- 1 What are the relative rates of efficacy and accuracy of various biopsy modalities in BSTTs?
- 2 Evidence summary and recommendations
- 3 References
- 4 Appendices
- 5 Further resources
What are the relative rates of efficacy and accuracy of various biopsy modalities in BSTTs?
Fine needle versus core versus open biopsy
Patients with suspected bone and soft tissue tumours (BSTTs) require accurate diagnostic biopsy prior to definitive treatment. Various biopsy techniques which are used include fine needle aspiration (FNA) cytology, needle core biopsy (NCB) and open (incisional) biopsy. Open biopsy was long heralded as the ‘gold standard’ in the diagnosis of BSTTs, but with the advent of less invasive procedures of FNA and NCB, use of this more invasive procedure has diminished. FNA and NCB are less expensive, less invasive, have a lower complication rate than open biopsy and generally do not lead to modification of the definitive surgical procedure. FNA and NCB allow for multiple passes to be performed in various directions increasing accuracy of subtyping, although theoretically this may impart a greater risk of recurrence or tumour spread.
The diagnostic benefits of various biopsy techniques have been reviewed in predominately retrospective studies including studies assessing open biopsy alone, of FNA alone, of NCB alone, or biopsies performed in various combinations Rougraff et al performed an extensive evidence based literature search on soft tissue biopsy modalities.
Rates of efficacy/accuracy of the various biopsy modalities
Although open biopsy is regarded as the “diagnostic standard to which all alternative biopsy techniques must be compared”, it may still be non-representative and technically poor. The reported diagnostic accuracy lies between 88% and 100%. Higher accuracy may be achieved with intraoperative frozen section assessment. Open biopsy allows the advantage of more tissue to be harvested to enable a broad range of ancillary studies. However, it requires general anaesthetic, care is needed to avoid an inappropriately placed incision which widens the required definitive resection size and it has a reported complication rate of 12-17% including haematoma, infection, wound dehiscence and tumour fungation. However, the risk of complication may not be as high if performed by an experienced surgeon.
Fine needle aspiration
FNA has the advantage of low cost, quick turnaround time and low incidence of complication. It has been considered to be a first-line investigation, as a simple method of patient triage or as a screening test. Studies tend to report accuracy with regard to general parameters such as benign versus malignant, as FNA lacks the ability to assess tissue architecture. As a result, sarcoma grading methods including the FNCLCC and NCI systems, which require tissue morphology as a whole, may not be applicable and limited cytological grading based on cellular pleomorphism is often employed. Reported accuracy rates for detecting sarcoma are as low as 60.5% to as high as 98% for categorisation as benign versus malignant, rather than giving a definitive diagnosis. Correct classification/subtyping of soft tumours may only be achievable in 50-60% of cases because of the inherent heterogeneity of soft tissue tumour types. Significantly, absence of tissue architecture in an FNA sample makes assessment difficult and subtyping less accurate than tissue biopsy.
Myxoid lesions may have the highest propensity to fall into a “suspicious for malignancy” category, whilst spindle cell lesions appear to be the most difficult in which to render a specific diagnosis. In bone lesions, the limitation of FNA has been the inability to obtain adequate diagnostic material from intraosseous, sclerotic and low-grade tumours. As the diagnosis of a primary bone tumour is often made radiologically, FNA may be a confirmatory rather than diagnostic test in that setting. It may be an efficient method in the diagnosis of primary osteosarcoma in conjunction with radiological and clinical data. In one study, chondrosarcoma caused greatest diagnostic difficulty and Ewing sarcoma the least. Fibroosseous lesions are also associated with sampling error. Specific sites such as the hand, where a limited number of common soft tissue tumours occur, may result in higher diagnostic accuracy.
Ancillary studies can increase the accuracy of FNA, which may include cell-block for morphology, immunohistochemical and molecular studies and flow-cytometric immunophenotyping. Successful FNA is also highly dependent upon the experience of the cytopathologist and close collaboration with the orthopaedic surgeon. CT-guided FNA accuracy rates may be lower than NCB because it is more operator and cytopathologist dependent and less material may be obtained for ancillary studies.
