Reference : Salunke AA, Nandy K, Puj K, Kamani M, Pathak S, Shah J, Bhalerao RH, Jain A, Sharma M, Warikoo V, Patel K, Rathod P, Bhatt S, Tank T, Pandya S. A proposed “Radiological Evaluation Score for Bone Tumors” (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor. Musculoskelet Surg. 2022 Dec;106(4):371-382. doi: 10.1007/s12306-021-00711-0. Epub 2021 May 12. Erratum in: Musculoskelet Surg. 2022 Dec;106(4):383. doi: 10.1007/s12306-021-00716-9. PMID: 33982208
Orthopaedic oncology balances two opposing principles in cancer surgery: maximal removal of cancerous tissue and preservation of function and appearance. While complete excision ensures the elimination of cancerous cells, it risks impairing the functionality and aesthetics of the affected area. Conversely, conservative removal preserves these aspects but may leave residual cancer. Navigating this delicate balance has been revolutionized by 3D printing technology, which constructs three-dimensional objects layer by layer based on digital models. This advancement has significantly enhanced both the planning and execution phases of bone cancer surgeries.
Enhanced Preoperative Planning
3D printing has greatly benefited bone cancer surgery by allowing the creation of accurate models of tumor-bearing bones. This is particularly advantageous for non-geometrically shaped bones such as the pelvis, sacrum, and spine. These detailed replicas provide orthopaedic oncologists with a better understanding of the tumor’s spatial relationship with the surrounding bone, leading to more precise clinicoradiological correlations.
Key benefits include:
Superior Preoperative Planning: Detailed models enable meticulous surgical planning, ensuring that all aspects of the tumor and its surrounding tissue are thoroughly considered.
Improved Team Communication: Surgeons and their teams can collaborate more effectively, using the 3D model as a tangible reference point during preoperative discussions.
Intraoperative Reference: The model serves as a constant reference during surgery, helping to guide decisions in real-time.
Clear Communication with Implant Manufacturers: Surgeons can convey their requirements more accurately to manufacturers, ensuring that custom implants meet the specific needs of the surgery.
Intraoperative Navigation
One significant challenge in bone cancer surgery is making precise cuts on the bone. Traditional methods often result in the removal of too much or too little bone. However, 3D printed jigs, which are customized guides for saw blades, have addressed this issue. These jigs ensure that cuts are made exactly as planned, based on preoperative consultations with radiologists.
Custom Implants for Reconstruction
3D printing is invaluable for creating custom implants used in limb salvage surgeries. Specific plates and prostheses can be designed to match the exact anatomical features of the affected bone. This is particularly crucial for:
Young Children: Custom plates are necessary to accommodate growing bones.
Irregular Bones: Prostheses for complex structures like pelvic bones, the talus, and the scapula require precise customization.
Joint-Sparing Implants: Unique implants that preserve joint function can be tailored to the patient’s anatomy.
Future of 3D Printing in Orthopaedic Oncology
Combined with computer navigation, 3D printing has become indispensable in orthopaedic oncology surgery. Its increasing adoption is transforming it from a novel innovation to a standard tool, promising enhanced patient care and superior surgical outcomes. As the technology evolves, it will further refine surgical precision, improve recovery rates, and optimize overall treatment effectiveness, marking a significant advancement in the fight against bone cancer.
A bone biopsy is a medical test that can help to know whether a patient is having bone cancer or any other disease after removing a tissue sample from the patient.
The bone tissue sample is examined by the pathologist in the laboratory with help of a microscope for histopathological examination and other tests.
In this article, we will read about what is this test and what to expect following a bone biopsy procedure.
GCT is a benign tumour that typically occurs in long bones. It has a potential for aggressive behaviour, high recurrence rate and capacity to metastasize. Although rarely it can spread to lungs and can be lethal.
2. WHY HAS IT OCCURRED TO ME??
There is no identified cause or known cause of giant cell tumour.
This is a rare tumour and affects 1 person in every 1 lakh people per year. And generally affects those aged 20 to 45 years of age.
3.HOW TO DIAGNOSE GIANT CELL TUMOUR??
