DIAGNOSTIC YIELD AND EFFICACY OF CT-GUIDED PERCUTANEOUS
BIOPSY IN DIAGNOSIS AND STAGING OF SCLEROTIC BONY LESIONS
By
Mohamed Abdel-Ghany, M.D.* and Ahmed Omar, M.D.**
Departments *Diagnostic radiology and **Orthopedics, El-Minia Faculty of Medicine
ABSTRACT:
Purpose: To determine the diagnostic efficacy of CT-guided percutaneous biopsy of
sclerotic bone lesions.
Materials and Methods: We performed a prospective study of 26 patients with
sclerotic bony lesions who underwent CT-guided percutaneous biopsy over a 24month period. A tryphine Ostycut needle, combined Ostycut/Trucut, or combined
Ostycut/fine needle aspiration biopsy (FNAB) needles were used to obtain a core of
tissue and specimens were sent for histopathological examination. Bone biopsy results
were analysed to yield diagnostic efficacy according to needle type, site of the lesion
and well as final pathological diagnosis.
Results: All twenty-six sclerotic lesion were biopsed under CT guidance. Ten of them
affected the axial skeleton and 16 affected long bones. Metastatic deposits were
detected in five patients, oestosarcoma (n = 7), chnodrosarcoma (n = 2), Ewing’s (n =
3), osteomyelitis (n = 4) and lymphoma, chordoma, synovioma. bone infarcts, and
oestoblastoma each (n = 1). The diagnostic efficacy according to used needle was
Ostycut needle 83%, combined Ostycut/ Tru-cut needles 100% and combined
Ostycut/ FNAB 80%. Diagnostic efficacy according to site of the lesion was 80% in
the axial skeleton and 93.7% in the long bones. Efficacy of CT-guided bone biopsy
according to pathological type of lesion was 83% for metastatic deposits, 83% for
oestosarcoma and 50% for chondroma. It was 100 for chondrosarcoma, lymphoma ,
Ewing’s, synovioma, bone infarcts, osteomyelitis, and Ostoblastoma. The overall
diagnostic efficacy and yield for CT-guided bone biopsy of sclerotic bony lesions was
85% after 1st biopsy and increased to 86.6% after 2nd biopsy.
Conclusion: Percutaneous CT- guided biopsy of sclerotic bone lesions is an important
tool in the evaluation of sclerotic bone lesions. It is a reliable procedure and yields
diagnostic information in a high proportion of patients. It has several advantages over
an open bone biopsy.
KEY WORDS:
CT-guided percutaneous biopsy
Sclerotic bone lesions
Introduction
Once a skeletal abnormality has been detected, clinical–radiologic–pathologic
correlation is essential to make a more accurate diagnosis and to improve patient care.
Neither clinical nor laboratory findings are usually useful for the diagnosis of bone
tumors and tumor-like lesions. (1,2)
Radiography offers more information and remains the cornerstone for the differential
diagnosis of skeletal tumors and tumor-like lesions. There are four techniques used in
bone tumor imaging:conventional radiography, CT, MRI and isotope bone scan.
Angiography is rarely used. Conventional radiography is the mainstay in guiding
subsequent manggement. Supplementary imaging studies are usually needed when
1
radiographic findings are questionable and/or the lesion will be submitted to surgery,
irradiation,chemotherapy or arterial embolization. These lesion susually require a
biopsy.(2.3.4)
Evaluation of some bone lesions would be incomplete without staging. Radiographs
are of limited value for this purpose and an absolute distinction between malignant
and benign lesions can not be made on radiological grounds alone. Image-directed
percutaneous biopsy is becoming an increasingly accepted modality for initial biopsy
in most musculoskeletal tumors. Biopsy refers to the removal of tissue from a living
body to establish a precise diagnosis, usually by microscopic examination. It can be
performed at surgery (open biopsy) or percutaneously (closed biopsy). Percutaneous
bone biopsies are usually performed under imaging guidance using a variety of
modalities such as fluoroscopy, computed tomography (CT), and less commonly,
ultrasonography , and magnetic resonance (MR) imaging. (5,6,7)
Compared to open biopsy, advantages of imaging guided closed biopsy are: lower
cost, time saving, no need for hospitalization, lower morbidity including avoidance of
general anesthesia- related problems, less risk of postoperative wound infection and
decreased likelihood of a pathologic fracture, earlier commencement of radiation
therapy, and biopsy of surgically-inaccessible or multiplesites . The biopsy is an
important and crucial part of staging and must be done with appropriate technique and
a clear view of the eventual surgical treatment.(8,9)
CT is well-suited for precise interventional needle guidance because it provides good
visualization of bone and surrounding soft tissues. It also avoids damage to adjacent
vascular, neurologic, and visceral structures. Histopathological diagnosis is a vital
step in the diagnostic analysis may be required in difficult situations. A sclerotic
lesion was defined as a lesion in which greater than 50% of its internal composition
was equal to the attenuation of bone on the basis of CT images, when available;
otherwise, this was determined on the basis of findings with plain film radiographs.
