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The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions Cover

The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions

Journal of Ultrasonography
Volume 21 (2021): Issue 84 (January 2021)
By: Paweł Szaro,  Andrew Wong,  Elena Blain,  Khaldun Ghali Gataa and  Mats Geijer  
Open Access
|Mar 2021

Figures & Tables

Fig. 1.

Flowchart: inclusion and exclusion criteria for the study
Flowchart: inclusion and exclusion criteria for the study

Fig. 2.

A 56-year-old patient presented to the emergency room because of pain in the thorax and clonus in the foot. An acute MRI of the whole spine revealed an about 10 cm long tumor ( A–C ; straight arrows – tumor). CT showed no calcifications ( D ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. US-CNB was performed ( E, F ; dashed arrows – biopsy needle). A histopathological diagnosis of chondrosarcoma was confirmed after excisional biopsy
A 56-year-old patient presented to the emergency room because of pain in the thorax and clonus in the foot. An acute MRI of the whole spine revealed an about 10 cm long tumor ( A–C ; straight arrows – tumor). CT showed no calcifications ( D ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. US-CNB was performed ( E, F ; dashed arrows – biopsy needle). A histopathological diagnosis of chondrosarcoma was confirmed after excisional biopsy

Fig. 3.

A 58-year-old patient presented to the emergency room with left-sided abdominal pain. Imaging revealed an about 17 cm long solid tumor (straight arrows) in the left retroperitoneal space. MRI showed solid and necrotic parts ( A, B ; curved arrow – solid parts). CT showed the solid tumor in the retroperitoneal space on the left side ( C ). The patient was referred for US-CNB with suspected liposarcoma. A coaxial US-CNB was performed ( D, E ). The pathological diagnosis was liposarcoma grade 1
A 58-year-old patient presented to the emergency room with left-sided abdominal pain. Imaging revealed an about 17 cm long solid tumor (straight arrows) in the left retroperitoneal space. MRI showed solid and necrotic parts ( A, B ; curved arrow – solid parts). CT showed the solid tumor in the retroperitoneal space on the left side ( C ). The patient was referred for US-CNB with suspected liposarcoma. A coaxial US-CNB was performed ( D, E ). The pathological diagnosis was liposarcoma grade 1

Fig. 4.

An 81-year-old patient who three years previously had been operated for an extraskeletal myxoid chondrosarcoma. For the last four months the patient experienced swelling in the operated area, leading to a suspicion of tumor recurrence. MRI ( A, B ) showed an abnormality in direct relation to the right femoral artery and vein. The patient was referred for US-CNB ( C–E ). The ultrasound examination revealed a hypoechogenic and vascularized mass. The histopathological diagnosis was inflammation. CT with intravenous contrast performed 2 months after the biopsy showed a fistula lateral to the femoral artery and vein, with an abscess on the medial side, calcifications and gas ( F ; asterisks – fistula, curved arrow – lesion)
An 81-year-old patient who three years previously had been operated for an extraskeletal myxoid chondrosarcoma. For the last four months the patient experienced swelling in the operated area, leading to a suspicion of tumor recurrence. MRI ( A, B ) showed an abnormality in direct relation to the right femoral artery and vein. The patient was referred for US-CNB ( C–E ). The ultrasound examination revealed a hypoechogenic and vascularized mass. The histopathological diagnosis was inflammation. CT with intravenous contrast performed 2 months after the biopsy showed a fistula lateral to the femoral artery and vein, with an abscess on the medial side, calcifications and gas ( F ; asterisks – fistula, curved arrow – lesion)

Fig. 5.

