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EDUCATION EXHIBIT |
Department of Radiology, Mayo Clinic Jacksonville, Florida
As to diseases, make a habit of two things—to help, or at least, to do no harm.—Hippocrates1 (460–377 BC)
It is an all-too-familiar scenario. You are assigned to CT for the day. The technologist informs you that the first biopsy patient is waiting to be consented. The patient is a 74-year-old man with a history of lung cancer who has come to you for biopsy of a lesion in the right distal femur. The patient was referred by a medical oncologist, and the biopsy was approved by your associate, who, unfortunately, has no additional information. The biopsy seems straightforward enough, and it is certainly understandable that confirmation of metastatic disease is required to determine appropriate therapy. You call, but the orthopedic oncologist you normally work with is in surgery and unavailable for a "curbside" consultation on the best approach for biopsy of the lesion. Because the expected diagnosis is metastasis, the percutaneous approach used really doesn’t matter—or does it? And what if the lesion is not a metastasis but a primary bone tumor? Will the approach matter then?
Although this account is fictional, similar events occur all too often, and an inappropriately performed biopsy can have disastrous consequences for the patient. In the classic studies by Mankin et al (2,3), approximately 18% of patients with primary musculoskeletal tumors required alteration of the optimum treatment plan as a result of biopsy-related issues. Although a suboptimal biopsy approach was only one of the many biopsy-related complications, this statistic serves as a sobering reminder of the harm that may be the unintended consequence of an inappropriate biopsy.
It is a great pleasure to have the opportunity to comment on the article by Liu et al (4) in this issue of RadioGraphics. The authors present a primer on the planning of image-guided core needle biopsy, setting forth a few fundamental principles and providing a set of planning guidelines that take into account the relevant anatomy in various locations in the upper and lower extremities. This information is critically important, and a thorough understanding of it is essential for planning a musculoskeletal biopsy. Equally important, the authors emphasize that musculoskeletal procedures should be approached as a team, with preprocedure coordination between the radiologist and the orthopedic surgeon. This coordination is essential and in keeping with a fundamental principle of orthopedic oncology, and every biopsy should be planned as carefully as the definitive surgery (2).
Liu et al (4) make a critical point when they note that a solitary bone lesion should be treated as though it may represent a primary tumor. In my (anecdotal) experience, such an approach, although it requires more time to coordinate, is not only prudent but essential for optimization of patient care.
I certainly agree with the authors’ approach to solitary bone lesions, yet I would caution readers that in many cases extraosseous tumor extension may significantly alter the biopsy approach. In addition to involving the adjacent anatomic spaces, such extraosseous tumor extension may alter the definitive resection, surgical incision, and biopsy approach that would be used for lesions that are confined solely to bone. Although the authors include the appropriate caveats, the need to plan each procedure in detail with the operating surgeon cannot be overemphasized.
As radiologists, we perform percutaneous biopsies routinely. The most difficult biopsy, however, is the one that is not performed. Anyone who has cancelled a scheduled biopsy is acutely aware of the time and energy required to consult with and counsel all concerned parties as to why it is in the best interest of the patient to cancel a procedure. Yet, in the case of a tumor-related musculoskeletal procedure, it is far better to cancel the procedure than to perform it in a manner that compromises optimal patient care. Always remember: Do no harm.
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