0:00

So let's talk about bone biopsies some very procedural and

0:03

procedural steps.

0:04

So it's important to prepare for the procedure preparation is

0:07

never wasted. So let's understand the informed consent.

0:10

So anytime we perform any procedure on

0:13

an individual. It's important to understand how we discuss the

0:16

risk the benefits of the procedure how we

0:19

discuss the Alternatives and more importantly theft

0:22

forgotten one the contingencies what

0:25

happens if something goes wrong do we have the appropriate risk

0:28

mitigation equipment in the room to prevent untoward

0:31

event. And if the underwater then occurs, what

0:34

are we going to do about it? The patient deserves snow and that's

0:37

all a part of the informed consent process and specific to

0:40

this setting the risk of biopsy and

0:43

Bone lesions. It's the risk of bleeding and infection. So

0:46

what we also want to know is we want to know how at

0:49

risk the patient is for leading.

0:52

We know that in part by the coagulation panel, of

0:55

course the pet and INR important as is

0:58

the PTT, which is not really something we typically get but platelets

1:01

absolutely greater than

1:04

75,000 or less than 75,000 greater

1:07

than 50,000 or less than fifty thousand. We

1:10

don't want low plated levels. We also want to know whether or not

1:13

the patient is coagulopathic from the standpoint of

1:16

liver disease in which case maybe a fibrinogen maybe

1:19

something of note. If the patient is thought of low fibergen

1:22

again last in 150 or 100 or if the

1:25

patient has a high blood urine nitrogen some individuals

1:28

may want to consider getting decimal person

1:31

in order to mitigate that you remix related

1:34

plate that dysfunction in this particular setting.

1:37

When there are other agents being taken other agents

1:40

being anticoagulation or anti-platelet agents.

1:43

It's important to know that these are on board because there's often

1:46

a recommended stop time for these

1:49

agents in order to ensure that they're Half-Life is

1:52

taken into consideration so that they don't have enough in

1:55

the bloodstream in order to provoke bleeding

1:58

or exacerbate bleeding post biopsy in

2:01

the case of anti-platelets such as aspirin usually five seven

2:04

days prior to procedure. They're stopped the case

2:07

of Coumadin five days or in some cases seven days

2:10

when it comes to heparin

2:12

The party line is usually two hours some individuals hold

2:15

it for four hours heparently usually having a half life of two hours

2:18

and it comes to some handsets individuals may stop

2:21

this for three days prior to the procedure just from

2:24

the standpoint of its conservative as possible. These

2:27

are some of the stoppage times. The second

2:30

thing that we really want to consider is what is

2:33

the route we talked about intervening structures, whether they

2:36

be blood vessels nerves or other

2:39

parts of the anatomy, but all

2:42

is something that we always want to consider, but we want to find the shortest

2:46

path.

2:47

To the site in question. So if there are

2:50

multiple lesions, we have a choice we can choose which

2:53

one's the most accessible one we want

2:56

to understand if we had a pet scan. For example,

2:59

are there lesions that actually are fdg active?

3:02

Whereas those that are not

3:05

in which case we probably want to one those that are

3:08

actually hot on Pat the ones that are metabolically

3:11

active because those gonna be the ones that are gonna give us the

3:14

higher diagnostic yield. We certainly don't want to perhaps see

3:17

necrotic sites which are dead tissue because we

3:20

may have to repeat the biopsy again. So again junk of information such

3:23

as what's metabolically active IE using

3:26

a pet for example in certain settings, maybe particularly helpful

3:29

to avoid a patient having a repeat biopsy because

3:32

a non-diagetical sample was obtained from a

3:35

lesion that was not mad about the active to begin with.

3:37

We also want to consider that many bone tumors

3:40

may actually see the tract.

3:42

So why is that important that's important? Because sometimes more

3:46

often than not we need to make sure that orthopedic surgery is involved.

3:49

Sometimes the primary team is not orthopedic surgery

3:52

in which case we're being asked to biopsy by maybe

3:55

the Hematology Oncology service or maybe the

3:58

medicine service in which case we

4:01

go to biopsy this when in fact we are now traversing and seeding.

4:05

Cross a resection plane. So instead of having a

4:08

biopsy that is right in the compartment that

4:11

the orthopedic surgeon would have used to remove the

4:14

actual site. They then have to extend their

4:17

extension into another compartment because of the route that

4:20

we chose to take. So row planning is very important. And sometimes we need

4:23

to do this in collaboration with in communication with

4:26

our orthopedic surgery teams question for you

4:29

if possible, which region should not be Traverse

4:32

dream biopsy of a long bone region and a skeletally immature

4:35

patient. Is it the faces the metaphysis?

4:38

Is it Rebecca Le bone or is

4:41

it the epiphysis?

4:42

If you set the prices or the growth

4:45

plate.

4:46

You'll be correct. And reason being is because if you damage the

4:49

growth plate you could essentially affect a compromise

4:52

an individual's limb development in this particular

4:55

location. So very important to be very mindful

4:58

of the anatomic locations in the bone.

