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DOI: 10.1148/rg.271065092
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Anatomically Based Guidelines for Core Needle Biopsy of Bone Tumors: Implications for Limb-sparing Surgery1

Patrick T. Liu, MD, Scott D. Valadez, MD, F. Spencer Chivers, MD, Catherine C. Roberts, MD and Christopher P. Beauchamp, MD

1 From the Departments of Radiology (P.T.L., S.D.V., F.S.C., C.C.R.) and Orthopedic Surgery (C.P.B.), Mayo Clinic College of Medicine, 13400 E Shea Blvd, Scottsdale, AZ 85259. Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received May 5, 2006; revision requested August 14 and received September 18; accepted September 21. P.T.L. is a research consultant for the Bracco Group, and C.P.B. is a consultant for Zimmer; all remaining authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Suboptimal biopsy of Ewing sarcoma in the distal right femur in a 36-year-old man. CT scan obtained during core needle biopsy performed at an outside institution without orthopedic oncologic surgical consultation reveals that the needle was incorrectly inserted using an anterior approach through the rectus femoris muscle. LSS was performed using the standard lateral approach, but the surgeon was forced to perform an additional resection of the anterior portion of the biopsy track. Postoperative knee extension was compromised. Despite the administration of preoperative radiation therapy and chemotherapy and clean surgical margins, the tumor recurred adjacent to the resected biopsy track 9 months later.

 

Figure 2
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  		Figure 2a.  Coronal (a) and axial oblique (b) multi-planar reformatted CT images (inset in b shows the location of the section) show a normal left hip. An angled subtrochanteric approach (green strip) should be used for biopsy of lesions in the femoral neck or head. The greater trochanter bursa (outlined in red in a) and the hip joint capsule should be avoided. GM = gluteus maximus muscle, GMed = gluteus medius muscle, TFL = tensor fascia lata muscle, VL = vastus lateralis muscle.

 

Figure 2
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  		Figure 2b.  Coronal (a) and axial oblique (b) multi-planar reformatted CT images (inset in b shows the location of the section) show a normal left hip. An angled subtrochanteric approach (green strip) should be used for biopsy of lesions in the femoral neck or head. The greater trochanter bursa (outlined in red in a) and the hip joint capsule should be avoided. GM = gluteus maximus muscle, GMed = gluteus medius muscle, TFL = tensor fascia lata muscle, VL = vastus lateralis muscle.

 

Figure 3
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  		Figure 3a.  Three-dimensional volume-rendered (VR) CT images show a normal thigh. The green line on the lateral image (a) shows the standard lateral surgical incision site for LSS of lesions in the femur. The green line on the medial image (b) shows an additional surgical incision site for distal femoral medial lesions. Horizontal white lines indicate the levels at which the CT scans in Figure 4 were obtained.

 

Figure 3
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  		Figure 3b.  Three-dimensional volume-rendered (VR) CT images show a normal thigh. The green line on the lateral image (a) shows the standard lateral surgical incision site for LSS of lesions in the femur. The green line on the medial image (b) shows an additional surgical incision site for distal femoral medial lesions. Horizontal white lines indicate the levels at which the CT scans in Figure 4 were obtained.

 

Figure 4
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  		Figure 4a.  Contrast-enhanced CT scans of the left thigh obtained at the level of the proximal femoral diaphysis (a), midfemoral diaphysis (b), distal femoral diametaphysis (c), distal femoral metaphysis (d), and femoral condyles (e) demonstrate the recommended biopsy paths (green strips). BF-LH = long head of the biceps femoris muscle, BF-SH = short head of the biceps femoris muscle, GM = gluteus maximus muscle, VI = vastus intermedius muscle, VL = vastus lateralis muscle, VM = vastus medialis muscle.

 

Figure 4
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  		Figure 4b.  Contrast-enhanced CT scans of the left thigh obtained at the level of the proximal femoral diaphysis (a), midfemoral diaphysis (b), distal femoral diametaphysis (c), distal femoral metaphysis (d), and femoral condyles (e) demonstrate the recommended biopsy paths (green strips). BF-LH = long head of the biceps femoris muscle, BF-SH = short head of the biceps femoris muscle, GM = gluteus maximus muscle, VI = vastus intermedius muscle, VL = vastus lateralis muscle, VM = vastus medialis muscle.