(10,11)
Patients and Methods
In a period extended from March 2004 to October 2005, twenty-six consecutive
patients (17 men and 9 women) , 8-70 years old were referred to radiology
department El-Mina university from orthopedic department El-Mina university and
El-Minia Oncology Center for CT- percutaneous bone biopsy. Every patient was
subjected to full history taking, thorough clinical examination, plain X-ray and CT
examination. This is followed by decision to perform biopsy which was made by
consultation with the referring orthopedic or oncologist. We received the
histopathological results of the 34 consecutive biopsies of the different bony lesions.
Patients selection and biopsy decision:
Inclusion Criteria (Indications):
We selected 26 patients with sclerotic bony lesion based on plain x-ray
appearance . The lesions showed either marginal sclerosis as dense as or
2
slightly denser than the bone cortex, geographic sclerosis as dense as or
slightly denser than bone cortex or with diffuse sclerosis denser than
cortex .
Exclusion criteria:
1- Sclerotic lesions that had pathognomonic benign radiological features.
2-The patient who had bleeding diathesis or skin infection were excluded
temporarily till the cause of contra-indication disappeared.
3-The lesions affected CV1or CV2, were excluded, being near to vital
respiratory center at medulla oblongata
Decision to perform biopsy was made by us and the referring orthopedics after
fulfemnet of the inclusion and exclusion criteria. Also in some cases the tract of the
biopsy was decided by both radiologist and orthopedicgist
CT TECHNIQUE
1-The used needles:
The used bone needle were:
1- Ostycut, Angio-Med, Berlin, Germany,. In sclerotic lesions, large 7-14-gauge
needles were used to take core biopsy in 20 patients
2- Combined Ostycut /spinal needle 19-20 G for FNAB were used to take core biopsy
in 4 patients.
3-Combined Ostycut/Tru-cut needle (autovac) 16-20 G were used to take core biopsy
in 2 patients
2-CT Guidance:
The patient was positioned to facilitate needle access to the lesion. Following
preliminary axial CT scanning, the most appropriate slice is selected to plan the
most appropriate route for directing the needle into the lesion. Generally, if there are
multiple lesions, the largest and most superficial lesion is chosen. In planning the
needle route, vital anatomic structures, e.g. major blood vessels, nerves, pleura,
peritoneal cavity and spinal canal, should be avoided.
3-Anesthesia
General anesthesia was used in children. In adults local anesthesia were used. The
skin, subcutaneous layers, muscles and periosteum were infiltrated with anesthetic
(1% lidocaine) with a 22-gauge needle (spinal needle).
4-Bone Puncture
A 2–4 mm skin incision after cleaning with antiseptic was made and the biopsy
needle is directed into the lesion. The cortex around the lesions was penetrated by
using the needle tip with manual pressure or gentle tapping with an orthopedic
hammer. After the initial core was successfully obtained, subsequent cores were easily
obtained through or adjacent to the same biopsy track. Fine-needle aspiration was also
performed in sclerotic lesions by placing an18-20 gauge needle through the largerbore needle.
3
5- Specimens management:
Specimens fixed in Formalin 4% and were sent for histopathological analysis.