STEPS TO DIAGNOSE-
A. BLOOD INVESTIGATIONS-
B.X RAY- to see the affected bone and size of the tumour
C. MRI- to see any soft tissue involvement
D.CT THORAX- to rule out lung metastasis
D. BONE BIOPSY- part of the disease is removed to check under microscope to confirm the disease. A procedure where a doctor places a small needle through the skin and into the lesion to withdraw a sample of the abnormal tissue. The tissue is analysed to confirm any findings.
4.STAGES OF GCT
Staging and grading are used to describe the severity of the disease. Staging is based on the following things
Location of tumour
Size and extent of the tumour
Whether cancer cells have spread to lymph nodes or anywhere else in the body.
The number of tumours present.
Doctors use tumour grade, cancer stage, and a patient’s age and general health to decide the course of treatment for the patient and determine prognosis. Prognosis describes all factors including the disease course, cure rate, chances of survival, and risk of recurrence of cancer.
5. WHAT IS TREATMENT PLAN??
The main aim of treatment is to remove the tumour, while maintaining as much of the cosmetic
appearance and functional normality of the bone as possible.
A. MEDICAL
Medical management has been utilized preoperatively to reduce the tumour size, diminish the tumour’s blood supply, and facilitate joint preservation procedures in periarticular locations.
Also it hardens the tumour which makes the surgery easy and reduces surgery related complications
Fresh Blood investigations are needed before each round of treatment.
1)ZOLENDRONIC ACID– given once a month , usually for 3 months
2) DENOSUMAB -usually given once a week initially then biweekly.
B.SURGICAL
1)EXTENDED CURRETAGE WITH CEMENTING-GCTs are benign yet locally aggressive tumours, a local intralesional surgical approach is deemed appropriate in most cases. Curettage surgery involves the removal of the tumour by scraping the tumour cells from the area. This procedure is commonly followed by ‘bone cementation’ – which aims to destroy any remaining tumour cells and fill the area following the tumours removal. Treatment include Curettage, extensive pulse lavage, application of hydrogen peroxide, heat cauterization and cementing with bone cement.
2)RESECTION– Resection may be the preferred option in benign tumours, particularly when bone salvageability through intralesional methods would cause a severe compromise in mechanical characteristics. This applies particularly to the “expendable bones,” such as the lower ulnar and upper fibular end, where excision may be the treatment of choice.
3)RESECTION AND RECONSTRUCTION-Used in extensive cases where the cortex has been breached and replacement is the only option available. In cases of GCT in the distal radius, resection and reconstruction with an allograft or an autograft are commonly undertaken.
7.WHAT COMPLICATIONS CAN OCCUR??
Tumour recurrence- most common complication
Osteoarthritis of the knee joint
Stress fracture
Limited movement
Pulmonary metastasis
Local and deep infections
Osteomyelitis
Joint degeneration
8. WHAT IS MY PROGNOSIS??
Early detection and treatment often leads to better outcomes .
GCT have a favourable prognosis and after good physiotherapy patients get good range of motion and no pain. Main complications that can occur and lead to poor prognosis are recurrence and lung metastasis.
9. WHAT IS MY FOLLOW UP SCHEDULE?
Follow ups are important to identify the complications like recurrence and metastatis.
After operative management patients usually need follow up every 3 month initially for routine check ups for routine X rays and CT scan of Thorax. Then after 2 years , patients are usually called 6 monthly for the same investigations.
10. WHAT ARE MY SURVIVAL CHANCES??
The survival rate for GCT patients is very good. The five-year recurrence-free survival rate is around 80-91% for both benign and malignant GCT.
A bone biopsy is a medical test that can help to know whether a patient is having bone cancer or any other disease after removing a tissue sample from the patient. The bone tissue sample is examined by the pathologist in the laboratory with help of a microscope for histopathological examination and other tests.
In this article, we will read about what is this test and what to expect following a bone biopsy procedure.
There are majorly seven broad heads:
Purpose
Risks, Benefits & Alternatives
Common queries
Preparations needed by the patient
Team of Health care professionals
Where and How to do the test
Results
Let us understand all these in detail.
Biopsy: What is this medical procedure or test?
A biopsy is a medical test in which a tissue sample is obtained from a patient and is sent to a pathology laboratory for histopathological examination to find whether it is having a disease or not. A biopsy is used to confirm the diagnosis of cancer or a tumor, to distinguish the specific type of cancer, and to diagnose whether there are other diseases like infection or an abnormality.
