Figure 1 # .. #{149}1 a. Al C. 549 Localization of Bone Lesions for Open Biopsy’ Jerry W. Froelich, M.D. Kenneth A. McKusick, M.D. ,b H. William Strauss, M.D. John E. Bingham, MB., M.R.C.P. Daniel B. Kopans, M.D. Salvatore A. DeLuca, M.D. e Two techniques are described to aid in the accurate localization of suspicious bone abnormalities detected by radionuclide scanning prior to surgical excision. Index terms: Bone neoplasms, biopsy #{149} Bone neoplasms, radionuclide diagnosis #{149} (Bone, radionuclide examination, 4[0].l299) Radiology 146: 549-550, February 1983 J HE SENSITIVITY of radionuclide scanning for the detection of bony metastases has been well established , i From the Division of Nuclear Medicine, The University of Michigan Medical Center, Ann Arbor (J.W.F.), the Department of Radiology, Division of Nuclear Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (K.A.M., H.W.S., D.B.K., SAD.), and Guy’s Hospital, London, England (J.B.B.). (Address re- print requests to J.W.F., Division of Nuclear Medicine, The Univ. of Michigan Med. Ctr., Ann Arbor MI 48109.) Received Apr. 8, 1982, and ac- cepted July 20. sb 2 This system was originally designed for lo- calization of occult breast lesions. Catalog #DKBL Breast Lesion Localizer, Cook Incorpo- rated, 925 5. Curry Pike, P.O. Box 489, Bloom- ington IN 47402 (1-2). The solitary bony abnormality, however, frequently requires a biopsy in order to confirm the presence or absence of a metastatic lesion. We have developed two preoperative techniques to accu- rately localize suspicious areas for biopsy. One method involves injecting a mixture of methylene-blue Xylocaine into the subcutaneous tissues and periosteum; the second method uses a spring/hooked wire that embeds itself into the soft tissues and the periosteum overlying the bony abnormality. Following surgical removal of the suspicious area, another image of the specimen is obtained to confirm the abnormal focus of activity. Technique Three hours following the intravenous injection of technetium-99m methylene- diphosphonate (Tc-99m MDP) (adult dose, 20 mCi [740 MBq]), the patient is situated under a gamma camera in a po- sition similar to that anticipated for the operation. A fine Tc-99m point source at the end of a small capillary tube is used to localize precisely the zone of abnormal bone uptake while moving the source and monitoring the camera’s persistence scope until the point source is directly over the suspicious area. Images are ac- cumulated with and without the external marker to determine the lesion site. Fol- lowing external localization, the under- lying bone is palpated to establish a su- perficial relationship to the image. A mixture of methylene blue (1 ml) and Xylocaine (2 ml) are infiltrated into the subcutaneous tissue and periosteum via a 1.5-inch (3.8-cm), 22-gauge needle. Because the methylene blue will dif- fuse out into soft tissue and will not be a useful marker during surgery, the sec- ond technique is used when more than four hours are expected to elapse be- tween the time of localization and sur- gical excision. A needle-spring/ hooked-wire system is employed (3 .4).2 The specially formed hooked wire can be retracted completely within the 20-gauge needle. The technique requires only a single pass through the skin without the need for a skin incision, and the needle tip can be repositioned until the correct location is obtained. After satisfactory positioning of the needle tip, the wire protruding at the hub end of the needle is held in place and the needle is with- drawn over the wire. The hook reforms and the wire is anchored in the tissues. The wire extending out of the skin is taped under a sterile dressing until sur- gery. The surgeon can then use the wire as a guide down to the suspicious area. This technique has been performed up to 36 hours before surgery. Case Reports Bone lesion sites were determined preoperatively for nine patients. In seven, methylene blue was used; in two, the hooked wire was also used. All of these patients had a history of primary malignancy. The bone biopsy revealed b. ‘1 a and b. These images were obtained during the localization procedure. The black arrow indicates the abnormal area of radionuclide uptake within the right posterior rib (a). The fine-point-source marker definitively localizes the rib lesion (b). C. Scintigram of the excised piece of rib. The white arrows indicate the ends of the rib specimen; the large open arrow points to the abnormal focus of activity as identified on the bone scan.