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Biopsy – Concept – Types – Indications – Planning

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For better understanding, we suggest that you first read the chapters: 

https://oncocirurgia.com.br/introducao-ao-estudo-dos-tumores-osseos/

https://oncocirurgia.com.br/diagnostico-dos-tumores/

Biopsy Considerations

Biopsy – Concept – Types – Indications – Planning

1.  Only after the clinical evaluation, with careful history taking and clinical examination, which will allow us to raise diagnostic hypotheses, should we request additional tests.

With the analysis of complementary exams, we should verify:

A- If our hypotheses are compatible with the tests and continue to qualify as possible diagnoses; 

B- A new hypothesis has appeared, which we had not thought of, and we will have to redo our clinical reasoning.

C- If the exams are correct, well done, images centered on the lesion, with good quality or we will have to repeat them.

          2.  Diagnosis hypotheses must first be made through clinical examination, laboratory tests and imaging.

    3.  Pathology   must be used as a  “tool”  to  confirm  or  not confirm the  suspected diagnosis.

If the anatomopathological examination reveals a diagnosis that was not on our list, we must reanalyze the case, redo our reasoning. If there is no  clinical, radiological and anatomopathological correlation  , something may be wrong and we will need to review it together, in a multidisciplinary team, to determine the best course of action. New biopsy?

4.  To reason about the diagnosis, it is first necessary to frame the condition we are analyzing within the five chapters of pathology, figures 1 and 2.

Biopsy – concept – types – indications – planning

Figura 1: Reunião Multidisciplinar - oncocirurgião, radiologista, patologista, oncologista, radioterapeuta, psicólogo, assistente social, fisioterapeuta, enfermagem e outros profissionais envolvidos no caso, ura.
Figure 1: Multidisciplinary Meeting - oncosurgeon, radiologist, pathologist, oncologist, radiotherapist, psychologist, social worker, physiotherapist, nursing and other professionals involved in the case, ura.
Figura 2: Em nossa biblioteca cerebral devemos pesquisar os cinco volumes da PATOLOGIA: 1- Malformações Congênitas, 2-Transtornos Circulatórios, 3- Processos Degenerativos, 4- Inflamações e 5- Neoplasias.
Figure 2: In our brain library we must research the five volumes of PATHOLOGY: 1- Congenital Malformations, 2- Circulatory Disorders, 3- Degenerative Processes, 4- Inflammations and 5- Neoplasms.

5.  If we conclude that our patient has a neoplasm, we need to carry out the reasoning exercise already described in the Introduction to the Study of Tumors and Tumor Diagnosis chapters (Links:  https://oncocirurgia.com.br/introducao-ao-estudo- dos-tumores-osseos/   and   https://oncocirurgia.com.br/diagnostico-dos-tumores/  ).

After these steps, we can think of the biopsy as a  “tool”  for the definitive diagnosis.

Before we address the topic  “biopsy”,  let’s analyze some cases.

Patient  A : figures 3 and 4.

Figura 3: Tomografia com lesão na parede abdominal. Abaulamento do músculo reto anterior e espessamento da musculatura lateral, assinalado em amarelo.
Figure 3: Tomography showing injury to the abdominal wall. Bulging of the anterior rectus muscle and thickening of the lateral muscles, marked in yellow.
Figura 4: Tomografia, ultrassom e aspecto clínico. Paciente ictérico, asmático, com grande equimose, internado havia dias para investigação.
Figure 4: Tomography, ultrasound and clinical appearance. Jaundiced, asthmatic patient, with severe bruising, hospitalized for days for investigation.

Thirty days ago, they requested a biopsy of an abdominal wall lesion on a patient admitted for investigation.

The patient’s doctor found me in the radiology room, analyzing the CT scan.

Following the  “how I think”  about injuries I asked myself: – what structures form the abdominal wall? The. skin  (squamous cell carcinoma, basal cell carcinoma, melanoma) ; B. subcutaneous  (lipoma, liposarcoma) ; w. muscular fascia  (desmoid fibroma) ; d. striated muscle  (fibroma, fibrosarcoma, desmoid fibroma, rhabdomyosarcoma) ; It is. vessel  (hemangioma, leiomyosarcoma) ; f. peritoneum and abdominal cavity  (no longer my jurisdiction).

It seemed like an extensive lesion and I suggested that I look for a surgeon in the area, as I wouldn’t know how to drive if it was a malignant neoplasm. Ideally, the biopsy should be performed by the person who will operate on the patient.

He told me that the patient was jaundiced, an ultrasound and several laboratory tests had been performed, insisting that I perform a biopsy. I asked him some information and as I didn’t know how to find out, I suggested that we visit the bed. We could extract the clinical history and examine the patient.

The patient reported being asthmatic and reported that the symptom began abruptly after a coughing fit eleven days ago, in a sudden change of weather, cold and drizzling. He had severe pain in the anterior wall of the abdomen, where a “ball” appeared. The bulging and pain were decreasing and the side wall had hardened.

Leaving the room, I suggested that we not do a biopsy, that we discharge the patient, that the jaundice with elevated bilirubin was the result of a large hematoma that had infiltrated the lateral wall, due to the spontaneous rupture of the anterior rectus abdominis. This lesion was already undergoing repair and the biopsy would only show the scarring inflammatory process  (with the risk of proliferative myositis).

Still not convinced, he asked me if I had ever seen a case of spontaneous rupture of the rectus abdominis muscle. I answered no, but that was what common sense said. Going down the stairs we met a general surgeon and I asked him about the matter. This clarified that it was common in patients with chronic bronchitis who were taking corticosteroids, as was the case with our patient.  The  clinical history  made the diagnosis.

Patients  B  and  C : Figures 5 and 6.
Pacientes B e C: Figuras 5 e 6.
Figura 5: Radiografia da pelve esquerda com lesões de rarefação no ramo ílio-isquiático, paciente mostrando a lesão, destacada em vermelho.
Figure 5: Radiograph of the left pelvis with rarefaction lesions in the ilio-ischial branch, patient showing the lesion, highlighted in red.
Figura 6: Lesão na coxa assinalada em azul, reação periosteal ao redor de corpo estranho, destacada em amarelo, ponta de lança de portão, circundada em vermelho.
Figure 6: Thigh injury marked in blue, periosteal reaction around a foreign body, highlighted in yellow, gate spearhead, circled in red.

Patients  B : Figure 5.

At the outpatient clinic, the resident asks:

– “By which access route should we perform the biopsy?”

I see the image and ask: – How old is the patient?

– “Um… Dona Maria, how old are you?”

 I reflect in silence, evaluating the learner’s lack of knowledge. The patient responds 67 years old DOCTOR!

… Sixty-seven years, multiple lesions, metastasis? Multiple myeloma? Brown tumor of hyperparathyroidism? – How long has she had symptoms?

– “Um… Dona Maria, how long have you had this problem?”

In the medical record I see symptoms of pain in the  ischial tuberosity noted , measurements of Ca ++ , P ++ , FA, Na + , K + , protein electrophoresis, blood count, ESR, blood glucose, urea, creatinine, ultrasound, x-rays,…, …

When examining the patient, I observed that the “tumor” is  anterior , in the inguinal region, and not  posterior , as noted in the medical record, “ischial tuberosity”.  The patient had not been examined !!! She had an inguinal-crural hernia. Pelvic x-ray images represent gas from the intestine. The “biopsy” would result in intestinal perforation.  The  physical examination  made the diagnosis. 

