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The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions

Paweł Szaro
Paweł Szaro
, 
Andrew Wong
Andrew Wong
, 
Elena Blain
Elena Blain
, 
Khaldun Ghali Gataa
Khaldun Ghali Gataa
 y 
Mats Geijer
Mats Geijer
   | 08 mar 2021
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Article Category: research-article
Publicado en línea: 08 mar 2021
Páginas: 22 - 33
Recibido: 21 oct 2020
Aceptado: 17 dic 2020
DOI: https://doi.org/10.15557/jou.2021.0004
Palabras clave
© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Fig. 1.

Flowchart: inclusion and exclusion criteria for the study
Flowchart: inclusion and exclusion criteria for the study

Fig. 2.

A 56-year-old patient presented to the emergency room because of pain in the thorax and clonus in the foot. An acute MRI of the whole spine revealed an about 10 cm long tumor ( A–C ; straight arrows – tumor). CT showed no calcifications ( D ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. US-CNB was performed ( E, F ; dashed arrows – biopsy needle). A histopathological diagnosis of chondrosarcoma was confirmed after excisional biopsy
A 56-year-old patient presented to the emergency room because of pain in the thorax and clonus in the foot. An acute MRI of the whole spine revealed an about 10 cm long tumor ( A–C ; straight arrows – tumor). CT showed no calcifications ( D ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. US-CNB was performed ( E, F ; dashed arrows – biopsy needle). A histopathological diagnosis of chondrosarcoma was confirmed after excisional biopsy

Fig. 3.

A 58-year-old patient presented to the emergency room with left-sided abdominal pain. Imaging revealed an about 17 cm long solid tumor (straight arrows) in the left retroperitoneal space. MRI showed solid and necrotic parts ( A, B ; curved arrow – solid parts). CT showed the solid tumor in the retroperitoneal space on the left side ( C ). The patient was referred for US-CNB with suspected liposarcoma. A coaxial US-CNB was performed ( D, E ). The pathological diagnosis was liposarcoma grade 1
A 58-year-old patient presented to the emergency room with left-sided abdominal pain. Imaging revealed an about 17 cm long solid tumor (straight arrows) in the left retroperitoneal space. MRI showed solid and necrotic parts ( A, B ; curved arrow – solid parts). CT showed the solid tumor in the retroperitoneal space on the left side ( C ). The patient was referred for US-CNB with suspected liposarcoma. A coaxial US-CNB was performed ( D, E ). The pathological diagnosis was liposarcoma grade 1

Fig. 4.

An 81-year-old patient who three years previously had been operated for an extraskeletal myxoid chondrosarcoma. For the last four months the patient experienced swelling in the operated area, leading to a suspicion of tumor recurrence. MRI ( A, B ) showed an abnormality in direct relation to the right femoral artery and vein. The patient was referred for US-CNB ( C–E ). The ultrasound examination revealed a hypoechogenic and vascularized mass. The histopathological diagnosis was inflammation. CT with intravenous contrast performed 2 months after the biopsy showed a fistula lateral to the femoral artery and vein, with an abscess on the medial side, calcifications and gas ( F ; asterisks – fistula, curved arrow – lesion)
An 81-year-old patient who three years previously had been operated for an extraskeletal myxoid chondrosarcoma. For the last four months the patient experienced swelling in the operated area, leading to a suspicion of tumor recurrence. MRI ( A, B ) showed an abnormality in direct relation to the right femoral artery and vein. The patient was referred for US-CNB ( C–E ). The ultrasound examination revealed a hypoechogenic and vascularized mass. The histopathological diagnosis was inflammation. CT with intravenous contrast performed 2 months after the biopsy showed a fistula lateral to the femoral artery and vein, with an abscess on the medial side, calcifications and gas ( F ; asterisks – fistula, curved arrow – lesion)

Fig. 5.

