Diagnostic Radiology
Trephine Bone Biopsy by Radiologists Results of 73 Procedures1 James W. Debnam, M.D., and Tom W. Staple, M.D. 2
Trephine bone biopsies were performed in 67 patients. Routine radiography, laminagraphy, and radioisotopic techniques were employed to determine areas of involvement and exact sites for biopsy. Sites were selected on the basis of accessibility, possible complications, and chances of recovering diagnostic material. The biopsy material wasinformative in 81 % of patients. One controllable hemorrhage, onetemporary sinus tract, a small pneumothorax requiring no therapy, and two benign vasovagal responses were the only complications. Widespread malignant disease and osteomyelitis, particularly disk-space infection, are the mostsuitable lesions for trephine biopsy. INDEX TERMS:
Biopsies, technique. Bones, biopsy
Radiology 116:607-609, September 1975
Table I: Clinical Indications for Biopsy
ALTHOUGH MODERN radiographic and radioisotopic imaging techniques and biochemical laboratory procedures have been shown to be increasingly accurate in detecting bone lesions, tissue biopsy remains the definitive method of pathological diagnosis. Closed trephine biopsy offers less morbidity than open biopsy, and image intensification and biplane videofluoroscopy have made this technique a feasible and comparatively simple diagnostic procedure. Radiologists skilled in special procedures are qualified to perform needle biopsy, since the instrument is positioned in a specific anatomical structure under local anesthesia and fluoroscopic control. We wish to report the results of 73 trephine biopsy procedures performed in 67 patients at this institution from February 1972 through September 1974.
1-\
No. of Patients Radiographic or scan evidence of bone rnetastasis from a previouslytreated primary neoplasm Breast Prostate Uterine cervix and corpus callosum Leukemia or lymphoma Colon and rectum Lung Kidney Pancreas
29 11 4 3 3
2 1 1 1 1 1 1
O~~
Thymus Myeloma Radiographic diagnosis of carcinoma of the lung; suspected bone metastasis Disseminated metastases suspected on the basis of a radiograph or scan; no known primary lesion Suspected bone or disk-space infection Suspected pathological fracture Suspected aseptic necrosis Suspected Paget's disease Suspected osseous sarcoid
MATERIALS AND METHODS
Most patients were referred for suspected metastatic disease reflecting the average age of 62 years (TABLE I). Included in the series were patients with previously treated primary neoplasms, especially in the breast and prostate, in whom bone lesions later developed. Patients with a radiographic diagnosis of carcinoma of the lung and a destructive bone lesion were referred not only to determine its histology by a simple means but also to prove dissemination. Percutaneous biopsy was the most direct method for diagnosis of metastatic disease when no primary lesion was apparent or when infection of a disk space was suspected. We made the decision as to the appropriateness of the procedure and chose the biopsy site. If warranted, we did not hesitate to recommend open biopsy. In patients with multiple lesions, the safest and least traumatic biopsy site was sought with bone scans and radiographs. Areas of increased scan activity were ra-
Total
12 10 9 3
2 1 1 67
diographed in detail, including laminagraphy, in order to accurately define the lesion. Anatomy, especially the positions of vessels and nerves, was reviewed in order to determine accessibility. The preferred biopsy site was a prominence in a non-weight-bearing bone: the pelvis and extremities were less difficult to biopsy than the vertebra and required fluoroscopy in a single plane, whereas vertebral biopsy required either biplane fluoroscopy or anteroposterior fluoroscopy plus lateral radiographs. The lumbar spine was preferred to the thoracic region for biopsy. All but 3 patients were biopsied under local anesthesia. Each patient was in a fasting state and was pre-