 

Figure 4
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  		Figure 4c.  Contrast-enhanced CT scans of the left thigh obtained at the level of the proximal femoral diaphysis (a), midfemoral diaphysis (b), distal femoral diametaphysis (c), distal femoral metaphysis (d), and femoral condyles (e) demonstrate the recommended biopsy paths (green strips). BF-LH = long head of the biceps femoris muscle, BF-SH = short head of the biceps femoris muscle, GM = gluteus maximus muscle, VI = vastus intermedius muscle, VL = vastus lateralis muscle, VM = vastus medialis muscle.

 

Figure 4
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  		Figure 4d.  Contrast-enhanced CT scans of the left thigh obtained at the level of the proximal femoral diaphysis (a), midfemoral diaphysis (b), distal femoral diametaphysis (c), distal femoral metaphysis (d), and femoral condyles (e) demonstrate the recommended biopsy paths (green strips). BF-LH = long head of the biceps femoris muscle, BF-SH = short head of the biceps femoris muscle, GM = gluteus maximus muscle, VI = vastus intermedius muscle, VL = vastus lateralis muscle, VM = vastus medialis muscle.

 

Figure 4
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  		Figure 4e.  Contrast-enhanced CT scans of the left thigh obtained at the level of the proximal femoral diaphysis (a), midfemoral diaphysis (b), distal femoral diametaphysis (c), distal femoral metaphysis (d), and femoral condyles (e) demonstrate the recommended biopsy paths (green strips). BF-LH = long head of the biceps femoris muscle, BF-SH = short head of the biceps femoris muscle, GM = gluteus maximus muscle, VI = vastus intermedius muscle, VL = vastus lateralis muscle, VM = vastus medialis muscle.

 

Figure 5
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  		Figure 5a.  Atypical bone infarct in the left femur at the level of the middiaphysis in a 64-year-old man. (a) CT scan obtained for prebiopsy planning with the patient in the left anterior oblique position shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during biopsy shows the biopsy needle track immediately anterior to the lateral intermuscular septum.

 

Figure 5
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  		Figure 5b.  Atypical bone infarct in the left femur at the level of the middiaphysis in a 64-year-old man. (a) CT scan obtained for prebiopsy planning with the patient in the left anterior oblique position shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during biopsy shows the biopsy needle track immediately anterior to the lateral intermuscular septum.

 

Figure 6
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  		Figure 6a.  Three-dimensional VR CT images show a normal lower leg. The green line on the anteromedial image (a) shows the standard surgical incision site for LSS of lesions in the tibia, whereas the green line on the lateral image (b) shows the standard surgical incision site for LSS of lesions in the fibula. Horizontal white lines indicate the levels at which the CT scans in Figure 7 were obtained.

 

Figure 6
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  		Figure 6b.  Three-dimensional VR CT images show a normal lower leg. The green line on the anteromedial image (a) shows the standard surgical incision site for LSS of lesions in the tibia, whereas the green line on the lateral image (b) shows the standard surgical incision site for LSS of lesions in the fibula. Horizontal white lines indicate the levels at which the CT scans in Figure 7 were obtained.

 

Figure 7
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  		Figure 7a.  Contrast-enhanced CT scans of the lower left leg obtained at the levels of the tibial plateau (a), proximal tibial metaphysis (b), middiaphysis (c), distal diaphysis (d), and distal metaphysis (e) demonstrate the recommended biopsy paths (green strips). EDL = extensor digitorum longus muscle, EHL = extensor hallucis longus muscle, FDL = flexor digitorum longus muscle, G-L = lateral head of the gastrocnemius muscle, PB = peroneus brevis muscle, PL = peroneus longus muscle, S = soleus muscle, TA = tibialis anterior muscle.

