L'agobiopsia percutanea è una procedura mininvasiva di radiologia interventistica che consente di ottenere, tramite un ago da biopsia introdotto sotto controllo TC e/o Ecografico, più campioni di tessuto da una lesione del sistema muscolo-scheletrico. Il tessuto prelevato serve per definire la natura dell'alterazione. Nell'approccio alla lesione bisogna tenere presenti diverse problematiche operative immediate (salvaguardia delle strutture nobili adiacenti, scelta della zona anatomopatologicamente più significativa, necessità tecniche per eseguire il prelievo, sede anatomica dell'alterazione, condizioni del paziente, ecc) e future (in particolare, scelta della via di approccio in funzione di un successivo trattamento chirurgico); per questo motivo riteniamo che l'agobiopsia debba essere eseguita nella stessa struttura ospedaliera che si prenderà carico del successivo trattamento del paziente. La procedura viene solitamente eseguita in anestesia locale con blanda sedazione generale, ma in casi più particolari o nel trattamento di pazienti pediatrici, vi è la possibilità di ricorrere a procedure in narcosi con il supporto anestesiologico, aumentando il confort e la sicurezza del paziente complesso. La procedura si effettua in regime di ricovero (day hospital-day surgery) ed il paziente viene dimesso in giornata dopo breve osservazione post-procedura. Il nostro istituto esegue più di 700 biopsie ECO-TC guidate /anno. Esami da eseguire L'agobiopsia si esegue dopo una stadiazione completa (Esame Radiografico, Tomografia Computerizzata e/o Risonanza Magnetica e Scintigrafia Scheletrica) che permette di ottenere tutte le informazioni di orientamento diagnostico sulla lesione e di pianificare al meglio la procedura agobioptica. Indicazioni L'agobiopsia è stata finora utilizzata a fini diagnostici soprattutto nel sospetto di lesioni infiammatorie (per confermare il sospetto e identificare il microrganismo patogeno) o neoplastiche (per confermare il sospetto), determinarne la natura (benigna o maligna) e l'istotipo, l'origine (primitiva o secondaria). L'esecuzione della biopsia è imprescindibile nel 'management' dei tumori muscolo-scheletrici, primitivi e secondari, nei quali consente di avere una diagnosi di certezza e un orientamento prognostico indispensabili per una corretta pianificazione terapeutica. Di recente questa procedura è utilizzata anche per valutare i fenomeni di osteointegrazione nei trapianti ossei, per identificare i recettori nelle metastasi da carcinoma mammario e pianificarne al meglio la terapia, per valutare il risultato della radio/chemioterapia. Controindicazioni Gli stati settici e soprattutto le importanti discrasie emorragiche costituiscono controindicazioni pressoché assolute all'esecuzione della procedura. Immagini Figura 1 - La scansione TC dimostra un evidente rimaneggiamento osteostrutturale di tipo misto del corpo e del peduncolo di Ds di L4 in una paziente di 57 anni. Figura 2 - I prelievo: la scansione TC dimostra l'esatto posizionamento della camicia introduttrice (8G) del set agobioptico e il corretto posizionamento dell'agobioptico (11 G) nel peduncolo. Figura 3 - II prelievo: dopo aver estratto la prima 'carota' di tessuto si procede al II prelievo attraverso la camicia introduttrice che resta in situ ma che è stata inclinata in senso cranio-caudale per ottenere un'altra 'carota'; la scansione TC dimostra la posizione adeguata dell'agobioptico prima della sua estrazione. Diagnosi: metastasi da adenocarcinoma mammario di grado 3. Autore: Dr. Marco Miceli, direttore della Struttura Complessa Radiologia diagnostica e interventistica, Istituto Ortopedico Rizzoli. Scheda revisionata il: 7 giugno 2021.

