Diagnostic performance of computed tomography-guided percutaneous bone biopsy in musculoskeletal oncology: A single-center cohort study

Table 1 Legacy Society of Interventional Radiology A-F outcome-based complication classification[10]

SIR class	Severity group	Definition
A	Minor complication	No therapy required; no consequence
B	Minor complication	Nominal therapy required; no consequence; may include overnight admission for observation only
C	Major complication	Requires therapy; minor hospitalization for less than 48 hours
D	Major complication	Requires major therapy, unplanned increase in level of care, prolonged hospitalization for more than 48 hours
E	Major complication	Results in permanent adverse sequelae
F	Major complication	Death

Table 2 Clinical categories and verification descriptions retained from the aggregate source record

Source clinical category	n	Reported sites (not exhaustive)	Recorded verification description
Secondary lesions: Prostate carcinoma	10	Iliac wing (4); ischial branch (1). Counts are incomplete	IHC-supported assessment and response to ADT, ADT + docetaxel, or ADT + docetaxel + ARPI. Independence of verification not established
Secondary lesions: Breast carcinoma	10	Iliac wing (2), femoral condyle, iliac body and iliac bone	IHC-supported assessment and response to CDK4/6 inhibition, trastuzumab-pertuzumab, dose-dense docetaxel, or epirubicin + cyclophosphamide, as listed in the source
Secondary lesions: Thyroid, colon, lung and urachal primaries	8	Scapula, femoral metaphysis, trochanter and L5 posterior element	IHC-supported assessment and response to cabozantinib, FOLFIRINOX, pembrolizumab or trastuzumab, as listed in the source
Osteoid osteoma, with radiofrequency ablation	4	Femoral trochanter and humeral condyle	Symptom resolution reported. Confirm actual biopsy histology and the reference-standard rule (AQ1-AQ2)
Benign lesions (enchondroma, cyst, vascular lesion)	8	Femoral condyle/head, humeral head and sternum	Surgical pathology or imaging follow-up; separate counts and dates not reported
Other primary/recurrent neoplasms: Chondrosarcoma, Ewing sarcoma, recurrent synovial sarcoma, giant cell tumor and multiple myeloma	12	Proximal femur, iliac wing (2), iliac bone, humeral head and scapula	Resection histology; myeloma assessed by IHC with response to D-VTD. Exact route counts not reported. The grouped category requires classification review
Combined discrepancy/non-neoplastic category	8	Peroneal malleolus, calcaneus, femoral condyle and iliac bone	Clinical/imaging follow-up reported; this mixed category is not equivalent to the six diagnosis-correction events
Non-diagnostic procedures	4	Iliac lesions	Final diagnosis/follow-up unavailable in the source description
Total source procedure records	64	Complete site counts pending	Verification methods are not mutually exclusive or individually enumerated

Source-data note: The three metastatic categories sum to 28 records, whereas an earlier narrative stated 59%; no replacement metastatic percentage has been asserted. Individual location counts in the source table were incomplete. These discrepancies require the original procedure-level records, not extrapolation from the older 32-case cohort. IHC: Immunohistochemistry; ADT: Androgen deprivation therapy; ARPI: Androgen receptor pathway inhibitor.

Table 3 Procedure-level outcomes and two-sided exact 95% confidence intervals

Outcome	Numerator/denominator	Estimate (%)	Exact 95%CI (%)
Diagnostic yield	60/64	93.75	84.8-98.3
Conditional recorded concordance	60/60	100.00	94.0-100.0
Full-cohort concordant diagnostic-result rate	60/64	93.75	84.8-98.3
Non-diagnostic procedures	4/64	6.25	1.7-15.2
Recorded minor complications	2/64	3.13	0.4-10.8
Recorded major complications	0/64	0.00	0.0-5.6
No recorded complication	62/64	96.88	89.2-99.6

The denominator of 60 excludes the four non-diagnostic procedures; the full-cohort endpoint counts them as failures. Final disease status in those four procedures remains unverified. Exact intervals quantify binomial sampling uncertainty and do not resolve verification, incorporation, selection, or surveillance bias. Independence of procedure records requires author confirmation (AQ1).

