The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 10

Scientific Articles | October 01, 2007

Magnetic Resonance Imaging-Guided Percutaneous Biopsy of Musculoskeletal Lesions

John A. Carrino, MD, MPH¹; Bharti Khurana, MD²; John E. Ready, MD²; Stuart G. Silverman, MD²; Carl S. Winalski, MD³

¹ Section of Musculoskeletal Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5165, Baltimore, MD 21287. E-mail address: jcarrin2@jhmi.edu
² Departments of Radiology (B.K. and S.G.S.) and Orthopedic Surgery (J.E.R.), Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
³ Department of Diagnostic Radiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Oct 01;89(10):2179-2187. doi: 10.2106/JBJS.F.01230

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Abstract

Background: Bone, soft-tissue, and articular lesions are often well visualized by magnetic resonance imaging. Our goal was to evaluate the diagnostic performance of magnetic resonance imaging-guided biopsies of selected musculoskeletal lesions.

Methods: In this retrospective case series, forty-five consecutive biopsies were performed in an open mid-field 0.5-T interventional magnetic resonance imaging unit with a real-time guidance system. The biopsies were performed at twenty bone, eighteen extra-articular soft-tissue, and seven intra-articular soft-tissue sites. The main reasons for using magnetic resonance imaging guidance were the need to improve lesion conspicuity compared with that provided by other imaging modalities, the need for site-specific targeting within the lesion, and the need for real-time guidance. Samples were obtained with fine-needle aspiration, core-needle biopsy, or a combination of these techniques. An independent reference standard was used to confirm the final diagnosis. Diagnostic performance was evaluated on the basis of the diagnostic yield (the proportion of biopsies yielding sufficient material for pathological evaluation) and diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value). Complications were identified as well.

Results: The diagnostic yield was 91% (forty-one of forty-five biopsies yielded sufficient material for a diagnosis) overall, 95% (nineteen of twenty) for the bone lesions, 94% (seventeen of eighteen) for the extra-articular soft-tissue lesions, and 71% (five of seven) for the intra-articular soft-tissue lesions. With regard to the diagnostic accuracy, the sensitivity was 0.86, the specificity was 1.00, the positive predictive value was 1.00, and the negative predictive value was 0.76 in the overall group. The respective values were 0.92, 1.00, 1.00, and 0.86 for the bone lesions; 0.77, 1.00, 1.00, and 0.57 for the extra-articular soft-tissue lesions; and 1.00, 1.00, 1.00, and 1.00 for the intra-articular soft-tissue lesions. There was one complication: exacerbation of neuropathic pain related to a biopsy of a peripheral nerve sheath tumor.

Conclusions: Magnetic resonance imaging-guided percutaneous biopsies of musculoskeletal lesions for which other imaging modalities might be inadequate have a good diagnostic performance overall. The performance can be very good for bone lesions, moderate for extra-articular soft-tissue lesions, and fair for intra-articular soft-tissue lesions.

Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Percutaneous biopsy is often a key step in the diagnosis of neoplastic, infectious, and tumor-like musculoskeletal lesions. Percutaneous biopsy of neoplasms facilitates accurate grading, staging, and treatment planning. Open surgical biopsies have been the traditional standard for obtaining adequate and representative samples of tissue for the diagnosis of musculoskeletal lesions. Image-guided percutaneous coreneedle biopsy and fine-needle aspiration have become useful alternatives. Fluoroscopy, ultrasound, and computed tomography have been the primary imaging modalities used for guidance of percutaneous interventional procedures, but each can be limited by poor visualization of the lesion or other modality-specific constraints. Magnetic resonance imaging provides superb detection of most musculoskeletal lesions, including those that cannot be identified with other imaging techniques. Open interventional magnetic resonance imaging systems combine the ability to obtain interactive access similar to that possible with ultrasound guidance while providing visualization of osseous structures similar to that possible with computed tomography guidance¹.

Limited access to the patient in high-field, closed-bore magnetic resonance imaging systems has prevented the widespread use of magnetic resonance imaging to guide biopsies. Open-configuration magnetic resonance imaging systems provide much better access to the patient for interventional procedures¹. Prior reports^2-9 describing magnetic resonance imaging guidance for musculoskeletal biopsies focused on proof of concept without providing magnetic resonance imaging-specific indications and clinical context. Our hypothesis was that magnetic resonance imaging guidance could serve as a niche modality for biopsies that might otherwise be difficult. The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging guidance used for percutaneous biopsy of musculoskeletal lesions.

