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Target-specific rib biopsy using the gamma probe
Target-Specific Rib Biopsy Using the Gamma Probe Darryl S. Fernandes, MD, Ralph W. Aye, MD, Daniel J. Garnett, MD, John Denny, MD, Seattle, Washington
Intraoperative localization of rib abnormalities identified on bone scan can be deceptively difficult. Previously used techniques have had limited sensitivity and accuracy. The gamma probe can help localize these bone scan “hot spots.” METHODS: Over the past 17 months, 5 patients underwent gamma-probe– directed limited rib resections following intravenous administration of Tc99m-MDP. Three patients required biopsies for suspected malignancy, and the other 2 underwent therapeutic resections for pain. The device was easy to work with following minimal training. RESULTS: Localization was excellent, limiting the extent of surgery needed. Comparison with rib counting and preoperative bone scan localization showed a discrepancy of up to 13 cm. Sensitivity and accuracy were each 100%. CONCLUSIONS: The gamma probe offers a simple and significant advance in the performance of rib biopsies for nonpalpable lesions. Am J Surg. 2000;179:389 –390. © 2000 by Excerpta Medica, Inc. BACKGROUND:
S
uccessful rib biopsy and limited rib resection require precise localization of the involved lesion. This can be deceptively difficult, especially when an abnormal bone scan is accompanied by no palpable abnormality and a lack of radiographic findings. Several techniques have been utilized to aid in the localization of rib lesions for biopsy. These include rib counting, preoperative skin marking,1 wire-guided biopsies,2 radiologically guided percutaneous biopsies,3–5 preoperative methylene blue staining,2, 6 – 8 and serial X-ray films or scintigraphy with radiopaque markers.9 Each of these has their limitations, and all of them are less than 100% sensitive and accurate. A simple and more promising technique that has been described in the literature involves using the hand-held gamma probe.10,11 This probe has become commercially available for its use in breast cancer lymphatic mapping
From the Department of Surgery, Swedish Medical Center, Seattle, Washington. Requests for reprints should be sent to Ralph W. Aye, MD, 1221 Madison Street, Suite #1220, Seattle, Washington 98104. Manuscript submitted January 20, 2000, and accepted in revised form March 6, 2000. Presented at the 86th Annual Meeting of the North Pacific Surgical Association, Vancouver, British Columbia, Canada, November 12–13, 1999.
© 2000 by Excerpta Medica, Inc. All rights reserved.
and sentinel lymph node identification.12 We report our early experience with gamma-probe– directed rib biopsies.
PATIENTS AND METHODS Over the past 17 months, 5 patients underwent gammaprobe– directed limited rib resections. Each patient presented with chest wall pain, no palpable abnormality, and an abnormal bone scan lesion. Twenty-five to 30 mCI of technetium 99m-MDP was administered intravenously, and bone scan localization was performed in the Nuclear Medicine Department 2 to 3 hours later. The patients were then taken to the operating room, and the gamma probe in a sterile sleeve was used to localize the area of greatest tracer uptake. A limited incision was made directly over this point, and the probe was placed into the wound to pinpoint the location of maximum tracer concentration. This portion of the rib was resected in the standard fashion, including margins with decreased tracer uptake.
RESULTS Three patients underwent biopsies for suspected malignancy, and 2 had therapeutic resections for pain. In each case, the incision site was easily selected since the area of greatest tracer uptake read 270% to 375% that of the background signals. This site differed markedly from the localization done in the Nuclear Medicine Department, as well as that done by rib counting. The difference was both in the anteroposterior and superoinferior dimensions, and up to 13 cm (Figure). Within the wound, the site to biopsy was obvious with the target lesion reading up to 1,220% of the background
Figure. Intraoperative photograph displaying the discrepancy between rib counting (“X”), skin marking during preoperative bone scanning (circled “X”), and the area of greatest tracer activity as detected by the gamma probe (square). The respective gamma probe readings are shown, as well as the background reading. Note that the discrepancy is in both the superoinferior and anteroposterior dimensions, and up to 13 cm. 0002-9610/00/$–see front matter PII S0002-9610(00)00364-0
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TARGET-SPECIFIC RIB BIOPSY USING THE GAMMA PROBE/FERNANDES ET AL
signals and 300% to 340% of the adjacent bone on the involved rib. After resection, the probe detected only background signals within the wound. Each specimen contained findings that were consistent with the associated bone scan lesion, thus producing 100% sensitivity and accuracy. The three biopsies revealed benign reactive changes in two, and a metastatic malignancy in the third. The two therapeutic resections contained fracture nonunions. A complication occurred in 1 patient, from which a small pneumothorax resulted. This resolved without the need for tube thoracostomy.
