Introduction:
  • Primary bone tumors are the third fatal cancer in the pediatric population, representing 6% of malignancies in children.
  • 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.
Indications:
  • 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.
Relative Contraindications:
  • 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.
Equipment:
  • 11-gauge or 14-gauge (coaxial screw) biopsy needle. Power drill (OnControl) or manual (Bonopty)
  • 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).
Pre-procedural evaluation:
1. Labs:
  • Coagulation profile, CBC
2. Imaging Review:
  • 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.
  • 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.
3. Risk-Benefit Assessment:
  • Weigh the potential complications of the biopsy against the diagnostic value it provides.
4. Anesthesia:
  • General anesthesia or sedation is required for pediatric bone biopsies.
14 yo boy with atypical chondroid tumor. A. STIR image demonstrates hyperintense lesion in proximal femoral diaphysis. B. Cone beam CT image shows appropriate positioning of coaxial needle. C. Core biopsy taken of the lucent lesion in the proximal femoral diaphysis.
​Procedure:
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.
 Imaging-Guided Planning:
  • 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.
  • Ultrasound can be useful for lesions with soft-tissue component or evidence of cortical destruction.
  • 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
Needle Tract Selection:
  • 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.
Biopsy Collection:
  • 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 coaxial needle carefully into the cortex of the bone, taking care not to disrupt the bone cortex more than once 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.
Complication Management:
  • After needle removal, apply a sterile dressing to the biopsy site.
  • If high-risk 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.
  • Assess the patient’s vital signs and clinical status and document any findings on imaging that may require further observation or intervention.
Post-procedural care:
  • 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.
  • Limit weight bearing with crutches and limited activity if biopsy of weight-bearing site, such as femoral neck.
Complications:
1. General Complications:
  • Pain, hematoma, bone fracture, and infection.
2. Site-specific Complications:
  • Rare complications such as pneumothorax, vascular injury, and spinal cord injury, depending on the biopsy site.
References:
  • Liu PT, Valadez SD, Chivers FS, Roberts CC, Beauchamp CP. Anatomically based guidelines for core needle biopsy of bone tumors: implications for limb-sparing surgery. Radiographics. 2007;27(1): 189–205.
  • Murphy WA, Destouet JM, Gilula LA. Percutaneous skeletal biopsy 1981: a procedure for radiologists— results, review, and recommendations. Radiology. 1981;139(3):545–9.
  • Carrasco CH, Wallace S, Richli WR. Percutaneous skeletal biopsy. Cardiovasc Intervent Radiol. 1991; 14(1):69–72.
  • Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. Epub 20130117. doi: 10.3322/caac.21166. PubMed PMID: 23335087.
  • Interiano RB, Malkan AD, Loh AHP, Hinkle N, Wahid FN, Bahrami A, Mao S, Wu J, Bishop MW, Neel MD, Gold RE, Rao BN, Davidoff AM, Fernandez-Pineda I. Initial diagnostic management of pediatric bone tumors. Journal of Pediatric Surgery. 2016;51(6):981-5. doi: https://doi.org/10.1016/j.jpedsurg.2016.02.068.
  • Trieu J, Schlicht SM, Choong PF. Diagnosing musculoskeletal tumours: How accurate is CT-guided core needle biopsy? Eur J Surg Oncol. 2016;42(7):1049-56. Epub 20160302. doi: 10.1016/j.ejso.2016.02.242. PubMed PMID: 27178775.
  • Suh CH, Yun SJ. Diagnostic Outcome of Image-Guided Percutaneous Core Needle Biopsy of Sclerotic Bone Lesions: A Meta-Analysis. AJR Am J Roentgenol. 2019;212(3):625-31. Epub 20181227. doi: 10.2214/ajr.18.20243. PubMed PMID: 30589380.
  • Nouh MR, Abu Shady HM. Initial CT-guided needle biopsy of extremity skeletal lesions: diagnostic performance and experience of a tertiary musculoskeletal center. Eur J Radiol. 2014;83(2):360-5. Epub 20131027. doi: 10.1016/j.ejrad.2013.10.012. PubMed PMID: 24239238.
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