Patient  C : Figure 6.

Passing through the emergency room, the person on duty asks:

– “Doctor, what tumor do you think this patient has? Can we schedule the biopsy?”

The resident knew nothing about the history and had only taken the frontal x-ray!!! When asked, the patient reports that the inflammatory symptoms began six months ago, with hot pain and the release of purulent secretions. When it was open, secreting, the symptoms improved. When he closed the fistula it started to swell, hurt and he had a fever.

With difficulty, as the patient often withholds information, we learned that he had been injured in the thigh two years ago, when he jumped over the guardrail of a house, which bled a lot, but did not seek treatment  ( clinical history ) . We requested a lateral x-ray which confirmed that it was a foreign body. The spear tip of the grid was surrounded by solid periosteal reaction, giving the false impression of a sclerotic tumor.  Appropriate imaging confirmed   the diagnosis.

After these important considerations, we will study the controversial topic of biopsy.

After these important considerations, we will study the controversial topic of biopsy.

WE NEED:

1-  Define the hypotheses of possible diagnoses, for our case, firstly with the  clinical history  and  physical examination ;

2-  Carry out  laboratory and imaging tests, to  corroborate  or  not  our hypotheses,  our reasoning  and

3-  Only after these steps can we perform the biopsy, for the pathology to “ recognize the signature ” of the diagnosis, previously thought out with our anamnesis, physical, laboratory and imaging examination.

“Pathological anatomy is not a short path to diagnosis. We must always correlate it with the clinic, laboratory and imaging tests”.

Figura 7: O médico precisa sentir o paciente.
Figure 7: The doctor needs to feel the patient.
Figura 8: A clínica é a base, que tem o maior peso. Os dados de imagem em equilíbrio com a patologia equilibram a pirâmide, definindo o DIAGNÓSTICO preciso.
Figure 8: The clinic is the base, which has the greatest weight. Image data in balance with pathology balances the pyramid, defining the precise DIAGNOSIS.
Figura 9: Quatro itens devem ser considerados em relação à biópsia.
Figure 9: Four items must be considered in relation to biopsy.
Figura 10: A amostra deve ser representativa da lesão, em qualidade e quantidade.
Figure 10: The sample must be representative of the lesion, in quality and quantity.
Figura 11: A escolha de cada tipo deve ser feita com critério.
Figure 11: The choice of each type must be made carefully.
Figura 12: Lesões que podem permitir a ressecção-biópsia. É preciso analisar caso a caso. Uma equipe multidisciplinar é fundamental.
Figure 12: Lesions that may allow resection-biopsy. It needs to be analyzed case by case. A multidisciplinary team is essential.

Regarding biopsy, we can subdivide musculoskeletal lesions into three groups:   

  1. Cases in which CLINICAL – RADIOLOGICAL diagnosis  (image)  is sufficient for diagnosis and treatment, and biopsy is not indicated.
  2. Cases that may not require this procedure due to difficulty in histological diagnosis, and due to the characteristics of  clinical  and  radiological aggressiveness  , the necessary surgical procedure should not be altered.
  3. Cases that require pathological confirmation for chemotherapy treatment prior to surgery

We will discuss the three groups, analyzing some examples, figures below.

GROUPS 1 and 2 : Biopsy is not necessary or does not change management.

  1a . OSTEOMA, figures 13 to 18.

IDENTITY:  Benign, well-defined neoplastic lesion, characterized by a homogeneous, sclerotic and dense tumor, mature bone tissue. It’s bone within a bone.

Figura 13: Paciente com 43 anos de idade, apresentando tumor no crâneo havia oito anos, indolor, que dificultava para pentear o cabelo. Radiografia com lesão esclerótica homogenia.
Figure 13: 43-year-old patient, with a painless skull tumor for eight years that made it difficult to comb her hair. Radiograph with homogeneous sclerotic lesion.
Figura 14: Tomografia exibindo osteoma no crâneo.
Figure 14: Tomography showing osteoma in the skull.
Figura 15: Radiografia com osteoma na falange proximal do terceiro dedo.
Figure 15: Radiograph showing osteoma in the proximal phalanx of the third finger.
Figura 16: Radiografia com osteoma na cabeça femoral. Enostose assintomática, achado casual em radiografia do quadril.
Figure 16: Radiograph showing osteoma in the femoral head. Asymptomatic enostosis, casual finding on hip radiography.
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Figure 17: Osteoma in the vertebral body, asymptomatic. Casual finding, observation and follow-up.
Figura 18: Osteoma na região frontal do crâneo. Indicação cirúrgica por alteração estética.
Figure 18: Osteoma in the frontal region of the skull. Surgical indication due to aesthetic changes.

These lesions are well-defined, homogeneous, without symptoms. They are diagnosed by occasional imaging findings or by presenting aesthetic changes. Occasionally, they may be symptomatic, as in a case where the nasal cavity was obstructed, making breathing difficult. The diagnosis is clinical and radiological, and does not require a biopsy. Treatment is restricted to observation and monitoring. They are rare and occasionally operated on. 

See:   http://osteoma     and     http://osteoma of the skull

1b . OSTEOID OSTEOMA, figures 19 to 26.

IDENTITY:  Benign neoplastic lesion, characterized by a circumscribed tumor, up to approximately one centimeter in diameter, which presents a central osteoid niche, surrounded by a halo of sclerosis and located in the cortex of the long bones, the most compact part.

Figura 19: TC e Radiografias de osteoma osteóide da região trocanteriana do fêmur. Lesão lítica, com nicho central e halo de esclerose, assinalada em amarelo e cortical marcada com perfuração por fio de Kirchner, assinalada em vermelho.
Figure 19: CT and radiographs of osteoid osteoma of the trochanteric region of the femur. Lytic lesion, with central niche and halo of sclerosis, marked in yellow and cortical marked with Kirchner wire perforation, marked in red.
Figura 20: Radiografia de osteoma osteóide no colo femoral. Lesão lítica, com nicho central e halo de esclerose, seta vermelha.
Figure 20: Radiograph of osteoid osteoma in the femoral neck. Lytic lesion, with central niche and halo of sclerosis, red arrow.

The femoral neck region is covered by a thin periosteum that does not present a periosteal reaction. This makes it difficult to locate the lesion during surgery.

Making a hole in the cortical bone, close to the lesion, guided by radioscopy, will facilitate the operation.

After this marking, we perform a tomography to measure the distance from the hole to the center of the lesion, locating it. See the complete technique at:  http://osteoid osteoma resection technique   

Figura 21: Tomografia com osteoma osteóide na região medial do colo femoral. Neste caso a marcação coincidiu com o centro da lesão, o que facilita, mas não é o ideal, pois perfura a lesão.
Figure 21: Tomography showing osteoid osteoma in the medial region of the femoral neck. In this case, the marking coincided with the center of the lesion, which makes it easier, but is not ideal, as it pierces the lesion.
Figura 22: Imagens com osteoma osteóide da tíbia e do pedículo da coluna vertebral. Não há indicação de biópsia e sim de ressecção-biópsia.
Figure 22: Images with osteoid osteoma of the tibia and spinal pedicle. There is no indication for biopsy, but rather for resection-biopsy.
Figura 23: Osteoma osteóide da cortical anterior da tíbia. Não ha indicação de biópsia.
Figure 23: Osteoid osteoma of the anterior cortical bone of the tibia. There is no indication for biopsy.
Figura 24: Osteoma osteóide periosteal da cortical interna do rádio. Não há indicação de biópsia.
Figure 24: Periosteal osteoid osteoma of the inner cortex of the radius. There is no indication for biopsy.
Figura 25: Osteoma osteóide do calcâneo. Não há indicação de biópsia.
Figure 25: Osteoid osteoma of the calcaneus. There is no indication for biopsy.
Figura 26: Osteoma osteóide sub talar do calcâneo. Não há indicação de biópsia.
Figure 26: Subtalar osteoid osteoma of the calcaneus. There is no indication for biopsy.