A 22-year-old patient presenting with knee pain. Radiography ( A, B ) showed no abnormality. The patient was referred for MRI, which revealed an uncalcified solid contrast-enhancing lesion ( C–E ; straight arrow – lesion) in the Hoffa fat pad. Localized nodular synovitis was suspected. Because of pain, the patient was referred for US-CNB ( F, G ; dashed arrow – biopsy needle, curved arrow – patellar tendon, P – patella, T – tibia). The pathological diagnosis was lipoma arborescens
A 22-year-old patient presenting with knee pain. Radiography ( A, B ) showed no abnormality. The patient was referred for MRI, which revealed an uncalcified solid contrast-enhancing lesion ( C–E ; straight arrow – lesion) in the Hoffa fat pad. Localized nodular synovitis was suspected. Because of pain, the patient was referred for US-CNB ( F, G ; dashed arrow – biopsy needle, curved arrow – patellar tendon, P – patella, T – tibia). The pathological diagnosis was lipoma arborescens

Fig. 6.

A 32-year-old patient presented with a painful mass in the popliteal fossa. MRI revealed an intramuscular tumor ( A–C ; straight arrow – tumor). Ultrasound showed a large hypoechoic mass ( D ). After suspicion of neurogenic tumor, the patient was referred for US-CNB ( E, F ; curved arrows – posterior surface of the tibia, dashed arrows – biopsy needle). The histopathological diagnosis was neuroma
A 32-year-old patient presented with a painful mass in the popliteal fossa. MRI revealed an intramuscular tumor ( A–C ; straight arrow – tumor). Ultrasound showed a large hypoechoic mass ( D ). After suspicion of neurogenic tumor, the patient was referred for US-CNB ( E, F ; curved arrows – posterior surface of the tibia, dashed arrows – biopsy needle). The histopathological diagnosis was neuroma

Fig. 7.

A 70-year-old patient with a history of malignant melanoma operated 3 years before presented with pain in the abdomen and right buttock. CT with intravenous contrast in the portal venous phase showed an intramuscular contrast-enhancing mass on the right ( A ; straight arrow – mass). MRI of the pelvis with intravenous contrast showed a solid contrast-enhancing tumor in the gluteal muscles ( B–E ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. The patient was referred for US-CNB ( F, G ; dashed arrows – biopsy needle, curved arrow – iliac bone). The histopathological diagnosis was extrapleural solitary fibrous tumor
A 70-year-old patient with a history of malignant melanoma operated 3 years before presented with pain in the abdomen and right buttock. CT with intravenous contrast in the portal venous phase showed an intramuscular contrast-enhancing mass on the right ( A ; straight arrow – mass). MRI of the pelvis with intravenous contrast showed a solid contrast-enhancing tumor in the gluteal muscles ( B–E ). MRI and CT were unspecific, with a wide spectrum of differential diagnoses. The patient was referred for US-CNB ( F, G ; dashed arrows – biopsy needle, curved arrow – iliac bone). The histopathological diagnosis was extrapleural solitary fibrous tumor

Fig. 8.

A 28-year-old patient presented with a chronically swollen trochanteric region and more discomfort during the last weeks. There was a clinical suspicion of greater trochanteric bursitis. The patient was referred for MRI, where a solid lesion, not bursitis, in close relation to the greater trochanter, was detected ( A ; straight arrow – lesion). After intravenous contrast administration ( B, C ) there was vivid contrast enhancement. No muscle atrophy was visible. The MRI was unspecific, with a wide spectrum of lesions in the differential diagnosis. The patient was referred for US-CNB ( D–F ; curved arrows –greater trochanter, dashed arrow – biopsy needle). A histopathological diagnosis of a benign lesion, with a suspicion of vascular malformation, was made, and the patient was referred for intravascular treatment ( G ; red dashed curved arrow – catheter) which produced a good effect
A 28-year-old patient presented with a chronically swollen trochanteric region and more discomfort during the last weeks. There was a clinical suspicion of greater trochanteric bursitis. The patient was referred for MRI, where a solid lesion, not bursitis, in close relation to the greater trochanter, was detected ( A ; straight arrow – lesion). After intravenous contrast administration ( B, C ) there was vivid contrast enhancement. No muscle atrophy was visible. The MRI was unspecific, with a wide spectrum of lesions in the differential diagnosis. The patient was referred for US-CNB ( D–F ; curved arrows –greater trochanter, dashed arrow – biopsy needle). A histopathological diagnosis of a benign lesion, with a suspicion of vascular malformation, was made, and the patient was referred for intravascular treatment ( G ; red dashed curved arrow – catheter) which produced a good effect