Difficult cases suited for magnetic resonance imaging-guided biopsy include lesions that can be visualized only with magnetic resonance imaging or are adjacent to critical structures and are thus better visualized with magnetic resonance imaging to gain access, lesions requiring site-specific targeting (e.g., heterogeneous lesions in which the internal composition is best depicted by magnetic resonance imaging), and lesions in locations where real-time guidance is preferred (superficial lesions or lesions near critical structures such as major neurovascular bundles) and for which ultrasonography or fluoroscopy is not suitable. Intra-articular locations represent a unique group for which lesion conspicuity and real-time guidance are both important issues. Thus, this investigation focused on a small subset of the musculoskeletal lesions that might be encountered in clinical practice.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

The Human Research Office Investigational Review Board approved this study. A radiologist who was experienced with interventional magnetic resonance imaging performed all needle biopsies in consultation with an experienced orthopaedic surgical oncologist (J.E.R.) as recommended by the Musculoskeletal Tumor Society^10,11.

Subject and Lesion Characteristics

We performed a retrospective study of the results of forty-five consecutive magnetic resonance imaging-guided musculoskeletal biopsies performed at our institution over a nine-year period from July 1, 1994, to August 31, 2003. During the same time-period at our institution, 685 image-guided biopsies of musculoskeletal lesions were done with computed tomography, 109 were done with ultrasonography, and seven were performed with fluoroscopy. The ages of the subjects included in the study ranged from fifteen to seventy-eight years (mean, 50.3 years); twenty-one patients were male, and twenty-four were female. The biopsies were stratified into three subgroups—bone (twenty), extra-articular soft tissue (eighteen), and intra-articular soft tissue (seven)—because there are differences among these lesions with respect to needle biopsy technique and pathological evaluation. Six bone lesions were located in the ilium; six, in the humerus; five, in a vertebra; two, in the femur; and one, in the tibia. The maximum dimension of the bone lesions ranged from 0.7 to 4.0 cm, with a mean of 2.8 cm. Eleven extra-articular soft-tissue lesions were located in the thigh; three, in the calf; two, in the pelvis; one, in the arm; and one, in the hand. The maximum dimension of those lesions ranged from 1.8 to 14 cm, with a mean of 4.3 cm. Five intra-articular soft-tissue lesions were in the knee, one was in the hip, and one was in the ankle.

Indications for Magnetic Resonance Imaging Guidance

The main reasons for using magnetic resonance imaging guidance were the need to improve lesion conspicuity compared with that provided by other modalities, the need for site-specific targeting within the lesion, and the need for realtime guidance. The indications for use of magnetic resonance imaging for the bone lesions included the need to produce superior tissue contrast for a lesion that could not be adequately visualized with computed tomography imaging (nine cases), with one case related to streak artifacts limiting the use of computed tomography to localize a lesion adjacent to an intramedullary rod; the need for real-time guidance for targeting a lesion where thin superficial tissues would have made it more difficult for the needle to remain firmly situated while the patient was moved in and out of a computed tomography scanner (five cases); the need for selective targeting to sample a specific portion of a heterogeneous lesion (three); avoidance of ionizing radiation (one); and a biopsy immediately preceding magnetic resonance imaging-guided cryoablation of a tumor (two). The indications for the extra-articular soft-tissue lesions included the need to provide lesion conspicuity that was superior to that provided by ultrasound and/or computed tomography in eight cases, with five of those cases representing an abnormality detected by surveillance magnetic resonance imaging in a patient who had undergone a resection of a sarcoma and one case related to severe streak artifacts limiting the use of computed tomography for localizing a lesion adjacent to an intramedullary rod. The other indications for the extra-articular soft-tissue lesions were a failed (nondiagnostic) ultrasound-guided biopsy (five cases) and the need for site-specific targeting (five). The indications for the intra-articular soft-tissue lesions were a primary diagnosis of a proliferative synovial process (four cases), the need to rule out recurrent pigmented villonodular synovitis (one), and an atypical-appearing ganglion (two). The majority of those cases were referred primarily for a magnetic resonance imaging-guided biopsy because of the intra-articular location of the lesion, and one was referred after a computed tomography-guided biopsy was nondiagnostic.