Osteoid osteoma is a lesion of the cortical bone. In the spine, it occurs in the pedicle, which is the most compact, hardest part, resembling the cortex.

It has a central niche with a halo of sclerosis around it and does not exceed one centimeter.

There is no such thing as a “giant osteoid osteoma”, larger than 1.5 cm, as in this situation there is cortical erosion, there is no delimitation by the sclerosis halo and, although it may present similar histology, we are dealing with an osteoblastoma, which is a benign lesion. , but locally aggressive. Osteoblastoma may or may not be associated with an aneurysmal bone cyst and may also require a differential diagnosis with teleangiectatic osteosarcoma. Read also: http://osteoid osteoma 

1c . OSTEOCHONDROMA, figures 27 to 32.

IDENTITY:  It is an exostosis in which the central cancellous bone continues with the medullary of the affected bone and the dense peripheral, cortical layer of the tumor continues with the cortical layer of the affected bone. It presents with an enlarged,  sessile,  or narrow,  pedicled base . It can be single or multiple  (hereditary osteochondromatosis).

Osteochondromas require surgical treatment when they alter aesthetics or function, displacing and compressing vascular-nervous structures, limiting movement or generating angular deformities. It is the most common benign bone lesion.

They generally grow while the patient is in the growth phase. When an osteochondroma increases in size after completion of skeletal maturity, it may mean post-traumatic bursitis or malignancy to chondrosarcoma and should be treated as such, resecting with an oncological margin. 

Solitary osteochondroma has a 1% malignancy rate. Multiple osteochondromatosis can reach 10%.

Figura 27: Exemplo de osteocondroma pediculado do fêmur e de osteocondroma pediculado da tíbia. A cortical do osso continua-se com a cortical da lesão e a medular do osso também se continua com a medular da lesão. Não há indicação de biópsia.
Figure 27: Example of pedicled osteochondroma of the femur and pedicled osteochondroma of the tibia. The bone cortex continues with the lesion cortex and the bone medullary bone also continues with the lesion medullary. There is no indication for biopsy.
Figura 28: Osteocondroma séssil da tíbia. Não há indicação de biópsia. Indicação de ressecção por bloqueio da flexão do joelho.
Figure 28: Sessile osteochondroma of the tibia. There is no indication for biopsy. Indication of resection by blocking knee flexion.
Figura 29: Osteocondromatose múltipla hereditária. Lesões múltiplas em irmãos, setas brancas, amarelas e azuis. Deformidade angular e encurtamento do membro superior.
Figure 29: Hereditary multiple osteochondromatosis. Multiple lesions in siblings, white, yellow and blue arrows. Angular deformity and shortening of the upper limb.
Figura 30: Osteocondroma múltiplos nos fêmures e nas tíbias. Epifisiodese medial da tíbia esquerda visando corrigir a deformidade angular.
Figure 30: Multiple osteochondromas in the femurs and tibias. Medial epiphysiodesis of the left tibia aiming to correct the angular deformity.
Figura 31: Osteocondroma séssil do fêmur, deslocando os vasos femorais. A cortical do osso continua-se com a cortical da lesão e a medular do osso também se continua com a medular da exostose.
Figure 31: Sessile osteochondroma of the femur, displacing the femoral vessels. The bone cortex continues with the lesion cortex and the bone medullary also continues with the exostosis medullary.
Figura 32: Osteocondroma da fíbula comprimindo lentamente a tíbia, durante o crescimento, e ocasionando deformidade angular em valgo e antecurvatum. Exostose no pé dificultando o uso de calçado. Peças e histologia.
Figure 32: Osteochondroma of the fibula slowly compressing the tibia during growth and causing angular deformity in valgus and antecurvatum. Exostosis in the foot making it difficult to wear shoes. Parts and histology.

The diagnosis of osteochondroma is clinical and radiological and does not require a biopsy for treatment. 

Read:  http://osteochondroma

1d . CONDROMA, figures 33 to 50.

IDENTITY:  Benign, painless, cartilage-forming tumor with foci of calcification in the short bones of the hands and feet, diagnosed by chance or due to deformity or fracture. It can be solitary or multiple  (enchondromatosis, Maffucci syndrome, Ollier disease).

Figura 33: Condromas das falanges, achado casual. Histologia de condroma, cartilagem madura.
Figure 33: Chondromas of the phalanges, casual finding. Chondroma histology, mature cartilage.
Figura 34: Condroma da falange com DOR. Consolidado após fratura havia cinco meses, tratada com imobilização. OPERAR?
Figure 34: Chondroma of the phalanx with PAIN. Healed after fracture five months ago, treated with immobilization. OPERATE?
Figura 35: Ressonância de condroma da falange após fratura há cinco meses, com DOR!
Figure 35: MRI of chondroma of the phalanx after fracture five months ago, with PAIN!
Figura 36: Cortical com insuflação fina causando dor. Captação de gadolínio. OPERAR?
Figure 36: Cortical with fine inflation causing pain. Gadolinium uptake. OPERATE?
Figura 37: Cortical com insuflações finas causando dor e desconforto. Indicação de curetagem e enxerto autólogo S/N.
Figure 37: Cortical with fine insufflations causing pain and discomfort. Indication of curettage and autologous graft S/N.
Figura 38: Acesso dorso lateral, curetagem cuidadosa da lesão, cavidade sem lesão, material cartilaginoso curetado e enxerto autólogo do ilíaco, para preenchimento da cavidade.
Figure 38: Dorso-lateral access, careful curettage of the lesion, cavity without injury, cartilaginous material curetted and autologous iliac graft to fill the cavity.

In the fingers and toes, cartilaginous lesions generally behave benignly.

The eventual unwanted evolution to chondrosarcoma, resulting from curettage surgery in these locations, does not compromise the possibility of a cure, as complete resection of the finger,  which is the treatment of chondrosarcoma , would continue to be possible.

CONTROVERSY :   CHONDROMA OR CHONDROSSARCOMA GRADE I?

        Chondroma occasionally occurs in the metaphysis of long bones  (distal femur, humerus and proximal tibia)  and limb roots  (shoulder, pelvis) . In these cases, it can be confused with bone infarction or grade I chondrosarcoma.

In occasional findings, as  the anatomopathological diagnosis  between chondroma and grade I chondrosarcoma  is controversial , it is preferable not to perform a biopsy and monitor clinically and radiographically whether there is progress.

Grade I chondrosarcoma is slow to evolve, which allows monitoring, enabling observation for a safe diagnosis of its activity or not.

The exams are repeated at one, three and six months, and then annually. The tumor must be treated surgically as  chondrosarcoma  at any time if comparison between images reveals changes in the lesion.

If the injury remains unchanged, the best course of action is to continue monitoring. Some patients ask until when? The answer is: – Always. Reevaluation should continue regardless, whether the patient undergoes surgery or not.