5:01

So let's talk about core needle biopsy in this particular setting. This

5:04

is the preferred option for primary bone tumors

5:07

given the preservation of the histologic.

5:10

structure of the tissue

5:12

so you want to keep in mind that there is that strong

5:15

recip bleeding within hypervascular bone tumors. We

5:18

talked about renal cell carcinoma being a source

5:21

of metastasis to the Bone very hypervascular tumor

5:24

when it is seen in the body. So

5:27

we want to be mindful of this particular case when possible

5:30

we also mean we use a small engage needle cutting needle

5:33

with a coaxial technique. So instead of using

5:36

a large 11 gauge or a 13-gauge bone

5:39

vaccine needle in the case of maybe in RCC

5:42

met to the Bone perhaps when you

5:45

only use an 18 gauge or 20 gauge side cutting

5:48

needle in this particular setting because it's soft tissue that's

5:51

prone to bleed just happens to be metastasized to

5:55

the Bone the preservation of histologic structure. The architecture

5:58

of the tissue is very important and that improves the

6:01

diagnosis of infection as well in addition

6:04

to cancer. So while I was going to be thinking about the use

6:07

of corn needle biopsies regardless of where suspecting infection

6:10

or malign,

6:13

Now when it comes to finally aspiration, it may be

6:16

suitable in certain situations where we want to confirm metastatic disease

6:19

or setting of tumor occurrence, but for

6:22

the most part, it's really unsuitable for primary diagnosis because

6:25

we will not get the appropriate amount of tissue needed and

6:28

one of the things that needs to be stated as

6:31

any time you employ finely aspiration finally aspirations

6:34

should be employed in the setting where a histopathologist A

6:38

cytologists or cytopathology Tech is

6:41

in the room so that you can then give that tissue to them directly in

6:44

the slide. They can identify whether or not you're in the

6:47

appropriate location.

6:48

And then if they need more to shoot, they will ask you for more

6:51

tissue we don't want to do is we don't want to do finding the

6:54

last operation. We think we're done. We let the patient leave the room send them

6:57

to the pathologist. They then say that they have inadequate tissue

7:00

and then we have to subject the patient to a second biopsy. What's

7:03

good about this FNA is that it's low risk

7:06

of bleeding per usual because of the higher gauge of

7:09

the needle I either smaller girth of the needle

7:12

So when it comes to pain biopsies.

7:15

technical consideration of course is route planning, but also

7:18

a very procedural consideration as the fact that an individual

7:21

may not actually be able to sort of really

7:24

Tolerate the biopsy because it can be painful.

7:27

So what do we do? We consider the sedation as

7:30

being particularly important factor in our

7:33

periposito considerations course Conscious Sedation

7:36

consists of using an anxiolytic a

7:39

sedative midazolam being a benzodiazepine for this

7:42

purpose along with fentano a pain. Med analgesic

7:45

Med, but in some situations as I

7:48

mentioned me may have an uncooperative patient that may require general anesthesia,

7:51

and it may be necessary in order to be technically successful.

7:54

We want to make sure that the patient if

7:57

they need to be still during the procedure they have enough sedation

8:00

to do so and sometimes conscious not enough.

8:03

Sometimes we have a corporative patient where a nerve blocked may

8:06

also be more appropriate whether that be in the hand or the foot and

8:09

so we want to think about these options in our armamentarium

8:12

as we move towards optimizing our biopsy. There

8:15

are certain tumor types such as neurogenic tumors

8:18

that are more susceptible to pain than others. So we want to keep these things

8:21

in mind the more we know the better we can serve

8:24

our patients and when possible we may want

8:27

to really consider the use of periostially administered

8:30

lidocaine when performing a biopsy because

8:33

that can also really reduce anesthesia Regional

8:36

to our intended trajectory.

8:39

So let's talk about accessing the lesion.

8:41

Of course when we're accessing the lesion during a CT guided

8:44

procedure, we have our Scout scan.

8:47

That helps us to map out and visualize the

8:50

biopsy path.

8:51

Here we have to the radar radiologist accessing a

8:54

spinal lesion. And what we have is a sterile Mallet

8:57

that's used to hammer our access needle

9:00

to the site in question. Once we've

9:03

chosen our route in this particular setting prior

9:06

to even get into this point. What we would have had

9:09

to do is to sterilize the overlying area with an

9:12

antiseptic. We would have had to drape the area

9:15

with four tile water and then we would have

9:18

had to obtain sterile CT control of our C2 philosophy

9:21

equipment. If that's what we're using in order to obtain our

9:24

images intra procedure what you can

9:27

see prior to this procedure which will evaluate in

9:30

a second is the use of anesthesia that dermal

9:33

anesthesia and that deeper very also anesthesia

9:36

using the one or two percent lidocaine that I

9:39

don't see needle actually maybe kept in place in the

9:42

purpose of keeping it in places to guide placement of the coaxial system,

9:45

which we see here.