A patient may undergo a biopsy if they are experiencing specific symptoms and signs of a suspected cancer disease or any other disease which requires tissue examination. The patient is examined clinically by the doctor and then evaluated with medical tests which include blood tests and imaging tests like X-rays, Ultrasound, MRI, CT Scan, and PET Scan which is followed by a biopsy test.
A tissue sample is removed from anywhere in the body as per the affected area which may be from head to toe and skin to any deeper body organ. The small tissue sample from a body part is removed with help of a needle or the lump/swelling is surgically removed for examination.
The needle biopsy is performed on an outpatient basis or in an operation theatre with or without imaging guidance and the patient is administered local or general anesthesia. The doctor will give information and instructions about the biopsy procedure to the patient and their relatives.
The biopsy sample is processed in the pathology laboratory and is examined by a pathologist (expert in pathology) under a microscope and with other tests to determine whether the patient is having cancer, which type of cancer, or having any other disease like an infection.
The patient is asked about medical conditions i.e. diabetes, heart diseases and hypertension, asthma, and about allergies; as these are important for local or general anesthesia. Information regarding medications like blood thinners i.e. Aspirin, Clopidogrel must be conveyed to the doctor as these need to be stopped prior to the biopsy procedure.
The patient is informed about the advantages and risks involved in performing a biopsy.
As the procedure is performed under general anesthesia the patient is instructed to be nil by mouth (NBM) means not allowed to eat food or drink fluids for around eight hours duration prior to the biopsy procedure. The biopsy procedure can be performed with local anesthesia in selected cases.
A bone biopsy is a procedure in which a small tissue sample of a bone is removed from the patient. And this sample is examined under a microscope by the pathologist.
Closed or Needle bone biopsy is a procedure in which a small incision is placed over the skin and the bone biopsy needle is inserted into the affected bone to obtain tissue samples for histopathological examination. Needle biopsy is a minimally invasive procedure. And this can be performed in a daycare surgical center under local anesthesia or general anesthesia.
Open bone biopsy is a procedure in which a big incision is placed over the skin and a larger amount of bone tissue sample is obtained from the affected bone for histopathological examination. Open biopsy is an invasive procedure and needs to be performed in an operation theatre under general anesthesia.
The tumors which are not palpable or located deep inside example in the pelvis or chest region may require image guidance for performing a biopsy. Image intensifier (IITV) or C Arm, CT Guidance, and Ultrasound guidance may be used to perform the biopsy procedure.
Why does the patient require a bone biopsy? What are some common uses of the bone biopsy procedure?
The bone biopsy needs to be performed to:
To distinguish benign (non-cancerous) bone cancer or tumor from malignant (cancerous) bone cancer or tumor
Bone cancer sub-classification (osteosarcoma: osteoblastic type, chondroblastic type, etc.)
To determine whether a bone tumor or infection exists (bacterial infection, tuberculosis, etc)
To determine whether the bone marrow is healthy and producing normal amounts of blood cells.
What are the advantages (benefits) and disadvantages (risks) of having a bone biopsy procedure?
Advantages (Benefits)
Biopsy is the most secure method for obtaining tissue samples
Aid in the identification of a type of lesion, with accurate results.
Histopathology distinguishes tumors, infections, and metabolic bone disease.
Biopsies cause little pain or discomfort
Require little healing time, and have a short recovery period.
Disadvantages (Risks)
Infection: Antibiotics or surgical treatment may be required.
Damage to neighboring blood vessels, nerves, or major organs
Inside the affected bone, the biopsy needle may break.
Fracture: It is possible that the affected bone will break or fracture
Bleeding from the biopsy site for an extended period of time.
The biopsy site may cause causing pain, bruising, and discomfort.
What are common queries by patients and family members prior to bone biopsy
Is it really necessary to perform a bone biopsy to get the exact diagnosis
Yes, a biopsy is a gold standard for reaching a final diagnosis in bone tumors
Will my diagnosis be delayed if we perform a bone biopsy
No, it takes around 7 to 10 days to receive a final histopathology report.
How will do the bone biopsy?
A trained doctor who will be treating the patient for a final disease that will be found after the biopsy reports.