Needle core biopsy
NCB, which may also be performed blind or with image guidance, is touted as the ‘new gold standard’ in the diagnosis of musculoskeletal tumours including of the spine. It is reported to be equally effective in BSTTs, but this may depend on site. One study reported only 33% accuracy in abdominal wall tumours. Conversely, high accuracy was reported in a study on the diagnosis of chest wall sarcomas. Overall accuracy is lower but comparable to that of open biopsy, and ranges from 71% to near 100%. It may be less accurate in soft tissue compared to bone as bone tumours often show specific imaging features, lacking in soft tissue tumours. In bone, diagnostic yield may be higher for lytic than sclerotic lesions. Accurate tumour subtyping and grading is achieved from 45.6% to or exceeding 90%. Grading is also more accurate in high-grade tumours.
NCB may show higher accuracy in grading than open biopsies if they are performed in a number of directions as they may sample more representative areas of a tumour, in contrast to sampling a single area in an incision biopsy. Adequate NCB sampling is also important to avoid misclassification due to tumour heterogeneity. Rimondi heralded NCB as the new gold standard in biopsy of the spine, although false negative results were recorded in cervical lesions. Jelenek recorded a high accuracy for both sclerotic and non-sclerotic lesions in primary bone tumours, but noted difficulty with cystic lesions. Diagnostic accuracy of NCB of sclerotic lesions of the spine was only 76% compared to 93% in lytic and mixed sclerotic/lytic lesions in a study by Lis.
Factors which have been shown to optimise the diagnostic yield of NCB, include the use of contrast-enhanced ultrasound and PET-scan guidance to detect the areas of a tumour which are most representative (i.e. with the worst histological features). In particular, myxoid lesions, which may cause diagnostic difficulty by NCB have showed improved diagnostic accuracy with contrast-enhanced ultrasound guidance. Vacuum assisted NCB showed overall 96% diagnostic accuracy compared to 99% by open biopsy in a study by Mohr. NCB adequacy by frozen section assessment in one study increased accuracy rate to near 100%. The diagnostic yield of CT or ultrasound guided NCB of BSTTs was shown to be greater with higher tissue yield by using longer needle cores and a minimum of 3 and 4 cores for the diagnosis of BSTTs respectively. In ultrasound guided NCB of soft tissue tumours, technical factors such as the number of cores, NCB gauge, experience of operator or site of biopsy had no influence on diagnostic yield when performed in a specialist department.
Some studies have compared the use of both FNA and NCB taken in the same procedure, or assessed their accuracy together. Hau had a diagnostic accuracy by FNA and NCB of 63% and 74% respectively. They found that pelvic lesions had the most diagnostic accuracy (81%), where as there was low accuracy of 61% for any lesion located in the spine. For both FNA and NCB, more tissue is required for diagnosis in low grade and benign lesions than for high-grade malignant tumours. Kasraelian performed FNA then NCB followed by open biopsy in a single procedure, the latter assessed by frozen section in a series of 57 patients. NCB was more accurate than FNA in determining malignancy, exact diagnosis and grade, and open biopsy was more accurate than both.
Evidence summary and recommendations
|FNA has a lower diagnostic accuracy than NCB, which itself has a lower diagnostic accuracy than open biopsy, but a rate that is never-the-less acceptable in light of it being a simple, less costly method, with a low complication rate. All techniques have higher accuracy if assessed at the time of collection by a pathologist, and if ancillary techniques are utilised where relevant.||IV||, |
|Biopsy technique of choice is needle core biopsy (NCB) performed in a specialist sarcoma unit setting with appropriate multidisciplinary input.||D|
In essence, generous numbers of needle cores of adequate length, performed with the aid of imaging, in various directions within the tumour, allows for tumour heterogeneity. In most cases this results in accurate diagnosis, grading and harvesting of adequate tissue for appropriate ancillary diagnostic techniques and, in appropriate circumstances, tissue banking. Refer to the Royal College of Pathologists of Australasia Soft Tissue Tumour Resection Structured Reporting Protocol 1st Edition (2011)
- Hau A, Kim I, Kattapuram S, Hornicek FJ, Rosenberg AE, Gebhardt MC, et al. Accuracy of CT-guided biopsies in 359 patients with musculoskeletal lesions. Skeletal Radiol 2002 Jun;31(6):349-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12073119.
