Principles of musculoskeletal tumors biopsy

Abstract

Biopsy remains a cornerstone in diagnosing musculoskeletal tumors, requiring meticulous planning and execution to ensure diagnostic accuracy while minimizing patient harm. Some benign lesions and hematological diseases can be diagnosed through imaging and laboratory results, negating the need for biopsy. However, if a biopsy is indicated, it should be performed in a specialized, multidisciplinary center where radiologists, pathologists, orthopedic surgeons, and oncologists collaboratively determine the most appropriate approach.
Several biopsy techniques are available, each suited to different clinical scenarios. Fine Needle Aspiration (FNA) is minimally invasive but limited by its inability to provide comprehensive histological data. Core Needle Biopsy (CNB) offers tissue samples sufficient for histological and molecular analyses and is nowadays the first-line choice due to its high diagnostic accuracy and low complication rate. Incisional biopsy, while invasive, is reserved for cases where extensive tissue sampling is required or the CNB is unsuccessful. Imaging guidance, such as ultrasound, fluoroscopy, or CT, can improve diagnostic accuracy and safety, especially for deep or complex lesions (13).
A well-planned biopsy respects oncological surgical principles, avoiding contamination of surrounding structures and preserving future treatment options. Errors in biopsy technique can delay diagnosis, impact prognosis, and reduce the feasibility of limb-sparing surgery in malignant cases.
Complementing traditional methods, liquid biopsies are emerging as a transformative tool in oncology. By analyzing circulating tumor cells (CTCs), tumor DNA (ctDNA), and extracellular vesicles (EVs), liquid biopsies offer real-time insights into tumor behavior, metastases, and chemoresistance. These advancements not only enhance diagnostic precision and personalized treatment but also promise to reduce healthcare costs and improve patient outcomes. 
This review highlights the importance of biopsy planning and selection in the context of musculoskeletal tumors, emphasizing the need for specialized, multidisciplinary input to optimize patient outcomes.