozen section -> definitive surgery during the same anaesthetic)
  3. Biopsy tract orientation & location is critical – will need to be included in the definitive surgery if lesion is malignant.
  4. Meticulous haemostasis to avoid tracking haematomas
  5. Send samples for microbiological analysis

types-biopsy

Open Biopsy

Aim for excisional biopsy when possible esp. in benign lesions
Incisional biopsy preferable in malignant lesions
After consultation with the pathologist and radiologist

  1. Longitudinal incision
  2. Sharp dissection should proceed directly to the tumour, through muscle not between muscle planes
  3. Uninvolved anatomic compartments should not be exposed
  4. Avoid all major neurovascular structures to prevent contamination
  5. Excise block of reactive tissue, pseudo capsule, capsule, and block of tumour -> formalin +/- frozen section
  6. Windows in bone should be as small as possible and oval to avoid stress risers and pathological fracture
  7. Release tourniquet prior to closure -> haemostasis
  8. Close with a subcut. stitch
  9. Drains should come out through the wound
  10. If proceed following biopsy -> new instruments and drapes to stop seeding

Needle Biopsy

  1. As for open biopsy
  2. Place the biopsy tract where it can be excised
  3. Fine needle biopsy: fine-needle

    • relies on cytological interpretation by an experienced pathologist
    • accuracy = 65 to 95%  (determined by the adequacy of the collected tissue sample)
    • does not allow for immunohistochemical analysis
  4. Core needle biopsy: Core Needle

    • uses trocar cannula system, with a outer sleeve which closes over the trocar, capturing the sample of tissue
    • provides more tissue than fine needle and allows for immuno-histochemical analysis
    • accuracy = 75 to 95%
  5. Disadvantage of needle biopsy = tissue obtained may be from necrotic portion of tumor and therefore not suitable for diagnosis, or tissue may be reactive in nature and not representative of actual tumor. Frozen section may thus be beneficial.

Frozen SectionFrozen-section

  1. Able to determine if specimen is adequate or representative
  2. Can decide if lesion is inflammatory and needs culturing
  3. Can determine if there is need to perform further investigations/tests
  4. Immediate diagnosis possible- can proceed to definitive surgery

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