9:47

When it comes to the system for penetrating the

9:50

born cortex, I'd actually varies depending on

9:53

operator preference and that could be using a drilled system

9:56

or a coaxial bone

9:59

access needle and a sterile

10:02

mallet.

10:04

It's also important to understand what are the sampling and

10:07

specimen preservation considerations?

10:09

So first of all, once we obtain coaxial

10:12

access the proceduralists, it's going

10:15

to take multiple samples. So in this particular case to

10:18

the right what we do see here is actually use

10:21

of a side cutting needle.

10:25

Which is actually the biopsy needle that's

10:28

Advanced through the coaxial introducer.

10:31

In this particular setting this would have been a softer

10:34

lesion such as a soft tissue lesion within

10:37

the bone which is why this particular technique would

10:40

have been used.

10:41

So let it components soft issue

10:44

components that are within bone are ones where you can actually

10:47

Advance a nice higher gauge or smaller needle

10:50

into the soft tissue or lytic

10:53

area in question and to take a nice safe sample that

10:56

soft tissue lesion can we can take multiple sites

10:59

in that region these tend to be more diagnostic

11:02

than sclerotic portions which are sort of the harder the

11:05

osteoblastic the more layered denser

11:08

bone where we need to use our bone biopsy

11:11

needle with either a mallet or our drill.

11:14

So when we think about corneal biopsy samples, they can be deposited into a

11:17

liquid medium. Some Pathologists can say when

11:20

it comes to concern for malignancy you

11:23

can place this directly into formalin in

11:26

many cases. You can place it into saline or

11:29

you can place it directly onto a nice saline moistened

11:32

telfa in a sterile cup

11:35

and then given to the pathologist for them to perform the analysis

11:38

on that night architecturally preserved

11:41

bone sample.

11:43

What you don't want to do is you don't want to play something

11:46

that is concerning for infection into

11:49

formalin because that's going to denature the sample.

11:52

Certainly you can have situations where

11:55

you suspect both infection as well as

11:58

formalin. And so when that is the case you want to

12:01

make sure that you take multiple samples one delivered

12:04

in formalin if that's your practice that your institution then

12:07

the other place in Saline sterily

12:10

on the table and then submitted for

12:13

microbiology culture sensitivity and Analysis.

12:17

There are sites that may actually not be fully solid

12:20

or soft tissue

12:23

in those particular sites. There may

12:26

be a little fluid area. Not just a Lucy

12:29

but actually fluid and if that's the case you may

12:32

actually want to sample those areas. Sometimes you

12:35

may not know that pre-precially and you place your needle and you get either

12:38

pass or some sort of material that sort

12:41

of liquid or fluid in nature back in which case you just aspirate

12:44

that put that into a sterile cup and then send that

12:47

on for both cytology analysis and or

12:50

microbiology analysis, depending on your suspicioning.

12:54

So let's talk about post procedural care.

12:57

So we typically perform cyclosure with a simple

13:00

bandage, you know, we're not performing excavation of

13:03

tissue to an open incision. We're

13:06

performing a percutaneous biopsy that usually

13:09

consists of two to three millimeter incision

13:12

in the Skin So bandage often suffices.

13:15

Now what's important for us to keep track

13:18

of is any signs of hematoma development

13:21

any swelling over the area any

13:24

signs of oozing leading at

13:27

that particular sign in the way we prevent that is

13:30

either by ensuring that we place our

13:33

fingers over the sight and apply manual

13:36

pressure for a few minutes usually two

13:39

three minutes after the procedure or

13:43

After performing the actual biopsy

13:46

some individuals depending

13:49

on what they had to cross in

13:52

order to get to the site. They may consider actually

13:55

embolize in the track. It's not as common as in solid

13:58

organ and other biopsies, but symbolization of

14:01

the track is a technique that could be employed. And so

14:04

we want to kind of keep that in mind.

14:07

After a procedure is performed. It's very important to observe

14:10

the patient in an area

14:13

where we are essentially monitoring them

14:16

on a regular basis. One of the things that is

14:19

of note is when we're performing biopsies of

14:22

the spine. Usually the patients are

14:24

Prone. So now when they're sort of

14:27

relaxing and this sort of post-procedural unit the recovery room,

14:30

they usually sitting up or laying down in which

14:33

case actually they're performing manual pressure themselves by them

14:36

laying on the site. So that actually ends up being a good thing. Of

14:39

course, if the patient had a biopsy through a

14:42

site that was more lateral in nature that may be

14:45

a little easier to see but we want to be mindful of where the site is

14:48

and the patient of course, we need them to

14:51

be mindful where it is so that if they feel anything and he

14:54

swelling any abnormal changes in the region where

14:57

we would have biopsy that they will alert us while we're observing them

15:00

to ensure that we can apply pressure immediately or

15:03

in some rare cases repeat a

15:06

CAT scan after the procedure if there's a concern for onto

15:09

some untoward consequence.