A 22-year-old patient presenting with knee pain. Radiography ( A, B ) showed no abnormality. The patient was referred for MRI, which revealed an uncalcified solid contrast-enhancing lesion ( C–E ; straight arrow – lesion) in the Hoffa fat pad. Localized nodular synovitis was suspected. Because of pain, the patient was referred for US-CNB ( F, G ; dashed arrow – biopsy needle, curved arrow – patellar tendon, P – patella, T – tibia). The pathological diagnosis was lipoma arborescens
A 22-year-old patient presenting with knee pain. Radiography ( A, B ) showed no abnormality. The patient was referred for MRI, which revealed an uncalcified solid contrast-enhancing lesion ( C–E ; straight arrow – lesion) in the Hoffa fat pad. Localized nodular synovitis was suspected. Because of pain, the patient was referred for US-CNB ( F, G ; dashed arrow – biopsy needle, curved arrow – patellar tendon, P – patella, T – tibia). The pathological diagnosis was lipoma arborescens

Fig. 6.

A 32-year-old patient presented with a painful mass in the popliteal fossa. MRI revealed an intramuscular tumor ( A–C ; straight arrow – tumor). Ultrasound showed a large hypoechoic mass ( D ). After suspicion of neurogenic tumor, the patient was referred for US-CNB ( E, F ; curved arrows – posterior surface of the tibia, dashed arrows – biopsy needle). The histopathological diagnosis was neuroma
A 32-year-old patient presented with a painful mass in the popliteal fossa. MRI revealed an intramuscular tumor ( A–C ; straight arrow – tumor). Ultrasound showed a large hypoechoic mass ( D ). After suspicion of neurogenic tumor, the patient was referred for US-CNB ( E, F ; curved arrows – posterior surface of the tibia, dashed arrows – biopsy needle). The histopathological diagnosis was neuroma

Fig. 7.

A 70-year-old patient with a history of malignant melanoma operated 3 years before presented with pain in the abdomen and right buttock. CT with intravenous contrast in the portal venous phase showed an intramuscular contrast-enhancing mass on the right ( A ; straight arrow – mass). MRI of the pelvis with intravenous contrast showed a solid contrast-enhancing tumor in the gluteal muscles ( B–E ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. The patient was referred for US-CNB ( F, G ; dashed arrows – biopsy needle, curved arrow – iliac bone). The histopathological diagnosis was extrapleural solitary fibrous tumor
A 70-year-old patient with a history of malignant melanoma operated 3 years before presented with pain in the abdomen and right buttock. CT with intravenous contrast in the portal venous phase showed an intramuscular contrast-enhancing mass on the right ( A ; straight arrow – mass). MRI of the pelvis with intravenous contrast showed a solid contrast-enhancing tumor in the gluteal muscles ( B–E ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. The patient was referred for US-CNB ( F, G ; dashed arrows – biopsy needle, curved arrow – iliac bone). The histopathological diagnosis was extrapleural solitary fibrous tumor

Fig. 8.

A 28-year-old patient presented with a chronically swollen trochanteric region and more discomfort during the last weeks. There was a clinical suspicion of greater trochanteric bursitis. The patient was referred for MRI, where a solid lesion, not bursitis, in close relation to the greater trochanter, was detected ( A ; straight arrow – lesion). After intravenous contrast administration ( B, C ) there was vivid contrast enhancement. No muscle atrophy was visible. The MRI was unspecific, with a wide spectrum of lesions in the differential diagnosis. The patient was referred for US-CNB ( D–F ; curved arrows –greater trochanter, dashed arrow – biopsy needle). A histopathological diagnosis of a benign lesion, with a suspicion of vascular malformation, was made, and the patient was referred for intravascular treatment ( G ; red dashed curved arrow – catheter) which produced a good effect
A 28-year-old patient presented with a chronically swollen trochanteric region and more discomfort during the last weeks. There was a clinical suspicion of greater trochanteric bursitis. The patient was referred for MRI, where a solid lesion, not bursitis, in close relation to the greater trochanter, was detected ( A ; straight arrow – lesion). After intravenous contrast administration ( B, C ) there was vivid contrast enhancement. No muscle atrophy was visible. The MRI was unspecific, with a wide spectrum of lesions in the differential diagnosis. The patient was referred for US-CNB ( D–F ; curved arrows –greater trochanter, dashed arrow – biopsy needle). A histopathological diagnosis of a benign lesion, with a suspicion of vascular malformation, was made, and the patient was referred for intravascular treatment ( G ; red dashed curved arrow – catheter) which produced a good effect

Fig. 9.