Treating an asymptomatic lesion, a casual finding, without changing the image with minor surgery is “ overtreatment”,  which will also require follow-up or worse, if the anatomopathological examination reveals malignant histology.

Exemplifying this conduct, we will analyze the following case, followed for 14 years, figures 39 to 42.

Figura 39: Paciente com dor na interlinha do joelho após esporte. Ressonância para estudo da articulação mostra achado casual de lesão na metáfise distal do fêmur. CONDROMA / CONDROSSARCOMA GRAU I? QUAL A MELHOR CONDUTA?
Figure 39: Patient with pain in the knee joint after sports. MRI to study the joint shows a casual finding of a lesion in the distal metaphysis of the femur. CHONDROMA / CHONDROSSARCOMA GRADE I? WHAT IS THE BEST CONDUCT?
Figura 40: Radiografia com lesão provavelmente cartilaginosa, na metáfise distal do fêmur. Achado casual: CONDUTA = OBSERVAÇÃO.
Figure 40: Radiograph showing a probably cartilaginous lesion in the distal metaphysis of the femur. Casual finding: CONDUCT = OBSERVATION.
Figura 41: Radiografia de controle após doze anos, queixa de dor recente no joelho. Calcificação na interlinha medial, paciente joga Squash! A dor não tem nada a ver com a lesão em acompanhamento, que continua inalterada.
Figure 41: Control x-ray after twelve years, complaint of recent knee pain. Calcification in the medial interline, patient plays Squash! The pain has nothing to do with the ongoing injury, which remains unchanged.
Figura 42: Controle após 14 anos de acompanhamento, sem biópsia. Inalterado e assintomático, discreta "sensação de? ..., desconforto, quando muda o tempo".
Figure 42: Control after 14 years of follow-up, without biopsy. Unchanged and asymptomatic, discreet "sensation of?..., discomfort, when the weather changes".

CHONDROMA or  CHONDROSSARCOMA?  In these cases  common sense  must prevail, he warns us that  the paper accepts any writing.

We must base ourselves on the clinical behavior of the lesion. Was there a change or not? If we choose to perform a biopsy, we can only add whether or not it is a  “cartilaginous lesion” . We cannot change our behavior:  OBSERVE OR  OPERATE AS CHONDROSSARCOMA .  To be safe, if we choose to operate, we must treat it surgically as chondrosarcoma, which is our only “ tool” , as they do not respond to chemotherapy or radiotherapy.

Continuing, let us analyze figures 43 to 50.
Figura 43: Lesão cartilaginosa latente, acompanhada desde 2003, sem a realização de biópsia, comportamento de condroma. Imagem em 2016 sem alteração. Conduta = manter o acompanhamento, se houver alteração deve ser tratada como condrossarcoma.
Figure 43: Latent cartilaginous lesion, monitored since 2003, without biopsy, chondroma-like behavior. Image in 2016 without changes. Management = maintain monitoring, if there is a change it should be treated as chondrosarcoma.
Figura 44: Lesão cartilaginosa no ramo ílio-púbico direito. Acompanhada havia dois meses, houve piora da imagem, com ruptura da cortical! Foi operado como condrossarcoma, com ressecção segmentar da lesão, sem a realização de biópsia, pois independente do resultado, fosse este condroma ou condrossarcoma o tratamento deve ser cirúrgico, com ressecção ampla.
Figure 44: Cartilaginous lesion in the right iliopubic branch. Followed up for two months, the image worsened, with cortical rupture! It was operated on as chondrosarcoma, with segmental resection of the lesion, without performing a biopsy, because regardless of the result, whether it was chondroma or chondrosarcoma, the treatment must be surgical, with wide resection.
Figura 45: Lesão cartilaginosa, focos de calcificação e erosão da cortical, em cuja amostra de biópsia ¨diagnosticou¨ CONDROMA. Operado com prótese convencional, sem ressecção com margem. Em pouco tempo houve evolução do tumor, CONDROSSARCOMA, levando a uma necessidade de hemipelvectomia, cirurgia ablativa.
Figure 45: Cartilaginous lesion, foci of calcification and cortical erosion, in which the biopsy sample ¨diagnosed¨ CHONDROMA. Operated with conventional prosthesis, without resection with margin. In a short time, the tumor, CHONDROSSARCOMA, evolved, leading to the need for hemipelvectomy, ablative surgery.
Figura 46: Lesão cartilaginosa do fêmur com todas as características de lesão agressiva. Deve ser tratada como CONDROSSARCOMA.
Figure 46: Cartilaginous injury of the femur with all the characteristics of an aggressive injury. It should be treated as CHONDROSSARCOMA.
Figura 47: Radiografia de lesão no úmero, com todas as características de agressividade da lesão cartilaginosa: dor, erosão da cortical, alargamento do canal medular por atividade do tumor - o comportamento não é latente: é ativo e agressivo. Na ressonância podemos acompanhar o trajeto da biópsia, contaminado pela implantação da neoplasia.
Figure 47: X-ray of a lesion in the humerus, with all the aggressive characteristics of a cartilaginous lesion: pain, cortical erosion, widening of the spinal canal due to tumor activity - the behavior is not latent: it is active and aggressive. On MRI we can follow the biopsy path, contaminated by the implantation of the neoplasm.
Figura 48: Laudo de biópsia realizada, revela tratar-se de lesão cartilaginosa sem atipias, nesta amostra recomendando nova biópsia? Precisa? Que conduta o médico tomaria se em uma eventual nova biópsia, a qual continuaria sendo uma amostra, continuasse a impressão de condroma? Deve-se considerar o comportamento evolutivo da lesão e tratar como condrossarcoma.
Figure 48: Biopsy report performed, reveals that it is a cartilaginous lesion without atypia, in this sample recommending a new biopsy? It needs? What action would the doctor take if in a possible new biopsy, which would still be a sample, the impression of chondroma continued? The evolutionary behavior of the lesion must be considered and treated as chondrosarcoma.
Figura 49: Paciente tratada como condrossarcoma. Peça de paciente operada sem nova biópsia. Podemos verificar em destaque a implantação da neoplasia agressiva nos tecidos moles, através do trajeto da biópsia.
Figure 49: Patient treated for chondrosarcoma. Part of a patient operated on without a new biopsy. We can clearly see the implantation of the aggressive neoplasm in the soft tissues, through the biopsy path.
Figura 50: Ressecção e reconstrução com endoprótese, no membro dominante de paciente odontóloga, após quatorze anos.
Figure 50: Resection and reconstruction with endoprosthesis, in the dominant limb of a dental patient, after fourteen years.
The message we want to leave is:

¨The doctor  can perform the biopsy , as it is an academic procedure, which gives him more support as to whether it is a cartilaginous lesion. But  you should not operate with a curettage technique , such as chondroma, as latent chondromas of long bones, casual findings, do not require surgical treatment but rather observation. The biopsy hinders this observation because we will not know whether the pain and changes in the image, which may occur after the biopsy, would be due to the aggression of the biopsy or whether it is a chondrosarcoma manifesting itself. In conclusion, if the doctor chooses to intervene,  he must operate on chondrosarcoma . We also remember that surgery, performed using any technique, will not eliminate the need for observation and monitoring¨.

Read:  http://chondrosarcoma or chondroma?

 1 and .  CHONDROBLASTOMA, figures 51 to 54.