Magnetic Resonance Imaging Interventional System

All procedures were performed with use of a 0.5-T open-configuration magnetic resonance imaging system (SIGNA SP; GE Healthcare, Waukesha, Wisconsin). The magnetic resonance imaging system has two toroidal magnet components separated by a 56-cm-wide vertically oriented opening providing access to the anatomy being imaged. During procedures, imaging is performed with use of a set of flexible, transmitreceive radiofrequency coils that have openings allowing placement of biopsy devices¹².

Biopsy Procedure

Patient Preparation

The patient and a flexible surface coil were positioned such that the entry point and the lesion were within the imaging field with the lesion as close to the magnet isocenter as possible. General anesthesia was used for five subjects, spinal anesthesia was used for one pregnant patient, intravenous conscious sedation was used for twenty-six patients, and local anesthesia only was used for thirteen patients. A sterile field, including sterile draping of the coil and the side walls of the magnet, was used. Local anesthesia (1% to 2% lidocaine for skin and subcutaneous infiltration and 0.25% bupivacaine for deep or periosteal infiltration) was administered in all cases.

Prospective Planning

Pre-intervention imaging was performed in two or three orthogonal planes prior to needle placement to determine the best needle approach and to optimize the pulse sequences for lesion visibility. Intravenous gadolinium-based contrast material was used when the operator thought that contrast enhancement might improve lesion visualization or identify more vascular portions of the lesion that might produce a better diagnostic yield. Intravenous gadopentetate dimeglumine (Magnevist; 0.1 mmol/kg of body weight) was used in four subjects (one bone lesion, two extra-articular soft-tissue lesions, and one intra-articular soft-tissue lesion).

Guidance Methods

The guidance method, which was chosen by the operator, consisted of externally referenced frameless stereotaxy with use of optical tracking (twenty-one lesions) or self-referencing with use of anatomical landmarks (twenty-four lesions). Accordingly, the biopsies were performed with use of an interactive or sequential imaging mode.

The interactive mode was performed with an externally referenced needle-guidance method. This method involved use of an integrated optical tracking system (Pixsys 3000 Flashpoint Position Encoder; Image-Guided Technologies, Boulder, Colorado). The optical tracking is achieved with a needle-holder that has two flashing infrared light-emitting diodes that are detected by three sensors mounted within the magnet system. Using simple triangulation, the magnetic resonance imaging system console computer has continuous information about the tip position and angle of the instrument. Images can be generated on the basis of the position of the instrument tip in any image plane. Positioning the optically tracked tools and selecting the related image planes provide an interactive way to localize targets, define trajectories, and review alternative access routes. This results in one-step localization. Because the needle-holder is localized during the biopsy, the images are in the same plane as the needle and the target can be visualized continuously while the needle is advanced. In this interactive mode, the needle location and trajectory are visualized on images acquired in nearly real-time while the intervention is being performed. Interactive imaging involved use of a fast gradient-echo sequence (repetition time, 15.7 msec; echo time, 7.5 msec; flip angle, 30°; 256 × 128 matrix; section thickness, 10 mm) such that images were updated about every two seconds.

The sequential mode involved use of a self-referenced guidance method. With this method, a marker that was visible on magnetic resonance imaging (a vitamin-E capsule or the operator's finger) was placed over the lesion and near the anticipated entry site. The trajectory is calculated from the position of the target relative to the markers. With self-referenced guidance, sequential imaging between needle manipulations was used. For localization of needle placement, spoiled gradient-echo (repetition time, 120.0 msec; echo time, 6.6 msec; 256 × 128 matrix; one signal acquired; section thickness, 10 mm) or fast spin-echo (repetition time, 200 msec; echo time, 102 msec; 256 × 128 matrix; one signal acquired; section thickness, 5 mm) image acquisitions were used to generate images in a three or five-section mode. Each pulse sequence took thirty to sixty seconds to acquire images, during which time the needle could be manipulated because it generated motion artifact. A more rapid method involves using a fast gradient-echo sequence (repetition time, 14.1 msec; echo time, 6.6 msec; flip angle, 60°; 256 × 128 matrix) in a single-section mode in which an image is displayed approximately every two seconds, allowing quicker needle manipulation and confirmatory imaging. Oblique and double-oblique planes were used when needed.