6- Post procedure care:
The patients were kept under observation for 60-90 minutes to role out the possibility
of early complication
such as hemorrhage and neuromuscular injury
7- Pathological examination and data analysis:
All Specimens were analyzed in Histopathology department El-mina University
Hospital. Final analysis of bone biopsy results included presence of malignancy, type
of tumor, and final grade of tumor. The data were collected and analyzed for
adequacy of the CT guided bone biopsy to yiled an accurate diagnosis which was
determined according to the final histopathological report compared either by
surgical treatment , follow up for patient's who required no surgical treatment or had
radio and chemotherapy for unresectsable tumor.
Results
Twenty-six patients with sclerotic bony lesions were underwent percutenous CT
guided bone biopsy which were performed at radiodiagnosis department El-Mina
University Hospital between Mar. 2004 and Oct. 2006. Seventeen patients were male
and 9 were female. The age of them was ranging between 8-70 years, average 40
years. All patients were biopsied. All patients were referred to radiology department
El-Mina University Hospital from El-Minia Oncology center or the orthopedic
department El-Minia University Hospital. According to age, the patients were
grouped into seven groups. Each group represented by the number of patients in each
decade. Sex patients in the third decade were the largest in these groups while the
smallest group (one patient) was in the seventh decade. The age and Sex distribution
of the involved patients are presented in Table I.
Table (I) shows the age and sex distribution:
Age
distribution
1-10ys
Male
2
Female
0
Total
2
11-20ys
2
2
4
21-30ys
4
2
6
31-40ys
2
1
3
41-50ys
2
3
5
51-60ys
2
0
2
61-70ys
3
1
4
4
The location and pathological diagnosis of the lesions are presented in Table III.
There were 10 biopsed lesions affecting the axial skeleton, 8 in the vertebrae (dorsal
n = 3, lumbar n = 4 and sacral n = 1, one in the pelvis and one in the scapula. Six of
the eight vertebral lesions affecting the body, while the remaining biopsied examined
2 lesion affecting the posterior neural arches. Five of these eight vertebral lesions
were metastatic deposits (metastatic prostatic carcinoma n = 3, metastatic breast
carcinoma n = 1, and metastatic gastric carcinoma n = 1. Lymphoma and chordoma
each was the final diagnosis in one patient. The pathological diagnosis of scapular and
pelvic lesion was chnodrosarcoma. There were 16 lesions affecting the long bones
distributed as follows: 9 lesions affecting the femur, 3 affecting the tibia, 2 affecting
the huemrus and 2 ulnar lesions. The final diagnosis for lesions affecting the long
bone was as follows: ( oestosarcoma n = 7 , Ewing’s n = 3 , synovioma n = 1 , bone
infarcts n = 1, and osteomyelitis n = 4). Table (II)
Table (II) shows the location and pathological diagnosis of the biopsied lesions:
Level
Pathological Number
Location
diagnosis
Thoracic
Metastases
3
D12 Body
Vertebrae
D10 Body
Lumbar
Vertebrae:
Metastasis
Lymphoma
Oestobalstoma
2
1
1
L1 Right pedicle
LV2 body
LV2 posterior neural arch
Coccygeal
vertebrae
Chordoma
1
Last cocygeal spine
Pelvis
chndrosacrcoma
1
Right iliac bone
Femur
Oestosarcoma
Ewings
Synovioma
Bone infarct
6
1
1
1
Tibia
Oestosacroma
Oestomylitis
1
2
3 Metaphysis and 3
metadipyseal
Diaphysis
Diaphysis
Metaphysis
Metaphysis
Diaphysis
Humerus
Oestomylitis
Ewings
1
1
Metaphysis and diaphysis
Metaphysis and diaphysis
Ulna
Oestomylitis
Ewings
Chondrosacroma
1
1
1
Metadipyseal
Metadipyseal
Near the angle
Scapula
5
Table (III) shows the diagnostic efficacy and accuracy according to used needle, site
as well as pathological diagnosis of the of the biopsied lesions. The Ostycut
Angiomed trephine needle used in 20 lesions, combined Ostycut and True-cut needles
in 2 cases and combined Ostycut and FNAB needles used in 4 lesions. The yield was
95% for the Ostycut needles after 1st time biopsy as 19 lesions were diagnosed from
20 performed biopsies. The yield was decreased to 83% after 2nd time biopsy as 20
lesions were diagnosed from 24 performed biopsies for the 2nd time. The yield for
combined Ostycut trephine and True-cut core biopsy needles was 100% after the 1st
time biopsy. The yield for combined use of both Ostycut trephine and FNA biopsy
needles was 75% after the first time biopsy as 3 lesions were diagnosed from 4
performed biopsies. The yield increased to 80% after the second time biopsy as 4
lesions were diagnosed from 5 biopsies as one lesion biopsied for the second time.