 

Figure 7
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  		Figure 7b.  Contrast-enhanced CT scans of the lower left leg obtained at the levels of the tibial plateau (a), proximal tibial metaphysis (b), middiaphysis (c), distal diaphysis (d), and distal metaphysis (e) demonstrate the recommended biopsy paths (green strips). EDL = extensor digitorum longus muscle, EHL = extensor hallucis longus muscle, FDL = flexor digitorum longus muscle, G-L = lateral head of the gastrocnemius muscle, PB = peroneus brevis muscle, PL = peroneus longus muscle, S = soleus muscle, TA = tibialis anterior muscle.

 

Figure 7
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  		Figure 7c.  Contrast-enhanced CT scans of the lower left leg obtained at the levels of the tibial plateau (a), proximal tibial metaphysis (b), middiaphysis (c), distal diaphysis (d), and distal metaphysis (e) demonstrate the recommended biopsy paths (green strips). EDL = extensor digitorum longus muscle, EHL = extensor hallucis longus muscle, FDL = flexor digitorum longus muscle, G-L = lateral head of the gastrocnemius muscle, PB = peroneus brevis muscle, PL = peroneus longus muscle, S = soleus muscle, TA = tibialis anterior muscle.

 

Figure 7
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  		Figure 7d.  Contrast-enhanced CT scans of the lower left leg obtained at the levels of the tibial plateau (a), proximal tibial metaphysis (b), middiaphysis (c), distal diaphysis (d), and distal metaphysis (e) demonstrate the recommended biopsy paths (green strips). EDL = extensor digitorum longus muscle, EHL = extensor hallucis longus muscle, FDL = flexor digitorum longus muscle, G-L = lateral head of the gastrocnemius muscle, PB = peroneus brevis muscle, PL = peroneus longus muscle, S = soleus muscle, TA = tibialis anterior muscle.

 

Figure 7
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  		Figure 7e.  Contrast-enhanced CT scans of the lower left leg obtained at the levels of the tibial plateau (a), proximal tibial metaphysis (b), middiaphysis (c), distal diaphysis (d), and distal metaphysis (e) demonstrate the recommended biopsy paths (green strips). EDL = extensor digitorum longus muscle, EHL = extensor hallucis longus muscle, FDL = flexor digitorum longus muscle, G-L = lateral head of the gastrocnemius muscle, PB = peroneus brevis muscle, PL = peroneus longus muscle, S = soleus muscle, TA = tibialis anterior muscle.

 

Figure 8
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  		Figure 8a.  Osteomyelitis of the left tibia at the level of the proximal metaphysis in a 45-year-old woman. (a) CT scan obtained for prebiopsy planning shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during core needle biopsy illustrates the recommended anteromedial approach.

 

Figure 8
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  		Figure 8b.  Osteomyelitis of the left tibia at the level of the proximal metaphysis in a 45-year-old woman. (a) CT scan obtained for prebiopsy planning shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during core needle biopsy illustrates the recommended anteromedial approach.

 

Figure 9
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  		Figure 9a.  Three-dimensional VR CT images show a normal upper arm. The green line on the anterior image (a) shows the standard surgical incision site for LSS of lesions in the humerus. The green line on the medial image (b) shows the standard medial surgical incision site for LSS of lesions in the distal humerus. Horizontal white lines indicate the levels at which the CT scans in Figure 10 were obtained.

 

Figure 9
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  		Figure 9b.  Three-dimensional VR CT images show a normal upper arm. The green line on the anterior image (a) shows the standard surgical incision site for LSS of lesions in the humerus. The green line on the medial image (b) shows the standard medial surgical incision site for LSS of lesions in the distal humerus. Horizontal white lines indicate the levels at which the CT scans in Figure 10 were obtained.

 

Figure 10
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  		Figure 10a.  Contrast-enhanced CT scans of the left humerus obtained at the levels of the humeral neck (a), proximal diaphysis (b), middiaphysis (c), distal diaphysis (d), and humeral epicondyles (e) demonstrate the recommended biopsy paths (green strips). B = brachialis muscle, BB = biceps brachii muscle, B-L = long head of the biceps muscle, Br = brachioradialis muscle, B-S = short head of the biceps muscle, C = coracobrachialis muscle, D = deltoid muscle, D-A = anterior portion of the deltoid muscle, D-P = posterior portion of the deltoid muscle, Ssc = subscapularis muscle.