Which information the patient needs to share with the doctor prior to the biopsy?
About prior medical comorbidities, medications, drug allergies, family history of cancer, etc.
Preparing for this test: How is the patient prepared for the procedure of a bone biopsy?
Your doctor will test your blood before your procedure to examine your bone, liver & kidney function and tests to know about see if your blood clots normally (bleeding & clotting time).
Before a bone biopsy, a plain radiograph of the affected limb, a chest radiograph, and an MRI of the affected limb will be taken.
Heart function is examined using an ECG and a 2-D Echo.
A pre-anesthesia examination is conducted
Moreover, let your doctor know about any recent illnesses and other health issues. And also whether you have any allergies, especially those that relate to anesthesia.
If a woman thinks she could be pregnant, she should always let her doctor know. Certain image-guidance techniques are not carried out by medical professionals during pregnancy because radiation can harm the fetus.
You should consult your doctor if you have diabetes and take insulin because your typical insulin dosage might need to be changed.
Three days before your biopsy, the doctor may advise you to cease taking aspirin or a blood thinner.
Before your biopsy, you might be told to fast for eight hours. Nonetheless, you’re welcome to take sips of water along with your typical prescriptions.
The patient will be told to have family members join them throughout the hospital during the procedure
Also, they will be advised to have a driver available for them once the anesthetic wears off because it takes time.
Jewellery, spectacles, and any other metal items or clothing that can obstruct the x-ray or CT scan images may also need to be taken off.
For the biopsy procedure exam, patients will be instructed to take off their clothes and will be requested to put on a gown.
Preparation for a biopsy procedure in children will be similar, and parents will be given specific instructions based on the needs of their children.
Consent for Bone Biopsy
The procedure will be explained to you, and any questions you may have can be directed to your doctor. To authorize the doctor to perform the procedure, you and a family member must sign a written informed consent form.
Which medical professionals will perform the bone biopsy test or procedure?
Your biopsy will be performed by a doctor who specializes in that particular medical field. A trained doctor who understands the radiology and anatomy of the affected bone, such as an orthopedic oncosurgeon, orthopedic surgeon, radiologist, and oncosurgeon, performs a bone biopsy test or procedure.
What instruments are used for a Needle bone biopsy?
For a bone biopsy, a special biopsy needle is used. This needle has a hollow core to obtain bone tissue for histopathological tests.
The biopsy needle has a diameter of around 8, 11, and 13 G and is several inches long (80 MM to 160 MM). Both mechanical biopsy needles and motorized biopsy gun systems are available.
These tests are performed under radiological guidance under CT Scan, Radiograph, and Ultrasound imaging as needed.
A blood pressure and heart rate monitor, as well as an intravenous (IV) line, may be used during this procedure.
A knife with a surgical blade, suture materials, scissors, forceps, and a needle holder are all necessary surgical tools.
Drugs for both general and local anesthesia can be used for anesthesia.
What actions are taken before a bone biopsy?
Bone biopsies are frequently carried out as outpatient operations in operating rooms or CT scan rooms depending on the circumstance.
A CT scan image or radiograph will be performed to confirm the precise location of the biopsied area.
A IV line is inserted into the arm or hand of a patient while they are lying on the operating table. And also monitors are set up to take their pulse, blood pressure, heart rate, and oxygen saturation readings.
In situations where general anesthesia is required, the patient is administered anesthetic medications intravenously prior to the procedure.
A local anesthetic will be used by the doctor to numb or anesthetize the skin and tissue in the needle’s path.
A small incision is made in the skin at the location where the biopsy needle will be inserted.
What are the key steps of a needle bone biopsy?
The correct site for the biopsy is found using image guidance from a CT scan, radiograph, or ultrasound.
A scrub and alcohol-based solution are used to sterilize the biopsy site, and a sterile drape is used to cover it.
The doctor places a small incision over the skin and then inserts a bone biopsy needle through the skin and into the bone.
To retrieve tissue for testing, the trocar is removed. And a needle is introduced deeper into the bone to obtain a sample.
Then the needle is removed from the bone and skin and the sample is collected into a container.
The biopsy sample container contains normal saline and formalin, as well as the tissue obtained from the bone biopsy. This container is labeled with the patient’s name, hospital ID, gender, age, and other information before being sent to the histopathology laboratory.
