Case Presentation - Continued.

This lesion needs to be biopsied. The procedure has to accomplish several distinct goals:

1) Obtain sufficient volume of material to allow a complete pathological analysis.
2) Avoid contamination of uninvolved tissues and structures.
3) Cause minimal surgical morbidity to the patient.
4) Provide access to this deeply placed lesion in an efficient and precise manner.
5) Avoid the creation of stress risers in the subtrochanteric region of the femur.

With all these issues to consider, do you think biopsy is a complicated procedure or a simple one? How would you proceed? We chose a minimally invasive method pictured here.

The procedure was performed in an outpatient setting. A two centimeter lateral incision over the greater trochanter was used, with the entry point into the femur place in the relatively safe inferior - lateral part of the greater trochanter, where the soft tissue envelope is minimal, the bone is thin and the risks of pathological fracture are low. A specially developed precision biopsy localization and access system was used with continuous image guidance, as shown. The pathologist was called to verify by frozen section that sufficient material for a diagnosis was obtained. A specially designed bone grafting instrument is used to fill the void left in the bone with graft material.

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The biopsy material is shown below. (Or pending)

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What is the diagnosis?

Click on an image to enlarge