The diagnostic efficacy according to the site of the lesions were 66%, 100% and 0%
after the first time biopsy for dorsal, lumbar & sacral spines respectively. The yields
for dorsal and sacral spines were increased to 75% & 50% after the second time
biopsy. Concerning dorsal level, 2 lesions were diagnosed from 3 performed biopsies
after first time biopsy and 3 lesions were diagnosed from 4 performed biopsies after
second time biopsy. Regarding sacral lesions, one lesion were diagnosed from 2
performed biopsies. The pelvic and scapular lesions diagnostic yield were 100 %. as
the 2 lesions were diagnosed from 2 performed biopsies. The femoral diagnostic yield
was 88% after first time biopsy as 8 lesions were diagnosed from 10 performed
biopsies. The tibial, humeral and ulnar lesions yields were 100% after first time
biopsy as all lesions were diagnosed from 1st performed biopsies. The diagnostic
yield according to pathological diagnoses of the biopsied lesions was as follows, 80%
after 1st biopsy for metastatic lesions, increased to 83% after the second time biopsy
as 5 lesions were diagnosed from 6 biopsies. Percutenouse CT bone biopsy for
oestosarcoma shows diagnostic yielded 85% after first time biopsy increased to 87%
after 2nd biopsy as 7 lesions were diagnosed from 8 performed biopsies. The single
included chordoma was diagnosed after performing 2 biopsies. The remaining
included pathological lesions shows diagnostic yield 100%. Figures 1,2,3,4,5 and 6
Table (IV): Diagnostic Yield According to choice of needles, site of the lesion and
pathological diagnosis:
Diagnostic Yield an accuracy
After 1st -time Accuracy
After 2ndbiopsy.
time biopsy
I-According to choice of needle:
Accur
Ostycut
Osty/Tru
Osty/FNAB
II-According to site of the lesion:
19/20
2/2
3/4
95%
100%
75%
20/24
4/5
8
Thoracic Vertebrae
Lumbar Vertebrae
Coccygeal vertebrae
2/3
4/4
0/1
66.%
100%
0%
3/4
1/2
7
6
8
5
Pelvis
Scapula
Femur
Tibia
Humerus
Ulna
IIIII-According to pathological diagnosis:
Metastatic deposits
Oestosarcoma
Chondrosarcoma
Chordoma
Lymphoma
Ewing’s
Synovioma
Bone infarcts
Osteomyelitis.
Ostoblastoma
1/1
1/1
8/9
3/3
2/2
2/2
100%
100%
88%
100%
100%
100%
9/10
-
4/5
6/7
2/2
0/1
1/1
3/3
1/1
1/1
4/4
1/1
80%
85%
100%
0%
100%
100%
100%
100%
100%
100%
5/6
7/8
1/2
-
Diagnostic yield of percutaneous biopsy is defined as the total number of conclusive
positive biopsies divided by the total number of biopsies and multiplied by 100. A
correct biopsy result from 1st biopsy with conclusive histopathological diagnosis
obtained in 23/26 (88.4%), increased to 86.6 % after 2nd biopsy. The specimen was
non-diagnostic in 3 patients. The inaccurate diagnoses included one patient with
osteosarcoma, another patients with chordoma and another patient breast metastasis,
in whom the first biopsy is not sufficient to yield a conclusive histopathological
diagnosis
Fig. (1): Male patient 54 years : plain x-ray showed diffusely sclerotic LV5, axial CT
scans of lumbar spine showed the trans-pedicular approach . Pathology revealed
lymphoma.
