piya kiatisevi 1, torsten nielsen 2, malcolm hayes 2, peter l munk 3, amy e lafrance 4, paul w...
TRANSCRIPT
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Piya Kiatisevi1, Torsten Nielsen2, Malcolm Hayes2, Peter L Munk3, Amy E LaFrance4, Paul W Clarkson4,
Bassam A Masri4
1Orthopaedic Oncology Lerdsin Hospital, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand2Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
3Department of Radiology, University of British Columbia, Vancouver, BC, Canada 4Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
Saturday, November 15, 2008
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Background
Open biopsy is the historical gold standard for diagnosing bone and soft-tissue lesions
Highly accurate 16% complication rate 12% treatment altered 1.2% unnecessary amputation
Mankin et al., J Bone Joint Surg Am. 1996;78(5):656-663
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Core Needle Biopsy (CNB)
Increasingly accepted for the diagnosis of bone and soft-tissue lesions
Reduced morbidity, time and cost Fewer complications
Concerns remain regarding accuracy of CNB
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Objectives
To assess and compare : Core Needle Biopsy (CNB) Open Biopsy (OB) Fine Needle Aspiration (FNA)
Diagnostic rate
Accuracy for Distinguishing benign vs. malignant Histological diagnosis Distinguishing low vs. high grade sarcoma
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Materials and Methods
Prospectively collected database 286 biopsies in 282 patients 2004-2007 165 males, 117 females Mean age 51 yrs (range 16-92 yrs)
Biopsy compared to final pathology
Included biopsies performed prior to referral but slides were re-reviewed by an experienced MSK pathologist
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Our Practice
Patients are assessed in MSK surgical clinic Site for CNB is marked with indelible marker Image-guided biopsy performed by radiologist
within pre-marked biopsy site 10mm biopsy incision so site is identifiable for
definitive resection
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Our Practice
If core needle biopsy is non-diagnostic, then proceed with open biopsy
Biopsy track excised en bloc with tumour during definitive resection
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229 CNB
32 OB
25 FNA
286 biopsies
Biopsy Types
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Tumour type Bone Soft-tissue Total
Benign tumours 29 90 119
Sarcomas 18 117 135
Non-sarcoma malignancies
8 12 20
Tumour-like lesions 1 11 12
Total 56 230 286
Types of Lesions
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ResultsResults
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Diagnostic Rate
92% 100% 72%
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Non-diagnostic SpecimensNon-diagnostic Specimens
Benign Malignant
Bone (B) 6 4
Soft-tissue (ST)
7 1
CNB (18/229 = 8%)
Benign Malignant
Bone (B) 0 0
Soft-tissue (ST)
6 1
FNA (7/25 = 28%)
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Accuracy for Distinguishing Benign vs. Malignant
Accuracy 89% 97% 68%
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Benign (at biopsy) Malignant (final pathology)
CNB (n=229)6 Benign lipomatous tumour Well-differentiated liposarcoma
(ST)
1 Fracture healing Adenocarcinoma metastasis (B)
OB (n=32)1 Leiomyoma Leiomyosarcoma (ST)
FNA (n=25)1 Mature fat Well-differentiated liposarcoma (ST)
Incorrect Diagnosis of Benign vs. Malignant
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Malignant (at biopsy) Benign (final pathology)
CNB (n=229)1 Lymphoma of ilium Osteomyelitis (B)
OB (n=32)0
FNA (n=25)0
Incorrect Diagnosis of Benign vs. Malignant
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Accuracy for Histological Subtype
Accuracy 70% 81% 40%
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Type Bone Soft-tissue Total
Benign tumors 29 90 119
Sarcoma 18 117 135
Non-sarcoma malignancy
8 12 20
Tumour-like lesions 1 11 12
Total 56 230 286
Accuracy for Distinguishing Low vs. High Grade Sarcoma
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Accuracy for Distinguishing Low vs. High Grade Sarcoma
Accuracy 90% 96% 72%
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Low grade (at biopsy) High grade (final pathology)CNB (n=92)
3
OB (n=24)
0
FNA (n=10)
2
High grade (at biopsy) Low grade (final pathology)None
1 Osteosarcoma (B)1 Liposarcoma (ST)1 Ossifying fibromyxoid tumour (ST)
1 De-diff. Chondrosarcoma (B)1 Myofibroblastic sarcoma (ST)
Incorrect Diagnosis of Low vs. High Grade Sarcoma
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Type nDiagnostic
Rate
Accuracy for benign vs. malignant
Accuracy for histological diagnosis
Accuracy for low vs. high
grade sarcoma
CNB 229 92% 203/229 (89%) 161/229 (70%) 89/99 (90%)
OB 32 100% 31/32 (97%) 26/32 (81%) 24/25 (96%)
FNA 25 72% 17/25 (68%) 10/25 (40%) 8/11 (72%)
Discussion
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Discussion
Perform CNB with care on fatty lesions
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Conclusion
Core needle biopsy is accurate for determining: Benign vs. malignant Histological subtype Low vs. high grade for sarcoma
Advantages of core needle biopsy Fewer complications Reduced cost of treatment High diagnostic accuracy
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Recommendations
CNB be used routinely for diagnosis, whenever possible
Open biopsy reserved for use when CNB is non-diagnostic
Given its high inaccuracy, FNA is not indicated for diagnosing musculoskeletal lesions in the extremities
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Thank you
Orthopaedic Oncology Lerdsin Hospital, Bangkok, Thailand
The University of British Columbia, Vancouver, BC, Canada
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TypeCNB (N= 229)
OB (N=32)
FNA (N=25)
Benign bone tumours 5 - -
Malignant bone tumours 2 - -
Benign soft-tissue tumours 5 - 6
Malignant soft-tissue tumours 1 - 1
Carcinoma and myeloma 2 - -
Tumour-like lesions 3 - -
Total 18 - 7
Non-diagnostic rate 8% 0% 28%
Diagnostic rate 92% 100% 72%
Non-diagnostic Specimens