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|Year : 2013 | Volume
| Issue : 6 | Page : 569-571
Biopsy of osteoporotic vertebral compression fractures
Department of Neurosurgery, Madurai Medical College, Madurai, Tamil Nadu, India
|Date of Submission||08-Nov-2013|
|Date of Decision||08-Nov-2013|
|Date of Acceptance||06-Dec-2013|
|Date of Web Publication||20-Jan-2014|
Muruganagam,138, Anna Nagar,Madurai - 625020,Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Muthukumar N. Biopsy of osteoporotic vertebral compression fractures. Neurol India 2013;61:569-71
With the increase in the life expectancy world-wide, the incidence of osteoporosis is bound to increase. A study conducted in the European Union has shown that in the calendar year 2010, 3.5 million fragility fractures were encountered out of which the hip fractures ranked first followed by vertebral fractures.  The economic burden of these osteoporotic fractures was estimated to be around 37 billion Euros.  If we extrapolate these data to the rest of the world, the social and economic impact of osteoporotic fractures is staggering. Vertebral compression fractures (VCFs) are estimated to affect around 200 million individuals world-wide.  Even though post-menopausal bone loss is the leading cause of VCFs, numerous malignant conditions can also cause VCFs. The diagnosis of osteoporotic VCFs is based on clinical and radiological observations including Dual Energy X-ray Absorptiometry examinations.  However, these do not reliably differentiate between osteoporotic and malignant VCFs. In the light of these data, the study by Chou et al. assumes importance.  As both osteoporosis and malignancy are common in the elderly, the question of possible malignancy lingers in the mind of the treating medical professional when he/she encounters an "osteoporotic" VCF. This study has tried to answer this question by performing biopsy in patients with suspected osteoporotic VCFs.
A recent study has shown that when the three findings of posterior cortical bulging, epidural mass formation, pedicle enhancement are present together, there is a high chance of such a VCF being malignant even though such features can also occur in benign fractures.  This study also showed that when the magnetic resonance findings were equivocal, fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography was helpful in differentiating the two pathological entities. However, certain studies have shown that at least some of these findings are not specific for malignant VCFs.  In addition, imaging techniques like FDG PET have their own limitations as shown by the study of Bredella et al.  In their study on the usefulness of FDG PET in differentiation of benign versus malignant VCFs, five benign fractures were falsely classified as malignant.  Therefore, imaging studies are not fool proof in eliminating/confirming malignancy and hence the importance of histopathological confirmation.
In a study by Muijs et al., nearly 3.8% of patients who underwent biopsy of VCFs harbored malignancy that was not suspected pre-operatively.  In their study, 9% of biopsy specimens obtained during percutaneous vertebroplasty procedures were not suitable for histopathological examinations.  Another interesting result of their study was even though 13% of their cohort had known malignancies, none of them had biopsy evidence of malignancy in the specimen obtained from the VCF.  It is therefore important to remember that a VCF in a patient with known malignancy does not always indicate a metastatic spread as VCF can occur in a patient with malignancy due to steroid use, use of chemotherapeutic agents and radiotherapy. In their series, there were no complications attributed to biopsy of VCFs and these authors recommended routine biopsy prior to cement injection in every VCF.
In another study by Zhang et al., biopsies were obtained from 546 patients with VCFs.  Only 89.9% of specimens were suitable for evaluation and unsuspected malignancy was diagnosed in 0.4% of their patient cohort. Interestingly, similar to the study by Muijs et al.,  in this study also among the 44 patients with known history of malignancy, nearly one-third did not have evidence of malignancy in the VCFs biopsied thereby highlighting the fact that every VCF in a patient with known malignancy does not imply a metastatic deposit and both malignancy and osteoporosis can co-exist in the same patient. In this study also, no complications were encountered after biopsy of VCFs.
In other similar studies, the incidence of unsuspected malignancy noted during biopsy of presumed osteoporotic VCFs range from 0.4% to 1.7% respectively. ,, In the index study reported by Chou et al., only 44% of their patients were subjected to biopsy.  It is possible that if all the patients who underwent vertebral augmentation were subjected to biopsy, the incidence of malignancy might have been higher.
Certain authors recommend biopsy only during the first vertebral augmentation procedure. , However, in more recent studies, given the near total absence of biopsy-related complications, authors have started advocating routine biopsy prior to every verterbral augmentation procedure. , However, a contrarian view was postulated by Pneumaticos et al. who obtained vertebral biopsies from 75 patients undergoing kyphoplasty and 11 of these patients were found to have histopathological evidence of malignancy.  However, their pre-operative work-up had identified malignancy in all but one of these patients and hence these authors suggested that routine biopsy was not necessary for patients with VCFs.
The histopathological diagnosis of malignancy depends upon the quality and quantity of the tissue obtained during biopsy. As shown by the studies of Muijs et al., Zhang et al., around 10% of tissue samples are not suitable for histopathological evaluation. , Studies have shown that a large diameter biopsy cannula, preferably 2.0 mm or more in diameter, increases the chance of obtaining significant biopsy material without crush injury for histopathological evaluation. 
As pointed out earlier in the discussion, studies have shown that every VCF in a patient with known systemic malignancy does not necessarily mean a metastatic deposit. , A study by Minart et al. has shown that in patients with a known history of malignancy, two-thirds had osteoporotic compression fractures without histological evidence of malignancy.  In the index study reported by Chou et al. also out of the 49 patients with known malignancy, histopathological evidence of malignancy was found only in 41% of patients.  This corollary to biopsying VCFs to identify malignancy in osteoporotic VCFs has not been adequately highlighted in the literature. Patients with known malignancy can develop osteoporotic VCFs and identification of this is important as a mistaken diagnosis of an osteoporotic VCF as a metastasis will lead to inappropriate treatment.
A study by Allen et al. has shown that nearly 20% of specimens obtained from VCFs were interpreted as having chronic inflammation/chronic osteomyelitis. However, further investigations and clinical follow up did not confirm the findings of infection and a re-review found varying stages of fracture healing.  This study highlights that one should not rush to treat a "presumed" osteomyelitis when the biopsy from an VCF is reported as chronic inflammation, especially, when there is no other evidence of infection, as such a finding may be the result of fracture healing.
The evidence available in the literature at present can be summarized as follows:
- Biopsy of presumed osteoporotic VCFs during the vertebral augmentation procedure is a safe procedure when done through the cannula used for vertebral augmentation procedure
- Biopsy of VCFs yields a diagnosis of unsuspected malignancy in 0.4-3.8% of patients undergoing vertebral augmentation procedures
- It is preferable to obtain a biopsy before every vertebral augmentation procedure
- While obtaining biopsy, the cannula size should be large enough to obtain sufficient biopsy specimen.
- When biopsy results obtained during vertebral augmentation indicate infection/inflammation, treatment for presumed osteomyelitis should be initiated only when such infection is confirmed by clinical or laboratory evidence as fracture healing can be misinterpreted as inflammation
- It is also important to remember, every VCF in a patient with known systemic malignancy need not necessarily be a metastatic deposit as many of these patients with known malignancy can also develop osteoporotic VCFs as both malignancy and osteoporosis can co-exist.
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