7
9
8
8
5
Fig. (2): Plian x-ray of showed diffuse permeative mixed humeral lesion with
sclerotic areas and perioesteal reaction. Axial CT scans showed the lesion punctured
by Ostycut needle. Pathology revealed oestomylitis
Fig (3) : Plain x-ray showed diffuse sclerotic lesion involving the right iliac bone.
Axial CT images showed Ostycut needle inserted within the lesion. Pathology
revealed chnodrsacrtcoma at right iliac bone
8
Fig 4: Plain revealed large dense sclerotic lesion affecting the distal femur with large
soft tissue componant. Axial CT examination showed ostycut needle seen inserted
within the lesion. Pathology revealed Osteosarcoma of the distal femur.
9
Fig. 5 : plian x-ray showed diffuse sclerotic lesion involving the distal ulna with
perioestal reaction. Axial CT scans showed the affectd ulna which is punctured by
Ostycut needle. Pathology revealed Ewing’s sarcoma.
Fig. (6): Plain X-ray (A-P & lateral views) and axial CT of upper right femur show
multiloculated lesion with dense sclerotic margins. Ostycut needle was inserted to it.
Pathology revealed Bone infarction.
Discussion
The varied clinical presentation of patients with bone tumors and the significant
differences in treatment necessitates a thorough pre-therapeutic evaluation. CT is well
suited for precise needle guidance as it provides good visualization of bone and
surrounding soft tissue, it also avoids damage of adjacent vascular, neurologic and
visceral structures. CT has been established as a reliable guidance method in bone
biopsies. Percutaneous biopsy is now a crucial step in the management of primary and
secondary bone tumors. (Viellard et al., 2005. A biopsy is indicated in benign
aggressive, malignant and suspicious lesions to confirm the diagnosis and classify the
lesion before deciding the therapeutic strategy.(11,12,13).
10
The present study consisted of 26 patients. Their age ranged between 8-70 years.
Seventeen patients were male and 9 were female. All patients were biopsied. The
studied lesions that are largely confined to certain age groups were osteosarcoma and
Ewing’s sarcoma in the long bones in children and young teenagers. Bone metastases
are noted at middle age and old ages between 45-70 years. Other studies by Salisbury
JR et al., 1998 (14) and Leffler SG et al., 1999 (15), confirmed this relation between
type of bony lesions and age.
In the present study, we used CT only as the guidance method in all biopsied lesions.
Many factors affect the efficacy and yield of percutaneous bone biopsy, including the
type of needle, site of the lesion, and pathological type of the lesions. In the present
study the used needle was (Ostycut Angio-Med) needles n=20, with diagnostic
efficacy and yield 83%) , combined Ostycut/ Tru-cut needles ( n= 2, with diagnostic
efficacy and yield 100%) and combined Ostycut/ FNAB ( n= 4, with diagnostic
efficacy and yield 80%). Gangi A et al., 2001 (16), Skrzynski MC et al., 1996 (17)
and Schweitzer ME et al., 1998 (18) stated that techniques of trephine and core
needle biopsy are well established and effective in evaluation of metastatic and
primary bone tumors of the spine. Jelink et al., 2002 (6) used Ostycut angiomed
needles in sclerotic lesions. They found a general diagnostic yield 88%. Leffler SG et
al., 1999 (15) also used Ostycut needles in sclerotic lesions under CT guidance.
Jelink et al., 2002 (6) and Leffler SG et al., 1999 (15) described Ostycut needles as
modern needle with sharp cutting edge. Both used the same large size 7-14-gauge. In
their study, the combined FNA and bone biopsy had diagnostic yield 82%.
In the present study, significant cores were taken from the lesions at different sites.
