Comparison of Ultrasound Fusion and Computed Tomography Guided Biopsy in Musculoskeletal Neoplasia Marnix van Holsbeeck, MD, Jad G. Khalil, MD, Michael P. MoG MD, Theodore W. Parsons III MD Department of Orthopaedic Surgery Henry Ford Hospital
Disclosure Ins:tu:onal support from GE healthcare research division No personal conflicts with this presenta:on
IntroducJon Percutaneous musculoskeletal biopsy Widely used method for musculoskeletal tumors Imaging needed for accurate needle guidance Ultrasound (US): blind to many lesions Computed Tomography (CT) Magne:c Resonance Imaging (MRI)
Drawbacks of CT and MRI Biopsies Difficulty in scheduling (scanners booked for diagnos:c imaging) Uncomfortable senng for pa:ents OOen lengthy process No real- :me feedback image adjustment and needle placement cannot be performed simultaneously
TradiJonal US guidance Pros Faster to schedule Obtained in an US suite (comfortable atmosphere) Real- :me feedback (biopsy tool directed under con:nuous imaging) No radia:on exposure Cons Low sensi:vity for the diagnosis of some lesions Low contrast resolu:on Intraosseous lesions invisible Operator dependent
US fusion technology Incorporates previously obtained CT or MRI scans into the US guided biopsy Computer sooware fuses CT or MR data with real :me US (naviga:on based on reference points) Can iden:fy areas on the US scan that correspond to specific cuts on CT or MRI No repeat scanning necessary
Equipment Dual Position sensing system Ultrasound probe
Equipment
Hypothesis and Endpoints Comparing US fusion (by CT or MRI) with CT guidance Diagnos:c yield; Accuracy Easier scheduling Faster procedure Improved pa:ent comfort
Methods 60 pa:ents recruited 47 pa:ents randomized and available at final follow- up Control group: CT guided biopsy Experimental group: US fusion guided biopsy U:lizing exis:ng CT or MRI scans
47 pa:ents available in follow- up US fusion N= 31 CT scan N= 16 Females = 13 Males = 18 Females = 8 Males = 8
Data CollecJon Demographic Clinical diagnosis Scheduling :me Procedure :me Pa:ent subjec:ve ques:onnaire including five ques:ons, each with five point ra:ng VAS pain score
Data CollecJon Physician collected data indica:ng poten:al complica:ons: Tenderness to palpa:on at the biopsy site Presence of erythema or celluli:s Hematoma (palpable or visible) Complica:on (including infec:on) requiring opera:on Adequacy of histologic specimen (Diagnos:c yield) Correla:on with surgical pathology (Diagnos:c accuracy)
PaJent subjecjve quesjonnaire The procedure was scheduled promptly The atmosphere in the treatment room was friendly and pleasant The procedure was performed quickly The procedure was painless If needed I would undergo the procedure again in the same manner 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient satisfaction questionnaire (1=Strongly agree; 2=Agree; 3= Neither agree or disagree; 4= Strongly disagree)
US fusion pa:ents N = 31 US/CT fusion N = 15 US/MRI fusion N = 16
Anatomic sites Pelvis 5 (CT=2 USF=3) Hip/femur/thigh 24 (CT=8 USF=16) Arm 6 (CT=3 USF=3) Leg 3 (CT=1 USF=2) F&A 3 (CT=0 USF=3) Rib/sternum 2 (CT=1 USF=1) Neck 1 (USF) Forearm 1 (USF) Wrist/hand 1 (USF) Paraspinal 1 (CT)
Needle
StaJsJcal Analysis SigmaStat v3.5 (Systat SoOware Inc, Chicago, IL) Fisher s Exact Test used for binary variables Mann- Whitney Rank Sum, student t- test for con:nuous variables Pearson Product Moment Correla:on Tests to compare con:nuous variables Kruskal- Wallis One- way ANOVAe on Ranks with Dunn s post- hoc Mul:ple Comparison Procedures to examine con:nuous variables as a func:on of categorical variables Alpha =0.05; Trends were noted at p<0.2
DiagnosJc Yield 29/31 pa:ents (94%) in the US fusion arm had a diagnos:c biopsy 15/16 pa:ents (94%) in the CT arm had a diagnos:c biopsy P=1.00
DiagnosJc Accuracy CT arm: 5/6 correlated with surgical pathology (83%) US fusion arm: 14/16 correla:on (88%) P=0.5
Temporal factors Time from request to biopsy (days) Biopsy time (minutes) fusion (average time, SD) CT (average time, SD) P value 3.0, 2.9 8.0, 7.7 0.02* 36, 17 53, 22 0.004* Timeframe needed to obtain an US fusion biopsy was significantly shorter than CT Actual biopsy :me was significantly shorter in the US fusion pa:ents
PaJent sajsfacjon measures fusion (median score) CT (median score) P value The procedure was scheduled promptly The atmosphere in the treatment room was friendly and pleasant The procedure was performed quickly 1.0 1.0 0.152^ 1.0 1.0 0.422^ 1.0 1.5 0.02* The procedure was painless If needed I would undergo the procedure again in the same manner 2.0 2.0 0.175^ 1.0 1.0 0.178^
CT guided biopsies (retrospecjve data) Hau: 359 pa:ents/ 1 year 71% overall accuracy (Skeletal Radiol (2002) 31:349 353) Altuntas: 127 pa:ents/ 4 years 80.3% overall accuracy (ANZ J. Surg. 2005; 75: 187 191) Chojniak: 1300 pa:ents/ 6 years 70-92% FNA, 82-100% cunng needle biopsies showed adequate specimen (Sao Paulo Med J. 2006;124(1):10-4.) Puri: 128 pa:ents/ 3 years 94.5% diagnos:c, 95.4% accuracy (Skeletal Radiol (2006) 35: 138 143)
Strengths of the study First look at new technology Randomized (with a twist) Single ter:ary care facility Single group of radiologists with standardized biopsy techniques Availability of on- site musculoskeletal pathologist
Weaknesses Low sta:s:cal power Musculoskeletal tumors rela:vely less common than other malignancies Pa:ent anri:on rate and follow- up Some pa:ents randomized to CT were converted to US fusion at the discre:on of the radiologist Felt safer performing an US fusion procedure than CT guided Introduces study bias Decreases level of evidence
Conclusions Comparable diagnos:c yield and accuracy Good safety profile Poten:al advantages over CT/MRI real- :me feedback Easier scheduling? Higher pa:ent sa:sfac:on No addi:onal radia:on at biopsy Quickly adopted by radiologists
Thank You! Jad G. Khalil, MD, Michael P. MoG MD, Trevor Banka MD, Marnix van Holsbeeck MD, Theodore W. Parsons III MD Department of Orthopaedic Surgery Henry Ford Hospital