Biopsy Technique and Needles

There was no specific protocol for performing a core-needle biopsy or a fine-needle aspiration or for obtaining a specific number of samples; these were determined by the operator at the time of the biopsy. The customary practice at our institution is to perform both a core-needle biopsy and a fine-needle aspiration whenever possible. Both procedures were performed for thirty-one lesions, only a core-needle biopsy was done for ten, and only a fine-needle aspiration was done for four. Therefore, there was a total of forty-one core-needle biopsies (for seventeen bone, seventeen extra-articular soft-tissue, and seven intra-articular soft-tissue lesions) and thirty-five fine-needle aspirations (for fourteen bone, fourteen extra-articular soft-tissue, and seven intra-articular soft-tissue lesions). Several types of commercially available magnetic resonance imaging-compatible needles were used in isolation or combination for each case.

Core-needle biopsy: For the twenty bone biopsies, cortical penetration was achieved by hand with use of a 3, 4, or 6-mm bone-penetration needle (Bone Biopsy set manual; In-vivo, Orlando, Florida). Power drills were not used. Multiple samples were then obtained coaxially. Initially a trephine was used for all twenty biopsies. The sample was then supplemented with use of a manual or semiautomatic side-cutting-needle biopsy gun (described below) in three cases and with a vacuum-assisted front-cutting needle (described below) in four cases because the initial sample quality and consistency had been noted to be insufficient by the radiologist performing the procedure. The core-needle-biopsy samples of the eighteen extra-articular soft-tissue lesions were obtained with one or a combination of three devices of various lengths: a 14, 16, or 18-gauge semiautomatic biopsy gun (MRI Devices, Schwerin, Germany), a 16 or 18-gauge biopsy gun (MRI BIO-GUN Automated Biopsy System; E-Z-EM, Lake Success, New York), or a 16-gauge vacuum-assisted front-cutting coring needle (Techna Cut Biopsy Needle; Manan Medical Products, Inc., Wheeling, Indiana). For deeply situated lesions, multiple biopsy samples were obtained through a single puncture site by using an introducer needle and a coaxial technique. The biopsy gun was used in all eighteen subjects, and the vacuum-assisted front-cutting coring needle was used in addition in five subjects because the quality of the initial small sample was not adequate. The biopsies of the seven intra-articular soft-tissue lesions were accomplished in a manner similar to that used at the extra-articular soft-tissue sites. A side-cutting needle (biopsy gun) was used in six subjects, and a vacuum-assisted front-cutting coring needle was used in one subject. Three to six biopsy specimens were routinely obtained and were sent in buffered formalin or saline solution for histological analysis.

Fine-needle aspiration: Fine-needle aspirations of bone, extra-articular soft-tissue, and intra-articular soft-tissue sites were typically accomplished coaxially by means of an introducer. In some soft-tissue areas that were superficial and in which it would have been difficult to maintain the introducer position, direct placement was performed. All fine-needle aspirations were performed with a cytotechnologist or cytopathologist present to prepare and review the retrieved sample to ensure the adequacy of its quality. Therefore, the number of passes varied (range, two to nine passes) as required for diagnosis. All thirty-five fine-needle aspirations involving bone, soft tissues, or articular sites were done with a 22-gauge magnetic resonance imaging-compatible Lufkin aspiration cytology biopsy needle (E-Z-EM) that was 5, 10, 15, or 20 cm long.

Pathological Analysis

Biopsy specimens were classified as diagnostic or nondiagnostic¹³. Diagnostic indicated that sufficient material had been obtained for a histopathological or cytological analysis to yield a diagnosis of a malignant or benign lesion. Nondiagnostic referred to cases with insufficient material for pathological or cytological analysis. All nondiagnostic cases underwent another diagnostic procedure. For each lesion, a surgical pathologist with experience diagnosing musculoskeletal lesions evaluated the histological features of the core-needle-biopsy samples and a cytopathologist with experience diagnosing musculoskeletal lesions evaluated the cytological features of the fine-needle-aspiration samples. The results of both the core-needle biopsies and the fine-needle aspirations were integrated into a summary pathological diagnosis.