Fig. 9.

An 83-year-old patient with pain in the left buttock and leg. MRI of the pelvis with intravenous contrast revealed a tumor in the greater sciatic foramen ( A–C ; straight arrow – tumor, curved arrow – sciatic nerve). The MRI was unspecific; however, a diagnosis of malignant peripheral nerve sheath tumor was made because of the tumor’s direct relation to the sciatic nerve. The patient was referred for US-CNB ( D–F ; dashed arrows – biopsy needle). No histopathological diagnosis could be made. The patient was referred once again for US-CNB, where the histopathological diagnosis of benign peripheral nerve sheath tumor was made and confirmed after excisional biopsy
An 83-year-old patient with pain in the left buttock and leg. MRI of the pelvis with intravenous contrast revealed a tumor in the greater sciatic foramen ( A–C ; straight arrow – tumor, curved arrow – sciatic nerve). The MRI was unspecific; however, a diagnosis of malignant peripheral nerve sheath tumor was made because of the tumor’s direct relation to the sciatic nerve. The patient was referred for US-CNB ( D–F ; dashed arrows – biopsy needle). No histopathological diagnosis could be made. The patient was referred once again for US-CNB, where the histopathological diagnosis of benign peripheral nerve sheath tumor was made and confirmed after excisional biopsy

Fig. 10.

A 20-year-old football player with pain in the thoracic spine. The patient was referred for spinal MRI, where a solid tumor with calcifications was revealed on the left side of Th12 ( A–C, E ; straight arrow – tumor). CT without intravenous contrast ( D, F ) showed calcifications both in the center and periphery of the lesion, which in combination with the patient’s pain was worrisome. The differential diagnosis included myositis ossificans, osteosarcoma, and osteoblastoma. US-CNB was performed ( G–I ; dashed arrows – biopsy needle). The final histopathological diagnosis of osteoblastoma was made on a repeated US-CNB
A 20-year-old football player with pain in the thoracic spine. The patient was referred for spinal MRI, where a solid tumor with calcifications was revealed on the left side of Th12 ( A–C, E ; straight arrow – tumor). CT without intravenous contrast ( D, F ) showed calcifications both in the center and periphery of the lesion, which in combination with the patient’s pain was worrisome. The differential diagnosis included myositis ossificans, osteosarcoma, and osteoblastoma. US-CNB was performed ( G–I ; dashed arrows – biopsy needle). The final histopathological diagnosis of osteoblastoma was made on a repeated US-CNB

Fig. 11.

A 41-year-old female presenting with pain at the left ischial tuberosity. MRI of the pelvis with intravenous contrast revealed a tumor, about 15 mm long, in relation to the left sciatic spine ( A–C ; curved arrow – tumor). MRI and CT were unspecific, with a wide spectrum of lesions in the differential diagnosis. US-CNB ( D, E ) was performed without a final histopathological diagnosis of a benign lesion. After a CT-guided biopsy ( F ) the final histopathological diagnosis was nodular fasciitis
A 41-year-old female presenting with pain at the left ischial tuberosity. MRI of the pelvis with intravenous contrast revealed a tumor, about 15 mm long, in relation to the left sciatic spine ( A–C ; curved arrow – tumor). MRI and CT were unspecific, with a wide spectrum of lesions in the differential diagnosis. US-CNB ( D, E ) was performed without a final histopathological diagnosis of a benign lesion. After a CT-guided biopsy ( F ) the final histopathological diagnosis was nodular fasciitis

