Journal of Surgical Oncology 2010;101:618–621

Local Recurrence Rate of Fine-Needle Aspiration Biopsy in

Primary High-Grade Sarcomas

BENJAMIN H. KAFFENBERGER, BS, PAUL E. WAKELY JR, MD, AND JOEL L. MAYERSON, MD*The Ohio State University College of Medicine, Columbus, Ohio

Background: Fine-needle aspiration biopsy (FNAB) is an emerging technique for diagnosis of bone and soft tissue lesions.

While multiple studies have demonstrated efficacy, cost-effectiveness, and convenience, none have attempted to determine if the modality

leads to an increased rate of local recurrence. Our objective was to determine whether FNAB could be linked to an increased rate of local

recurrence.

Methods: We reviewed a database containing records of 388 patients who underwent FNAB without surgical biopsy tract excision between

September 2002 and December 2006 in the orthopedics department at our institution. After application of rigid criteria to minimize confounding

variables, 20 patients were retrospectively examined for local recurrence and distant metastasis.

Results: In this cohort, no local recurrences were seen over a mean follow-up of 45 months. Fifteen percent of our patients developed one or more

distant metastases over the same time interval. Our experience offers preliminary evidence for the safety of this method.

Conclusions: While further studies are needed, our data combined with already reported studies on efficacy, cost-effectiveness, and convenience

are encouraging for expanding the use of FNAB in the diagnosis of bone and soft tissue tumors.

J. Surg. Oncol. 2010;101:618–621. � 2010 Wiley-Liss, Inc.

KEY WORDS: fine needle aspiration; biopsy; bone lesions; soft tissue lesions

INTRODUCTION

Fine-needle aspiration biopsy (FNAB) is an emerging modality for

diagnosing primary bone and soft tissues and is constrained largely by

pathologist experience [1]. After several reports detailing efficacy in

diagnosis of high-grade sarcomas (HGS) by FNAB at our institution

[2,3], we attempted to create a database to assess retrospectively for

local recurrences and further study the modality. The database was

constructed to allow a descriptive analysis of patients who underwent

FNAB without biopsy tract excision and then follow patients for

recurrences.

Our primary end point was assessment of whether FNAB

without excision of the needle tract would lead to unacceptably

high rates of local recurrence. Very little published material has

examined FNAB and local recurrences. However, one institution

with 200 soft tissue FNAB determined only one local recurrence [4]. A

large study of sarcomas primarily diagnosed by FNAB showed a

decreased rate of local recurrences when compared to earlier

data possibly because increased use of FNAB [5]. Otherwise, no local

recurrences specifically associated with FNAB were reported in

publications detailing thousands of sarcomas although the overall

recurrence rates ranged from 7% to 38% [6–12]. We hypothesized

that the rate would be within this spectrum and accepted the

upper range as the point to reconsider biopsy tract excision after

FNAB.

To further examine our final cohort, distant metastases were also

disclosed within the database. While studies have previously detailed

factors affecting likelihood of distant metastases [8,10,11], we

attempted only a descriptive review of our cohort.

The purpose of this report is threefold: to formulate the first single

surgeon experience of extremity soft tissue HGS diagnosed by FNAB

that addresses confounding prognostic implications, to use this cohort

to publish a preliminary rate of local recurrences following FNAB, and

to report the distal recurrences in this population.

METHODS

Study Design

Patients of our orthopedic oncology service were examined

retrospectively from visits in September 2002 until December 2006

to allow for 2 years of follow-up. Between this period, 388 FNAB were

performed. Patient information was entered consecutively into

a secured database consistent with Institutional Review Board

regulations. The database was constructed to allow isolation of

patients by exclusion criteria (Fig. 1) in order to form a cohort

with minimal confounding variables. Follow-up notes were read by

a medical student to document local recurrence and/or distant

metastasis.

Clinical Encounters

Patients with a tissue diagnosis either by surgery or needle modality

prior to referral were not included. Once referred, patients had imaging

reviewed and with sufficient clinical suspicion, FNAB was performed.