An 83-year-old patient with pain in the left buttock and leg. MRI of the pelvis with intravenous contrast revealed a tumor in the greater sciatic foramen ( A–C ; straight arrow – tumor, curved arrow – sciatic nerve). The MRI was unspecific; however, a diagnosis of malignant peripheral nerve sheath tumor was made because of the tumor’s direct relation to the sciatic nerve. The patient was referred for US-CNB ( D–F ; dashed arrows – biopsy needle). No histopathological diagnosis could be made. The patient was referred once again for US-CNB, where the histopathological diagnosis of benign peripheral nerve sheath tumor was made and confirmed after excisional biopsy
An 83-year-old patient with pain in the left buttock and leg. MRI of the pelvis with intravenous contrast revealed a tumor in the greater sciatic foramen ( A–C ; straight arrow – tumor, curved arrow – sciatic nerve). The MRI was unspecific; however, a diagnosis of malignant peripheral nerve sheath tumor was made because of the tumor’s direct relation to the sciatic nerve. The patient was referred for US-CNB ( D–F ; dashed arrows – biopsy needle). No histopathological diagnosis could be made. The patient was referred once again for US-CNB, where the histopathological diagnosis of benign peripheral nerve sheath tumor was made and confirmed after excisional biopsy

Fig. 10.

A 20-year-old football player with pain in the thoracic spine. The patient was referred for spinal MRI, where a solid tumor with calcifications was revealed on the left side of Th12 ( A–C, E ; straight arrow – tumor). CT without intravenous contrast ( D, F ) showed calcifications both in the center and periphery of the lesion, which in combination with the patient’s pain was worrisome. The differential diagnosis included myositis ossificans, osteosarcoma, and osteoblastoma. US-CNB was performed ( G–I ; dashed arrows – biopsy needle). The final histopathological diagnosis of osteoblastoma was made on a repeated US-CNB
A 20-year-old football player with pain in the thoracic spine. The patient was referred for spinal MRI, where a solid tumor with calcifications was revealed on the left side of Th12 ( A–C, E ; straight arrow – tumor). CT without intravenous contrast ( D, F ) showed calcifications both in the center and periphery of the lesion, which in combination with the patient’s pain was worrisome. The differential diagnosis included myositis ossificans, osteosarcoma, and osteoblastoma. US-CNB was performed ( G–I ; dashed arrows – biopsy needle). The final histopathological diagnosis of osteoblastoma was made on a repeated US-CNB

Fig. 11.

A 41-year-old female presenting with pain at the left ischial tuberosity. MRI of the pelvis with intravenous contrast revealed a tumor, about 15 mm long, in relation to the left sciatic spine ( A–C ; curved arrow – tumor). MRI and CT were unspecific, with a wide spectrum of lesions in the differential diagnosis. US-CNB ( D, E ) was performed without a final histopathological diagnosis of a benign lesion. After a CT-guided biopsy ( F ) the final histopathological diagnosis was nodular fasciitis
A 41-year-old female presenting with pain at the left ischial tuberosity. MRI of the pelvis with intravenous contrast revealed a tumor, about 15 mm long, in relation to the left sciatic spine ( A–C ; curved arrow – tumor). MRI and CT were unspecific, with a wide spectrum of lesions in the differential diagnosis. US-CNB ( D, E ) was performed without a final histopathological diagnosis of a benign lesion. After a CT-guided biopsy ( F ) the final histopathological diagnosis was nodular fasciitis

