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15
Fine Needle Aspiration Biopsy of Osteolytic Metastatic Lesions
Olga and
Alexander
Adler1
The use of fine
Rosenberger1
needle
aspiration
biopsy
of solitary
osteolytic-type
The radiologic radiographs offers were
the
osteolytic institute used
criteria
appearance valuable for making
of metastatic osteolytic lesions information. In the past, morphologic the
diagnosis
metastatic lesions still can proper therapy, exact diagnosis
fine
needle
suspected
aspiration
of having
positive
biopsy
osteolytic
of the
underlying
Radiography
to obtain
metastatic
cytologic
lesion;
in two
in order
directions
to obtain
often
information
sterilely
is applied
Department
bam Medical
re-
of Diagnostic Radiology, RamCenter, Faculty of Medicine-Tech-
nion, Haifa, Isreal. Address
reprint request
complemented
prepared.
Local
anesthesia
is not
1979 American 0361-803X/79/1331-0015
with
the
plunger
to aspirate
material.
of the negative pressure. The content smears are prepared, and the slides
Thereafter all of our cytologic
However,
in 24
patients
the diagnosis
was
by tomography and
they are patients
stained by the Papanicolau a single puncture yielded
depth
preceded of the
lesion.
the exPatients
department. With the aid of on the skin is marked and the
performed.
There is a feeling of lack of resistance is connected to the needle and suction
The
needle
of the needle are immersed method enough
should
be removed
only
after
is blown on dry, sterile glass immediately in 90% ethanol.
for cytologic material
to
examination. In almost permit a satisfactory
examination.
to 0.
Results
Adler.
©
after
material
in 21 patients
on the morphology
A 22-gauge fine needle is used for the puncture. when the needle reaches the lesion. A 20 ml syringe
accepted
pathology.
present diagnostic problems; in order to is mandatory. For this purpose we have
underwent no preparation before coming to the radiology television-monitored fluoroscopy, the projection of the lesion
release plates,
conventional features alone
and Methods
amination
region
on
for malignancy.
Materials
Received August 1 4, 1 978; vision February 7, 1979.
bone metastases
in 24 patients is described. A positive diagnosis of malignancy was obtained in 21 patients, as the softness of the osteolytic lesion yielded enough cell material for cytologic examination. No complications were encountered. The procedure can be performed with ease, even on an outpatient basis, without discomfort to the patient.
Roentgen
Ray Society $00.00
lytic
Of the 24 patients, 22 each bone lesions; two patients
had one fine needle had two biopsies
aspiration biopsy of solitary each (cases 5 and 7). The
16
ADLER
AND
ROSENBERGER
TABLE Relation Primary
of Primary
Malignancy/Case
Malignancy
July
1979
1
to Metastatic
Age and Gender
No.
AJR:133,
Metastatc
Site and Cytology Site
Cytology
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Hypernephroma: 70, 60,
4
60, M
Breast 5 6 7 8 9 10 11 12 13 14 Lung: 15 16 Retroperitoneal 17
Basal cell, Unknown:
M M
37, 42, 62, 62, 49, 52,
F F F F F F
58,
F F F
55,
M
10th
Hypernephroma
process
Myeloma Anaplastic
rib
Pubis
Adenocarcinoma
Right humerus 7th rib Sternum Rib Humerus Rib Humerus
Adenocarcinoma
Clavicle
Squamous Squamous
Pubis
58, 67,
Right Skull
Adenocarcinoma Adenocarcinoma Anaplastic Malignant cells Adenocarcinoma Adenocarcinoma cell cell
fibrosarcoma,
18
F F
70, F
22
44, F 18, M 48, M
15, 70,
23
24 -Cases
major
L4 transverse
29. M
19 20 21
Note
Hypernephroma
Rib Trochanter
46. F 51, 59,
Hypernephroma Inadequate material
Femur Left fibula
64, M 2 3
S and
7 had
two
punctures:
F M
humerus
Inadequate Basal cell
material
L4 L5
Compatible Blood
breast
Rib
Hypernephroma Squamous cell Hypernephroma Malignant cells
Femur Humerus Femur
au others
had
one.
There
were
no complications
Fig. 1 -Case
homogeof left clayide. B, Fragment of malignant epithelial tumor. Wide eosinophylic cytoplasm may suggest squamous origin. neous
I.
lytic
1 5. A, Small
lesion
in inner
tip
Fr: B
known and
primary
malignancies,
cytologic diagnoses The biopsies yielded
sites
of the
metastatic
lesions,
are summarized in table 1. a positive cytologic diagnosis
for
malignancy in 21 of the 24 patients. No complications were encountered and the patients did not require hospitalization. The radiologic part of the examination took about 1 0 mm. The
discomfort
dure was anesthesia,
felt
relatively because
by the
patient
was
painless. We even the pain caused
for anesthesia is identical in intensity fine gauge puncture needle itself.
minimal-the dispensed with by the needle to that
caused
procelocal used by the
Representative
Case
Case 15 A 55-year-old nodule squamous
in the
Reports
man had fine needle right
cell
upper
lobe
carcinoma.
otherwise
normal,
negative.
pulmonary
and
of the
Since
the
bronchoscopy resection
aspiration lung; chest and
was
biopsy
cytologic
of a stellate
diagnosis
radiograph mediastinoscopy
contemplated.
was
appeared were Subsequent
chest films revealed suspicion of a small homogenous lytic lesion in the inner tip of the left clavicle (fig. 1 A). Fine needle aspiration biopsy
therefore ment.
of this
lesion
referred
revealed
squamous
to the oncology
cells,
department
and
the
patient
for nonsurgical
was
treat-
AJR:133,
July
FINE
1979
NEEDLE
OSTEOLYTIC
BIOPSY
17
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Fig. 2.-Case 5. A, Lytic lesion in left transverse process of L4. B, Smear with atypical monocytic leukocytes. Two cells in center clearly show excentric nucleitypical of plasma cells in myeloma.
