Introduction:
1. Labs:
- Primary bone tumors are the third fatal cancer in the pediatric population.
- Recent studies in adult patients have shown high diagnostic yields of 74-96% and accuracy rates of 77.3-99% for image-guided percutaneous core needle biopsy (PCNB) in bone lesions.
- It is also validated as a safe alternative to open biopsy for diagnosing pediatric and adult bone tumors while setting off the costs of the procedure and the need for anesthesia.
- Differentiating between benign and malignant musculoskeletal lesions (e.g., primary bone tumors, metastatic disease).
- Assessing the nature of bone tumors for diagnosis and treatment planning.
- Conducting microbiological studies in patients with suspected bone infections (osteomyelitis).
- Collecting samples for tissue bio-banking and research purposes.
- Challenging locations with a higher potential of collateral injury to surrounding and/or critical structures.
- Potential for soft tissue infection or bone contamination during the biopsy.
- Patients with uncorrectable coagulopathy should avoid percutaneous bone biopsies.
- Avoid bone biopsy if suspecting a lymphatic leak in the vicinity.
- 11-gauge or 14-gauge (coaxial screw) biopsy needle.
- 16-gauge or 18-gauge if biopsying the associated soft-tissue component.
- Extended or power drill when bone penetration is difficult.
- Fluoroscopy, cone-beam CT, conventional CT, ultrasound (for soft tissue component).
1. Labs:
- Coagulation profile, CBC
- Carefully study all available previous imaging to plan the biopsy, avoiding unnecessary procedures for benign lesions. Additionally, functional imaging such as PET-CT, PET-MRI, contrast ultrasound, diffusion-weighted, and apparent diffusion-weighted sequences of the MRI should be reviewed to visualize mitotically active areas of the tumor.
- Weigh the potential complications of the biopsy against the diagnostic value it provides.
- General or moderate anesthesia is required for pediatric bone biopsies.
Biopsy Needle inserted in the left iliac lytic bone lesion (suspected eosinophilic granuloma
Procedure:
Anesthesia Administration:
1. General Complications:
Anesthesia Administration:
- Ensure the patient is in a comfortable position on the procedure table.
- Administer general/moderate anesthesia to the pediatric patient, following standard protocols for induction and monitoring.
- Confirm adequate anesthesia depth before proceeding with the biopsy to ensure the patient remains immobile and pain-free during the procedure.
- Review all available previous imaging studies (e.g., X-rays, MRI, prior CT scans) to identify the lesion’s location and characteristics.
- Position the patient on the CT or fluoroscopy table, ensuring the area of interest is accessible and well-aligned for imaging.
- Collaborate with the orthopedic surgeon, if applicable, to plan the needle tract. Ensure the path avoids critical structures like tendons, nerves, blood vessels, and vital organs.
- Perform initial imaging scans (CT or fluoroscopy) to confirm the lesion’s exact location and adjust the patient's position as necessary.
- Mark the entry point on the skin, corresponding to the optimal needle tract identified in the imaging
- For long bone biopsies, determine the entry angle. Insert the biopsy needle orthogonally to the cortex to minimize needle deflection and reduce the risk of damaging adjacent soft tissues.
- For vertebral biopsies, choose between a transpedicular or intercostovertebral route depending on the vertebral level and proximity to the segmental nerves. Confirm the chosen route with imaging.
- For pelvic biopsies, particularly in the sacral area, select a path that avoids the lumbosacral or femoral nerve plexus. Ensure the trajectory is clear of major blood vessels and neural structures.
- Sterilize and drape the biopsy area to maintain a sterile field.
- Administer local anesthetic at the planned entry site, even though the patient is under general anesthesia, to reduce post-procedural discomfort.
- Make a small skin incision at the marked entry point to facilitate needle insertion.
- Under continuous CT or fluoroscopic guidance, insert the biopsy needle through the skin and subcutaneous tissues toward the target lesion.
- Advance the needle carefully into the cortex of the bone, taking care not to disrupt the bone cortex to avoid contamination or unnecessary injury.
- Collect the tissue sample by advancing the biopsy needle into the lesion and extracting a core of tissue.
- If using a coaxial technique, withdraw the inner biopsy needle while leaving the outer guide needle in place. Repeat the biopsy as needed to obtain additional samples.
- Carefully remove the needle after sample collection and immediately apply pressure to the site to minimize bleeding.
- After needle removal, apply a sterile dressing to the biopsy site.
- Perform immediate post-biopsy imaging (e.g., CT or ultrasound) to check for complications such as hematoma formation, pneumothorax, or other injuries.
- If any complications are detected (e.g., hematoma, vascular injury), initiate appropriate interventions such as applying additional pressure, embolizing the needle tract, providing fluids, or consulting interventional radiology for further management.
- Monitor the patient in the recovery area for signs of complications, including pain, bleeding, or neurologic changes.
- Perform a follow-up CT or ultrasound scan as needed to confirm the absence of immediate complications, particularly in high-risk biopsy sites.
- Assess the patient’s vital signs and clinical status and document any findings on imaging that may require further observation or intervention.
- Once the patient has recovered from anesthesia and is stable, provide post-procedural care instructions to the guardians or caregivers, including signs of complications to monitor at home.
- Schedule a follow-up appointment to review the biopsy results and discuss further management or treatment options.
- Instruct the patient and caregivers to avoid strenuous activities for a few days to reduce the risk of complications such as bleeding or hematoma formation.
1. General Complications:
- Pain, hematoma, bone fracture, and infection.
- Rare complications such as pneumothorax, vascular injury, and spinal cord injury, depending on the biopsy site.
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