Soft-Tissue and Bone Biopsies

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Computed Tomography: 1.50
Procedures: 1.50
Head, Spine, and Musculoskeletal: 1.50

Magnetic Resonance Imaging: 1.50
Procedures: 1.50
Musculoskeletal: 1.50

Radiography: 1.50
Procedures: 1.50
Extremity Procedures: 1.50

Registered Radiologist Assistant: 3.50
Patient Care: 0.25
Pharmacology: 0.25
Procedures: 3.25
Musculoskeletal and Endocrine Sections: 3.25

Sonography: 2.00
Procedures: 2.00
Superficial Structures and Other Sonographic Procedures: 2.00

Outline

1. Introduction
2. Preprocedural Considerations
3. Problem-Solving Tools and Diagnostic Dilemmas for Evaluation of Biopsy Requests
   1. Value of Contrast Material and Color Doppler US
   2. Evaluation of Joint-Based Abnormalities and Tumor Arthrography
   3. Stress versus Pathologic Fracture
   4. Tumor versus Infection
   5. Hematoma versus Hemorrhagic Neoplasm
   6. Recognizing Diffuse Marrow Infiltration
4. Biopsy Planning
   1. Biopsy Planning with the Orthopedic Oncologist
   2. Primary Tumor versus Metastases
   3. Modality Selection
5. Factors the Affect Biopsy Yield
   1. Intralesional Targeting
6. Planning the Primary Tumor Biopsy Route
   1. Upper Extremities
      1. Humerus
      2. Forearm
   2. Lower Extremities
      1. Hip and Pelvis
      2. Thigh
      3. Lower Leg
   3. Technically Challenging Biopsies
   4. Patient Factors
   5. Coagulation Parameters and Anticoagulants
   6. Local Anesthetics and Moderate Sedation
      1. Common Local Anesthetics
      2. Minimal and Moderate Sedation
      3. Common Moderate Sedation Medications
      4. Pharmacologic Reversal Agents
7. CT- and US-Guided Biopsy Techniques
   1. CT-Guided Biopsy
   2. US-Guided Biopsy
8. Order Entry and Specimen Handling
9. Interpreting Biopsy Results
   1. Value of Nondiagnostic Biopsy Results
   2. When to Consider Repeat Biopsy
   3. Radiologic-Pathologic Correlation
10. Posttreatment Imaging and Surveillance
11. Tumor Recurrence
12. Conclusion

Objectives

Upon completion of this course, students will:

1. describe the benefits of percutaneous biopsies
2. list post-procedural considerations for soft-tissue and bone biopsies
3. describe how intralesional vascularity can be diagnosed
4. state the benefit of direct MR and CT arthrography in the diagnosis and determination of soft-tissue ganglia
5. recall the patient population most often affected by pathologic fracture
6. list where pathologic fractures most commonly occur
7. state the preferred imaging modality for further evaluation of stress versus pathologic fractures
8. state the most helpful MR imaging sequences to differentiate between pathologic and stress fracture
9. state the percent of pathologic fractures that never fully heal
10. describe the penumbra sign
11. state the sensitivity of the penumbra sign for isolated soft-tissue infections
12. compare Ewing sarcoma to osteomyelitis
13. state the imaging modality used to differentiate between bland hematoma and hemorrhagic sarcoma
14. describe the wall of a bland hematoma
15. describe hemorrhagic sarcomas as seen at MR imaging
16. explain the pitfalls of not planning appropriately for biopsies
17. state the complication rate for open biopsy
18. list the factors to consider when selecting a lesion for core needle biopsy
19. list the considerations for selecting the best imaging modality for performing biopsies
20. choose the modality that is not typically feasible or necessary for guided biopsy
21. choose the modality that is ideal for percutaneous sampling of superficial soft-tissue lesions
22. name the type of probe useful for superficial biopsies in regions with irregular or sharply rounded contours and narrow acoustic windows
23. choose the preferred modality for image-guided biopsies of lesions in the bones, deep soft tissues, or extensive subcutaneous fat superficial to a lesion
24. state the diagnostic yield for all core needle biopsies
25. list the operator technical factors that affect biopsy yield
26. list the benefits of using a coaxial battery-powered bone biopsy system
27. choose the lesions most likely to produce a diagnostic sample
28. state the patient position for a humeral biopsy
29. choose the correct approach for a biopsy of the radial head and neck
30. state areas in the forearm that should be avoided during biopsy
31. give the patient position for a biopsy of the distal femoral diaphysis and adjacent soft tissue
32. give the patient position for a biopsy of the tibia and fibulal
33. ist the challenges associated with biopsy of the ribs or sternuml
34. ist the factors associated with increased diagnostic yield in image-guided rib biopsiesr
35. ecall patient responsibilities during biopsies
36. compare the use of local anesthesia to moderate sedation or anesthesia
37. list the levels of sedation as defined by the American Society of Anesthesiologists
38. list the steps that should be taken in the case of an overly sedated patient
39. choose what step is repeated during CT-guided biopsy in order to obtain adequate specimens
40. list the factors associated with higher risk of local tumor recurrence