After achieving hemostasis, a suture is placed at the biopsy site and a sterile dressing is applied.
What happens to the patient following the bone biopsy procedure?
The patient’s vital parameters including pulse, blood pressure, heart rate, and oxygen saturation are observed for a required period as per the clinician’s advice.
The intravenous line(i/v) line is removed from the patient’s arm prior to he leaves for home.
The average time required to complete a needle bone biopsy is around 1 hours period
The patient’s vital parameters, such as pulse, blood pressure, heart rate, and oxygen saturation, are monitored for the necessary duration. It is in accordance with the specialists’ recommendations.
Before the patient departs for home, the intravenous line (i/v) is removed from his arm.
The average time required to complete a needle bone biopsy is approximately one hour.
Problems or Side effects: Who should I contact if I have issues after the biopsy test?
The patient will experience pain at the biopsy site and will be given pain-relieving medication for a short period of time.
In the event of increased pain, swelling, local warmth at the biopsy site, fever, or any other problems, the patient should contact the treating doctor as soon as possible.
What is the average time required to receive bone biopsy reports?
The average time to generate a bone biopsy report is around 7 to 10 days.
The pathologist generates a pathology report based on the findings seen under the microscope. The report is very technical, with terms that other pathologists and treating doctors will inform the patient.
The treating doctor discusses and shares the final diagnosis with the patient and their family members based on the histology reports and radiological findings from radiographs, MRIs, and CT scans.
What happens to the bone tissue sample obtained from the biopsy procedure, and who analyses the sample?
The bone biopsy tissue sample or specimen is sent to the histopathology and microbiology laboratories for analysis.
The pathologist is a medical professional who examines the material under a microscope and is skilled in histological evaluation.
The microbiologist is a medical professional who examines the sample and determines which microorganism is infecting the patient.
The pathologist examines the tissue under the microscope and may perform immuno-histochemistry (IHC) tests if necessary. And the average time to generate a biopsy report is 7 to 10 days.
Why are Immuno-histochemistry (IHC) markers, Molecular, and Genetic tests required?
Due to their overlapping radiologic and histologic characteristics, primary bone tumors can be difficult to diagnose. Several immunohistochemical and molecular markers have been developed to assist in the detection of bone tumors. It is as a result of recent progress in our understanding of their biology. IHC is used to assist in the diagnosis and to distinguish between different types of bone tumors.
Which restrictions or limitations apply to needle bone biopsy?
In a small number of cases, needle biopsy does not result in a diagnosis. And may need to be repeated to get a definitive diagnosis.
It is challenging to perform a bone biopsy on patients who have comorbid medical conditions and bleeding disorders.
How should I maintain the biopsy samples using slides and blocks?
When a patient undergoes a biopsy or surgery, the surgeon will frequently remove diseased tissue for examination by the pathology department at the hospital.
The term “tissue block” refers to the processed sample of this tissue that is made with wax.
The pathologist will slice the tissue block into very thin layers, which will be examined under a microscope on a glass slide. This enables the pathologist to assist the surgeon in confirming the diseased tissue’s diagnosis.
The slides and blocks, along with the histopathology reports, are given to the patient, who must keep them in a proper box or container.
How to obtain another or second opinion on the biopsy slides and blocks?
The slides and blocks, along with the histopathology reports, can be sent to another pathology laboratory so that the pathologist can review the histology and make a diagnosis.
What are the alternative tests or procedures for a bone biopsy?
With a traditional bone biopsy, tissue is removed from the affected bone and sent for histopathological examination. A recent alternative for earlier detection and to assist with clinical decision-making is a liquid biopsy. In order to identify cancerous cells or cancerous DNA that develops from malignant or nonmalignant cells in the body, a liquid biopsy is the removal of blood or another bodily fluid. Currently, liquid biopsy is performed in limited situations.
What is the average cost of a bone biopsy test?
The cost of a biopsy is determined by factors such as the type of medical examination performed, the equipment used, and so on.
Conclusion
The purpose of this write-up is for patient education only and it is not an alternative to an expert doctor’s opinion. This is an attempt to explain about bone biopsy to patients and family members in an easy format.
