THE CLASSIC: The Hazards of Biopsy in Patients with Malignant Primary Bone and Soft-Tissue Tumors
A study employing questionnaires, performed by the Musculoskeletal Tumor Society, sought to assess the accuracy of diagnoses made from the findings of biopsies, the incidence of complications associated with the biopsy procedure, the effects of errors in diagnosis and of complications on the patient's course, and whether these problems occurred with greater frequency when the initial biopsy was performed in a referring institution or in a treating center. Each member of the Society was asked to submit data on twenty sequential, unselected, newly diagnosed patients with malignant primary tumors of bone or soft tissue who had had a biopsy and a subsequent definitive procedure. Twenty orthopaedic surgeons in sixteen treating centers submitted information on 329 patients with a wide range of diagnoses (but generally conforming to the distribution of these tumors in the general population). The mean age of the patients was36.5 years (range, two weeks to eighty-three years). Two hundred and twenty-two lesions were primary in bone and 107 arose in soft tissue. One hundred and forty-three of the tumors were biopsied in the referring institution and 171, in the treating center.
Analysis of the results of the study showed sixty (18.2 per cent) major errors in diagnosis and thirty-four (10.3 per cent) non-representative or technically poor biopsies. Problems arose in the skin, soft tissue, or bone of the biopsy wounds of fifty-seven patients (17.3 per cent), and the optimum treatment plan had to be altered as a result of problems related to the biopsy in sixty patients (18.2 per cent). In fifteen patients (4.5 per cent) an unnecessary amputation was performed as a result of problems with the biopsy, and in twenty-eight patients (8.5 per cent) the prognosis and outcome were considered to have been adversely affected.
The biopsy-related problems occurred from three to more than five times more frequently when the biopsy was performed at a referring institution rather than in a treating center. On the basis of these observations, the Society suggests that the biopsy should be planned as carefully as definitive surgery and that careful attention should be paid to asepsis, skin-handling, hemostasis, and wound closure. The skin incision should be placed in such a manner so as not to compromise subsequent surgery. The tissue obtained should be sufficient in amount and sufficiently representative of the lesion so that the pathologist can provide a definitive diagnosis. If the surgeon or the institution is not prepared to perform accurate diagnostic studies or proceed with definitive treatment for these patients, the patients should be referred to a treating center prior to biopsy.