- •The absence of ionizing radiation.
- •The utility of color Doppler to identify highly vascular or necrotic/cystic areas of the lesion to avoid.
- •Visualization of adjacent neurovascular bundles.
Advanced real-time 3D fluoroscopy guidance using Cone Beam CT
- •Early diagnosis and staging: PET/CT can demonstrate anatomically occult lesions by demonstrating increased metabolic activity.
- •Increased diagnostic yield: This modality can demonstrate viable tissue in tumors with necrosis or inhomogeneous FDG uptake.
- •It can demonstrate viable/recurrent metabolically active tissue at the sites where anatomic alteration by prior surgery or radiotherapy makes diagnosis difficult.6(Fig. 4).
- •In the case of multiple lesions, the most metabolically active lesion can be targeted.
Needle placement optimization using PET/CT
- •Use of limited / one-table-position PET/CT can confirm needle placement within the hypermetabolic region of interest.
- •Fusion imaging utilizing image data from intraprocedural CT and prior PET/CT can be utilized for confirmation of correct needle placement.
- •Real-time PET/CT guidance utilizing electromagnetic needle tracking and navigation system. A weak electromagnetic field and positioning sensor on the needle provides real-time tracking of the position and orientation of the biopsy needle under ultrasound or CT guidance. The software also has the capability of fusing needle position with prior cross-sectional imaging.
Pre-procedure preparation (Clinical, Biochemical and Imaging review)
- Davidson JC
- Rahim S
- Hanks SE
- et al.
Biopsy needle selection
Fine aspiration needles
Soft tissue core biopsy needles
Bone biopsy needles
Patient and equipment positioning
Important consideration for suspected sarcoma
Common Biopsy approaches
- •Peripheral bones: Orthogonal approach to the bone cortex can help avoid needle slippage. Avoid uncontaminated muscle compartments and neurovascular bundles.
- •Flat bones (eg, ribs, sternum, and skull): Approach with the angle of 30°-60° to the surface and opposite in direction to the curvature of the bone allows access with reduced risk to underlying structures. The use of a beveled tip needle may offer a better surface grip than a diamond tip in these cases.
- •Bony Pelvis: Generally favors intraosseous routes avoiding uncontaminated muscle compartments and neural foramina.
- •Vertebral bodies: The approach varies depending on the location of the lesion; however, lesions in the vertebral body are generally accessed via a transpedicular approach.
- •Shoulder: Anterior deltoid approach may be favored as resection of posterior deltoid results in a denervated anterior deltoid. Also, the deltopectoral groove and pectoralis muscles should be avoided as the pectoral muscles are utilized in reconstructive surgery.
- •Humerus: Anterolateral approach may be appropriate to avoid nerve damage.15Beware of the spiral course of the radial nerve, however.
- •Femur: Biopsy route should spare the rectus and quadriceps muscles are essential for functional limb sparing surgery.14For the proximal femur, posterolateral approach through vastus lateralis may be desired. Alternatively medial approach is possible through the adductor longus.1In the distal femur an approach through vastus medialis may be desired. Alternatively, a lateral approach through the vastus lateralis.Tibia: Anteromedial cortical approach may be preferred as there is very little overlying functional soft tissue.14
- •After obtaining informed consent, the patient is positioned on the table to allow best access and ensure patient and operator comfort.
- •An IV line is maintained. ECG monitor and a pulse oximeter is attached for monitoring. The patient's vitals are recorded before the procedure as well as every 15 minutes during the procedure. If indicated IV fluid or blood product infusion may be administered.
- •IV sedative is administered, usually midazolam and/or fentanyl.
- •The site is marked and then cleansed with antiseptic solution and drapes are applied. Be aware that needles/ blades passing through marking ink may generate a small tattoo.
- •Using a 22-25 G needle for local anesthesia to the skin, subcutaneous soft tissues, muscles and periosteum.
