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Percutaneous Conchotome Muscle Biopsy. a Useful Diagnostic and Assessment Tool CHRISTINA DORPH, INGER NENNESMO, and INGRID E

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Percutaneous Conchotome Muscle Biopsy. a Useful Diagnostic and Assessment Tool CHRISTINA DORPH, INGER NENNESMO, and INGRID E Percutaneous Conchotome Muscle Biopsy. A Useful Diagnostic and Assessment Tool CHRISTINA DORPH, INGER NENNESMO, and INGRID E. LUNDBERG ABSTRACT. Objective. To evaluate the diagnostic yield, performance simplicity, and safety of the percutaneous conchotome muscle biopsy technique for clinical and research purposes in an outpatient rheuma- tology clinic. Methods. Biopsies taken by rheumatologists in an outpatient clinic during 1996 and 1997 were eval- uated for histopathological and clinical diagnoses. Results. A total of 149 biopsies were performed on 122 patients. Physicians learned the method easily. Samples were of adequate size and quality to allow for diagnostics. In total 106 biopsies were taken due to different diagnostic suspicions: 24 polymyositis (PM) or dermatomyositis (DM); 43 PM, DM, or vasculitis in addition to another rheumatic condition; 19 systemic vasculitis; and 20 myalgias. Criteria for definite or probable PM/DM were fulfilled in 21 patients, 18 with positive biopsies. Thirteen patients received vasculitis as clinical diagnosis, 3 with positive biopsies. No patient with myalgia had a biopsy with inflammatory changes. Fifteen of 43 rebiopsies performed to assess disease activity had signs of active inflammation. In 48% there were changes in immuno- suppressive therapy after biopsy results. Four complications occurred; one was a serious subfascial hematoma. Conclusion. The percutaneous conchotome muscle biopsy technique gives a good size sample that allows for diagnostic evaluation and has a high yield in patients with myositis. It is a simple proce- dure, easy to learn and to perform, with a low complication rate and minimum discomfort for the patient. The method can preferably be used as a diagnostic tool and to perform repeated biopsies to assess the effect of a given therapy for both clinical and research purposes. (J Rheumatol 2001;28:1591–9) Key Indexing Terms: MUSCLE BIOPSY MUSCULAR DISEASES POLYMYOSITIS DERMATOMYOSITIS The idiopathic inflammatory myopathies (IIM) are charac- body myositis (IBM)1. Treatment of the IIM is mainly based terized by cellular inflammatory infiltrates in muscle tissue on corticosteroids in large doses for extended periods, often that are, more or less, a prerequisite for the diagnosis of IIM. in combination with other immunosuppressive drugs2-5. Histopathological evaluation of muscle biopsies is also However, only one-third of patients recover completely and important to exclude other myopathies and to identify side effects of corticosteroids are common6-8. Thus, there is subsets of IIM. Based on different histopathological as well a need for improved therapies. A muscle biopsy technique as clinical features, 3 subsets of IIM have been identified, that allows for repeated biopsies is thus important to assess polymyositis (PM), dermatomyositis (DM), and inclusion the effect of treatment on the tissue level. One such muscle biopsy technique could be the percuta- From the Unit of Rheumatology, Department of Medicine, Karolinska neous conchotome biopsy, or the semi-open muscle biopsy9. Institutet; Department of Rheumatology, Karolinska Hospital; and Division of Pathology, Huddinge Hospital, Karolinska Institutet, This method has become widely used in Sweden and other Stockholm, Sweden. Scandinavian countries, including in our rheumatology Supported by grants from Swedish Reumatoid Association, Åke Wiberg clinic, during the last 20 years for both diagnostic and Foundation, Prof. Nanna Svartz Foundation, Börje Dahlin Foundation, 9-13 Axel and Eva Wallström Foundation, and Research Foundations from the research purposes , but has received little attention Karolinska Institutet. outside Scandinavia. C. Dorph, MD, Unit of Rheumatology, Department of Medicine, The percutaneous conchotome biopsy technique was Karolinska Institutet; I.E. Lundberg, MD, PhD, Associate Professor, Unit reported to share the advantages of the percutaneous needle of Rheumatology, Department of Medicine, Karolinska Institutet and Department of Rheumatology, Karolinska Hospital; I. Nennesmo, MD, biopsy method — it can be performed with local anesthesia PhD, Associate Professor, Division of Pathology, Huddinge Hospital, in an outpatient clinic, the procedure involves only slight Karolinska Institutet. discomfort and inconvenience for the patient, and it leaves a Address reprint requests to Dr. C. Dorph, Unit of Rheumatology, CMM small scar that is important in order to perform repeat biop- Hus L8:04, Karolinska Hospital, S-171 76 Stockholm, Sweden. 