Reference Standard

An independent reference standard was used for all cases except for twelve in which the magnetic resonance imaging-guided biopsy led to a definitive diagnosis of metastatic neoplasm or high-grade malignant tumor and treatment was instituted on the basis of that biopsy result. In the remaining cases, the reference standard consisted of pathological examination of specimens obtained at a subsequent surgical procedure (a biopsy or resection; eighteen cases) or with a subsequent repeat imaging-guided biopsy (one), or it consisted of follow-up imaging performed for at least six months (average ten months; range, six to twenty-four months), which showed no progression (fourteen cases). This information was integrated into the final diagnosis. The final diagnoses for the twenty bone lesions were metastasis (nine), normal marrow (three), fibrosis (three), lipoma (one), Paget disease (one), sarcoidosis (one), hemangioendothelioma (one), and infection (one). The final diagnoses for the extra-articular soft-tissue lesions were fibrosis (four, with no recurrent neoplasm), sarcoma (four, including two pleomorphic liposarcomas, one epithelioid sarcoma, and one myxosarcoma), a vascular lesion (three, including one vascular malformation, one intramuscular angioma, and one hemangioma), peripheral nerve sheath tumor (two), amyloid deposit (one), metastasis (one), myxoma (one), and infection (one). The final diagnoses for the seven intra-articular soft-tissue lesions were pigmented villonodular synovitis (one), synovial chondromatosis (one), normal (two, with no recurrence of pigmented villonodular synovitis), ganglion (one), nonspecific synovitis (one), and a malignant tumor (one undifferentiated round and spindle-cell neoplasm).

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Fig. 1-A: Figs. 1-A, 1-B, and 1-C A seventy-four-year-old woman with a femoral fracture after resection and radiation of a sarcoma in the thigh. Fig. 1A Pre-procedural computed tomography imaging showed a poorly defined soft-tissue mass anterior and posterior to an intramedullary rod that was partially obscured by streak artifact.

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Fig. 1-B: Intra-procedural contrast-enhanced fat-saturated T1-weighted fast spin-echo image showing an enhancing component only posteriorly (arrow). Thus, that area was targeted for the biopsy.

Complications

Complications were determined by reviewing the radiology and hospital information systems and clinic notes. Major complications were defined, according to the American College of Radiology guidelines for percutaneous biopsy¹⁴, as complications that result in admission to the hospital for therapy (for outpatient procedures), an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae, or death.

Statistical Analysis

The results were analyzed for the entire group overall and separately for each site subgroup (bone, extra-articular soft tissue, and intra-articular soft tissue). Diagnostic performance was assessed by determining diagnostic yield and diagnostic accuracy. Diagnostic yield was calculated by the formula: [number of diagnostic cases/total number of cases] × 100%, with the numerator equaling the number of interpretable samples and the denominator equaling the number of samples submitted for interpretation. (For this study, one biopsy procedure equals one sample obtained with a core-needle biopsy and one obtained with a fine-needle aspiration, when both procedures were done for a single lesion). Diagnostic accuracy was determined on the basis of the diagnostic cases, with the nondiagnostic cases excluded. Each diagnostic case was classified as either true-positive, true-negative, false-positive, or false-negative, and the sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

Diagnostic Performance

Asummary of the diagnostic performance is presented in Table I.

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TABLE I Diagnostic Performance of Magnetic Resonance Imaging-Guided Percutaneous Biopsies of Musculoskeletal Lesions (N = 45)

	No. of Biopsies										Positive Predictive Value	Negative Predictive Value
Site	Total	Non-Diagnostic	True-Positive	True-Negative	False-Positive	False-Negative	Sensitivity	Specificity
Bone	20	1	12	6	0	1	0.92	1.00	1.00	0.86
Extra-articular soft tissue	18	1	10	4	0	3	0.77	1.00	1.00	0.57
Intra-articular soft tissue	7	2	2	3	0	0	1.00	1.00	1.00	1.00
All sites	45	4	24	13	0	4	0.86	1.00	1.00	0.76

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TABLE I Diagnostic Performance of Magnetic Resonance Imaging-Guided Percutaneous Biopsies of Musculoskeletal Lesions (N = 45)