- Strauss DC, Qureshi YA, Hayes AJ, Thway K, Fisher C, Thomas JM. The role of core needle biopsy in the diagnosis of suspected soft tissue tumours. J Surg Oncol 2010 Oct 1;102(5):523-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20872955.
- Kitagawa Y, Ito H, Sawaizumi T, Matsubara M, Yokoyama M, Naito Z. Fine needle aspiration cytology for soft tissue tumours of the hand. J Hand Surg Br 2003 Dec;28(6):582-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14599833.
- Clayer M. Open incisional biopsy is a safe and accurate technique for soft tissue tumours. ANZ J Surg 2010 Nov;80(11):786-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20969684.
- Amin MS, Luqman M, Jamal S, Mamoon N, Anwar M. Fine needle aspiration biopsy of soft tissue tumours. J Coll Physicians Surg Pak 2003 Nov;13(11):625-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14700487.
- Costa MJ, Campman SC, Davis RL, Howell LP. Fine-needle aspiration cytology of sarcoma: retrospective review of diagnostic utility and specificity. Diagn Cytopathol 1996 Jul;15(1):23-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8807248.
- Dey P, Mallik MK, Gupta SK, Vasishta RK. Role of fine needle aspiration cytology in the diagnosis of soft tissue tumours and tumour-like lesions. Cytopathology 2004 Feb;15(1):32-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14748789.
- Domanski HA, Akerman M. Fine-needle aspiration of primary osteosarcoma: a cytological-histological study. Diagn Cytopathol 2005 May;32(5):269-75 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15830363.
- Domanski HA, Akerman M, Rissler P, Gustafson P. Fine-needle aspiration of soft tissue leiomyosarcoma: an analysis of the most common cytologic findings and the value of ancillary techniques. Diagn Cytopathol 2006 Sep;34(9):597-604 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16900474.
- Fleshman R, Mayerson J, Wakely PE Jr. Fine-needle aspiration biopsy of high-grade sarcoma: a report of 107 cases. Cancer 2007 Dec 25;111(6):491-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17941014.
- Gautam U, Srinivasan R, Rajwanshi A, Bansal D, Marwaha RK. Comparative evaluation of flow-cytometric immunophenotyping and immunocytochemistry in the categorization of malignant small round cell tumors in fine-needle aspiration cytologic specimens. Cancer 2008 Dec 25;114(6):494-503 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19073016.
- Jorda M, Rey L, Hanly A, Ganjei-Azar P. Fine-needle aspiration cytology of bone: accuracy and pitfalls of cytodiagnosis. Cancer 2000 Feb 25;90(1):47-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10692216.
- Kreicbergs A, Bauer HC, Brosjö O, Lindholm J, Skoog L, Söderlund V. Cytological diagnosis of bone tumours. J Bone Joint Surg Br 1996 Mar;78(2):258-63 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8666638.
- Maitra A, Ashfaq R, Saboorian MH, Lindberg G, Gokaslan ST. The role of fine-needle aspiration biopsy in the primary diagnosis of mesenchymal lesions: a community hospital-based experience. Cancer 2000 Jun 25;90(3):178-85 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10896331.
- Nagira K, Yamamoto T, Akisue T, Marui T, Hitora T, Nakatani T, et al. Reliability of fine-needle aspiration biopsy in the initial diagnosis of soft-tissue lesions. Diagn Cytopathol 2002 Dec;27(6):354-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12451566.
