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Percutaneous Biopsy of the Appendicular Skeleton
Percutaneous biopsy of the appendicular skeletal lesion is a minimally invasive, safe, and inexpensive procedure compared with open biopsy. Therefore, this procedure is indicated in many cases.
Indications
Bone Metastases
A suspicion of bone metastasis is the main indication for percutaneous biopsy of skeletal lesions. This procedure is particularly helpful in patients with no known primary bone tumor who present with multiple lesions consistent with metastases or in patients with a known primary malignancy who develop single or multiple lesions that are not in agreement with the stage of the malignancy. Percutaneous biopsy of the pelvis is frequently performed for this indication. However, the radiologist should keep in mind that a single, focal osteolytic lesion in this location in a patient older than 50 years of age may represent a chondrosarcoma, and a careful analysis of CT or MR images is necessary before biopsy to look for signs of such a primary lesion (e.g., cartilaginous calcifications, hyperintense cartilaginous lobules on T2-weighted images).
Primary Bone Tumors
Percutaneous biopsy of a suspected primary bone tumor is usually reserved to specialized centers with access to the skills of a dedicated bone tumor surgeon. Such biopsies are prone to sampling bias (portions of primary tumors may have a different appearance and histologic aggressiveness), yielding lower diagnostic accuracy than an open biopsy. If a closed biopsy is performed in a case of suspected primary bone tumor, the puncture site and approach must be carefully selected with the definitive surgeon (the surgeon who will perform the resection and limb salvage surgery) so as not to contaminate overlying tissue that can be used for a surgical flap. This is especially true in the case of chondrosarcoma because of a higher risk of tumor implantation in the biopsy needle tract. It is essential to avoid contamination of additional compartments, and, therefore, the biopsy route must match the surgeon's preferred surgical resection approach. It is equally important to discuss the nature of the lesion and the form of biopsy with the pathologist who will be asked to review the material.
Skeletal Infections
Percutaneous biopsy is helpful in cases of skeletal infection to determine the nature of the microorganism involved, thereby facilitating directed antibiotic therapy. In the case of suspected infection, this technique has a relatively high yield. Although clinicians usually accept positive results when infection is suspected, they may question or ignore negative results.
Other Indications
Percutaneous skeletal biopsy may also be indicated when there is a suspicion of other malignant lesions (osseous lymphoma, plasmocytoma) or when the benign nature of the lesion cannot be confirmed by clinical, biologic, or imaging features (e.g., Langerhans cell histiocytosis, bone changes induced by radiation therapy).
Contraindications
There is no absolute contraindication to percutaneous skeletal biopsy. However, such a biopsy should not be performed if its result does not affect treatment or management of the patient. When there is a suspicion of a highly vascular lesion, such as metastases from kidney or thyroid carcinomas, aspiration with a thin needle should be performed before core biopsy to assess for potential bleeding.
Equipment and Technical Aspects
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