COMMENTS The operative localization of an abnormal bone scan rib lesion presents obstacles that are inherent to the procedure itself. First, nuclear images may not clearly identify the lesion in three dimensions, making localization difficult from the very start. Subsequent skin marking over the abnormality during bone scanning can be misleading due to the marked shifting of skin and soft tissues in relation to bone that occurs during repositioning. This is particularly true in the thorax, where significant shifting occurs not only with repositioning of the torso but also with positioning of the arms. Last, rib counting may be inaccurate and can be hampered by obesity or a muscular habitus. Out of the various techniques that have been previously listed, the two that appear to be most reliable are radiologically guided procedures and preoperative methylene blue staining. Image-directed rib biopsies have had sensitivities reported in the 70 to 90 percentile range.3–5 A major limitation with this method, however, is that the lesion needs to be radiographically visible. One series revealed that the sensitivity of needle biopsies dropped to 33% when bone scan lesions lacked radiographic findings.4 Preoperative methylene blue staining of the skin, soft tissues, and periosteum overlying an abnormal bone scan lesion has achieved sensitivities between 90% and 100%.6 – 8 Drawbacks with this technique include the tedious nature of the staining process, which involves repeated scintigraphic scans from different angles to localize the area for methylene blue injection. In addition, soft tissue shifting and dye diffusion can affect incision placement and may require extensive specimen resection. Another scintigraphic scan is then needed to confirm that the appropriate tissue was removed. Our own experiences, as well as those documented in the literature,10,11 reveal a 100% sensitivity and accuracy using the gamma probe-directed technique. This method allows for quick localization, optimal incision placement, limited dissection, and smaller wound closures. Thus, a less morbid procedure and a brief operative time are achieved. The extremely accurate pinpointing of the target lesion is not
390
affected by patient positioning or soft tissue shifting. Also, patient habitus becomes a minor issue since the technique works well on muscular and obese persons. In addition, our cases displayed the inaccuracies of rib counting and skin marking, at times being up to 13 cm off from the lesion of interest. Also, in the event that the incision and dissection are carried down to the middle of an interspace with two ribs that are equidistant, the gamma probe will select the appropriate rib and target the lesion. The other localization techniques are obviously less helpful in this predicament. Target-specific rib biopsy using the gamma probe is a simple approach with a very short learning curve. After a brief familiarization with the equipment, our first case was performed competently and confidently. This technique eliminated intraoperative uncertainty regarding whether the correct rib and appropriate site was being resected. We have found the gamma probe to be a simple yet significant tool for the biopsy of ribs with abnormal bone scan lesions, especially when no clear palpable or radiographic findings are present.
REFERENCES 1. Durzinsky DS, Messing EM, Myerowitz PD, et al. Method for assuring accuracy of bone biopsy using technetium 99 bone scan. Cancer. 1987;59:723–725. 2. Froelich JW, McKusick KA, Strauss HW, et al. Localization of bone lesions for open biopsy. Radiology. 1983;146:549 –550. 3. Hardy DC, Totty, WG, Funk KC. CT-directed rib biopsy. J Comput Assist Tomogr. 1987;11:994 –997. 4. Debnam JW, Staple TW. Needle biopsy of bone. Radiol Clin North Am. 1975;13:157–164. 5. Ng CS, Salisbury JR, Darby AJ, Gishen P. Radiologically guided bone biopsy: results of 502 biopsies. Cardiovasc Intervent Radiol. 1998;21:122–128. 6. Moores DWO, Lines B, Dziuban SW Jr, McKneally MF. Nuclear scan-guided rib biopsy. J Cardiovasc Surg. 1990;99:620 – 621. 7. Little AG, DeMeester TR, Kirchner PT, et al. Guided biopsies of abnormalities on nuclear bone scans. J Thorac Cardiovasc Surg. 1983;85:396 – 403. 8. Prasad R, Olson WH. Bone marking for biopsy using radionuclide bone imaging. Cancer. 1987;60:2205–2207. 9. Renzoni SA, Convery FR, Ashburn W, Vasquez, TE. Intraoperative osteoscintigraphy as an aid to bone biopsy. Clin Nucl Med. 1986;9:619 – 621. 10. Krag DN, Ford PV, Patel M, et al. A simplified technique to resect abnormal bony radiolocalizations using a gamma counter. Surg Oncol. 1992;1:371–377. 11. Robinson LA, Preksto D, Muro-Cacho C, Hubbell DS. Intraoperative gamma probe-directed biopsy of asymptomatic suspected bone metastases. Ann Thorac Surg. 1998;65:1426 – 1432. 12. Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276:1818 –1822.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 179 MAY 2000