Elastofibroma dorsi is a rare benign soft-tissue tumor composed predominantly of elastic and fibrous connective tissue. It typically develops in the subscapular region, between the scapula and the chest wall, and is often asymptomatic. Although the exact cause of elastofibroma dorsi is not fully understood, its development appears to be associated with repetitive mechanical stress involving the shoulder girdle, chronic microtrauma, and prolonged friction or pressure between the scapula and the chest wall. The condition is frequently bilateral.Diagnostic TestsThe diagnosis of elastofibroma dorsi is based on a combination of clinical examination and imaging studies, with biopsy required only in selected cases. On physical examination, the physician may identify a palpable, usually non-tender mass in the subscapular region, which may become more prominent during forward movement of the shoulder and scapula. Imaging studies, particularly Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) (Figure 1), are used to confirm the presence of the lesion, assess its size and anatomical relationships, and evaluate the surrounding tissues. Biopsy is not routinely required when clinical and radiological findings are typical. However, tissue sampling may be indicated when imaging findings are atypical or raise suspicion of a malignant soft-tissue tumor.TreatmentIn many cases, elastofibroma dorsi does not require active treatment, particularly when the lesion is small, asymptomatic, and does not cause functional impairment. Surgical treatment may be considered when the lesion becomes large or symptomatic, causes significant discomfort or pain, or interferes with normal shoulder and scapular movement. Surgery is performed under general anesthesia and consists of complete excision of the lesion through a subscapular incision, with careful preservation of the surrounding muscles and other anatomical structures (Figure 2).Post-operative course The usual post-operative hospital stay is approximately 4-5 days, with particular attention paid to pain management and wound care. Potential complications include bleeding, surgical-site infection, and post-operative seroma formation. Bleeding and infection are relatively uncommon, whereas seroma formation is more frequent, particularly after the removal of large lesions. When clinically indicated, a post-operative seroma may require one or more percutaneous aspirations. In selected cases, microbiological analysis of the aspirated fluid and antibiotic therapy may also be necessary.Patients may occasionally be discharged with a subfascial drain in place. The drain can subsequently be removed once the daily volume of fluid has decreased to an appropriate level. Patients are generally followed closely during the first month after surgery. A further surgical follow-up visit is recommended approximately three months after the procedure, usually accompanied by an ultrasound examination of the soft tissues in the scapular region.In conclusion, elastofibroma dorsi is a rare benign soft-tissue tumor that requires an individualized approach to management. Accurate diagnosis based primarily on clinical assessment and imaging allows patients with typical asymptomatic lesions to be managed conservatively, while surgical excision can provide effective treatment for symptomatic or functionally limiting lesions. Author: Dr. Fabio Davoli, head of General & Thoracic Surgery Unit, IRCCS Rizzoli Orthopaedic Institute.Scheda revisionata il: 13 novembre 2023.

Percutaneous vertebroplasty is a minimally-invasive therapeutic radiological procedure for the treatment of painful vertebral fractures due to osteoporosis and primary or secondary tumours.A third of all vertebral fractures are due to osteoporosis, which in Italy amount to 100,000 cases (a third of which produce severe vertebral pain). "Conventional" treatment involves long immobilization (30-60 days), combined analgesic therapy, with the risk of complications (thrombo-phlebitis or pneumonia).The first vertebroplasty was performed by Hervè Deramond in Amiens in 1984, due to an expanded angioma of the odontoid process. The operation consists of the percutaneous, CT-guided introduction of a needle of appropriate caliber through which, having reached the centre of the vertebral body, a few millilitres of cement is injected under arthroscopic control. The cement solidifies quickly and consolidates the vertebra almost immediately). Percutaneous vertebroplasty is performed under local anesthesia.In 2002 38.000 vertebroplasties were performed in the United States, a 28% rise in comparison with the previous year.IndicationsThe main indications are:Recent fracture due to osteoporosis, aching, unresponsive to the medical treatmentPrimary or secondary tumour responsible for pain (metastases, lymphomas, plasmocytomas, myelomas, angiomas, etc.).Side effectsSepsisHaemorrhagic dyscrasia Unstable fractures Posterior wall ruptureOsteoporotic fracturesIn osteoporotic fractures multiple vertebrae can be treated, at the most three in the same session. The choice of vertebra or vertebrae to treat is not based only on how they appear on radiographic examination; magnetic resonance also highlights vertebrae with intracancellous edema, a sign that fractures are recent; this finding has then to be correlated with the precise location of the pain reported by the patient (to do this it is useful to palpate for pain with the fingers).Most patients that have undergone this therapy have reported a reduction or resolution of the pain between the first hour and the 14th day, with a mean of 72 hours; this eliminates the need for wearing a corset, reduces or eliminates the assumption of analgesic drugs, and therefore improves the quality of life.MetastasesIn the vertebra involved by metastases vertebroplasty provides rapid stabilization and reduction/resolution of pain within 12-24h after treatment (radio- or chemotherapy achieve the objective of analgesia in 2-4 weeks) in 96-98% of cases, with significant improvement in the patient’s quality of life.Primary vertebral tumours (expansive Angioma, Myeloma, Plasmacytoma)As for metastases, vertebroplasty provided an immediate analgesic effect and the stabilization of the vertebra, thus avoiding the risk of its collapse.In conclusion, vertebroplasty appears to be a very effective procedure in the treatment of vertebral fracture due to osteoporosis and tumour.