A simplified encounter is shown in Figure 2.

*Correspondence to: Joel L. Mayerson, MD, Associate Professor ofOrthopaedic Surgery, Director, Musculoskeletal Oncology, The ArthurJames Cancer Hospital at The Ohio State University, Program Director,Orthopaedic Surgery Residency, Co-Director, Bone Tumor Clinic, Nation-wide Children’s Hospital, 4100 Cramblett Hall, 456 West 10th Ave.,Columbus, OH 43210. Fax: 614-293-3747E-mail: joel.mayerson@osumc.edu

Received 13 November 2009; Accepted 3 February 2010

DOI 10.1002/jso.21552

Published online in Wiley InterScience(www.interscience.wiley.com).

� 2010 Wiley-Liss, Inc.

FNAB Technique

Percutaneous FNAB was performed using standard technique as

described in several previous reports [2,13]. A preliminary interpreta-

tion was made and telephoned to the clinic within 20 min. If the

preliminary result was non-diagnostic, the pathologist could return to

the suite for additional cytology.

Surgery

The surgical operation was chosen based on tumor location, size,

spread, and patient goals. Surgeries were intended to create a 1 cm

gross margin prior to electrocautery in soft tissue tumors and 3–5 cm in

bone resections. The needle tract was only excised in amputations.

Concurrent chemotherapy was offered to all patients with HGS

extending deep to superficial fascia. Post-operative radiation

therapy was recommended in all HGS patients without active

contraindications.

Outcome Measures

The database was analyzed in a descriptive manner of patient

characteristics. The primary end point was comparing local recur-

rences within our cohort to currently published data. The patients

were secondarily examined for distant metastases.

RESULTS

Twenty cases of HGS met inclusion criteria. The mean age was

53 and ranged from 27 to 81. Twelve cases were female, representing

60% of our total study population. Sarcoma subtypes were based on the

final pathology (Table I). Total follow-up ranged from 24 to 60 months

with a mean time of 45.1 months. Margins after surgery were negative

in all study participants. After electrocautery, these margins ranged

from less than 1 mm to 5.7 cm. Sixteen patients (80%) received

adjuvant and/or neoadjuvant therapy. Fifteen (75%) of the patients

received post-operative radiation therapy. Twelve patients did not have

full follow-up and were excluded. Of these, four patients died within

2 years without local recurrences. Three patients had no follow-up after

surgery and the other five patients had no recurrences in follow-up

ranging from 3 to 15 months.

In our study group, no local recurrences developed over a mean time

of 45.1 months (Table I). One patient had a soft tissue metastasis but it

was not within the wound bed and was included under metastases.

Over the same period, three distant metastases were noted. Patient 6

had neurofibromatosis type 1 and after a solitary lung metastasis

resection at 17 months followed a disease free post-operation course.

Patient 9 had a superficial inguinal lymph node not arising from the

wound bed at 42 months. Patient 19 had multiple lung metastases at 12,

20, and 32 months after the original operation.

DISCUSSION

At the study department, use of FNAB has been performed for

almost 10 years, although the technique was introduced almost

80 years ago [14]. It offers advantages in cost [15,16], and studies have

shown between 80% and 97% success rates identifying sarcomas and

other lesions using FNAB [2,13,17–23]. Difficulties in identifying

sarcoma subtypes [23–25] have lessened with molecular techniques

[26–28]. However, despite broad support for FNAB, studies have not

ascertained the rate of local recurrence in HGS.

Journal of Surgical Oncology

Fig. 1. Exclusion criteria used in the study.

Fig. 2. Sarcoma management algorithm. AMP, amputation; CNB, core biopsy; EB, excisional biopsy; FNAB, fine-needle aspiration biopsy;HGS, high-grade sarcoma; LGS, low-grade sarcoma; NADJ, neoadjuvant therapy; WE, wide excision.