Intraoperative localization of rib abnormalities identified on bone scan can be deceptively difficult. Previously used techniques have had limited sensitivity and accuracy. The gamma probe can help localize these bone scan “hot spots.” METHODS: Over the past 17 months, 5 patients underwent gamma-probe– directed limited rib resections following intravenous administration of Tc99m-MDP. Three patients required biopsies for suspected malignancy, and the other 2 underwent therapeutic resections for pain. The device was easy to work with following minimal training. RESULTS: Localization was excellent, limiting the extent of surgery needed. Comparison with rib counting and preoperative bone scan localization showed a discrepancy of up to 13 cm. Sensitivity and accuracy were each 100%. CONCLUSIONS: The gamma probe offers a simple and significant advance in the performance of rib biopsies for nonpalpable lesions. Am J Surg. 2000;179:389 –390. © 2000 by Excerpta Medica, Inc. BACKGROUND:
S
uccessful rib biopsy and limited rib resection require precise localization of the involved lesion. This can be deceptively difficult, especially when an abnormal bone scan is accompanied by no palpable abnormality and a lack of radiographic findings. Several techniques have been utilized to aid in the localization of rib lesions for biopsy. These include rib counting, preoperative skin marking,1 wire-guided biopsies,2 radiologically guided percutaneous biopsies,3–5 preoperative methylene blue staining,2, 6 – 8 and serial X-ray films or scintigraphy with radiopaque markers.9 Each of these has their limitations, and all of them are less than 100% sensitive and accurate. A simple and more promising technique that has been described in the literature involves using the hand-held gamma probe.10,11 This probe has become commercially available for its use in breast cancer lymphatic mapping
From the Department of Surgery, Swedish Medical Center, Seattle, Washington. Requests for reprints should be sent to Ralph W. Aye, MD, 1221 Madison Street, Suite #1220, Seattle, Washington 98104. Manuscript submitted January 20, 2000, and accepted in revised form March 6, 2000. Presented at the 86th Annual Meeting of the North Pacific Surgical Association, Vancouver, British Columbia, Canada, November 12–13, 1999.
© 2000 by Excerpta Medica, Inc. All rights reserved.
and sentinel lymph node identification.12 We report our early experience with gamma-probe– directed rib biopsies.
PATIENTS AND METHODS Over the past 17 months, 5 patients underwent gammaprobe– directed limited rib resections. Each patient presented with chest wall pain, no palpable abnormality, and an abnormal bone scan lesion. Twenty-five to 30 mCI of technetium 99m-MDP was administered intravenously, and bone scan localization was performed in the Nuclear Medicine Department 2 to 3 hours later. The patients were then taken to the operating room, and the gamma probe in a sterile sleeve was used to localize the area of greatest tracer uptake. A limited incision was made directly over this point, and the probe was placed into the wound to pinpoint the location of maximum tracer concentration. This portion of the rib was resected in the standard fashion, including margins with decreased tracer uptake.
RESULTS Three patients underwent biopsies for suspected malignancy, and 2 had therapeutic resections for pain. In each case, the incision site was easily selected since the area of greatest tracer uptake read 270% to 375% that of the background signals. This site differed markedly from the localization done in the Nuclear Medicine Department, as well as that done by rib counting. The difference was both in the anteroposterior and superoinferior dimensions, and up to 13 cm (Figure). Within the wound, the site to biopsy was obvious with the target lesion reading up to 1,220% of the background
Figure. Intraoperative photograph displaying the discrepancy between rib counting (“X”), skin marking during preoperative bone scanning (circled “X”), and the area of greatest tracer activity as detected by the gamma probe (square). The respective gamma probe readings are shown, as well as the background reading. Note that the discrepancy is in both the superoinferior and anteroposterior dimensions, and up to 13 cm. 0002-9610/00/$–see front matter PII S0002-9610(00)00364-0
389
TARGET-SPECIFIC RIB BIOPSY USING THE GAMMA PROBE/FERNANDES ET AL
signals and 300% to 340% of the adjacent bone on the involved rib. After resection, the probe detected only background signals within the wound. Each specimen contained findings that were consistent with the associated bone scan lesion, thus producing 100% sensitivity and accuracy. The three biopsies revealed benign reactive changes in two, and a metastatic malignancy in the third. The two therapeutic resections contained fracture nonunions. A complication occurred in 1 patient, from which a small pneumothorax resulted. This resolved without the need for tube thoracostomy.
