In 1983, Little and colleagues developed a targeting technique to mark the proper rib and facilitate biopsy by the surgeon . 99mTc-diphosphonate is injected intravenously into the patient 6-12 h before the operation. Then, in the nuclear medicine department, the patient is positioned below the gamma camera to image the appropriate area. While the patient is imaged on the real-time scintiview screen, a radioactive point source is moved over the patient and simultaneously visualized. When the external point source overlaps the hot spot on the screen, the skin in that location is marked with indelible ink. After local anesthesia with lidocaine, a needle is inserted down to the rib in that area and a small amount of the tracer is injected to mark the hot spot deeper. The needle is left in place while the patient is repositioned and viewed from different angles under the gamma camera to be sure that the percutaneously injected tracer is superimposed over the bone scan abnormality. Several injections may be needed until the correct area is marked. Subsequently, methylene blue is injected into the same needle to stain the underlying periosteum and soft tissue up to the skin. The patient is then taken promptly to the surgery room for an open biopsy of the methylene blue-stained rib before the dye diffuses away.
Using the rib marking technique, Little and associates reported success in 15 patients with known cancer to enable them to biopsy 13 ribs, one skull, and one scapula . A pathological diagnosis was found in all patients, but only eight of 15 (53%) had metastatic cancer. The other patients had a variety of benign diagnoses, including hypercellular marrow (2), old rib fractures (2), Pag-et's disease, granuloma, and osteoporosis. This methylene-blue targeting technique appears to work in experienced hands but requires careful coordination of the nuclear medicine department and surgical schedule. That is, a surgery room should be immediately available to accept the rib biopsy patient for surgery so that the blue dye does not have time to diffuse to other ribs. The surgeon performing only an occasional bone biopsy guided by this technique might find it difficult to duplicate the excellent results of Little and colleagues.
Moores and colleagues published a later series of 33 bone biopsies using the methylene-blue technique in 1990 . A histological abnormality was found in 97% of their biopsies, but only 52% of the total had metastatic cancer in the bone. Their false positive rate of 48% was very similar to that of Little and colleagues . In the 17 patients with an abnormal bone scan but normal plain bone radiographs, the false positive rate was even higher at 71%.
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