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Sonographically Guided Biopsy of Bone and Soft Tissue Tumors

To the Editor: We read with great interest the article by Torriani et al about the efficacy of sonographically guided biopsy of bone and soft tissue tumors.1 Using a 14-gauge Tru-Cut–type needle and performing at least 5 passes of the needle, the authors obtained high-quality specimens in 96% of cases, with sensitivity of 97% and specificity of 100%, and recommended the use of sonographic guidance to carry out the biopsy of lesions with some degree of extraosseous extension. We strongly agree with such a recommendation, after reviewing the records of 46 patients with bone or soft tissue tumors admitted into our Department of Internal Medicine and referred to the Ultrasound Section for sonographic examination. Eight of these patients had intraosseous lesions without cortical disruption, not amenable to sonographically guided biopsy. The remaining 38 patients underwent sonographically guided biopsy. Nine of them had histories of malignancy but no known metastatic dissemination in other organs. The lesions measured between 1.5 and 9 cm, and their sites were as follows: intercostal soft tissues (7 cases), ilium (7), sternum (4), soft tissues of the shoulder (4), femur (4), thigh (3), clavicle (3), humerus (2), radius (2), pubis (1), and paravertebral soft tissues (1). After local anesthesia (5 mL of 1% lidocaine), the biopsies were carried out with an 18-gauge Tru-Cut–type semiautomatic needle fashioned to allow the choice between 2 different needle throws (1 and 2 cm; Precisa; HS Hospital Service, Pomezia, Italy). Up to 3 passes of the needle were carried out, according to the needle throw selected and the adequacy of the sampling on visual inspection. The mean duration of the procedure was 20 minutes, and no complications were observed. In 36 patients (94.7%), biopsy specimens yielded a definitive and specific diagnosis (32 cases, 84.2%) or the identification of a malignant lesion without a specific diagnosis (4 cases, 10.5%); in 2 patients, biopsy specimens were inadequate. Among the 32 patients with a definitive diagnosis, 7 had benign lesions (2 bone cysts, 2 lipomas, 1 desmoid tumor, 1 suppurated synovial cyst, and 1 chondroblastoma), and 25 had malignant lesions (4 lymphomas, 2 malignant fibrous histiocytomas, 1 osteosarcoma, 1 leiomyosarcoma, 1 plasmacytoma, and 16 metastases: 4 from lung cancer, 4 from breast cancer, 3 from gastrointestinal cancer, 2 from renal carcinoma, 2 from thyroid follicular carcinoma, and 1 from mesothelioma). Clinical follow-up, surgical intervention, and instrumental investigations detecting the primary tumor suggested by the sonographically guided biopsy confirmed the reliability of the diagnosis yielded by the biopsy specimens. Our data confirm the safety and accuracy of sonographically guided biopsy of bone and soft tissue lesions reported by Torriani et al and suggest that a lower number of passes with a medium-gauge needle may be sufficient for sampling adequate specimens when sonographic examination shows cortical disruption with extraosseous extension and soft tissue involvement. Although fluoroscopy and computed tomography are commonly considered the methods of choice for guiding percutaneous biopsy of the musculoskeletal system,2,3 the advantages of sonography in terms of lower costs, absence of the risk of ionizing radiation, quickness in carrying out the procedure, and continuous real-time visualization of the needle are well established, and we agree with Torriani et al that sonographic examination should be added to the workup of bone and soft tissue lesions for evaluating the presence of areas amenable to percutaneous needle biopsy.