COMMENTS The operative localization of an abnormal bone scan rib lesion presents obstacles that are inherent to the procedure itself. First, nuclear images may not clearly identify the lesion in three dimensions, making localization difficult from the very start. Subsequent skin marking over the abnormality during bone scanning can be misleading due to the marked shifting of skin and soft tissues in relation to bone that occurs during repositioning. This is particularly true in the thorax, where significant shifting occurs not only with repositioning of the torso but also with positioning of the arms. Last, rib counting may be inaccurate and can be hampered by obesity or a muscular habitus. Out of the various techniques that have been previously listed, the two that appear to be most reliable are radiologically guided procedures and preoperative methylene blue staining. Image-directed rib biopsies have had sensitivities reported in the 70 to 90 percentile range.3–5 A major limitation with this method, however, is that the lesion needs to be radiographically visible. One series revealed that the sensitivity of needle biopsies dropped to 33% when bone scan lesions lacked radiographic findings.4 Preoperative methylene blue staining of the skin, soft tissues, and periosteum overlying an abnormal bone scan lesion has achieved sensitivities between 90% and 100%.6 – 8 Drawbacks with this technique include the tedious nature of the staining process, which involves repeated scintigraphic scans from different angles to localize the area for methylene blue injection. In addition, soft tissue shifting and dye diffusion can affect incision placement and may require extensive specimen resection. Another scintigraphic scan is then needed to confirm that the appropriate tissue was removed. Our own experiences, as well as those documented in the literature,10,11 reveal a 100% sensitivity and accuracy using the gamma probe-directed technique. This method allows for quick localization, optimal incision placement, limited dissection, and smaller wound closures. Thus, a less morbid procedure and a brief operative time are achieved. The extremely accurate pinpointing of the target lesion is not
390
affected by patient positioning or soft tissue shifting. Also, patient habitus becomes a minor issue since the technique works well on muscular and obese persons. In addition, our cases displayed the inaccuracies of rib counting and skin marking, at times being up to 13 cm off from the lesion of interest. Also, in the event that the incision and dissection are carried down to the middle of an interspace with two ribs that are equidistant, the gamma probe will select the appropriate rib and target the lesion. The other localization techniques are obviously less helpful in this predicament. Target-specific rib biopsy using the gamma probe is a simple approach with a very short learning curve. After a brief familiarization with the equipment, our first case was performed competently and confidently. This technique eliminated intraoperative uncertainty regarding whether the correct rib and appropriate site was being resected. We have found the gamma probe to be a simple yet significant tool for the biopsy of ribs with abnormal bone scan lesions, especially when no clear palpable or radiographic findings are present.
REFERENCES 1. Durzinsky DS, Messing EM, Myerowitz PD, et al. Method for assuring accuracy of bone biopsy using technetium 99 bone scan. Cancer. 1987;59:723–725. 2. Froelich JW, McKusick KA, Strauss HW, et al. Localization of bone lesions for open biopsy. Radiology. 1983;146:549 –550. 3. Hardy DC, Totty, WG, Funk KC. CT-directed rib biopsy. J Comput Assist Tomogr. 1987;11:994 –997. 4. Debnam JW, Staple TW. Needle biopsy of bone. Radiol Clin North Am. 1975;13:157–164. 5. Ng CS, Salisbury JR, Darby AJ, Gishen P. Radiologically guided bone biopsy: results of 502 biopsies. Cardiovasc Intervent Radiol. 1998;21:122–128. 6. Moores DWO, Lines B, Dziuban SW Jr, McKneally MF. Nuclear scan-guided rib biopsy. J Cardiovasc Surg. 1990;99:620 – 621. 7. Little AG, DeMeester TR, Kirchner PT, et al. Guided biopsies of abnormalities on nuclear bone scans. J Thorac Cardiovasc Surg. 1983;85:396 – 403. 8. Prasad R, Olson WH. Bone marking for biopsy using radionuclide bone imaging. Cancer. 1987;60:2205–2207. 9. Renzoni SA, Convery FR, Ashburn W, Vasquez, TE. Intraoperative osteoscintigraphy as an aid to bone biopsy. Clin Nucl Med. 1986;9:619 – 621. 10. Krag DN, Ford PV, Patel M, et al. A simplified technique to resect abnormal bony radiolocalizations using a gamma counter. Surg Oncol. 1992;1:371–377. 11. Robinson LA, Preksto D, Muro-Cacho C, Hubbell DS. Intraoperative gamma probe-directed biopsy of asymptomatic suspected bone metastases. Ann Thorac Surg. 1998;65:1426 – 1432. 12. Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276:1818 –1822.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 179 MAY 2000