- Ng VY, Thomas K, Crist M, Wakely PE Jr, Mayerson J. Fine needle aspiration for clinical triage of extremity soft tissue masses. Clin Orthop Relat Res 2010 Apr;468(4):1120-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19763717.
- Wakely PE Jr, Kneisl JS. Soft tissue aspiration cytopathology. Cancer 2000 Oct 25;90(5):292-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11038426.
- Adams SC, Potter BK, Pitcher DJ, Temple HT. Office-based core needle biopsy of bone and soft tissue malignancies: an accurate alternative to open biopsy with infrequent complications. Clin Orthop Relat Res 2010 Oct;468(10):2774-80 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20582496.
- Altuntas AO, Slavin J, Smith PJ, Schlict SM, Powell GJ, Ngan S, et al. Accuracy of computed tomography guided core needle biopsy of musculoskeletal tumours. ANZ J Surg 2005 Apr;75(4):187-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15839962.
- Ashford RU, McCarthy SW, Scolyer RA, Bonar SF, Karim RZ, Stalley PD. Surgical biopsy with intra-operative frozen section. An accurate and cost-effective method for diagnosis of musculoskeletal sarcomas. J Bone Joint Surg Br 2006 Sep;88(9):1207-11 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16943474.
- De Marchi A, Brach del Prever EM, Linari A, Pozza S, Verga L, Albertini U, et al. Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours. Eur Radiol 2010 Nov;20(11):2740-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20582701.
- Hain SF, O'Doherty MJ, Bingham J, Chinyama C, Smith MA. Can FDG PET be used to successfully direct preoperative biopsy of soft tissue tumours? Nucl Med Commun 2003 Nov;24(11):1139-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14569167.
- Heslin MJ, Lewis JJ, Woodruff JM, Brennan MF. Core needle biopsy for diagnosis of extremity soft tissue sarcoma. Ann Surg Oncol 1997;4(5):425-31 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9259971.
- Hoeber I, Spillane AJ, Fisher C, Thomas JM. Accuracy of biopsy techniques for limb and limb girdle soft tissue tumors. Ann Surg Oncol 2001;8(1):80-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11206230.
- Issakov J, Flusser G, Kollender Y, Merimsky O, Lifschitz-Mercer B, Meller I. Computed tomography-guided core needle biopsy for bone and soft tissue tumors. Isr Med Assoc J 2003 Jan;5(1):28-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12592954.
- Omura MC, Motamedi K, UyBico S, Nelson SD, Seeger LL. Revisiting CT-guided percutaneous core needle biopsy of musculoskeletal lesions: contributors to biopsy success. AJR Am J Roentgenol 2011 Aug;197(2):457-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21785094.
- Peer S, Freuis T, Loizides A, Gruber H. Ultrasound guided core needle biopsy of soft tissue tumors; a fool proof technique? Med Ultrason 2011 Sep;13(3):187-94 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21894288.
- Pramesh CS, Deshpande MS, Pardiwala DN, Agarwal MG, Puri A. Core needle biopsy for bone tumours. Eur J Surg Oncol 2001 Nov;27(7):668-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11669596.
- Ray-Coquard I, Ranchère-Vince D, Thiesse P, Ghesquières H, Biron P, Sunyach MP, et al. Evaluation of core needle biopsy as a substitute to open biopsy in the diagnosis of soft-tissue masses. Eur J Cancer 2003 Sep;39(14):2021-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12957456.
- Rimondi E, Staals EL, Errani C, Bianchi G, Casadei R, Alberghini M, et al. Percutaneous CT-guided biopsy of the spine: results of 430 biopsies. Eur Spine J 2008 Jul;17(7):975-81 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18463900.
- Rimondi E, Rossi G, Bartalena T, Ciminari R, Alberghini M, Ruggieri P, et al. Percutaneous CT-guided biopsy of the musculoskeletal system: results of 2027 cases. Eur J Radiol 2011 Jan;77(1):34-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20832220.