Those of axial skeleton (dorsal spine n =3 , lumber spine n = 4 , sacral spine n= 1,
pelvis n= 1 and scapula n= 1 ) showed some difficulty than those affecting
appendicular system (femur n= 9, tibia n = 3 , humerus n= 2, and ulna n= 2). This is in
keeping with studies were done by Ward JC et al. 1996 (19) and Ghelman et al.
1991 (10) whom found diagnostic rates ranging from 86 to 100% in the percutaneous
vertebral biopsy.
In the present study, the final diagnosis of biopsied lesion, with CT guided biopsy
efficacy and yield as follows: Metastatic deposits ( n=5, with diagnostic efficacy and
yield 83%), oestosarcoma ( n= 7, with diagnostic efficacy and yield 87%), chondroma
( n=1, with diagnostic efficacy and yield 50%), chondrosarcoma (n=2), lymphoma
(n=1), Ewing’s(n=3), synovioma (n=1), bone infarcts ( n=1),Osteomyelitis (n=4), and
Ostoblastoma ( n=1), with diagnostic efficacy and yield for the latter 8 different
pathological diagnosis 100%. The distribution of diagnosis varies widely across
studies.
In our study, the overall yield was 85%. After 1st biopsy and increased to 86.6 % after
2nd biopsy This is lower than the results reported by Jelink et al., 2002 (6) 88% as
well as Charboneau JW et al., 1990 (20), 88.9%. This may be explained by our less
experience in this subject, as it is first time to perform percutaneous CT-guided bone
biopsy in our department. Also, we did not have the enough experienced
musculoskeletal cytologist and pathologist. There is considerable difference between
our diagnostic yield 85% and other articles in which patients with sclerotic lesions,
diagnostic yields ranged from 69% by Leffler SG et al., 1999 (15) to 82% by Jams
11
S et al., 2002 (11). The higher sclerotic yield 85% in our study may be attributed to
selection of cases in an accessible sites. The present overall diagnostic yield after
second biopsy is higher than that reported by Marie-Hélène V. et al., 2005 (21) who
found it 79% after first biopsy and decreased to 68.5% after second biopsy.
So we are coincident with James S et al., (11) and Leffler SG et al., 1999 (15), in
that biopsy of sclerotic tumors is no longer difficult. They stated the same mentioned
factors that aid in the success of obtaining adequate cores in sclerotic lesions. In the
past, obtaining a diagnostic sample of sclerotic bone tumors at biopsy was a major
problem ( Oland J et al 1988 (22)., , Vieillard et al. 2005 (21).
CONCLUSIONS
CT-guided biopsy is an accurate investigation that has a high diagnostic yield in
patients with sclerotic bone tumors and it is a viable alternative to open surgical
biopsy. It offers a high degree of accuracy, histopathological diagnosis and ability to
differentiate benign from malignant tumors. Factors associated with higher yields
