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Review Question - QID 213059

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QID 213059 (Type "213059" in App Search)
A 65-year-old man with a 20-pack-year tobacco history and a remote history of small cell lung carcinoma presents with thigh pain and radiographs demonstrated in Figure A. He undergoes a full femur MRI and a CT chest, abdomen, and pelvis, both of which reveal no other areas of disease. What is the next best step in management?
  • A

Open biopsy using an intermuscular interval

18%

403/2234

Open biopsy using an intramuscular interval

62%

1379/2234

Antegrade intramedullary nailing with reamings sent to pathology

10%

217/2234

Proximal femoral replacement

9%

201/2234

ORIF with plate and screws, followed by radiation

0%

9/2234

  • A

Select Answer to see Preferred Response

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New osseous lesions with inconclusive diagnoses on imaging studies require a biopsy prior to any surgical intervention, with ultimate treatment based on biopsy results. A biopsy should be performed through the involved compartment of the tumor to avoid contamination.

In patients with a history of malignancy and a solitary destructive bone lesion, imaging staging workup should include a CT chest, abdomen, and pelvis as well as a bone scan. Laboratory workup may include CBC, BMP, ESR, LFTs, AFP, PSA, SPEP, UPEP. Although such patients are more likely to have bone metastasis, needle or open biopsy of the solitary bone lesion should be performed to rule out a primary bone sarcoma, as surgical stabilization of a presumed bone metastasis can compromise a patient's limb. Key principles for open biopsy in preventing tissue contamination include the use of longitudinal incisions in approaching the involved compartment, avoiding exposure of neurovascular structures and adjacent compartments, and coordination of definitive surgery with the orthopedic oncologist.

Piccioli et al. reviewed the epidemiology and principles of management of bony metastases of unknown origin. They reported that adenocarcinoma was the most common histological type, accounting for 70 % of cases, with lung being the majority. They recommend surgery for bone lesions after biopsy when lesions are solitary and/or the occult primaries have a good prognosis.

Traina et al. reviewed the current concepts in the biopsy of musculoskeletal tumors. They reported that open incisional biopsies appeared to be more accurate than core needle biopsy and fine needle aspiration. However, they stated that, compared to an open biopsy, the advantages of a percutaneous technique were its low risk of contamination and its minimally invasive nature. They recommended a core needle biopsy, augmented by image guidance, due to the low risk of contamination and the low cost.

Figure A demonstrates lytic lesions in the femoral diaphysis.

Incorrect Answers:
Answer 1: Open biopsy through an intermuscular or internervous planes should be avoided due to the potential to contaminate multiple compartments.
Answers 3, 4, & 5: Biopsy of the solitary bone lesion should be performed prior to surgical intervention, as surgical stabilization of a presumed bone metastasis that turns out to be a primary sarcoma can compromise a patient's limb.

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