1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo. Presented at the Sixtieth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Dec. 1-6, 1974. 2 Present address: Memorial Hospital Medical Center, 2801 Atlantic Ave., P.O. Box 1428, Long Beach, Calif. 90801. sjh
607
Vol. 116
609
TREPHINE BONE BIOPSY BY RADIOLOGISTS
only by scanning; radiographic study of these areas was negative. A successful diagnosis was made in 3 of 9 biopsies with adequate follow-up (33 % ). No serious complications were encountered. Minor complications included a sinus tract of a tuberculous disk infection which closed spontaneously after 2 weeks. During biopsy of a metastasis in one case, moderate bleeding was controlled by reinsertion of the guide through the cannula for 10 minutes. A 20 % pneumothorax following rib biopsy in another patient resolved without chest intubation. DISCUSSION
Our success rate of 81 % per patient or 74% per site is higher than those in other reported trephine biopsy series (1, 4, 12). Selection of patients and biopsy site, the use of bone scanning, detailed radiographic study of involved sites, and careful biopsy under fluoroscopic control contributed to the high rate of return. Trephine biopsy was performed more commonly in patients with suspected metastatic disease or a diffuse neoplasm such as reticulum-cell sarcoma, which requires irradiation or chemotherapy rather than surgery. Suspected multiple myeloma was first excluded by tests for abnormal serum proteins; if these were positive, we recommended marrow aspiration. Lesions requiring surgery, such as primary bone tumors or impending pathological fracture in weight-bearing bone, are best managed by the orthopedic surgeon. A detailed radiographic examination of the biopsy site is essential to accurate positioning of the instrument. Only one-third of our biopsies were successful when the site was localized by scanning without any radiographic alteration; exact localization of the pathological focus is impossible due to the poor scanner resolution. Intense radioisotopic activity may be produced by a small lesion which is easily missed by the needle. Ribs are difficult to biopsy, and currently available instruments are cumbersome and inadequate. To avoid pneumothorax, we try to avoid inserting the trephine into the inner cortex. If the needle penetrates the rib, ingress of air into the pleural cavity via the open cannula is prevented by removing the cannula and needle together. We are unwilling to biopsy a solitary area of increased scan activity in a rib without radiographic change because the exact area cannot be localized. Complications can include hemorrhage. wound infection, collapse of already destroyed bone, and damage to the spinal cord. Nagel et el. described acute paraplegia and complete block after closed biopsy of the third lumbar vertebra; at laminectomy. a large epidural hematoma was found (8). Patients with disseminated metastases are susceptible to spinal complications. which may occur concurrently and be unrelated to biopsy. Stahl and Jacobs reported acute paraplegia after closed biopsy of the twelfth thoracic vertebra; subsequent exploration revealed invasion of the spinal cord by tumor, with nothing to implicate the biopsy procedure (12). In our
Diagnostic Radiology
series. acute paraplegia with complete block from the ninth through the twelfth thoracic level occurred 24 hours after biopsy of the humerus in a patient with known carcinoma of the breast. Epidural metastases were found at decompression laminectomy. Interestingly, we had chosen not to biopsy the second lumbar vertebra, which was partially collapsed, because we preferred a less complicated biopsy site. Aspiration bone biopsy by the radiologist has been described recently (7, 11). We prefer trephine biopsy. as the undisrupted specimen can be prepared by the usual histological methods and does not require cytological interpretation. Although we have had no experience with biopsy of the high thoracic and cervical vertebral bodies (9. 10), we would prefer using a thin needle in these areas. Needle aspiration could also be performed when only material for bacteriological study is needed. as in disk-space infection; this could be obtained with little risk under fluoroscopic control. We have been impressed with the facility with which trephine biopsy can be carried out. Patient tolerance is excellent and tissue diagnosis can be made quickly, producing early. definitive treatment and shorter hospitalization. Mallinckrodt Institute of Radiology 510 S. Kingshighway St. Louis, Mo. 63110