	No. of Biopsies										Positive Predictive Value	Negative Predictive Value
Site	Total	Non-Diagnostic	True-Positive	True-Negative	False-Positive	False-Negative	Sensitivity	Specificity
Bone	20	1	12	6	0	1	0.92	1.00	1.00	0.86
Extra-articular soft tissue	18	1	10	4	0	3	0.77	1.00	1.00	0.57
Intra-articular soft tissue	7	2	2	3	0	0	1.00	1.00	1.00	1.00
All sites	45	4	24	13	0	4	0.86	1.00	1.00	0.76

Diagnostic Yield

The diagnostic yield was 91% (forty-one of the forty-five biopsies yielded sufficient material for a diagnosis) overall, 95% (nineteen of twenty) for the bone lesions, 94% (seventeen of eighteen) for the extra-articular soft-tissue lesions, and 71% (five of seven) for the intra-articular soft-tissue lesions. In each nondiagnostic case, a subsequent procedure was performed to ascertain the diagnosis. In the nondiagnostic case at the bone site, analysis of specimens obtained with a subsequent surgical excision showed acute-on-chronic osteomyelitis. In the nondiagnostic case at the extra-articular soft-tissue site, analysis of specimens obtained with a subsequent surgical excision showed a hematoma. One intra-articular soft-tissue lesion (in the knee) for which the original biopsy was nondiagnostic was found to be villonodular synovitis when a subsequent biopsy was done during arthroscopy. The other nondiagnostic case at an intra-articular soft-tissue site was an incidental lesion in a hip joint that demonstrated imaging characteristics favoring a diagnosis of synovial chondromatosis. The patient declined to have surgery and a repeat biopsy but underwent surveillance imaging and clinical follow-up, which revealed no aggressive features of the lesion.

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Fig. 1-C: Intra-procedural axial T2-weighted fast spin-echo image showing a biopsy needle (arrow) within the lesion. Note that there is minimal artifact from the intramedullary rod. The biopsy showed recurrent myxofibrosarcoma, which was confirmed by analysis of specimens taken at the time of an above-the-knee amputation.

Diagnostic Accuracy

Calculation of the diagnostic accuracy for all forty-one lesions from which sufficient specimens had been obtained revealed a sensitivity of 0.86, a specificity of 1.00, a positive predictive value of 1.00, and a negative predictive value of 0.76. The respective values for the nineteen bone lesions from which sufficient specimens had been obtained were 0.92, 1.00, 1.00, and 0.86. There were twelve true-positive results (nine metastases, one hemangioendothelioma, one ossifying lipoma, and one case of Paget disease) and six true-negative results (three cases of fibrosis and three cases of normal bone). There were no false-positive results. There was one false-negative result; this was an iliac lesion in a patient with sarcoidosis from which the biopsy obtained only normal bone and bone marrow. The lesion subsequently increased in size from 2 to 3.5 cm and became visible on computed tomography imaging. A computed tomography-guided biopsy done eighteen months after the magnetic resonance imaging-guided biopsy showed noncaseating granulomas, confirming the diagnosis of sarcoidosis.

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Fig. 2-A and 2-B: Figs. 2-A through 2-D A twenty-four-year-old man presented with a two-month history of pain and fullness of the right knee. Pre-procedural sagittal T1-weighted conventional spin-echo (Fig. 2-A) and sagittal short tau inversion recovery (Fig. 2-B) images demonstrate a slightly heterogeneous lesion behind the posterior cruciate ligament (arrows).

Calculation of the diagnostic accuracy for the seventeen extra-articular soft-tissue lesions from which sufficient specimens had been obtained showed a sensitivity of 0.77, a specificity of 1.00, a positive predictive value of 1.00, and a negative predictive value of 0.57. There were ten true-positive results (two sarcomas, two recurrent sarcomas [Figs. 1-A, 1-B, and 1-C], one peripheral nerve sheath tumor, one myxoma, one angioma, one metastasis, one amyloid deposit, and one infection). In two extra-articular soft-tissue lesions for which a prior surgical biopsy had been considered either indeterminate (one case) or to show only a low-intermediate-grade sarcoma (the other case), magnetic resonance imaging-guided biopsy showed high-grade material and allowed the institution of appropriate therapy. There were four true-negative results (two cases of fibrosis at the postoperative site of a previous resection of a sarcoma, one case of cartilage metaplasia and fibrous tissue, and one case of chronic inflammation related to a reactive lymph node). There were no false-positive results. There were three false-negative results. In these cases, the biopsy specimens showed some normal tissue, fibrotic reaction, and inflammation but the final diagnoses established with a surgical excision or biopsy were a peripheral nerve sheath tumor, a soft-tissue hemangioma, and intramuscular vascular malformation.