Distribution of lesions in 73 ultrasound-guided core needle biopsies

Upper extremity26
Shoulder11
Upper arm7
Elbow3
Forearm5
Lower extremity35
Pelvis and hip13
Thigh12
Knee5
Lower leg4
Ankle1
Trunk12
Chest wall5
Abdominal wall and retroperitoneal space4
Paravertebral soft tissue3
Total73

Final diagnosis for 12 accurate biopsies

Final diagnosis for accurate biopsies in alphabetical order
Benign peripheral nerve sheath tumor (Fig. 9)
Endometriosis
Giant cell tumor
Metastatic chondroblastoma
Myositis ossificans
Nodular fasciitis (Fig. 11)
Osteoblastoma (Fig. 10)
Unclear case, malign tumor, probably low-grade myxofibrosarcoma,
[1 mitosis per 10 high power fields]
Benign, mesenchymal tissue, without atypia
Vascular malformation (Fig. 8), 2 patients
Well-differentiated liposarcoma

Final histopathology results in 73 ultrasound-guided core needle biopsies, ordered by quantity

Benign Malignant
Inflammation8Well-differentiated liposarcoma7
Lipoma6Chondrosarcoma2
Desmoid5Metastatic gastric cancer2
Vascular malformation4Metastatic malignant me-2
Intramuscular lipoma3Pleomorphic spindle cell sarcoma (high grade)2
Myxoma3Dedifferentiated liposarcoma1
Neurofibroma2Leiomyosarcoma1
Pigmented villonodular synovitis2Lymphoma1
Atheroma1Metastatic breast cancer1
Endometriosis1Metastatic chondroblastoma1
Fibroma1Metastatic lung cancer1
Giant cell tumor (CT)1Metastatic prostate cancer1
Hematoma1Metastatic squamous cell carcinoma1
Hibernoma1Myeloma/plasmocytoma1
Lipoma arborescens1Recurrent Ewing’s sarcoma1
Myositis ossificans (CT)1 n = 25
Nodular fasciitis (CT)1 Unclear
Osteomyelitis1Benign, mesenchymal tissue, without atypia1
Schwannoma1Malign, unclear case, probably low-grade myxofibro-sarcoma1
Solitary fibrous tumor1[1 mitosis per 10 high power fields]
Vascular hamartoma1 n = 2
n = 46 n = 73

Type of lesion and biopsy success in 73 ultrasound-guided core needle biopsies

BiopsyMalignant lesion n = 26Benign n =lesion 47Overall n = 73
n%n%n%
Diagnostic2388%3881%6184%
Accurate312%919%1216%
Inaccurate00%00%00%
Successful26100%47100%73100%

Differences between age, gender, tumor character, presence of fat and calcifications, volume and depth in accurate and diagnostic biopsies

Accurate Diagnostic p
Average age [years]4760
SDmin26.1818.2150.13
max7589
Male [n]%68.2%3142.5%0.96
Benign [n]%912.3%3852.1%0.35
Malign [n]%34.1%2331.5%0.28
Fat [n]%22.7%1317.8%0.44
Calcification [n]%34.1%34.1%0.27
Volume [cm3]154.227.8
SDmin494.70.364.00.02<0.001
max1724.8415.8
Depth [mm]12.89.7
SDmin7.647.810.18
max27.431.5
DOI: https://doi.org/10.15557/jou.2021.0004 | Journal eISSN: 2451-070X | Journal ISSN: 2084-8404
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Language: English
Page range: 22 - 33
Submitted on: Oct 21, 2020
|
Accepted on: Dec 17, 2020
|
Published on: Mar 8, 2021
Published by: MEDICAL COMMUNICATIONS Sp. z o.o.
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
ultrasound,
biopsy,
solid tumor,
musculoskeletal system,
diagnostic biopsy
Related subjects:
Medicine,
Basic medical science,
Basic medical science, other

© 2021 Paweł Szaro, Andrew Wong, Elena Blain, Khaldun Ghali Gataa, Mats Geijer, published by MEDICAL COMMUNICATIONS Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

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