Local Recurrences After FNAB 619

Multiple limitations exist in this study. The retrospective nature

appears unavoidable given the rarity of the disease and the cost of long-

term prospective randomized trials. Length of follow-up is always a

concern; however, several studies report that up to 66% of local

recurrences will occur within 2 years and up to 84% within 3 years

[10,12]. Our mean follow-up was 45 months. A small percentage, up to

7%, of recurrences may occur after 5 years [12]. Early recurrences,

such as those less than 3 years, are associated with a worse prognosis

than those greater than 3 years [8]. We plan to continue our follow-up

of this database and report again as our patient population expands

and ages, but at this point it appears justified to assess the most

adverse local recurrences. Another weakness is the small sample size.

However, adding patients with low-grade tumors, previous recur-

rences, or metastatic disease would all affect future recurrence and/or

survival curves [9–11]. The eight patients with HGS lost to follow-up

is 7% of our HGS patients and is consistent with other reports of loss of

follow-up [10].

Developing a database for FNAB follow-up has been performed

previously at our institution and others, but we believe this is the first to

assess recurrence rates in HGS.

The primary purpose of this article was to examine our database for

local recurrences after FNAB with an intact biopsy tract. Studies have

shown increased rates of local recurrence after diagnosis by incisional

biopsy and core needle biopsy when the tract is not excised [6,7].

Previously published reports of FNAB experience have shown only

one local recurrence in up to 200 biopsies; however, it was not a

sarcoma and the authors do not state whether tract excision was

performed [4]. A study of 1,851 patients divided a 15-year period and

found the later half was significantly less likely to develop local

recurrences [5]. Eighty-one percent of patients received FNAB, and it

may be possible that later patients were more likely to receive FNAB

for diagnosis. While limitations do exist in our study, having no local

recurrences in 20 patients with HGS is reassuring to continue using

FNAB without excising the biopsy tract. Our data will hopefully spur

further analysis into the local recurrence rate to complement extensive

data on efficacy.

As a secondary objective, our data included results of distant

metastases to disclose future prognosis. We do not suspect that FNAB

causes hematogenous spread. Rather it is likely previous prognostic

variables previously defined such as grade and tumor size [8,10,11] are

responsible for distal recurrences present in 15% of our patients.

Based our preliminary study, it appears that FNAB offers a safe

method to obtain a sarcoma tissue diagnosis. We examined a large

FNAB database and created a homogenous sample that has minimal

variables affecting local recurrence. Our experience is encouraging for

expanding FNAB use in diagnosis of bone and soft tissue lesions

without tract excision based on a high efficacy rate, diminished biopsy

costs, convenience, and our preliminary data showing a minimal rate of

local recurrences.

ACKNOWLEDGMENTS

The authors wish to thank Martha Crist, RN, and Vincent Ng, MD,

for their assistance with IRB procurement and database organization,

respectively.

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Journal of Surgical Oncology

TABLE I. Results

Patient Age Sex Surgical pathology Location

Recurrence

Distal Time (months) SurgeryLocal Time (months)

1 74 F LEIO R thigh 0 60 0 60 WE

2 64 F PUS R thigh 0 64 0 64 WE

3 40 F LIPO L thigh 0 48 0 48 WE

4 37 M OST L tibia 0 60 0 60 WEþTK

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8 54 F PUS R arm 0 51 0 51 WE

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10 27 F OST L arm 0 24 0 24 WE

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13 60 M PUS R thigh 0 48 0 48 EH

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15 35 F CCS R calf 0 28 0 28 WE

16 46 F HGS EPITH L thigh 0 45 0 45 WE

17 42 M SPIN R thigh 0 34 0 34 WE

18 77 M PUS R thigh 0 36 LUNG, PI 12, 20, 21 WE

19 49 M LEIO R thigh 0 29 0 29 WE

20 81 F P-R OST L arm 0 28 0 28 FA

Surgical pathology as follows: CCS, clear cell sarcoma; HGS EPITH, high-grade sarcoma with epithelioid features; HG MYXO, high-grade myxofibrosarcoma;

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