 

Figure 10
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  		Figure 10b.  Contrast-enhanced CT scans of the left humerus obtained at the levels of the humeral neck (a), proximal diaphysis (b), middiaphysis (c), distal diaphysis (d), and humeral epicondyles (e) demonstrate the recommended biopsy paths (green strips). B = brachialis muscle, BB = biceps brachii muscle, B-L = long head of the biceps muscle, Br = brachioradialis muscle, B-S = short head of the biceps muscle, C = coracobrachialis muscle, D = deltoid muscle, D-A = anterior portion of the deltoid muscle, D-P = posterior portion of the deltoid muscle, Ssc = subscapularis muscle.

 

Figure 10
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  		Figure 10c.  Contrast-enhanced CT scans of the left humerus obtained at the levels of the humeral neck (a), proximal diaphysis (b), middiaphysis (c), distal diaphysis (d), and humeral epicondyles (e) demonstrate the recommended biopsy paths (green strips). B = brachialis muscle, BB = biceps brachii muscle, B-L = long head of the biceps muscle, Br = brachioradialis muscle, B-S = short head of the biceps muscle, C = coracobrachialis muscle, D = deltoid muscle, D-A = anterior portion of the deltoid muscle, D-P = posterior portion of the deltoid muscle, Ssc = subscapularis muscle.

 

Figure 10
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  		Figure 10d.  Contrast-enhanced CT scans of the left humerus obtained at the levels of the humeral neck (a), proximal diaphysis (b), middiaphysis (c), distal diaphysis (d), and humeral epicondyles (e) demonstrate the recommended biopsy paths (green strips). B = brachialis muscle, BB = biceps brachii muscle, B-L = long head of the biceps muscle, Br = brachioradialis muscle, B-S = short head of the biceps muscle, C = coracobrachialis muscle, D = deltoid muscle, D-A = anterior portion of the deltoid muscle, D-P = posterior portion of the deltoid muscle, Ssc = subscapularis muscle.

 

Figure 10
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  		Figure 10e.  Contrast-enhanced CT scans of the left humerus obtained at the levels of the humeral neck (a), proximal diaphysis (b), middiaphysis (c), distal diaphysis (d), and humeral epicondyles (e) demonstrate the recommended biopsy paths (green strips). B = brachialis muscle, BB = biceps brachii muscle, B-L = long head of the biceps muscle, Br = brachioradialis muscle, B-S = short head of the biceps muscle, C = coracobrachialis muscle, D = deltoid muscle, D-A = anterior portion of the deltoid muscle, D-P = posterior portion of the deltoid muscle, Ssc = subscapularis muscle.

 

Figure 11
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  		Figure 11a.  Chondromyxoid fibroma of the proximal left humerus in a 21-year-old man. (a) CT scan obtained for prebiopsy planning shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during core needle biopsy shows the biopsy track just lateral to the cephalic vein and deltopectoral groove.

 

Figure 11
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  		Figure 11b.  Chondromyxoid fibroma of the proximal left humerus in a 21-year-old man. (a) CT scan obtained for prebiopsy planning shows the biopsy site facing upward. (b) CT fluoroscopic image obtained during core needle biopsy shows the biopsy track just lateral to the cephalic vein and deltopectoral groove.

 

Figure 12
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  		Figure 12a.  Three-dimensional VR CT images show a normal forearm. The green line on the dorsolateral image (a) shows the standard incision site for LSS of lesions in the radius. The green line on the dorsomedial image (b) shows the standard surgical incision site for LSS of lesions in the ulna. Horizontal white lines indicate the levels at which the CT scans in Figure 13 were obtained.

 

Figure 12
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  		Figure 12b.  Three-dimensional VR CT images show a normal forearm. The green line on the dorsolateral image (a) shows the standard incision site for LSS of lesions in the radius. The green line on the dorsomedial image (b) shows the standard surgical incision site for LSS of lesions in the ulna. Horizontal white lines indicate the levels at which the CT scans in Figure 13 were obtained.

