Journal of Orthopaedic Surgery 2010;18(3):361-3

Biopsy of vertebral tumour metastasis for diagnosing unknown primaries

Orhan Buyukbebeci,1 Gunhan Karakurum,1 Ediz Tutar,2 Akif Gulec,3 Omer Arpacioglu1
1 2

Orthopaedics and Traumatology Department, Medicine Faculty, Gaziantep University, Gaziantep, Turkey Pathology Deparment, Medicine Faculty, Gaziantep University, Gaziantep, Turkey 3 Orthopaedics and Traumatology Department, Bagcilar Education and Research Hospital, Istanbul, Turkey

unknown primary tumours. ABSTRACT Purpose. To examine patients with vertebral tumour metastasis using transpedicular biopsy for diagnosing unknown primary tumours. Methods. 13 men and 8 women aged 41 to 80 (mean, 61) years with vertebral tumour metastasis of unknown primary origin underwent transpedicular biopsy of the affected vertebra. Results. The origins of the primary tumours were lung cancer (n=6), prostate cancer (n=5), colorectal cancer (n=5), kidney cancer (n=4) and lymphoma (n=1). All the specimens matched pathological characteristics of their corresponding primary tumours, except in one patient. This 42-year-old man had stage-4 colon cancer, in whom the pathologic findings could not enable differentiation between colon and prostate cancer. Conclusion. Transpedicular biopsy of the vertebra is a cost-effective diagnostic tool for evaluating
Key words: biopsy; neoplasms; pathology

INTRODUCTION Many organ cancers metastasise to bone, especially spine. The primary tumour is unknown at the initial diagnosis in 0.5 to 7% of the oncologic patients.1,2 In 15 to 25% of such cases, the primary site cannot be identified even at necropsy.3 Conventional techniques for evaluation of primary tumour foci (thyroid, colon, prostate, lung) are time-consuming and expensive. Fluorodeoxyglucose positron emission tomography and computed tomography have been used to diagnose, stage, and restage a variety of cancers,4 but false-negative and false-positive results are possible.57 Advanced diagnostic methods in pathology (immunohistochemistry and immunofluorescence) enable accurate diagnosis of the origin of primary tumours by biopsy of the metastatic

Address correspondence and reprint requests to: Dr Orhan Buyukbebeci, Orthopedic and Traumatology Department, Medicine Faculty, Gaziantep University, Gaziantep, Turkey. E-mail: orbuyukbebeci@yahoo.com

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(a)

(b)

Figure (a) A 74-year-old man with metastasis of renal cell carcinoma to L2, and (b) a 48-year-old man with metastasis of colon carcinoma to L5.

area. We therefore examined 21 patients with vertebral tumour metastasis using transpedicular biopsy. MATERIALS AND METHODS Between February 2000 and March 2009, 13 men and 8 women aged 41 to 80 (mean, 61) years with vertebral tumour metastasis of unknown primaries underwent transpedicular biopsy for diagnosing the primaries. Patients with known primary tumours were excluded. The location of the metastasis and its proximity to the spinal cord were assessed using radiography and magnetic resonance imaging. Under biplanar fluoroscopy, biopsies using 11- to 14-gauge bone needles were performed, under propofol/ketamine intravenous sedation and local anaesthesia. Specimens from 21 vertebrae: T9 (n=1), T10 (n=2), T11 (n=2), L1 (n=4), L2 (n=3), L3 (n=3), L4 (n=2), and L5 (n=4) were evaluated histopathologically. RESULTS The origins of the primary tumours were lung cancer (n=6), prostate cancer (n=5), colorectal cancer (n=5), kidney cancer (n=4) and lymphoma (n=1) [Fig.]. All the specimens matched the pathological characteristics of their corresponding primary tumours, except in one patient. This 42-year-old man had stage-4 colon cancer (formerly known as Dukes D colon cancer8),

in whom the pathologic findings could not enable differentiation between colon and prostate cancer. No complications occurred throughout the procedures; radiation exposure was minimal. DISCUSSION When the primary site of a metastatic cancer is known, biopsy is usually not required. When the site is unknown, biopsy is necessary for an accurate diagnosis. Cancers of unknown primary origin have increased substantially.9 60 to 70% of patients with systemic cancers have metastasis in the spine, in some the primary site is unkown.10,11 In a postmortem study of such patients, the lung and the large intestine were the most frequent sites for primary tumours.12 Open biopsies of vertebral tumours carry a potential risk of complications,13,14 whereas percutaneous biopsy has several advantages.15,16 Small-diameter needles should be used first, as largebore needles are associated with higher complication rates.17,18 Complication rates of transpedicular biopsy are 0 to 26%; pulmonary, neurologic, and infectious complications are considered the most common.1921 Percutaneous biopsy of the vertebra can be performed on an outpatient basis under local anaesthesia. The necessary surgical equipment is cheap and the procedure does not require extra assistance. It is a cost-effective diagnostic tool for evaluating patients with unknown primary tumours.

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