- Shin HJ, Amaral JG, Armstrong D, Chait PG, Temple MJ, John P, et al. Image-guided percutaneous biopsy of musculoskeletal lesions in children. Pediatr Radiol 2007 Apr;37(4):362-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17340168.
- Tsukushi S, Nishida Y, Yamada Y, Yoshida M, Ishiguro N. CT-guided needle biopsy for musculoskeletal lesions. Arch Orthop Trauma Surg 2010 May;130(5):699-703 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20033699.
- Willman JH, White K, Coffin CM. Pediatric core needle biopsy: strengths and limitations in evaluation of masses. Pediatr Dev Pathol 2001;4(1):46-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11200490.
- Wu JS, Goldsmith JD, Horwich PJ, Shetty SK, Hochman MG. Bone and soft-tissue lesions: what factors affect diagnostic yield of image-guided core-needle biopsy? Radiology 2008 Sep;248(3):962-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18710986.
- Yao L, Nelson SD, Seeger LL, Eckardt JJ, Eilber FR. Primary musculoskeletal neoplasms: effectiveness of core-needle biopsy. Radiology 1999 Sep;212(3):682-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10478232.
- Carrino JA, Khurana B, Ready JE, Silverman SG, Winalski CS. Magnetic resonance imaging-guided percutaneous biopsy of musculoskeletal lesions. J Bone Joint Surg Am 2007 Oct;89(10):2179-87 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17908894.
- Domanski HA, Akerman M, Carlén B, Engellau J, Gustafson P, Jonsson K, et al. Core-needle biopsy performed by the cytopathologist: a technique to complement fine-needle aspiration of soft tissue and bone lesions. Cancer 2005 Aug 25;105(4):229-39 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15918176.
- Jelinek JS, Murphey MD, Welker JA, Henshaw RM, Kransdorf MJ, Shmookler BM, et al. Diagnosis of primary bone tumors with image-guided percutaneous biopsy: experience with 110 tumors. Radiology 2002 Jun;223(3):731-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12034942.
- Lis E, Bilsky MH, Pisinski L, Boland P, Healey JH, O'malley B, et al. Percutaneous CT-guided biopsy of osseous lesion of the spine in patients with known or suspected malignancy. AJNR Am J Neuroradiol 2004 Oct;25(9):1583-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15502142.
- Yang YJ, Damron TA. Comparison of needle core biopsy and fine-needle aspiration for diagnostic accuracy in musculoskeletal lesions. Arch Pathol Lab Med 2004 Jul;128(7):759-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15214827.
- Skrzynski MC, Biermann JS, Montag A, Simon MA. Diagnostic accuracy and charge-savings of outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors. J Bone Joint Surg Am 1996 May;78(5):644-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8642019.
- Mohr Z, Hirche C, Klein T, Kneif S, Hünerbein M. Vacuum-assisted minimally invasive biopsy of soft-tissue tumors. J Bone Joint Surg Am 2012 Jan 18;94(2):103-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22257995.
- Kasraeian S, Allison DC, Ahlmann ER, Fedenko AN, Menendez LR. A comparison of fine-needle aspiration, core biopsy, and surgical biopsy in the diagnosis of extremity soft tissue masses. Clin Orthop Relat Res 2010 Nov;468(11):2992-3002 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20512437.
- Rougraff BT, Aboulafia A, Biermann JS, Healey J. Biopsy of soft tissue masses: evidence-based medicine for the musculoskeletal tumor society. Clin Orthop Relat Res 2009 Nov;467(11):2783-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19597901.
- Kachroo P, Pak PS, Sandha HS, Nelson SD, Seeger LL, Cameron RB, et al. Chest wall sarcomas are accurately diagnosed by image-guided core needle biopsy. J Thorac Oncol 2012 Jan;7(1):151-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21900839.
- Khoja H, Griffin A, Dickson B, Wunder J, Ferguson P, Howarth D, et al. Sampling modality influences the predictive value of grading in adult soft tissue extremity sarcomas. Arch Pathol Lab Med 2013 Dec;137(12):1774-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24283858.