REFERENCES 1. Ackermann W: Application of the trephine for bone biopsy. Results in 635 cases. JAMA 184:11-17,6 Apr 1963 2. Ackermann W: Vertebral trephine biopsy. Ann Surg 143: 373-385, Mar 1956 3. Craig FS: Vertebral-body biopsy. J Bone Joint Surg [Am] 38-A:93-102, Jan 1956 4. Cramer LE, Kuhn C JII, Stein AH Jr: Needle biopsy of bone. Surg Gynecol Obstet 118:1253-1256, Jun 1964 5. Debnam JW, Staple TW: Needle biopsy of bone. Radiol Clin North Am 13:157-164, Apr 1975 6. Ellis LD, Jensen WN, Westerman MP: Needle biopsy of bone and marrow. An experience with 1,445 biopsies. Arch Intern Med 114:213-221, Aug 1964 7. Lalli AF: Roentgen-guided aspiration biopsies of skeletal Ieslons. J Can Assoc Radiol 21:71-73, Jun 1970 8. Nagel DA, Albright JA, Keggi KJ, et al: Closer look at spinal lesions: open biopsy of vertebral lesions. JAMA 191:975-978, 22 Mar 1965 9. Ottolenghi CE: Aspiration biopsy of the spine. Technique for the thoracic spine and results of twenty-eight biopsies in this region and over-all results of 1050 biopsies of other spinal segments. J Bone Joint Surg [Am] 51-A:1531-1544, Dec 1969 10. Ottolenghi CE, Schajowicz F. De Schant FA: Aspiration biopsy of the cervical spine. Technique and results in thirty-four cases. J Bone Joint Surg [Am] 46-A:715-733, Jun 1964 11. Rabinov K, Goldman H, Rosbash H, et al: The role of aspiration biopsy of focal lesions in lung and bone by simple needle and fluoroscopy. Am J RoentgenoI101:932-938, Dec 1967 12. Stahl DC, Jacobs B: Diagnosis of obscure lesions of the skeleton. Evaluation of biopsy methods. JAMA 201:229-231,24 Jul 1967 13. Tenopyr J, Silverman I: The importance of biopsy in tumor diagnosis. A report of experience with a new biopsy needle. Radiology 36:57-60, Jan 1941 14. Turkel H, Bethell FH: Biopsy of bone marrow performed by a new and simple instrument. J Lab Clin Med 28: 1246-1251, Jul 1943
Trephine Bone Biopsy by Radiologists Results of 73 Procedures1 James W. Debnam, M.D., and Tom W. Staple, M.D. 2
Trephine bone biopsies were performed in 67 patients. Routine radiography, laminagraphy, and radioisotopic techniques were employed to determine areas of involvement and exact sites for biopsy. Sites were selected on the basis of accessibility, possible complications, and chances of recovering diagnostic material. The biopsy material wasinformative in 81 % of patients. One controllable hemorrhage, onetemporary sinus tract, a small pneumothorax requiring no therapy, and two benign vasovagal responses were the only complications. Widespread malignant disease and osteomyelitis, particularly disk-space infection, are the mostsuitable lesions for trephine biopsy. INDEX TERMS:
Biopsies, technique. Bones, biopsy
Radiology 116:607-609, September 1975
Table I: Clinical Indications for Biopsy
ALTHOUGH MODERN radiographic and radioisotopic imaging techniques and biochemical laboratory procedures have been shown to be increasingly accurate in detecting bone lesions, tissue biopsy remains the definitive method of pathological diagnosis. Closed trephine biopsy offers less morbidity than open biopsy, and image intensification and biplane videofluoroscopy have made this technique a feasible and comparatively simple diagnostic procedure. Radiologists skilled in special procedures are qualified to perform needle biopsy, since the instrument is positioned in a specific anatomical structure under local anesthesia and fluoroscopic control. We wish to report the results of 73 trephine biopsy procedures performed in 67 patients at this institution from February 1972 through September 1974.