10,11 E-mail: [email protected] sies . However, there is still debate whether this tech- Submitted October 19, 2000; revision accepted January 31, 2001. nique provides a tissue sample large enough with sufficient Personal non-commercial use only. The Journal of Rheumatology Copyright © 2001. All rights reserved. Dorph, et al: Conchotome muscle biopsy 1591 Downloaded on September 29, 2021 from www.jrheum.org quality to allow required diagnostic procedures such as graphy (EMG) results, cortisone dose, and clinical symptoms at time of histopathology and biochemistry analyses. It has also been biopsy were also registered. In the histopathology report, the presence of questioned whether the sample size with this method is large the following pathological variables was noted: inflammatory cellular infil- trate, type 2 muscle fiber atrophy, degenerating or regenerating muscle enough to provide a high diagnostic yield, especially in fibers, centrally located nuclei, ring fibers, signs of neuropathy, fatty tissue myositis diagnostics, since patchy distribution of the inflam- deposits in muscle fibers, ragged red fibers, endothelial involvement matory infiltrates and skip lesions has been reported14-16. (perivascular inflammation and/or inflammation in blood vessel walls), and The open muscle biopsy technique, which results in larger positive immunohistochemical analyses. biopsy samples, has often been advocated to increase the For a clinical diagnosis of myositis the criteria proposed by Bohan and Peter were used21,22 and patients fulfilling the criteria for definite or prob- 17 diagnostic sensitivity for this patient group . Still, in most able PM or DM were classified as having myositis. For clinical diagnosis studies, roughly 25–30% of patients with myositis have of vasculitis we used the 1990 classification criteria of the American negative biopsies8,10,18-20. Moreover, the safety of the College of Rheumatology23. The following definitions of certain muscle conchotome biopsy technique as a routine diagnostic tool biopsy findings were used: (1) myositis was defined as in Bohan and has not been evaluated in a rheumatology setting. Peter’s definition of the histopathological findings in myositis; (2) vasculitis was defined as inflammation in blood vessel walls and endothe- We evaluated the utility and safety of the percutaneous lial involvement; (3) “unspecific findings” were used for muscle biopsies conchotome muscle biopsy technique performed in a that displayed some pathological variables, but not enough for a specific rheumatology clinic. The majority of the investigated histopathological diagnosis; and (4) normal biopsies were without evident patients were suspected of having an inflammatory muscle pathological variables. disease. Due to the easily available method, a large number Muscle biopsy procedure. The biopsy procedure was performed in the of biopsies have been taken from patients with myalgia outpatient clinic or, in some cases, in the intensive care unit by a rheuma- tologist assisted by a nurse. Under local anesthesia, a 5 to 10 millimeter inci- without other signs of muscle disease, thus presenting a sion of the skin and muscle fascia was carried out with a scalpel. Two to 4 vague suspicion of myopathy. We also evaluated the diag- samples of muscle tissue were removed using Weil-Blakesly’s conchotome nostic outcome of these biopsies. We assessed the utility and (article no. 72-0222, Stille Surgical AB, Stockholm, Sweden) (Figure 1). safety of the technique as a tool for repeated biopsies. The The closed jaw of the conchotome is inserted into the muscle. To remove the patients who were subject to these rebiopsies had previously sample, the jaw is opened, closed, and then rotated 180°, thus cutting off been diagnosed with IIM. These biopsies were performed tissue. The conchotome’s sharp-edged jaw (3.6 mm width, 8 mm length) is opened and closed similarly to scissors. A steristrip was applied to close the due to the persisting muscle symptoms of weakness, fatigue, incision, and the patient was mobile immediately after the procedure. The and/or pain. samples were transported on a moist tissue kept cool in a jar on ice to the Neuropathology Laboratory at Huddinge Hospital. This transport takes MATERIALS AND METHODS about 30 minutes. After orientation of the material using a stereo micro- We completed a retrospective evaluation of all muscle biopsies performed scope, it was snap frozen in isopenthane and dry ice and kept in a freezer during 1996 and 1997 at the Department of Rheumatology, Karolinska (–20°C) until further preparation. Six to 8 µm thick sections were cut in a Hospital, Stockholm. The percutaneous conchotome muscle biopsy tech- cryostat. The routine analyses included staining for hematoxylin-eosin, nique was used in all cases. Medical records and pathology reports were Gomori trichrome, periodic acid-Schiff (PAS), oil red, NADH (the reduced reviewed. The following information was registered for all 149 biopsies: form of nicotinamide-adenine
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