IDENTITY: Benign epiphyseal  neoplastic lesion   of the growing skeleton  (1st and  2nd decades  ),  characterized by bone rarefaction, erosion of the articular cartilage with inflation, cartilaginous cells  (chondroblasts), giant cells  and foci of calcification.

Figura 51: Condroblastoma, tumor epifisário ou apofisário dos ossos longos DO ESQUELETO EM CRESCIMENTO.
Figure 51: Chondroblastoma, epiphyseal or apophyseal tumor of the long bones OF THE GROWING SKELETON.
Figura 52: Lesão com matriz cartilaginosa, epifisária, em adolescente (esqueleto em crescimento), halo de esclerose, erosão da cartilagem articular e da cortical óssea, com focos de calcificação = CONDROBLASTOMA.
Figure 52: Lesion with cartilaginous matrix, epiphyseal, in an adolescent (growing skeleton), halo of sclerosis, erosion of the articular cartilage and cortical bone, with foci of calcification = CHONDROBLASTOMA.
Figura 53: Lesão com matriz cartilaginosa, epifisária, em criança (esqueleto em crescimento), halo de esclerose, com focos de calcificação = CONDROBLASTOMA.
Figure 53: Lesion with cartilaginous matrix, epiphyseal, in a child (growing skeleton), halo of sclerosis, with foci of calcification = CHONDROBLASTOMA.
Figura 54: Acesso póstero medial à cabeça femoral, para permitir o tratamento cirúrgico da lesão com curetagem, eletro termia e reconstrução com enxerto autólogo do ilíaco.
Figure 54: Posteromedial access to the femoral head, to allow surgical treatment of the injury with curettage, electrothermia and reconstruction with an autologous iliac graft.

Adjuvant curettage and electrothermal surgery for this neoplasm, in these locations and in small-sized lesions, is nothing more than an incisional biopsy, in which the macroscopic appearance of cartilage allows complete curettage of the tumor. The presence of the pathologist in the surgery is useful to corroborate and assist the surgeon. Read:  http://chondroblastoma

 1f . SIMPLE BONE CYST – COS, figures 55 to 58.

IDENTITY: Pseudoneoplastic lesion, unicameral, surrounded by a membrane, well delimited, filled with serous fluid, central metaphyseal  location  , which does not exceed its width and occurs in children and adolescents.  

Figura 55: Cisto ósseo simples do úmero. Lesão bem delimitada que não ultrapassa a largura da metáfise. Descoberta devido à dor por micro fratura. Com o crescimento distancia-se da linha epifisial. Cavidade única, revestida por membrana contendo líquido seroso.
Figure 55: Simple bone cyst of the humerus. Well-defined lesion that does not exceed the width of the metaphysis. Discovery due to pain due to micro fracture. With growth it distances itself from the epiphyseal line. Single cavity, lined with a membrane containing serous fluid.
Figura 56: Cisto ósseo simples na fíbula. Esta é a única localização que pode eventualmente ser mais largo do que a metáfise, devido à cortical fina poder insuflar-se. A fíbula não é osso de carga, podemos observar. Com o crescimento afasta-se da linha epifisial e mineraliza, evoluindo para cura.
Figure 56: Simple bone cyst in the fibula. This is the only location that may eventually be wider than the metaphysis, due to the thin cortex being able to inflate. The fibula is not a load-bearing bone, we can see. As it grows, it moves away from the epiphyseal line and mineralizes, progressing towards healing.
Figura 57: Cisto ósseo simples da tíbia. Dor por tração da tuberosidade tibial pelo ligamento patelar, devido ao afilamento da cortical.
Figure 57: Simple bone cyst of the tibia. Pain caused by traction of the tibial tuberosity by the patellar ligament, due to cortical thinning.
Figura 58: Cisto ósseo simples. Cavidade única, bem delimitada, com conteúdo líquido envolto por uma membrana, seta em vermelho (captação de contraste apenas na periferia).
Figure 58: Simple bone cyst. Single, well-defined cavity, with liquid content surrounded by a membrane, red arrow (contrast capture only at the periphery).

Read: http://simple bone cyst 

          1g . JUSTAARTICULAR BONE CYST – GANGLION, figures 59 to 62.

IDENTITY:  Pseudoneoplastic lesion,  epiphyseal in location , unicameral, surrounded by synovial membrane, well defined and filled with serous fluid, which communicates with the adjacent joint.

Figura 59: Lesão epifisária de rarefação óssea bem delimitada. Ressonância sagital revelando pertuito na cartilagem articular comunicando o líquido da articulação com o do conteúdo da cavidade. GANGLION (cisto ósseo justa articular).
Figure 59: Well-defined epiphyseal bone rarefaction lesion. Sagittal resonance revealing a hole in the articular cartilage communicating the joint fluid with the contents of the cavity. GANGLION (just articular bone cyst).
Figura 60: Lesão homogênea, com conteúdo líquido (baixo sinal em T1 e Alto sinal em T2). Em sagital T1 com contraste observamos captação apenas na periferia da lesão, destacando a membrana sinovial secretora do líquido seroso que preenche a cavidade.
Figure 60: Homogeneous lesion, with liquid content (low signal on T1 and high signal on T2). In sagittal T1 contrast, we observed uptake only at the periphery of the lesion, highlighting the synovial membrane that secretes the serous fluid that fills the cavity.
Figura 61: Lesão epifisária de rarefação óssea bem delimitada. Ressonância coronal e axial destacando o aspecto homogêneo e circunscrito da lesão. Ganglion? Provavelmente não, pois não há comunicação com a articulação. Provável cárie óssea, sequela de processo inflamatório.
Figure 61: Well-defined epiphyseal bone rarefaction lesion. Coronal and axial resonance highlighting the homogeneous and circumscribed appearance of the lesion. Ganglion? Probably not, as there is no communication with the joint. Probable bone caries, sequelae of an inflammatory process.
Figura 62: Ressonâncias sagitais T1 e com contraste evidenciando a delimitação periférica da lesão, que não se comunica com a articulação. Lesão de conteúdo líquido homogêneo e muito pequena, pode ser tratada sem biópsia.
Figure 62: Sagittal T1 and contrast-enhanced MRI scans showing the peripheral delimitation of the lesion, which does not communicate with the joint. Lesion with homogeneous liquid content and very small, can be treated without biopsy.

These lesions do not require a biopsy for treatment.

          1h . CORTICAL FIBROUS DEFECT / NON-OSSIFYING FIBROMA, figures 63 and 64.

IDENTITY:  Pseudoneoplastic lesion in the  cortical bone  with precise limits, asymptomatic. Occasional find.

Figura 63: Radiografia com lesão circunscrita na cortical do fêmur. Na tomografia observamos que é homogênea, pequena, menor que 1.5 cm, delimitada por halo de esclerose. Defeito fibroso cortical operado por desconforto leve, devido à inserção do músculo adutor.
Figure 63: Radiograph with circumscribed lesion in the cortical bone of the femur. On the tomography we observed that it is homogeneous, small, less than 1.5 cm, delimited by a halo of sclerosis. Cortical fibrous defect operated for mild discomfort, due to the insertion of the adductor muscle.
Figura 64: Lesão circunscrita na cortical lateral da tíbia, maior que 1.5 cm. Neste fibroma não ossificante, observamos que a lesão se distancia da linha epifisial e ocorre discreta mineralização. Achado de exame, acompanhamento sem biópsia.
Figure 64: Circumscribed lesion in the lateral cortex of the tibia, greater than 1.5 cm. In this non-ossifying fibroma, we observed that the lesion distances itself from the epiphyseal line and slight mineralization occurs. Examination finding, follow-up without biopsy.
These lesions occur in the  cortical bone  and do not require a biopsy for treatment/monitoring.