1-\
No. of Patients Radiographic or scan evidence of bone rnetastasis from a previouslytreated primary neoplasm Breast Prostate Uterine cervix and corpus callosum Leukemia or lymphoma Colon and rectum Lung Kidney Pancreas
29 11 4 3 3
2 1 1 1 1 1 1
O~~
Thymus Myeloma Radiographic diagnosis of carcinoma of the lung; suspected bone metastasis Disseminated metastases suspected on the basis of a radiograph or scan; no known primary lesion Suspected bone or disk-space infection Suspected pathological fracture Suspected aseptic necrosis Suspected Paget's disease Suspected osseous sarcoid
MATERIALS AND METHODS
Most patients were referred for suspected metastatic disease reflecting the average age of 62 years (TABLE I). Included in the series were patients with previously treated primary neoplasms, especially in the breast and prostate, in whom bone lesions later developed. Patients with a radiographic diagnosis of carcinoma of the lung and a destructive bone lesion were referred not only to determine its histology by a simple means but also to prove dissemination. Percutaneous biopsy was the most direct method for diagnosis of metastatic disease when no primary lesion was apparent or when infection of a disk space was suspected. We made the decision as to the appropriateness of the procedure and chose the biopsy site. If warranted, we did not hesitate to recommend open biopsy. In patients with multiple lesions, the safest and least traumatic biopsy site was sought with bone scans and radiographs. Areas of increased scan activity were ra-
Total
12 10 9 3
2 1 1 67
diographed in detail, including laminagraphy, in order to accurately define the lesion. Anatomy, especially the positions of vessels and nerves, was reviewed in order to determine accessibility. The preferred biopsy site was a prominence in a non-weight-bearing bone: the pelvis and extremities were less difficult to biopsy than the vertebra and required fluoroscopy in a single plane, whereas vertebral biopsy required either biplane fluoroscopy or anteroposterior fluoroscopy plus lateral radiographs. The lumbar spine was preferred to the thoracic region for biopsy. All but 3 patients were biopsied under local anesthesia. Each patient was in a fasting state and was pre-
1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo. Presented at the Sixtieth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Dec. 1-6, 1974. 2 Present address: Memorial Hospital Medical Center, 2801 Atlantic Ave., P.O. Box 1428, Long Beach, Calif. 90801. sjh
607
Vol. 116
609
TREPHINE BONE BIOPSY BY RADIOLOGISTS
only by scanning; radiographic study of these areas was negative. A successful diagnosis was made in 3 of 9 biopsies with adequate follow-up (33 % ). No serious complications were encountered. Minor complications included a sinus tract of a tuberculous disk infection which closed spontaneously after 2 weeks. During biopsy of a metastasis in one case, moderate bleeding was controlled by reinsertion of the guide through the cannula for 10 minutes. A 20 % pneumothorax following rib biopsy in another patient resolved without chest intubation. DISCUSSION
Our success rate of 81 % per patient or 74% per site is higher than those in other reported trephine biopsy series (1, 4, 12). Selection of patients and biopsy site, the use of bone scanning, detailed radiographic study of involved sites, and careful biopsy under fluoroscopic control contributed to the high rate of return. Trephine biopsy was performed more commonly in patients with suspected metastatic disease or a diffuse neoplasm such as reticulum-cell sarcoma, which requires irradiation or chemotherapy rather than surgery. Suspected multiple myeloma was first excluded by tests for abnormal serum proteins; if these were positive, we recommended marrow aspiration. Lesions requiring surgery, such as primary bone tumors or impending pathological fracture in weight-bearing bone, are best managed by the orthopedic surgeon. A detailed radiographic examination of the biopsy site is essential to accurate positioning of the instrument. Only one-third of our biopsies were successful when the site was localized by scanning without any radiographic alteration; exact localization of the pathological focus is impossible due to the poor scanner resolution. Intense radioisotopic activity may be produced by a small lesion