Adequate Tissue Sampling Research Articles

Factors affecting KRAS mutation detection in colorectal cancer tissue

BackgroundWith the recent development of molecular tests for various biomarkers, it has become even more important to prepare adequate tissue samples. However, little is known about how the effect of cold ischemia time or formalin fixation time can affect KRAS mutation detection in colorectal cancer. MethodsThis study included the results of KRAS mutation tests for colorectal cancer in 401 specimens. We investigated clinicopathologic factors that may affect DNA quality of formalin-fixed, paraffin-embedded (FFPE) tissue including specimen type, cold ischemia time, and formalin fixation time and assessed the detection rate of the KRAS mutation in samples with varying DNA quality. ResultsSample DNA quality for KRAS mutation test was better in biopsy specimens, which showed markedly shorter cold ischemia time and shorter formalin fixation time compared to resection specimens. A cold ischemia time of one hour or less was associated with better sample DNA quality. But the formalin fixation time was not a significant factor when it fell within the range performed in routine pathology diagnosis. When prolonged formalin fixation was tested, we confirmed that the specimen DNA quality gradually got worse from one month to three months. ConclusionsThe biopsy specimens showed better sample DNA quality for KRAS mutation test compared to resection specimens. In a routine diagnostic pathology setting, the cold ischemia time was an important factor affecting DNA quality and the formalin fixation had a wide time range for optimal DNA quality.

Open-label phase II/III study of nivolumab plus standard of care versus standard of care for first-line treatment of metastatic colorectal cancer: Checkmate-9X8.

TPS718 Background: 5-FU-containing regimens with oxaliplatin or irinotecan and a biologic agent such as the VEGF inhibitor bevacizumab (BEV) are standard-of-care (SOC) options for the treatment of first-line (1L) metastatic colorectal cancer (mCRC). However, the objective response rate (ORR) with these regimens is 38%, and median progression-free survival (PFS) and median overall survival (OS) are 9.4 months and 21.3 months, respectively (Saltz et al. JCO 2007). Thus, there is a need for therapies that will provide durable clinical responses and improved survival. mCRC tumors represent classic “cold” tumors characterized by low expression of inflammatory and immune signatures. Emerging evidence suggests that there may be subtypes of mCRC that could benefit from synergistic immunogenic stimuli with immunotherapy agents combined with other compounds. The immune checkpoint inhibitor nivolumab (NIVO) enhances antitumor T-cell activity through the inhibition of the programmed death-1 receptor. Chemotherapy and BEV may have potential synergistic immune-stimulatory effect on the tumor and its microenvironment. Therefore, combining NIVO with SOC may enhance the antitumor immune response and improve clinical activity in 1L mCRC. The international, multicenter, open-label phase 2/3 CheckMate-9X8 (NCT03414983) trial will evaluate efficacy and safety of the combination of NIVO+SOC, compared with SOC alone, in previously untreated patients with mCRC. Methods: An estimated 180 patients aged ≥ 18 years with histologically confirmed mCRC, no prior therapy for mCRC, Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, and an adequate tissue sample, will be randomized to receive either NIVO+SOC or SOC alone. Patients who have had prior treatment with a checkpoint inhibitor; have autoimmune, cardiovascular, or hepatic disease; or test positive for hepatitis B or C (indicating detectable virus) will be excluded. The primary endpoint is PFS assessed by blinded independent central review (BICR) using RECIST v1.1. Secondary endpoints include ORR, disease control rate, duration of response, and time to response, all by BICR; OS; and safety. Clinical trial information: NCT03414983.

Prospective, multicenter, observational study of tissue acquisition through EUS-guided fine-needle biopsy using a 25G Franseen needle.

Background:Recently, EUS-guided fine-needle biopsy (EUS-FNB) using a Franseen needle was developed for histological tissue acquisition. However, the yield of a 25G Franseen needle when acquiring histological core tissue has been unclear.Patients and Methods:We performed a prospective, multicenter, and observational cohort study that included 100 solid lesions scheduled for EUS-FNB using a 25G Franseen needle at eight centers in Hokkaido, Japan. Only EUS-FNB specimens acquired at the first pass were evaluated without a rapid on-site evaluation. The tissue acquisition rate, acquisition rate of an adequate specimen for histological assessment, the quality of tissue sample, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, and adverse events were evaluated.Results:We analyzed a total of 100 solid lesions in 100 patients. The patients were 57 males and 43 females with a median age of 70 years. The technical success rate was 100%. The tissue acquisition rate was 95.0%. The acquisition rate of an adequate specimen for histological assessment was 82.0%. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 87.0%, 100%, 100%, 40.0%, and 88.0%, respectively. The adverse event rate was 1.0%, and it was reported in only one patient who had a moderate pancreatic fistula.Conclusions:EUS-FNB using the 25G Franseen needle was feasible, and adequate histological core tissue samples were acquired with this method.