1i . FIBROUS DYSPLASIA OF THE  TIBIA  / OSTEOFIBRODYSPLASIA, figures 65 to 70.

IDENTITY:  Pseudoneoplastic lesion in the  tibial diaphysis  with bone rarefaction of intermediate density, as if the bone had been  “erased” , with a ground-glass appearance. It can occur in more than one location. Its evolution is variable and can cause deformity, dedifferentiation or harmonious growth, stabilizing at skeletal maturity. 

Figura 65: Lesão diafisária em criança com um ano de idade, com aumento acentuado e deformidade progressiva em dezoito meses. OSTEOFIBRODISPLASIA.
Figure 65: Diaphyseal injury in a one-year-old child, with marked increase and progressive deformity in eighteen months. OSTEOFIBRODYSPLASIA.
Figura 66: Paciente operada sem biópsia prévia, com ressecção da lesão, controlando sua progressão e corrigindo a deformidade. Reconstrução biológica com enxerto autólogo e homólogo.
Figure 66: Patient operated on without prior biopsy, with resection of the lesion, controlling its progression and correcting the deformity. Biological reconstruction with autologous and homologous graft.
Figura 67: Paciente com cinco anos de idade. Em 1990, foi encaminhado para “amputação” devido a lesão na tíbia! Displasia fibrosa? Osteofibrodisplasia? Adamantinoma da tíbia? Conduta: OBSERVAÇÃO.
Figure 67: Five-year-old patient. In 1990, he was sent for “amputation” due to an injury to his tibia! Fibrous dysplasia? Osteofibrodysplasia? Adamantinoma of the tibia? Conduct: OBSERVATION.
Figura 68: Acompanhamento anual. Crescimento proporcional da lesão e alinhamento harmônico da perna. Conduta: OBSERVAÇÃO, sem biópsia.
Figure 68: Annual monitoring. Proportional growth of the lesion and harmonious alignment of the leg. Management: OBSERVATION, without biopsy.
Figura 69: Cintilografia e radiografias de 2016, após vinte e cinco anos de observação, sem biópsia. Paciente adulto, tíbia alinhada.
Figure 69: Scintigraphy and radiographs from 2016, after twenty-five years of observation, without biopsy. Adult patient, tibia aligned.
Figura 70: Aspecto clínico e funcional do paciente, após vinte e cinco anos de observação, sem biópsia. Não se deve tratar um rótulo.
Figure 70: Clinical and functional appearance of the patient, after twenty-five years of observation, without biopsy. A label should not be treated.

 1J . MYOSITIS OSSIFICANS, figures 71 and 72.

IDENTITY:  Injury located close to a bone and in soft tissues, related to previous trauma, whose ossification begins in the periphery. 

Figura 71: Dor na face medial da coxa esquerda havia oito meses, após trauma. Hipotrofia do quadríceps denotando lesão cônica. Radiografia e cintilografia revelando ossificação.
Figure 71: Pain on the medial side of the left thigh for eight months, after trauma. Quadriceps hypotrophy denoting conical injury. Radiography and scintigraphy revealing ossification.
Figura 72: Tomografia e ressonância evidenciando ossificação em tecidos moles, principalmente na periferia da lesão. A biópsia pode dar falso diagnóstico de osteossarcoma!
Figure 72: Tomography and resonance showing ossification in soft tissues, mainly on the periphery of the lesion. Biopsy can give a false diagnosis of osteosarcoma!

1k . SOFT TISSUE TUMOR –  SOME , figures 73 to 78.

IDENTITY:  Delimited, homogeneous lesions, with typical images, without contrast uptake or with uptake only in the periphery, can be operated on without prior biopsy, when the surgical approach would not be different, even in the case of a malignant neoplasm.

Figura 73: Tumor de tecidos moles da região glútea, homogêneo, densidade de gordura em T1, que continua com o mesmo aspecto na saturação. LIPOMA.
Figure 73: Soft tissue tumor of the gluteal region, homogeneous, fat density on T1, which continues with the same appearance at saturation. LIPOMA.
Figura 74: Ressonância confirmando ser tecido gorduroso homogêneo, captação de contraste apenas na periferia do tumor. Ressecção da lesão envolta em sua pseudocápsula. LIPOMA.
Figure 74: MRI confirming that it is homogeneous fatty tissue, contrast uptake only at the periphery of the tumor. Resection of the lesion enclosed in its pseudocapsule. LIPOMA.

Malignant soft tissue tumors would have the same surgical resection procedure, with the narrow margins presented in the case above and would be complemented with local radiotherapy.  Soft tissue sarcomas, to date, do not respond to chemotherapy nor show an improvement in the patient’s survival rate.

See:  http://soft tissue sarcomas / chemotherapy

Figura 75: Ressonância evidenciando lesão em tecidos moles no trajeto do nervo interósseo posterior. Sinal de tinel positivo. SCHWANNOMA. Ressecção biópsia, abrindo o perineuro e enucleando o tumor, que se desprende facilmente ("como o caroço do abacate").
Figure 75: MRI showing injury to soft tissues in the path of the posterior interosseous nerve. Positive tinel sign. SCHWANNOMA. Biopsy resection, opening the perineurium and enucleating the tumor, which detaches easily ("like an avocado pit").
Figura 76: Radiografia com tumor no cavo poplíteo. Ressonância em T1 e T2 desenhando a “cauda de cometa” em trajeto nervoso. Exérese da lesão que parece uma cebola. Abre-se cuidadosamente a bainha (“casca da cebola”) e a lesão é retirada por completo, sem lesar o nervo.
Figure 76: Radiograph showing tumor in the popliteal cavity. MRI in T1 and T2 drawing the “comet tail” in the nervous path. Excision of the lesion that looks like an onion. The sheath (“onion skin”) is carefully opened and the lesion is removed completely, without damaging the nerve.

A possible biopsy could cause nerve damage and would not change the management.

Figura 77: Tumor heterogêneo da região posterior da coxa, deslocando os vasos femorais e o nervo ciático. SARCOMA DE TECIDOS MOLES.
Figure 77: Heterogeneous tumor of the posterior region of the thigh, displacing the femoral vessels and the sciatic nerve. SOFT TISSUE SARCOMA.
Figura 78: Ressecção com margens exíguas, apenas com sua pseudocápsula, liberando-se o nervo da lesão. Patologia confirma a hipótese de lipossarcoma mixóide. Após a completa cicatrização da ferida operatória, é realizada a radioterapia adjuvante.
Figure 78: Resection with tight margins, with only its pseudocapsule, freeing the nerve from the lesion. Pathology confirms the hypothesis of myxoid liposarcoma. After complete healing of the surgical wound, adjuvant radiotherapy is performed.

Biopsy can be performed, it is academic, it complements the case studies, but surgical resection must prevail, even in the case of malignant neoplasia. Soft tissue sarcomas, to date, do not benefit from neoadjuvant treatment and ablative surgery does not alter survival.

GROUPS  3 : Biopsy is necessary for treatment  (surgery; with/without neoadjuvance) 

We need to emphasize that the biopsy must be  performed/ monitored  by the surgeon who will perform the surgery. Your presence is essential for this to be carried out in accordance with the surgery planning.