which is easily missed by the needle. Ribs are difficult to biopsy, and currently available instruments are cumbersome and inadequate. To avoid pneumothorax, we try to avoid inserting the trephine into the inner cortex. If the needle penetrates the rib, ingress of air into the pleural cavity via the open cannula is prevented by removing the cannula and needle together. We are unwilling to biopsy a solitary area of increased scan activity in a rib without radiographic change because the exact area cannot be localized. Complications can include hemorrhage. wound infection, collapse of already destroyed bone, and damage to the spinal cord. Nagel et el. described acute paraplegia and complete block after closed biopsy of the third lumbar vertebra; at laminectomy. a large epidural hematoma was found (8). Patients with disseminated metastases are susceptible to spinal complications. which may occur concurrently and be unrelated to biopsy. Stahl and Jacobs reported acute paraplegia after closed biopsy of the twelfth thoracic vertebra; subsequent exploration revealed invasion of the spinal cord by tumor, with nothing to implicate the biopsy procedure (12). In our
Diagnostic Radiology
series. acute paraplegia with complete block from the ninth through the twelfth thoracic level occurred 24 hours after biopsy of the humerus in a patient with known carcinoma of the breast. Epidural metastases were found at decompression laminectomy. Interestingly, we had chosen not to biopsy the second lumbar vertebra, which was partially collapsed, because we preferred a less complicated biopsy site. Aspiration bone biopsy by the radiologist has been described recently (7, 11). We prefer trephine biopsy. as the undisrupted specimen can be prepared by the usual histological methods and does not require cytological interpretation. Although we have had no experience with biopsy of the high thoracic and cervical vertebral bodies (9. 10), we would prefer using a thin needle in these areas. Needle aspiration could also be performed when only material for bacteriological study is needed. as in disk-space infection; this could be obtained with little risk under fluoroscopic control. We have been impressed with the facility with which trephine biopsy can be carried out. Patient tolerance is excellent and tissue diagnosis can be made quickly, producing early. definitive treatment and shorter hospitalization. Mallinckrodt Institute of Radiology 510 S. Kingshighway St. Louis, Mo. 63110
REFERENCES 1. Ackermann W: Application of the trephine for bone biopsy. Results in 635 cases. JAMA 184:11-17,6 Apr 1963 2. Ackermann W: Vertebral trephine biopsy. Ann Surg 143: 373-385, Mar 1956 3. Craig FS: Vertebral-body biopsy. J Bone Joint Surg [Am] 38-A:93-102, Jan 1956 4. Cramer LE, Kuhn C JII, Stein AH Jr: Needle biopsy of bone. Surg Gynecol Obstet 118:1253-1256, Jun 1964 5. Debnam JW, Staple TW: Needle biopsy of bone. Radiol Clin North Am 13:157-164, Apr 1975 6. Ellis LD, Jensen WN, Westerman MP: Needle biopsy of bone and marrow. An experience with 1,445 biopsies. Arch Intern Med 114:213-221, Aug 1964 7. Lalli AF: Roentgen-guided aspiration biopsies of skeletal Ieslons. J Can Assoc Radiol 21:71-73, Jun 1970 8. Nagel DA, Albright JA, Keggi KJ, et al: Closer look at spinal lesions: open biopsy of vertebral lesions. JAMA 191:975-978, 22 Mar 1965 9. Ottolenghi CE: Aspiration biopsy of the spine. Technique for the thoracic spine and results of twenty-eight biopsies in this region and over-all results of 1050 biopsies of other spinal segments. J Bone Joint Surg [Am] 51-A:1531-1544, Dec 1969 10. Ottolenghi CE, Schajowicz F. De Schant FA: Aspiration biopsy of the cervical spine. Technique and results in thirty-four cases. J Bone Joint Surg [Am] 46-A:715-733, Jun 1964 11. Rabinov K, Goldman H, Rosbash H, et al: The role of aspiration biopsy of focal lesions in lung and bone by simple needle and fluoroscopy. Am J RoentgenoI101:932-938, Dec 1967 12. Stahl DC, Jacobs B: Diagnosis of obscure lesions of the skeleton. Evaluation of biopsy methods. JAMA 201:229-231,24 Jul 1967 13. Tenopyr J, Silverman I: The importance of biopsy in tumor diagnosis. A report of experience with a new biopsy needle. Radiology 36:57-60, Jan 1941 14. Turkel H, Bethell FH: Biopsy of bone marrow performed by a new and simple instrument. J Lab Clin Med 28: 1246-1251, Jul 1943