Correlating laryngoscopic appearance of laryngeal lesions with histopathology

Meticulous scrutiny of laryngeal lesions with laryngoscopes and microscopes often identify angiogenic activity, one of the hallmarks of neoplastic and preneoplastic lesions. The aim of this study was to determine if there is an association between laryngoscopic appearance and histopathology of laryngeal lesions based on operative biopsies. Retrospective case-control study. One hundred forty-four laryngeal biopsies from 92 patients between 2015 and 2017 met inclusion criteria. Cases were patients who had biopsy-proven laryngeal dysplasia or malignancy. Controls were patients who had benign laryngeal pathology. All of the laryngeal lesions had either keratosis or vascular stippling, an indication of angiogenic activity. Medical records, videostroboscopies and operative findings of these patients were reviewed. Multivariable logistic regression was used to examine the correlation between laryngoscopic appearance of laryngeal lesions and presence or absence of dysplasia and invasive carcinoma. Fifty percent of the 144 laryngeal lesions were classified either as dysplastic or malignant by histopathology. Vascular stippling was present in 31% of all laryngeal lesions. On logistic regression, vascular stippling was significantly associated with dysplastic and malignant lesions (P = .0018). Overall sensitivity and specificity of vascular stippling and the presence of dysplasia and malignancy were 51% and 89%, respectively. Laryngoscopic and microscopic appearance of vascular stippling could inform clinicians on diagnostic sampling of suspicious laryngeal lesions that reduces delay in diagnosis. The low sensitivity of vascular stippling underlies the importance of maintaining high clinical suspicion and proceeding to the operating theater for adequate tissue sampling. 3 Laryngoscope, 129:1308-1312, 2019.

Thickened Gastric Folds: Approach

ABSTRACTThickened gastric folds (TGF) are not an uncommon finding on radiological imaging or endoscopy. It is an enigmatic condition requiring a systematic approach with correlation between clinical, laboratory, radiological, endoscopic, and histological parameters to reach a final diagnosis. It has a varied number of differential diagnosis and reaching the final diagnosis is often challenging even to an astute clinician. Findings on endoscopy are similar and biopsy results often equivocal. Differentiating between benign and malignant conditions is challenging. Routine pinch biopsy usually does not sample deep enough to get an adequate tissue sample, and other methods of biopsy may be required. Newer modalities, such as endoscopic ultrasound (EUS) and EUS‑guided sampling, are helpful in differentiating benign from malignant causes. At times, exploratory laparotomy and full‑thickness biopsy may be required for final diagnosis. In this review, we discuss the various differentials of TGF, with special emphasis on how to approach a case of TGF.

Diagnosing Lung Cancer: The Complexities of Obtaining a Tissue Diagnosis in the Era of Minimally Invasive and Personalised Medicine.

The role of the respiratory physician in diagnosing lung cancer has increased in complexity over the last 20 years. Adenocarcinoma is now the prevailing histopathological sub-type of non-small cell lung cancer (NSCLC) resulting in more peripheral cancers. Conventional bronchoscopy is often not sufficient to obtain adequate tissue samples for diagnosis. Radiologically guided transthoracic biopsy is a sensitive alternative, but carries significant risks. These limitations have driven the development of complimentary bronchoscopic navigation techniques for peripheral tumour localisation and sampling. Furthermore, linear endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is increasingly being chosen as the initial diagnostic procedure for those with central lesions and/or radiological evidence of node-positive disease. This technique can diagnose and stage patients in a single, minimally invasive procedure with a diagnostic yield equivalent to that of surgical mediastinoscopy. The success of molecular targeted therapies and immune checkpoint inhibitors in NSCLC has led to the increasing challenge of obtaining adequate specimens for accurate tumour subtyping through minimally invasive procedures. This review discusses the changing epidemiology and treatment landscape of lung cancer and explores the utility of current diagnostic options in obtaining a tissue diagnosis in this new era of precision medicine.