Transverse incisions should not be made, nor extensive incisions where there is no musculature for subsequent coverage, such as on the leg, for example. The suture should not have points far from the incision, as this will require a larger resection of tissue and much less more than one incision, figures 79 (tables A, B, C and D) and 80.

Figura 79: Quadro A - incisão transversa INADEQUADA; quadro B - incisão grande e larga na tíbia lesando a pata de ganso; quadro C - pontos de sutura distantes da linha da incisão e quadro D - uma, duas, TRÊS INCISÕES !!!
Figure 79: Chart A - INADEQUATE transverse incision; table B - large and wide incision on the tibia damaging the pes ansus; frame C - suture points distant from the incision line and frame D - one, two, THREE INCISIONS!!!
Figura 80: Duas incisões !!! Distantes e com nódulo subcutâneo de implantação de tumor de células gigantes !!!
Figure 80: Two incisions!!! Distant and with a subcutaneous nodule of giant cell tumor implantation!!!
 See the complete case of figure 80 at:  http://tgc-prótese intraepifisária
Figura 81: Duas incisões!!! Trajetos inadequados dificultando a ressecção com margem do condrossarcoma. Foi necessária uma ressecção extra articular e reconstrução com uma artrodese empregando-se uma prótese rígida de joelho, feita sob medida.
Figure 81: Two incisions!!! Inadequate routes making resection with chondrosarcoma margin difficult. An extra-articular resection and reconstruction with arthrodesis using a custom-made rigid knee prosthesis were necessary.
Figura 82: Incisão transversa!!! Trajeto inadequado dificultando a ressecção com margem deste condrossarcoma da pelve. Foi necessária uma ampla ressecção de pele nesta hemipelvectomia interna.
Figure 82: Transverse incision!!! Inadequate path making it difficult to resect this chondrosarcoma of the pelvis with margin. A wide skin resection was required in this internal hemipelvectomy.
See the complete case in figure 82 at: http://internal pelvectomy

Below, we exemplify two cases of biopsies performed correctly, figures 83 to 86.

Figura 83: BIÓPSIA CORRETA. Puntiforme, com agulha de Jamshid, permitindo a ressecção do tumor com margem, juntamente com o trajeto da biópsia.
Figure 83: CORRECT BIOPSY. Punctate, with a Jamshid needle, allowing resection of the tumor with a margin, along with the biopsy path.
Figura 84: Peça ressecada com margem, incluindo o trajeto da biópsia. Reconstrução com dispositivo de fixação interna extensível e autotransplante com a cartilagem de crescimento da fíbula.
Figure 84: Resected piece with margin, including the biopsy path. Reconstruction with an extensible internal fixation device and autotransplantation with fibula growth cartilage.
*See the complete case of figures 83 and 84 at:  http://growth cartilage transplant
Figura 85: Radiografia e ressonância de osteossarcoma. A seta indica o ponto correto para a coleta da biópsia.
Figure 85: Radiography and resonance of osteosarcoma. The arrow indicates the correct point for biopsy collection.
Figura 86: Cicatriz puntiforme de BIÓPSIA CORRETA, realizada com agulha de Jamshid, permitindo a ressecção do tumor com margem, juntamente com o trajeto da biópsia.
Figure 86: Punctate scar from CORRECT BIOPSY, performed with a Jamshid needle, allowing resection of the tumor with a margin, along with the biopsy path.
*See the complete case of figures 85 and 86 at:  http://partial rotational prosthesis
PLANNING AND EXECUTION OF BIOPSIES :  CONSIDERATIONS – HOW TO PERFORM 
Case 1 Considerations :  We will describe how we proceeded in this female patient, 40 years old, with pain in the right posterior superior iliac crest for six months, figures 87 to 116.
Figura 87: Radiografia de bacia obturatriz com lesão na crista ilíaca direita, seta e círculo em vermelho.
Figure 87: X-ray of the obturator pelvis with injury to the right iliac crest, arrow and circle in red.
Figura 88: Radiografia de bacia em alar com áreas de rarefação e outras de condensação (focos de calcificação?).
Figure 88: X-ray of the alar pelvis with areas of rarefaction and others of condensation (calcification foci?).
Figura 89: Tomografia axial evidenciando a lesão lítica agressiva no ilíaco direito, com erosão da cortical e tumor extra cortical com focos salpicados de condensação óssea.
Figure 89: Axial tomography showing the aggressive lytic lesion in the right iliac, with cortical erosion and extra-cortical tumor with speckled foci of bone condensation.
Figura 90: Tomografia coronal. Observamos a lesão na crista ilíaca, círculo vermelho e a região póstero inferior sem lesão, podendo-se preservar uma ponte sacro ilíaca, seta amarela.
Figure 90: Coronal tomography. We observed the lesion on the iliac crest, red circle and the inferior posteroregion without injury, with a sacroiliac bridge being able to be preserved, yellow arrow.
In the MRI analysis, we studied the involvement of the lesion, planned the surgical access and resection tactics with margin, and then chose the most appropriate and safe route for our biopsy, figures 91 and 92.
Figura 91: Ressonância axial exibindo os limites do tumor. A lesão extraóssea está delimitada internamente pelo peritônio, seta vermelha, externamente pelo músculo glúteo, seta amarela, recoberta pelo plano gorduroso, seta branca. O trajeto ideal para a biópsia deve ser pela crista ilíaca, seta azul.
Figure 91: Axial resonance showing the limits of the tumor. The extraosseous lesion is delimited internally by the peritoneum, red arrow, externally by the gluteal muscle, yellow arrow, covered by the fatty plane, white arrow. The ideal route for the biopsy should be through the iliac crest, blue arrow.
Figura 92: Ressonância coronal destacando a lesão, círculo vermelho e o plano de corte planejado, seta amarela.
Figure 92: Coronal resonance highlighting the lesion, red circle and the planned cutting plane, yellow arrow.
Thus, the planned resection is to be accessed through an incision following the iliac crest, dissecting externally through the fat plane and internally detaching the peritoneum. We intended to place the patient in the supine position, but while dressing the patient was anesthetized and placed in the prone position, which made the procedure difficult, in our opinion, figures 93 and 94.
Figura 93: Paciente anestesiada em decúbito prono, realizada a marcação da incisão por sobre a crista ilíaca, que permitisse abordar ambos os lados da lesão, linha azul.
Figure 93: Patient anesthetized in prone position, marking the incision above the iliac crest, which allowed both sides of the lesion to be approached, blue line.
Figura 94: Controle tomográfico da lesão, com o paciente em decúbito prono.
Figure 94: Tomographic control of the lesion, with the patient in the prone position.

The Rx operator argued that that position was the best and that we could easily obtain the material for the histological study and… made an X where he would obtain the sample! Figures 95 and 96.

