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EDUCATION EXHIBIT |
Department of Radiology, Mayo Clinic, Jacksonville, Florida
I am pleased to have the opportunity to comment on the article by Stacy and Dixon in this issue of RadioGraphics (1). Since soft-tissue musculoskeletal malignancies are uncommon and osseous malignancies are even rarer, it is helpful for radiologists to be aware of commonly misinterpreted processes that may result in evaluation at a tertiary care center.
At our institution, we have a similar rate of referrals to our orthopedic oncology surgeon for conditions that are ultimately deemed nonmalignant. Various marrow, articular, and juxta-articular abnormalities are nicely outlined in the article by Stacy and Dixon, and they are probably representative of those encountered in others’ practices as well. Radiologists may be conscientious, may participate in continuing medical education, and may use appropriate reference materials, and yet may be inconclusive in offering a diagnosis. Orthopedic oncology referrals at our institution may be due to uncertainty about the malignancy or benignity of a lesion found by the referring radiologist or orthopedic surgeon or to a patient’s desire for a second opinion about a lesion that was interpreted as benign. Early phases of benign diseases may be confusing, and sometimes follow-up imaging at our institution helps provide a specific diagnosis in such processes as developing myositis ossificans, osteonecrosis, and Paget disease.
A complete imaging work-up, full staging studies, and consultation with an orthopedic oncologic surgeon are desirable before performing a percutaneous needle biopsy. It was reassuring that the nearly 400 patients in this study did not have a tissue biopsy-based diagnosis from their referring medical facilities. I believe that a biopsy could easily have been performed in a portion of these cases but was not performed because of the referring physician’s awareness of potential complications related to erroneously performed biopsies (2). Contamination of uninvolved compartments may convert intracompartmental lesions into extracompartmental lesions (3), result in higher tumor staging, and possibly preclude limb salvage surgery. Since tertiary care centers see a disproportionate amount of musculoskeletal tumors and may have more expertise in diagnosing such rare entities, referrals are always welcome, and false-positive examinations are expected. Patient care is always the primary concern.
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Department of Radiology, University of Chicago, Chicago, Illinois
We are grateful for Dr Bancroft’s commentary and words of wisdom regarding the referral and work-up of patients with bone and soft-tissue tumors. Her statements that warn of the consequences of erroneously performed biopsies of aggressive lesions are particularly important. Our opinion is that the radiologist should not agree to perform a biopsy of any potential bone or soft-tissue sarcoma without first consulting with the surgeon who will ultimately be responsible for removal of the tumor—preferably, an orthopedic oncologist who specializes in the work-up and treatment of such neoplasms. When we encounter a suspicious lesion in our own practice, our impressions in the dictated report will include a statement such as "We recommend referral to an orthopedic oncologist" rather than "We recommend biopsy."
As a point of clarification, the nearly 400 patients alluded to in our article that were referred to the Orthopaedic Oncology Clinic without a tissue biopsy-based diagnosis did not constitute the entire population of new patient referrals during the year: More than 800 new patients were referred to the clinic during that 12-month period. For the purposes of our article, we excluded (a) any patient referred with a diagnosis based on histologic specimens obtained at the referring institution, including patients who were inappropriately treated at the referring institution; (b) any patient with a potential recurrence of a known treated tumor; (c) any patient with a pathologic fracture through a known benign or malignant tumor who was presenting for fixation; (d) any patient seen by the orthopedic surgeon for a documented reason other than a potential tumor (eg, for a nonpathologic fracture); (e) any patient who brought images that we were unable to review (eg, because of an inability to load a CD-ROM disk); and (f) any patient who did not bring images or for whom we could not reasonably determine the reason for referral. With regard to criterion (c), we wish to emphasize that a pathologic fracture through an underlying bone lesion often may result in an incredibly confusing appearance on radiographs and magnetic resonance images. An otherwise benign-appearing lesion may seem more aggressive after a fracture, because of adjacent periosteal reaction and soft-tissue edema. Referral of such patients to an orthopedic oncologist for follow-up or fixation, in our opinion, may be appropriate.
Finally, we do not wish to imply that all bone and soft-tissue lesions should be confidently diagnosed as either benign or malignant; frequently, they cannot be so diagnosed. As Dr Bancroft has affirmed, patient care is always the primary concern. As radiologists at a tertiary care center, we readily offer our expertise so that patients may be comforted and cared for in the appropriate manner.
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