Mo1351 THE SAFETY AND FEASIBILITY OF ENDOSCOPIC ULTRASOUND-GUIDED PARENCHYMAL LIVER BIOPSY AT A LARGE COMMUNITY HOSPITAL

Parenchymal liver biopsy is important for diagnosis and management for many liver disease patients. Percutaneous image-guided liver biopsy is currently the most widely used method; however, endoscopic ultrasound (EUS)-guided liver biopsy with newer flexible large-bore core needles represents an emerging approach for sampling. EUS-guided liver biopsy (EUS-LB) offers certain advantages over traditional methods such as doppler assistance to avoid intervening vessels and the ability to image both hepatic lobes to minimize sampling error. Our aim is to evaluate the feasibility and safety of EUS-LB in obtaining adequate tissue samples for diagnosis of unexplained liver disease and to compare our results to percutaneous liver biopsy at our institution. We conducted a retrospective chart review of patients who underwent EUS-LB at Santa Clara Valley Medical Center in San Jose, California between January 1 and October 30, 2017. All patients who underwent EUS-LB had 2 passes taken. For comparative purposes, we also identified patients who underwent a percutaneous liver biopsy for similar indications. We collected data on procedure duration, adverse events, complete portal tracts (CPTs), inflammation grade, and fibrosis grade. To date, there have been 10 patients who have undergone EUS-LB with a 19-gauge Acquire needle (Boston Scientific) at our institution. The indications for EUS-LB included unexplained abnormal LFTs (n=8), staging of hepatitis B (n=1), and cirrhosis of unclear etiology (n=1). The average procedure duration for EUS-LB and percutaneous liver biopsy was 19 minutes and 28 minutes, respectively. The average number of CPTs was 9.8 (range 6-13) and 9.6 (range 6-14), respectively. More than two-thirds of patients in the EUS-LB group were determined to have mild inflammation (7/10, 70%). Most patients had 0 stage of fibrosis (8/10, 80%). Recovery time for EUS-LB patients averaged 29 minutes while percutaneous liver biopsy patients were all placed under observation for 240 minutes prior to discharge. No patients experienced any adverse events. EUS-LB is feasible, safe, and produces a comparable sample adequacy for histologic examination compared to percutaneous liver biopsy at our community hospital. In addition, EUS-LB requires less time to complete, both in procedure time and recovery time. Further study regarding EUS-LB is warranted for optimal technique (e.g. the use and amount of suction) as well as direct comparison to percutaneous approach in terms of possible cost reduction and improved patient satisfaction.

Treatment of malignant pleural effusion.

Malignant pleural effusion (MPE) is a very disabling condition that often affects patients with advanced neoplasm. Conservative approach, repeated thoracentesis, pleurodesis and use of indwelling pleural catheters (IPC) are the main methods to deal with this condition. The ideal treatment must focus on symptom relief and has to take into account patient underlying diseases, performance status and necessity of adequate tissue sample for diagnosis. In a video we show techniques to perform video assisted thoracic surgery (VATS) pleural biopsy and talc poudrage pleurodesis.

Indications and results of renal biopsy in children: a 36-year experience.

This study was conducted to investigate retrospectively the indications for renal biopsy (RB) in native kidneys and to analyze pathological findings in a single tertiary pediatric hospital in Southern Italy for the last 36years. All patients who underwent RB at our hospital from 1979 to 2014 were included. All renal tissue specimens were studied under light and immunofluorescent microscopy, while electron microscopy was performed only for specific clinical indications. The study group included 213 patients (female43.2%) who underwent 225 percutaneous native kidney biopsies. Median age was 10.4years (range 0.6-24years). The most frequent indication for RB was nephrotic syndrome (44.4%), followed by proteinuria (27.6%), asymptomatic hematuria (17.3%) and acute kidney injury (9.8%). Gross hematuria appeared after biopsy in less than 5% of the patients, but none of them needed blood transfusion. Adequate renal tissue sample was obtained in 95.5% of the renal biopsies. Primary glomerulonephritis (GN) was the most common finding (61.4%), followed by secondary GN (21.4%), tubulointerstitial diseases (3.7%) and hereditary nephropathy (2.8%), while in 10.7% of the cases, normal renal tissues were found. According to histopathological diagnosis, the most common causes of primary GN were IgA nephropathy (20.9%), followed by minimal change disease (18.1%) and focal segmental glomerulosclerosis (11.6%). The epidemiology of glomerular disease in our single-center cohort is similar to that shown in other national and international reports. Moreover, our study shows that percutaneous ultrasound-guided RB is a safe, reliable and effective technique in children.

