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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