Sometimes it is possible to perform a percutaneous needle biopsy of a suspected bony metastasis for histological confirmation of tumor when there is a soft-tissue mass or large lytic lesion in the bone. A computed tomographic (CT)-guided biopsy of a spine lesion is also possible on occasion. Nevertheless, there is always the possibility of a sampling error when the needle biopsy is nondiagnostic.
An open surgical biopsy may be needed when the staging and ultimate treatment recommendation hinge on the histological confirmation of osseous lesions. Localizing the precise area to biopsy intraoperatively is usually easy if
Figure 1 (a) Anterior view of scintigraphy of the entire skeleton of patient number 26 with adenocarcinoma of the lung. Asymptomatic areas of increased tracer activity (the dark areas on the ribs bilaterally in the image) are seen in the anterolateral area of the left 4th, 5th, and 6th ribs and the right 7th rib. (b) Coned down left anterior oblique view of just the thorax show the three ribs with increased tracer uptake. Plain rib detail radiographs of these suspected rib metastases were normal. The left 5th rib (arrow) was biopsied using gamma probe guidance. Benign hypercellularity and bone remodeling were found, probably from a healing fracture.
there are localizing symptoms and corresponding plain bone radiograph abnormalities, particularly when the target bone is a rib and the patient is thin. It is more challenging to find the correct area for biopsy in an obese or muscular patient, and it generally requires using a much larger incision and numerous intraoperative localizing radiographs. The real difficulty occurs when the asymptomatic patient with cancer has a bone scan with one or more abnormalities while the plain radiographs of the corresponding areas are normal. Most bone radiologists will report that the lesions depicted on the scintigraphy images in this setting probably represent metastatic disease . A typical example of this situation is found in Figure 1 which shows the images of an asymptomatic patient with known adenocarcinoma of the lung who had a screening bone scan and was found to have multiple lesions in the ribs but normal plain bone radiographs.
The scintigrams in Figure 1 were initially read as showing probable bone metastases, but this reading was proven incorrect with a subsequent open rib biopsy that showed benign bone remodeling. The commonly held belief that the presence of metastases is proven with a positive bone scan in this setting is frequently incorrect because of the high incidence of other lesions being visualized, ranging from 47-71% in various studies [3,8,11,12]. With such a high incidence of benign bone lesions accounting for the bone scan abnormalities, a comfirma-tory biopsy is a necessity. However, a needle biopsy is not feasible when only a bone scan serves as the guide.
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