With regard to the diagnostic accuracy for the five intraarticular soft-tissue lesions from which sufficient specimens had been obtained, the sensitivity was 1.00, the specificity was 1.00, the positive predictive value was 1.00, and the negative predictive value was 1.00. There were two true-positive results (one undifferentiated sarcoma [Figs. 2-A, 2-B, 2-C, 2-D] and one ganglion) and three true-negative results (two cases of normal tissue [no evidence of pigmented villonodular synovitis] and one case of nonspecific synovitis). There were no false-positive or false-negative results.

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Fig. 2-C and 2-D: Fig. 2-C An intra-procedural axial T2-weighted image shows the planned approach for the intra-articular soft-tissue biopsy with use of a self-referenced method with the operator's finger at the skin surface (arrow). Fig. 2-D Intra-procedural axial T2-weighted fast spin-echo image showing the needle at the margin of the lesion (arrow). The biopsy showed an undifferentiated round and spindle-cell neoplasm.

Complications

All lesions referred for biopsy were visible on the images obtained with the 0.5-T open-configuration interventional magnetic resonance imaging system. In all cases, a safe approach was possible with use of the magnetic resonance imaging guidance and the needle could be visualized on the images. There was one major complication: a patient experienced an exacerbation of neuropathic-type pain, with a new lancinating quality, during a soft-tissue biopsy of a peripheral nerve sheath tumor. This was managed conservatively with pain medication and amitriptyline hydrochloride (Elavil). The pain decreased substantially after forty-eight hours but did not completely resolve until the time of excision about three weeks later. There were no procedure-related major complications such as hemorrhage or vascular injuries. There was no documented tumor recurrence along any biopsy tract during the follow-up period. No infections resulted from the needle biopsies, and there was no complication related to the use of the magnetic resonance imaging system or to the magnetic environment.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

This study showed that magnetic resonance imaging-guided percutaneous biopsy of selected musculoskeletal lesions is safe and has favorable diagnostic performance characteristics. The overall accuracy of non-magnetic resonance imaging-guided musculoskeletal biopsies in reported case series has ranged from 50% to 96%^15-25. The variability of these results may be due to variations in sample size (the number of lesions biopsied), the spectrum of lesions (the study population), specimen types, and reference standard definitions. The results in our series were similar or superior to those in the above investigations. In particular, they were similar to those of Carrasco et al.²⁰, who reported that the diagnostic accuracy was generally higher for malignant tumors than for benign lesions. Among the bone lesions in our study, one case of sarcoidosis was missed. Similarly, the biopsies were false-negative for three extra-articular soft-tissue lesions, which were ultimately shown to be benign tumors (peripheral nerve sheath tumor, hemangioma, and intramuscular vascular malformation). The diagnostic performance of the biopsies of the bone and extra-articular soft-tissue lesions in our series was also similar or superior to that in several reports on diagnostic magnetic resonance imaging-guided musculoskeletal biopsies^2-9, in which the number of biopsies ranged from five to thirty-six.

As a guidance modality, magnetic resonance imaging has several favorable characteristics, including superb image contrast between tissues, a cross-sectional technique with an easily adjustable imaging plane, and no ionizing radiation. As a result of superior contrast between soft tissue and bone marrow, magnetic resonance imaging can identify cystic and necrotic areas more readily than unenhanced computed tomography can. Careful assessment of the internal composition of the tumors was important for targeting the needle toward solid components in our study. We also used contrast medium in selected circumstances to optimize diagnostic yield and accuracy by targeting the most aggressive components of a lesion. Furthermore, there are certain lesions, particularly marrow abnormalities, that may be visualized only by magnetic resonance imaging. The multiplanar capabilities and virtually unlimited section orientation of magnetic resonance imaging guidance are particularly helpful for targeting masses that are not safely accessible in the direct axial plane. Magnetic resonance imaging allows easy localization of neurovascular structures and the ability to use flow-sensitive pulse sequences that depict vascular anatomy in order to avoid complications. Lewin et al. reported their experience with an interactive magnetic resonance imaging-guided biopsy system for a variety of lesions throughout the body, including twenty-three musculoskeletal lesions³, and Ojala et al. evaluated the feasibility of the use of a magnetic resonance imaging-compatible optical tracking-guided bone-biopsy system (similar to ours) in five different anatomic areas⁴. These reports emphasized that access to sites throughout the body was achieved with successful needle placement in all cases. Likewise, we were able to safely access all of the lesion sites in our series. A lack of ionizing radiation is an advantage of using ultrasound and magnetic resonance imaging instead of fluoroscopy, computed tomography, and computed tomography fluoroscopy. Computed tomography imaging is extremely useful and the predominant modality for targeting bone lesions. It is not likely to be replaced by magnetic resonance imaging guidance in the near future. However, the use of realtime computed tomography fluoroscopy increases the radiation dose to the operator and the patient. The avoidance of exposure to ionizing radiation was relevant for a pregnant patient in our series.