Combined Fluoroscopy and Ultrasound-Guided Transjugular Kidney Biopsy in Cirrhotic Patients

PurposeTo evaluate the safety and diagnostic yield of combined fluoroscopy and ultrasound-guided transjugular kidney biopsy (TJKB) in cirrhotic patients with suspected renal parenchymal disease. Materials and MethodsA retrospective review was made of 27 patients (21 men; overall mean age 44.7 y) who underwent TJKB from June 2013 to June 2016; 21 patients had coagulopathy and/or thrombocytopenia, 4 underwent simultaneous TJKB with transjugular liver biopsy, and 1 patient each had severe obesity and gross ascites. All procedures were performed with the use of fluoroscopy and simultaneous transabdominal ultrasound guidance. The data were analyzed for number of passes taken, number of glomeruli in the tissue cores, adequacy of tissue core for histopathologic diagnosis, and incidence and severity of complications. ResultsThe average number of passes per case was 3.6 (range 2–6). The total length of tissue cores ranged from 0.4 cm to 2.5 cm. The mean numbers of glomeruli per procedure on light microscopy were 6.7 (range 0–17). Diagnostic biopsy specimens were obtained in 23 out of 27 patients (85%). Eleven patients had minor complications. One patient had major complication in the form of hemoglobin drop of 2.1 mg/dL which required embolization and blood transfusion. ConclusionsCombined use of fluoroscopy and ultrasound guidance for TJKB yielded adequate tissue samples with fewer passes and a low rate of complications in high-risk patients with cirrhosis.

Clinical and misdiagnosed analysis of primary pulmonary lymphoma: a retrospective study

BackgroundThe primary pulmonary lymphoma (PPL), with a low incidence, was highly misdiagnosed in clinic. The present study analyzes the clinical features, laboratory and imaging data, pathologic characteristics, and summarizes misdiagnosis reasons of PPL cases, aims to provide a better understanding and increase the accuracy of early diagnosis and minimize the misdiagnosis of PPL.MethodsThe clinical data of 19 cases were collected from the first affiliated hospital of Wenzhou medical university (PRC) from April 2010 to May 2016. All cases were confirmed by pathology. The process of misdiagnosis was described. This study retrospectively analyzed the incidence, clinical presentation, laboratory examination, Chest CT scan and diagnosis of the cases.ResultsThe symptoms of the 19 cases were dyspnea, fever, hemoptysis, chest pain or physical findings without obvious symptoms. Five patients were pneumonia-like, nine patients had lung single nodule or mass and four patients got pleural effusion, which were reported by computed tomography (HRCT) scan. There were 2 cases of Hodgkin lymphoma (HL), and 17 cases of non-Hodgkin lymphoma (NHL). In NHL cases, 12 cases were confirmed mucosa associated lymphoid tissue B lymphoma type, 3 cases were confirmed diffuse large B-cell lymphoma, angioimmunoblastic T-cell lymphoma and ALK positive anaplastic large cell lymphoma were one case separately. Clinical and imaging manifestation of PPL is untypical, but there are still some hints: 1) Fuzzy shadow at the edge of lung mass with air bronchogram; 2) Lung mass shadow stable for a long time; 3) Pneumonia-like changing without infections clinical and lab manifestation. Thirteen patients (68.4%) were misdiagnosed as pneumonia, lung cancer and tuberculosis initially. The term between initial diagnosis and final diagnosis lasted for half a month up to 2 years, with median time of 6 months. Two cases were misdiagnosed as tuberculosis. One case was misdiagnosed as small cell lung cancer.ConclusionClinical and imaging manifestation of PPL is untypical. Biopsies should be taken actively if the imaging findings don’t match the symptoms or the anti-infection treatments to “lung infection” don’t work. Accurate diagnosis requires adequate tissue sampling with appropriate ancillary pathologic studies. If clinical manifestation and the diagnosis don’t match, repeated biopsy should be ordered.

Accuracy and safety of ultrasound-guided percutaneous needle core biopsy of renal masses: A single center experience in China.