- •A small skin incision (0.5-1 cm) is made and the biopsy introducer is advanced in preplanned trajectory under imaging guidance till the bone surface is reached. For sarcoma cases, the incision should ideally generate a small scar that will guide the orthopedic surgeon's biopsy track excision.
- •A surgical hammer or drill allows the introducer to breach the osseous cortex and advance the needle to the lesion. The outer sheath tip must be placed in a stable position within or through the cortex to prevent movement and loss of access. The needle should not be advanced into the lesion area for biopsy with stylet in situ otherwise a hollow track may be created which will impair tissue collection by the hollow biopsy needle.
- •The inner stylet of the introducer is removed, and the biopsy trochar is advanced into the lesion via hand or power drilling (Figs. 8 and 9). This is usually passed beyond the cannula tip over the desired length of the sample core. Power drilling is often necessary for sclerotic lesions, but care should be taken to advance slowly and intermittently to avoid overheating and resulting needle tip shear. Ideally, three cores should be obtained.The biopsy specimen is assessed for adequacy and fixed in 10% formalin and sent for histopathology. If a bacteriological analysis is requested, then the sample is typically placed in saline and sent for culture. Samples for lymphoma and genetics may have special requirements, always confirm with the pathologist. The biopsy needle should be cleansed in saline before each return pass into the patient to avoid contamination of the biopsy site with toxic formalin.
- •At this point, if desired, any additional procedure such as cryoablation or cementoplasty can be carried out using the same sheath. (Fig. 10)
- •Remove the sheath. Ensuring adequate hemostasis by applying local pressure and apply an adhesive bandage to the puncture site.
Avoiding, recognizing, and treating complications
- •Anaphylactic reactions to medications. An emergency equipment trolley including Epinephrine, antihistamine, corticosteroid and IV fluids should be easily accessible.
- •Vasovagal reaction is usually avoided by having the patient recumbent for the procedure.
- •Hardware failure/needle fracture with retained fragments: Excercise caution and intermittent biopsy needle advancement, especially when using the drill in sclerotic bone. Should this occur, surgical consults and covering antibiotics may be required. Needles that become stuck within the bone should have the stylet replaced to reinforce the cannula and may be removed with an orthopedic torque device. Gentle intermittent rotation of the introducer during advancement can ensure the needle can be rotated and, thus, can be removed. Do not further advance the needle if significant bending is seen.
- •Bleeding: Active bleeding from a highly vascular tumor or injury to a large vessel may lead to hypovolemic shock, though such severe bleeding/injury is rare under image guidance. Pre-embolization can be considered for high-risk cases. Localized hematomas can usually be managed with 5-10 minutes of local manual pressure followed by a pressure dressing. Use of hemostatic materials via the cannula could be considered. Severe cases necessitate resuscitation and surgical consult.
- •Infections: Soft tissue, bone, joint and epidural infections can occur. However, the incidence is low, particularly compared to open surgical biopsies.1The risk of infection is around 1% if proper sterile precautions are used.15Patients should be advised to look out for symptoms of infection at time of consent and seek prompt medical attention if required.
- •Pain: Most patients experience some soreness at the biopsy site for up to 4-5 days.15It can be managed with cold pack application and analgesics.16Sudden severe pain may indicate pathological fracture, and a low threshold for reimaging in such cases is advised.
- •Neurological complications: Peripheral nerve injury can occur during needle placement. Avoid yawing motions of the needle tip within the soft tissue during placement, which increases the risk of neurovascular injury; retract, angle correct, and advance instead. An intraspinal hematoma may cause spinal cord compression, suspicion for which should prompt emergent MRI and surgical consult.
- •Pneumothorax or hemothorax may result from thoracic biopsies. Small pneumothorax can be observed and followed radiographically. Larger volumes require chest tubes and admission.
- •Injury to other adjacent soft tissues/organsReflex sympathetic dystrophy (very rare).
- •Tumor dissemination in the biopsy track. Advise coaxial system use and prior surgical planning.
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Conflict of interest: None.
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