Fig.
3.-Case
superior Cluster entation
7.
A.
Lytic
lesion
A
B
A
B
A
B
of
ramus of right pubic bone. B, of tumor cells with columnar oriand a few cell vacuoles obin cytoplasm suggest adenocar-
served cinoma.
Fig. 4.-Case 21. A, Lytic lesion in part of eighth right rib. B, Cellular fragment composed of large tumor cells exhibiting wide lacy cytoplasm, oval nuclei, and marked nucleoli typical posterior
of hypernephroma.
Case
5
A 47-year-old seen
of pain
Radiography verse
woman
because
of the
process
survey
yielded
and
of bone
cells
had in the
region the
scan
compatible
a mastectomy lower
lumbar
revealed
fourth were
7 years region
a lytic
lumbar negative.
lesion
vertebra Fine
with myeloma
for
needle
before
in the (fig.
being
a few
weeks.
left
trans-
2A).
Skeletal
aspiration
biopsy
due to a lytic lesion of the superior ramus of the right pubic bone (fig. 3A). Skeletal survey and bone scan were negative. Two punctures were required to obtain sufficient cell material for a cytologic diagnosis;
Case
it was
Case 7
the woman
discomfort
had a mastectomy in the
right
inguinal
adenocarcinoma
(fig.
3B).
21
in his
A 62-year-old
for
(fig. 2B). A 70-year-old
developing
positive
(Ti NOMO) 1 year before region.
This
proved
to be
upper
pain
revealed
otherwise
back
for
to the course a lytic
(fig. 4A). The
lesion cytologic
healthy
a few
man had a feeling
weeks.
of a rib. in the diagnosis
Physical
Subsequent
posterior of fine
of discomfort
examination
part
chest of
needle
the
localized
radiography
eighth
aspiration
right
rib
biopsy
ADLER
18
was hypernephroma (fig. 4B). Subsequent angiography confirmed the diagnosis.
excretory
AND
urography
and
ROSENBERGER
needle aspiration examination. We rapidity,
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Solitary lytic metastatic bone lesions in a patient with known malignancy can occur after years of well being or may be the initial symptom of an unknown malignancy. In our cases, Most often
25% the
suggestive
of the diagnosis.
of the patients belonged radiologic pattern of However,
to the latter group. the lesion is highly
sibilities cannot ment. In our hospital begin therapy and the potent of malignancy of
morphologic
descrip-
be accepted
today
as a guideline
use
tary
bone
rate,
and
clinical
without cytotoxic are not
oncologist
is often
a specific diagnosis. drugs used today innocuous; specificity
therapy
make exact
according
diagnosis
and
cutting
offered The
lesions of the
to the
osteolytic
no resistance 90% positive
routine patients.
diagnostic
the
bone
had
osteolytic
due
to the
for the introduce in
the
metawith
lesions;
damaged
to the fine gauge needle. rate of success and the to
dis-
osteolytic of our patients
lesion
procedure
minimal
to
the cortex
ease
of per-
patient and the rathis method as a evaluation
of
these
reluctant
to
Radiotherapy in the treatment and diversifi-
to
the
underlying
in our
cancer
We thank for providing
Dr. E. Malberger, cytologist, for his cooperation the cytologic material presented here.
and
REFERENCES
essential.
needles
examination. to enable an exact lesion
softness
for
ACKNOWLEDGMENT
the
cytotoxic
of trephine histologic In order
secondary
1979
for treat-
Fine needle aspiration biopsy of bone lesions has been described [1, 2], but the method did not gain wide acceptance and the radiologic literature on this subject is scant. Most reports on closed bone biopsies [3, 4] deal with the for
complication
forming the examination-both diologist-encouraged us
tion by the radiologist of metastatic bone lesion in the cancer patient and the enumeration of differential diagnostic pos-
pathology
its low
July
biopsies that provided cells for cytologic chose this procedure for its simplicity and
comfort caused. We limited ourselves static lesions for two reasons: most
Discussion
cation
AJR:133,
for obtaining
tissue
core
diagnosis
of suspected
soli-
patients,
we
fine
performed
1. De Santos LA, Lukeman JM, Murray JA, Ayala AG: Percutaneous needle biopsy of bone in the cancer patient. AJR 130: 641-649, 1978 2. Hajdu SI, Melamed MA: Needle biopsy of primary malignant bone tumors. Surg Gynecol Obstet 133:829-832, 1971 3. Gladstein MO, Grantham SA: Closed skeletal biopsies. Clin Orthop 103:75-79, 1974 4. Debnam JW, Staple TW: Needle biopsy of bone. Radiol Clin NorthAm 13:157-164, 1975