include choice of needle type, location of then lesion ( axial or peripheral) as well as
pathological type of the lesion. The overall diagnostic efficacy and yield was 85%
after 1st biopsy and 86.6 % after 2nd biopsy
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:‫الملخص العربى‬
‫دراسه الدقه و الكفاءه التشخيصيه الستخدام ابره العينات بتوجيه االشعه المقطعيه المحسوبه اليا بالكمبيوتر‬
‫فى تشخيص االصابات العظميه الصلبه‬
‫ الذى‬2004 ‫اجريت هذه الرااهذب بم ذال اه ذعب الصيخ ذ ب و ق ذال العاذ بج معذب المي ذ ا ذى الهصذر مذ مذ ا‬
‫ م اهن ث) و تراوحت اعم ا المرضذى‬9 ‫ م اله كوا و‬17 ( ‫ مريض‬26 ‫ أ صملت الرااهب على‬. 2005‫أكصوبر‬
‫ جم ع المرضذى الذهي ا ذصملت علذ لال الرهذ لب كذ نوا يعذ نوا مذ امذ ب ل عام ذب مذل ب و قذر‬. ‫ ع م‬70- 8 ‫م‬
‫ااهلوا الى ق ال اه عب بطريق مصص ل ب خالل الهصر الهكوا ه بم م ق ال العا ألاخه ع ي ل م هه اهم ب ل‬
‫ال ل ب بأهصخرا ابر الع ي ل بصوج ب اه عب الممطع ب المح وبب ال ب لكم وتر و قر تال اخص ا المرضذى و تحريذر‬
13
‫اهم ب ل العام ب ال ل ب بي ء على موا ا عب اكذ و تذال اهذص ع ع بعذم المرضذى مذ الرااهذب و لذ لوجذوع‬
‫ال ب ل العام ب ال ل ب بجواا اعض ء ملمب لصه عى اى احصم ل هم بصيل ‪.‬‬
‫خضع جم ع المرضى بعر اهصي ا ط ب العا الى اخه الع ي ل بصوج ب اه عب الممطع ب المح ذوبب ال ذ و بعذر‬
‫اه ه ء الخطوال تال انج ز اخه الع يب ام بأهصخرا ابذر اوهذص وك ت كذأبر اه هذ ب هخذه الع يذ ل و لذ لمذراتل‬
‫على اخصراق لح ء العا و أيض قراتل على عمل صحب ى العاال تمكي م أخه ع يب ك ب مذ الجذ ء الم ذ‬
‫و قذذر أهذذصخرمت ابذذر اوهذذص وك ت ميهذذرع او مجصمعذذب مذذع أبذذر تروكذذت او ابذذر ال ذذحب الرق مذذب م ذ ذذال ااهذذلت‬
‫الع ي ل بعر تث صل ى الهوام ل الى معمل ال ولجى ل صال ح ل مجلري للومول الى نذوع اهمذ بب حم ذر أو‬
‫خ ثب و نوع الخل ب الخ ثب ‪.‬‬
‫و قر ك ا توزيع اهم ب ل الصى تال أخه ع يذ ل ميلذ كمذ يلذى ( الهمذرال ال ذرايب ‪ 3‬و الهمذرال المطي ذب ‪ 4‬و‬
‫‪1‬و عامذذب الهخذذه ‪ 9‬و عامذذب الم ذ ب ‪ 3‬و عامذذب‬
‫الهمذذرال العج يذذب ‪ 1‬و الحذذو= ‪1‬و عامذذب اللذذو‬
‫العضر ‪ 2‬و عامب ال عر ‪. ) 2‬‬
‫و قر تذال تحريذر اله هذر و الكهذ ء الصيخ ذ ب ألخذه الع يذ ل مذ اهمذ ب ل العام ذب ال ذل ب بيذ ء علذى نذوع اهبذر‬
‫الم صخرمب و مك ا اهم بب و نوع اهم بب و قر توملت اليصذ ه الذى اا و الكهذ ء الصيخ ذ ب ألخذه الع يذ ل‬
‫م اهم ب ل العام ب ال ل ب بي ء على نوع اهبر الم صخرمب كم يلى ابر اوهذص وك ت ميهذرع ‪ %83‬ح ذ‬
‫تال تيخ ص ‪ 20‬ام بب م خالل ‪ 24‬ع يب ‪.‬كم تومذلت اليصذ ه الذى اا و الكهذ ء الصيخ ذ ب ألخذه الع يذ ل مذ‬
‫اهم ب ل العام ب ال ل ب بي ء علذى مكذ ا اهمذ بب كمذ يلذى ‪ %100‬ذى عاذ اهطذراا مذ عذرا عامذب الهخذه‬
‫‪ %90‬ب يم وملت الى ‪ %75‬ى العموع الهمرى‪.‬‬
‫وقر خل ت الرااهب الى اا تيخ ص اهم ب ل العام ب ال ل ب بواهطب ابذر الع يذ ل بصوج ذب اه ذعب الممطع ذب‬
‫الممطع ب المح وبب ال ب لكم وتر ال هر ع ل ب ى تيخ ص اهم ب ل العام ب ال ل ب بروا الح جب هجراء‬
‫الجراحب المهصوحب ألاخه الع يب و ل يه ر ى هرعب تيخ ص المذر= ممذ ي ذ عر علذى تذو ر الوقذت ذى ال ذرء‬
‫ب لعالج‬
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