Distribution of lesions in 73 ultrasound-guided core needle biopsies

Upper extremity 26
Shoulder 11
Upper arm 7
Elbow 3
Forearm 5
Lower extremity 35
Pelvis and hip 13
Thigh 12
Knee 5
Lower leg 4
Ankle 1
Trunk 12
Chest wall 5
Abdominal wall and retroperitoneal space 4
Paravertebral soft tissue 3
Total 73

Final diagnosis for 12 accurate biopsies

Final diagnosis for accurate biopsies in alphabetical order
Benign peripheral nerve sheath tumor (Fig. 9)
Endometriosis
Giant cell tumor
Metastatic chondroblastoma
Myositis ossificans
Nodular fasciitis (Fig. 11)
Osteoblastoma (Fig. 10)
Unclear case, malign tumor, probably low-grade myxofibrosarcoma,
[1 mitosis per 10 high power fields]
Benign, mesenchymal tissue, without atypia
Vascular malformation (Fig. 8), 2 patients
Well-differentiated liposarcoma

Final histopathology results in 73 ultrasound-guided core needle biopsies, ordered by quantity

Benign Malignant
Inflammation 8 Well-differentiated liposarcoma 7
Lipoma 6 Chondrosarcoma 2
Desmoid 5 Metastatic gastric cancer 2
Vascular malformation 4 Metastatic malignant me- 2
Intramuscular lipoma 3 Pleomorphic spindle cell sarcoma (high grade) 2
Myxoma 3 Dedifferentiated liposarcoma 1
Neurofibroma 2 Leiomyosarcoma 1
Pigmented villonodular synovitis 2 Lymphoma 1
Atheroma 1 Metastatic breast cancer 1
Endometriosis 1 Metastatic chondroblastoma 1
Fibroma 1 Metastatic lung cancer 1
Giant cell tumor (CT) 1 Metastatic prostate cancer 1
Hematoma 1 Metastatic squamous cell carcinoma 1
Hibernoma 1 Myeloma/plasmocytoma 1
Lipoma arborescens 1 Recurrent Ewing’s sarcoma 1
Myositis ossificans (CT) 1 n = 25
Nodular fasciitis (CT) 1 Unclear
Osteomyelitis 1 Benign, mesenchymal tissue, without atypia 1
Schwannoma 1 Malign, unclear case, probably low-grade myxofibro-sarcoma 1
Solitary fibrous tumor 1 [1 mitosis per 10 high power fields]
Vascular hamartoma 1 n = 2
n = 46 n = 73

Type of lesion and biopsy success in 73 ultrasound-guided core needle biopsies

Biopsy Malignant lesion n = 26 Benign n = lesion 47 Overall n = 73
n % n % n %
Diagnostic 23 88% 38 81% 61 84%
Accurate 3 12% 9 19% 12 16%
Inaccurate 0 0% 0 0% 0 0%
Successful 26 100% 47 100% 73 100%

Differences between age, gender, tumor character, presence of fat and calcifications, volume and depth in accurate and diagnostic biopsies

Accurate Diagnostic p
Average age [years] 47 60
SDmin 26.18 18.215 0.13
max 75 89
Male [n]% 68.2% 3142.5% 0.96
Benign [n]% 912.3% 3852.1% 0.35
Malign [n]% 34.1% 2331.5% 0.28
Fat [n]% 22.7% 1317.8% 0.44
Calcification [n]% 34.1% 34.1% 0.27
Volume [cm3] 154.2 27.8
SDmin 494.70.3 64.00.02 <0.001
max 1724.8 415.8
Depth [mm] 12.8 9.7
SDmin 7.64 7.81 0.18
max 27.4 31.5
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