Although there are some inherent advantages of using magnetic resonance imaging as a guidance modality, there are also several disadvantages. These include the cost of deploying and maintaining a specialized magnet or modifying an existing magnet and suite for interventional use and the currently higher cost of magnetic resonance imaging-compatible biopsy equipment. There are fewer choices for needles when they must be compatible with magnetic resonance imaging. There are also specific contraindications to the use of magnetic resonance imaging, including the presence of pacemakers, certain cerebral aneurysm clips, cochlear implants, or other strongly ferromagnetic material near critical locations. In addition, the performance of procedures in a magnetic resonance imaging interventional suite requires specially designed and tested equipment for patient monitoring, but this need is similar to that for a diagnostic magnetic resonance imaging suite.

A unique aspect of our series is the inclusion of intraarticular soft-tissue lesions. There has been little work involving image-guided synovial biopsies. In our study, the diagnostic yield in this subgroup (71%; five of seven) was inferior to that in the other lesion subgroups. The intra-articular soft-tissue biopsies that yielded sufficient material were highly accurate, but this finding must be viewed in the context of the restricted diagnostic possibilities (the purpose of most of these biopsies was to confirm or exclude a diagnosis of pigmented villonodular synovitis) and the small number of procedures. With respect to obtaining a large specimen, the configuration of some joints and the access route that is achievable are not favorable for using a side-cutting biopsy needle and thus a front-cutting vacuum-assisted needle was found to be better. A method for performing synovial biopsy under ultrasound guidance with use of a portal and forceps was described to have a diagnostic yield of 89% (thirty-three of thirty-seven)²⁶. Development of a similar magnetic resonance imaging-compatible device may increase the diagnostic yield of biopsies of intra-articular soft-tissue lesions.

Our study had some limitations. There was no direct comparison of magnetic resonance imaging with computed tomography, fluoroscopy, or ultrasound as the guiding modality. In our series, magnetic resonance imaging guidance was predominantly used for a specific reason, which introduced a selection bias. However, the lesions were often chosen because they would have been difficult to biopsy with use of other imaging modalities for guidance. We also did not compare the usefulness of different needles. We employed a variety of needles during our study, and in some cases more than one needle was used. We did not focus on cost analysis or procedure time, which may be important characteristics to compare with other modalities and between guidance methods.

In summary, magnetic resonance imaging-guided percutaneous musculoskeletal biopsies of bone and extra-articular soft-tissue lesions can be performed safely and accurately. This technique may be considered supplementary to other imaging modalities for biopsy guidance and can serve a problem-solving role as a tool for lesions that would be difficult to visualize, access, or monitor with the other modalities. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank the MRT (Magnetic Resonance Therapy) team at the Brigham and Women's Hospital for their valuable assistance: Marsha O'Neil, MS, Angela Kanan, RN, BSN, CNOR, Janice Fairhurst, RT(R) (MR), Daniel Kacher, MS, and Paul Morrison, MS.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Topics

biopsy ; needle device ; vibration

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John A. Carrino, Bharti Khurana, John E. Ready, Stuart G. Silverman, Carl S. Winalski; Magnetic Resonance Imaging-Guided Percutaneous Biopsy of Musculoskeletal Lesions. The Journal of Bone & Joint Surgery. 2007 Oct;89(10):2179-2187.

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