A review of excised biopsy tract histology for primary bone tumours: Is excision necessary?

Price A, Maxwell C, Beardsall J, Jeys L

Background• Biopsy tracts are excised at the point of definitive

surgery.

• Theoretical risk of malignant seeding of the biopsy tract.

• Cases of malignant seeding of the needle biopsy tracts in other malignancies.

• Insufficient evidence to suggest that biopsy tracts pose a risk to local recurrence

• Case reports and small studies are conflicting.

Aims1. To investigate how frequently biopsy

tract excision is carried out at ROH.

2. To establish the incidence of seeding of biopsy tracts in our patients.

3. Evaluate whether certain tumour types are more likely to seed a biopsy tract.

4. Determine whether the excision of biopsy tracts reduces the rate of local recurrence.

Methods• A retrospective analysis of 278 patients with

primary bone tumours• 1/1/08-31/12/09 • Minimum 3 years follow up.

Histology reports for all patients were reviewed.

The database was used to find:• Diagnosis• Age at diagnosis• Type and date of biopsy• Type and date of surgical procedure• Local recurrence, metastases and death.

Statistical analysis was carried out using Statsview (Berkley, California).

278Primary bone tumours

between 2008-2009

203Surgery recorded at

ROH

109Biopsy tract excised

108Negative biopsy tract

histology

1Positive biopsy tract

histology

94Biopsy tract not

commented upon in pathology report

75No surgery recorded at

ROH

Patient selection

203 patients at ROH• Mean age at diagnosis was 33yrs

(range 3-90yrs).• 88% underwent needle biopsy as the

method of biopsy.• Wide range of definitive surgical

procedures.

109 had a biopsy tract excision

94 did not have a tract excision mentioned – 45 amputations - ?tract excised– The remainder could not be identified at

the time of surgery?– Average time from biopsy to procedure for

these patients 4mths

109 patients with excised biopsy tract

• The primary diagnosis varied considerably

• 108 patients had no evidence of seeding.

• 1 patient had histological evidence of seeding within the biopsy tract:

“..along the needle track, a 3mm solid nodule of high grade sarcoma similar to the high grade component of the intraosseous tumour. This nodule most likely

represents an implant.”

One case of malignant infiltration• 72yr old with dedifferentiated

chondrosarcoma of the distal femur.

• Needle biopsy 20 days prior to EPR and excision of the biopsy tract.

• Large local recurrence within 5 months of diagnosis.

• The patient died 10 months later with metastatic disease.

Local recurrence rates• The group who did not have a biopsy tract

excision had less LR than the excised group

9 vs. 19%, p=0.04

• This probably reflects a higher rate of amputation in the non biopsy group.

• Not excising the tract does not necessarily increase the risk of local recurrence.

Time to local recurrence

0

.2

.4

.6

.8

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Cum

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0 5 10 15 20 25 30 35 40Time

Event Times (tract)

Cum. Survival (tract)

Event Times (No tract)Cum. Survival (No tract)

Kaplan-Meier Cum. Survival Plot for TimeToLRCensor Variable: LrcensorGrouping Variable: Tract?

Survival

0

.2

.4

.6

.8

1

Cum

. Sur

viva

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0 10 20 30 40 50 60Time

Event Times (tract)Cum. Survival (tract)

Event Times (No tract)Cum. Survival (No tract)

Kaplan-Meier Cum. Survival Plot for TimeAliveCensor Variable: CensoredGrouping Variable: Tract?

Discussion• Our study shows that biopsy tract excision was not commented upon in 46%

cases, of those 48% underwent amputation.

• 49 patients (24%) had no biopsy tract excised at definitive surgery, as it may be that the tract was difficult to locate.

• Local recurrence rate was lower in patients who did not undergo biopsy excision, however, this is most likely to be due to the large number of amputations carried out in this group.

• Survival and time to LR recurrence remained the same in both groups.

• We have since become aware of three previous incidences of biopsy tract seeding in patients at the ROH between 1996-1999. These were all in chrondrosarcomas.

Conclusion• Removal of biopsy tract remains the gold

standard.• Association between local recurrence and

biopsy tracts is difficult to confirm.• The biopsy tract may be at higher risk in

tumours such as chondrosarcomas which do not receive chemotherapy.

Take home messageOverall the rate of seeding in our cohort is low.

This reassures us that the patient is unlikely to be compromised if identification or removal of the biopsy tract proves difficult.

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