 

Figure 13
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  		Figure 13a.  Contrast-enhanced CT scans of the forearm obtained at the level of the elbow (a), proximal forearm (b), middle forearm (c), distal forearm (d), and distal radioulnar joint (e) demonstrate the recommended biopsy paths (green strips) for LSS of lesions in the ulna and radius. A = anconeus muscle, APL = abductor pollicis longus muscle-tendon, Br = brachialis muscle-tendon, ECRB = extensor carpi radialis brevis muscle-tendon, ECRL = extensor carpi radialis longus muscle-tendon, ECU = extensor carpi ulnaris muscle-tendon, EI = extensor indicis muscle, EPB = extensor pollicis brevis muscle-tendon, FDP = flexor digitorum profundus muscle, R = radius, U = ulna.

 

Figure 13
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  		Figure 13b.  Contrast-enhanced CT scans of the forearm obtained at the level of the elbow (a), proximal forearm (b), middle forearm (c), distal forearm (d), and distal radioulnar joint (e) demonstrate the recommended biopsy paths (green strips) for LSS of lesions in the ulna and radius. A = anconeus muscle, APL = abductor pollicis longus muscle-tendon, Br = brachialis muscle-tendon, ECRB = extensor carpi radialis brevis muscle-tendon, ECRL = extensor carpi radialis longus muscle-tendon, ECU = extensor carpi ulnaris muscle-tendon, EI = extensor indicis muscle, EPB = extensor pollicis brevis muscle-tendon, FDP = flexor digitorum profundus muscle, R = radius, U = ulna.

 

Figure 13
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  		Figure 13c.  Contrast-enhanced CT scans of the forearm obtained at the level of the elbow (a), proximal forearm (b), middle forearm (c), distal forearm (d), and distal radioulnar joint (e) demonstrate the recommended biopsy paths (green strips) for LSS of lesions in the ulna and radius. A = anconeus muscle, APL = abductor pollicis longus muscle-tendon, Br = brachialis muscle-tendon, ECRB = extensor carpi radialis brevis muscle-tendon, ECRL = extensor carpi radialis longus muscle-tendon, ECU = extensor carpi ulnaris muscle-tendon, EI = extensor indicis muscle, EPB = extensor pollicis brevis muscle-tendon, FDP = flexor digitorum profundus muscle, R = radius, U = ulna.

 

Figure 13
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  		Figure 13d.  Contrast-enhanced CT scans of the forearm obtained at the level of the elbow (a), proximal forearm (b), middle forearm (c), distal forearm (d), and distal radioulnar joint (e) demonstrate the recommended biopsy paths (green strips) for LSS of lesions in the ulna and radius. A = anconeus muscle, APL = abductor pollicis longus muscle-tendon, Br = brachialis muscle-tendon, ECRB = extensor carpi radialis brevis muscle-tendon, ECRL = extensor carpi radialis longus muscle-tendon, ECU = extensor carpi ulnaris muscle-tendon, EI = extensor indicis muscle, EPB = extensor pollicis brevis muscle-tendon, FDP = flexor digitorum profundus muscle, R = radius, U = ulna.

 

Figure 13
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  		Figure 13e.  Contrast-enhanced CT scans of the forearm obtained at the level of the elbow (a), proximal forearm (b), middle forearm (c), distal forearm (d), and distal radioulnar joint (e) demonstrate the recommended biopsy paths (green strips) for LSS of lesions in the ulna and radius. A = anconeus muscle, APL = abductor pollicis longus muscle-tendon, Br = brachialis muscle-tendon, ECRB = extensor carpi radialis brevis muscle-tendon, ECRL = extensor carpi radialis longus muscle-tendon, ECU = extensor carpi ulnaris muscle-tendon, EI = extensor indicis muscle, EPB = extensor pollicis brevis muscle-tendon, FDP = flexor digitorum profundus muscle, R = radius, U = ulna.

 




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