Figura 95: Marca onde pretendiam puncionar! Fora do trajeto planejado!
Figure 95: Mark where they intended to puncture! Off the planned route!
Figura 96: Tomo da pretendida punção! Como resgatar este trajeto na ressecção? Marca onde pretendiam puncionar! Fora do trajeto planejado!
Figure 96: Tome of the intended puncture! How can this path be recovered during resection? Mark where they intended to puncture! Off the planned route!
I explained that we should not change the direction of the planned surgical incision, as this would make internal access to the pelvis difficult. We advise you to puncture at the lateral point of the crest, despite the difficulty in angulating the needle, due to the prone position. This procedure is described as  ¨freezing biopsy¨ , figures 97 to 102.
Figura 97: Orientação para lateralizar o ponto de punção da biópsia, seta amarela.
Figure 97: Orientation to lateralize the biopsy puncture point, yellow arrow.
Figura 98: Controle tomográfico do novo posicionamento, o mais lateral possível, sobre a linha de incisão planejada.
Figure 98: Tomographic control of the new positioning, as lateral as possible, on the planned incision line.
Figura 99: Biópsia sob sedação e controle de tomografia.
Figure 99: Biopsy under sedation and tomography control.
Figura 100: Tomografia com esquema detalhando o planejamento da ressecção, com margem oncológica, incluindo o trajeto da biópsia.
Figure 100: Tomography with a diagram detailing the resection planning, with oncological margin, including the biopsy path.
Figura 101: Agulha de Tru-cut e material de anestesia local.
Figure 101: Tru-cut needle and local anesthesia material.
Figura 102: Estudo da amostra colhida pelo patologista, na sala de radiologia, conhecida como biópsia de congelação.
Figure 102: Study of the sample collected by the pathologist, in the radiology room, known as frozen section biopsy.
With the confirmation of a cartilaginous tumor, likely chondrosarcoma GII, we performed partial resection of the right pelvis, as planned, without neoadjuvance, figures 103 to 116.
Figura 102: Estudo da amostra colhida pelo patologista, na sala de radiologia, conhecida como biópsia de congelação.
Figure 103: Frozen biopsy report and subsequent paraffin review: Chondrosarcoma GII.
Figura 104: Paciente posicionada em decúbito lateral, marcação da incisão planejada na pele, com ressecção do trajeto da biópsia.
Figure 104: Patient positioned in lateral decubitus, marking of the planned skin incision, with resection of the biopsy path.
Figura 105: Incisão e hemostasia cuidadosa. Trajeto de biópsia, seta em azul.
Figure 105: Incision and careful hemostasis. Biopsy path, blue arrow.
Figura 106: Dissecção pelo plano gorduroso, que reveste os músculos glúteos a serem ressecados como margem. Hemostasia cuidadosa, não há sangramento.
Figure 106: Dissection through the fatty plane, which covers the gluteal muscles to be resected as a margin. Careful hemostasis, there is no bleeding.
Figura 107: Peça ressecada, face externa, plano gorduroso cobrindo a musculatura glútea ressecada.
Figure 107: Dried piece, external face, fatty plane covering the dry gluteal muscles.
Figura 108: Peça ressecada, face interna, margem exígua da pseudo cápsula, peritônio rebatido.
Figure 108: Resected piece, internal surface, narrow margin of the pseudo capsule, folded peritoneum.
Video 1: Exposure of the internal surface of the pelvis and delicate osteotomy, performed with minimally invasive drills.
Figura 109: Corte da peça ressecada, observando-se as margens marcadas com tinta nanquim.
Figure 109: Section of the dried piece, observing the margins marked with Indian ink.
Figura 110: Hematoxilina e eosina, histologia de Condrossarcoma grau II.
Figure 110: Hematoxylin and eosin, grade II chondrosarcoma histology.
Figura 111: Erosão óssea por neoplasia cartilaginosa.
Figure 111: Bone erosion due to cartilaginous neoplasia.
Figura 112: Neoplasia cartilaginosa, com mitoses atípicas e hipercromasia.
Figure 112: Cartilaginous neoplasm, with atypical mitoses and hyperchromasia.
Figura 113: Neoplasia cartilaginosa, com polimorfismo celular.
Figure 113: Cartilaginous neoplasm, with cellular polymorphism.
Figura 114: Laudo da peça cirúrgica. Condrossarcoma GII, com focos entre 5 a 10 % de GIII.
Figure 114: Report of the surgical specimen. Chondrosarcoma GII, with foci between 5 and 10% of GIII.
Case 2 Considerations :  Let’s now discuss the biopsy in this eleven-year-old patient, with pain and a tumor in the left thigh for two weeks. Probable osteosarcoma, figures 115 to 118.
Figura 115: Radiografia de frente com lesão na face lateral da metáfise distal do fêmur esquerdo, seta em vermelho e face posterior, radiografia em perfil.
Figure 115: Frontal radiograph with lesion on the lateral aspect of the distal metaphysis of the left femur, arrow in red and posterior aspect, lateral x-ray.
Figura 116: Tomografia axial destacando a lesão que ocupa a região central do osso e ultrapassa a cortical nas faces anterior, lateral e posterior, lesão osteoblástica, agressiva.
Figure 116: Axial tomography highlighting the lesion that occupies the central region of the bone and goes beyond the cortex on the anterior, lateral and posterior surfaces, an aggressive, osteoblastic lesion.
Figura 117: Ressonância coronal T1, com supressão de gordura destacando a extensão medular da lesão, que compromete a cartilagem de crescimento.
Figure 117: Coronal T1 resonance, with fat suppression highlighting the medullary extension of the lesion, which compromises the growth cartilage.
Figura 118: Ressonância axial T1, com supressão de gordura, lesão intramedular e extra cortical. Seta amarela aponta a fáscia lata. A seta amarela indica o trajeto adequado para a biópsia.
Figure 118: Axial T1 resonance, with fat suppression, intramedullary and extra-cortical lesion. Yellow arrow points to the fasciae latae. The yellow arrow indicates the appropriate path for the biopsy.

We very frequently see patients with biopsy scars performed in the anterolateral region of the distal metaphysis of the femur. The  red arrow  points to the fascia lata, which is most often interrupted by the biopsy path, carried out by professionals who will not operate on the patient, making it difficult to cover future surgery and the function of this limb that will need to be reconstructed.

The  yellow arrow  indicates the posterolateral path, most suitable for biopsy and reconstruction, providing the best coverage and function.

To perform the biopsy using this route, the appropriate positioning of the patient is in the prone position, figures 119 to 122.

Figura 119: Paciente em decúbito prono, para facilitar a realização da biópsia, posteriormente à inserção da fáscia lata, seta em vermelho. A Seta amarela destaca o controle tomográfico da posição.
Figure 119: Patient in prone position, to facilitate the biopsy, after insertion of the fascia lata, red arrow. The yellow arrow highlights the tomographic control of the position.
Figura 120: Paciente sob sedação, anestesia local e controle tomográfico do procedimento.
Figure 120: Patient under sedation, local anesthesia and tomographic control of the procedure.
Figura 121: Biópsia realizada abaixo da fáscia lata. Setas em vermelho, controle tomográfico do procedimento, seta amarela.
Figure 121: Biopsy performed below the fascia lata. Red arrows, tomographic control of the procedure, yellow arrow.
Figura 122: Patologia de congelação realizada atesta neoplasia maligna de grandes células, provável osteossarcoma.
Figure 122: Frozen section pathology performed attests to a large cell malignancy, likely osteosarcoma.

For the treatment of tumors of the distal end of the femur, such as this lesion, with this degree of involvement and location, we recommend biopsy as described and neoadjuvant induction chemotherapy, resection with oncological margin and reconstruction with modular prosthesis and adjuvant chemotherapy.

The patient in this example is out of treatment, with excellent function, and the complete case can be seen at Link:  http://osteosarcoma-length discrepancy  .

The performance of musculoskeletal biopsy, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals.

“Carrying out musculoskeletal biopsies, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals and with the participation of the surgeon who will be managing the case”. 

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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