Table 4 Availability of final verification and follow-up information

Verification item	What the supplied record supports	What remains unresolved
All included procedures	64 records	Unique patient count, repeat-procedure handling, and all screened/excluded totals (AQ1)
Diagnostic procedures with recorded final assessment	60/64, all reported concordant	Case-level matching of diagnoses, malignancy/subtype/grade rules, adjudicator identity and blinding (AQ2)
Surgical histopathology	Used for some resected lesions	Exact n/64 and n/60, dates, and independence from the index interpretation (AQ2)
IHC-supported oncologic work-up	Reported for the three metastatic categories (10 + 10 + 8) and for some myeloma cases	Exclusive route counts, source specimen, overlap with surgery/follow-up, and category reconciliation (AQ2/AQ4)
Clinical and imaging follow-up	Used in several source categories; six-month minimum stated previously	Actual duration for each case, median/range, final cutoff, number with ≥ 6 months, and losses to follow-up (AQ3)
Non-diagnostic procedures	4/64; no confirmed final diagnosis/follow-up reported	Subsequent outcome and any repeat procedure; do not reclassify as benign or false-negative without evidence
Adverse-event surveillance	Immediate CT assessment; two delayed local fistulas described	Complete surveillance interval and missing follow-up for all 64 (AQ7)
Baseline and procedural variables	Aggregate sex, morphology, anesthesia, guidance categories	Age, lesion size/depth, complete sites, actual cores, treatment exposure, and missingness counts (AQ4-AQ5)

“Not reported” identifies a gap in the supplied summary, not proof that information was never collected. No exclusive reference-standard counts, missingness frequencies, or follow-up durations have been manufactured from the grouped categories. CT: Computed tomography; IHC: Immunohistochemistry.

Table 5 Selected external studies and reviews used for narrative context; outcomes are reported with their original populations and denominators, not pooled

Ref.	Design and population	Verified endpoint/finding	Interpretive boundary
Wang et al[16], 2019	Retrospective; 31 patients with bone lymphoma	Diagnosis and subtype established in 26/31 (83.9%). PET/CT findings informed target selection	Selected lymphoma population; not a general bone-tumor accuracy denominator
Dablan et al[17], 2025	Retrospective; 211 patients, 226 biopsies; CT and ultrasound guidance	Adequacy 148/211 patients (70.1%). Higher SUV was associated with adequacy within the PET-imaged subset	70.1% uses patients, not 226 procedures. Neither CT-only nor an external control group
Filippiadis et al[18], 2018	Narrative review of biopsy of bone metastases	Technical guidance on indication, targeting, specimen acquisition, and safety	No original study denominator; not an independent cohort or pooled performance estimate
Maciel et al[19], 2014	Retrospective; 186 procedures	Adequate material in 183/186 (98.4%); three complications, including fracture, functional paresthesia, and needle breakage requiring removal	Specimen adequacy is not verified diagnostic accuracy; complications were not all trivial
Ferreira et al[20], 2023	Systematic review/meta-analysis; 29 studies	Pooled CNB yield 91.4%, accuracy 92.7%; FNA yield 88.5%, accuracy 82.5%; combined yield 96.5%	Secondary evidence, not a separate primary cohort. Do not pool again with potentially overlapping primary reports
Li et al[21], 2014	Retrospective; 162 biopsies in 155 patients	Yield 81.5%; lytic 89.9% vs sclerotic 48.5%; lesions ≥ 3 cm 89.2% vs smaller lesions 73.4%	Associations belong to that study; size threshold is ≥ 3 cm. Repeated procedures may differ from unique patients
Hwang et al[22], 2011	Retrospective; 800 CT-guided bone biopsies	Initial results: 69% diagnostic, 31% indeterminate. CT features related to diagnostic/indeterminate outcomes were evaluated	Initial yield is distinct from subsequent final diagnosis. This is the CT-feature study, not Hoang et al[26]
Suh and Yun[23], 2019	Meta-analysis; 15 studies of sclerotic lesions	Pooled yield 74% (95%CI: 62%-84%; 969 lesions); accuracy 87% (95%CI: 77%-93%; 242 lesions)	Different denominators contribute to yield and accuracy. Restricted to sclerotic lesions
Toffart et al[24], 2020	Retrospective; 50 lytic lesions in patients suspected of lung cancer	Pathological diagnosis 50/50 (100%); molecular-testing success 35/37 (94.6%)	Molecular success is a separate endpoint among tested specimens, not overall biopsy accuracy
Monfardini et al[25], 2014	Retrospective; 308 procedures in 286 cancer patients	Adequacy 290/308 (94.1%); sensitivity 96.7% under the study’s diagnostic/follow-up definition	Adequacy and sensitivity are not interchangeable; final verification differed from the current cohort
Hoang et al[26], 2019	Retrospective; 115 patients with suspected osteomyelitis	Positive cultures in 24/115 (20.9%); treatment changed in 10 of the 24 culture-positive cases	Microbiological yield, not oncologic histopathological accuracy; not specific to bone tuberculosis

The table is a non-systematic selection of clinical cohorts and secondary evidence. Published estimates retain study-specific definitions and are not combined into a “literature average.” Bibliographic years refer to the issue publication year (Ferreira et al[20], 2023; Toffart et al[24], 2020). CNB: Core-needle biopsy; FNA: Fine-needle aspiration; SUV: Standardized uptake value; PET/CT: Positron emission tomography/computed tomography.