Our aim is to determine the sufficiency, accuracy, and safety of ultrasound-guided percutaneous needle core biopsy of renal masses in Chinese patients.Patients who had undergone ultrasound-guided needle core renal mass biopsy from June 2012 to June 2016 at West China Hospital, China were retrospectively reviewed. The information obtained included demographics, mass-related parameters, biopsy indications, technique, complications, pathologic results, and follow-up. Concordance of surgical resection pathology and follow-up data were assessed.Renal mass biopsies were performed in 106 patients. Thirty-nine (36.8%) were asymptomatic. The male/female ratio was 60/46, with a median age of 49.5 years. Median mass size was 8.1 cm (range 1.8–20). Biopsy was performed through a 16-gauge needle, with median cores of 2 taken (range 1–5). Only one significant biopsy-related complication (hemorrhage requiring transfusion) was encountered. An adequate tissue sample was obtained in 97.2% (103/106) of biopsies. Eighty-seven biopsies (82.1%) showed malignant neoplasms, 16 (15.1%) yielded benignity, and 3 (2.8%) were nondiagnostic. After biopsy, 46 patients (43.4%) underwent surgery. Compared with the subsequent mass resection pathology, the biopsy diagnoses were identical in 43 cases. The accuracy rate of biopsy distinguishing malignant from benign lesions was 99.1%, and the rate for determining tumor histological type (excluding the nondiagnostic biopsies) was 95.1%. The sensitivity and specificity in detecting malignancy were 98.9% and 100%, respectively.In several situations, there is still a role for biopsy before intervention. Percutaneous needle core biopsy under ultrasonography guidance is highly accurate and safe, and can determine the proper management of undefinable masses.

Structured Diagnostic Approach and Risk Assessment in Mucous Membrane Pemphigoid with Oesophageal Involvement.

Oesophageal involvement in mucous membrane pemphigoid is considered rare, but it may be underdiagnosed. To assess the incidence of oesophageal involvement in a group of patients with newly diagnosed mucous membrane pemphigoid we retrospectively analysed the medical records of 30 consecutive patients with mucous membrane pemphigoid diagnosed between 2006 and 2016 at the Department of Dermatology, University Hospital Würzburg. Twenty-one patients (70%) reported symptoms indicative of oesophageal mucous membrane pemphigoid. Twelve patients (40%) underwent oesophagogastroduodenoscopy, and oesophageal pathology compatible with mucous membrane pemphigoid was endoscopically found in 9 cases (30%). In all patients indirect and direct immunofluorescence were performed. Patients with and without oesophageal involvement did not differ with regard to the results of indirect immunofluorescence on salt-split human skin and monkey oesophagus. Study results demonstrate the necessity of a standardized diagnostic work-up, including adequate tissue samples for direct immunofluorescence, to prevent underdiagnosis of oesophageal mucous membrane pemphigoid.

Abnormal Uterine Bleeding- evaluation by Endometrial Aspiration.

Endometrial evaluation is generally indicated in cases presenting with abnormal uterine bleeding (AUB), especially in women more than 35 years of age. AUB encompasses a variety of presentation, for example, heavy menstrual bleeding, frequent bleeding, irregular vaginal bleeding, postcoital and postmenopausal bleeding to name a few. Many methods are used for the evaluation of such cases, with most common being sonography and endometrial biopsy with very few cases requiring more invasive approach like hysteroscopy. Endometrial aspiration is a simple and safe office procedure used for this purpose.Materials and Methods:We retrospectively analyzed cases of AUB where endometrial aspiration with Pipette (Medgyn) was done in outpatient department between January 2015 and April 2016. Case records (both paper and electronic) were used to retrieve data.Results:One hundred and fifteen cases were included in the study after applying inclusion and exclusion criteria. Most cases were between 46 and 50 years of age followed by 41–45 years. No cases were below 25 or more than 65 years of age. Heavy menstrual bleeding was the most common presentation of AUB. Adequate samples were obtained in 86% of cases while 13.9% of cases' sample was inadequate for opinion, many of which were later underwent hysteroscopy and/or dilatation and curettage (D and C) in operation theater; atrophic endometrium was the most common cause for inadequate sample. Uterine malignancy was diagnosed in three cases.Discussion:Endometrial aspiration has been compared with traditional D and C as well as postoperative histopathology in various studies with good results. Many such studies are done in India as well as in western countries confirming good correlation with histopathology and adequate tissue sample for the pathologist to give a confident diagnosis. No complication or side effect was noted with the use of this device.Conclusion:Endometrial aspiration is a simple, safe, and effective method to sample endometrium in cases of AUB avoiding risk of anesthesia and is less time-consuming. Many similar devices are also available in the market and need to be popularized in all parts of the country.

A Rare Case of Gastric Chronic Lymphocytic Leukemia and Linitis Plastica

Introduction: Chronic lymphocytic leukemia (CLL) and gastric adenocarcinoma of linitis plastic type (LP) are both rare causes of gastric cancer. We present a case with initial diagnosis of gastric CLL in which symptoms persisted despite therapy. He was eventually diagnosed with LP on subsequent work-up. This case highlights the need to continually investigate if initial symptoms are not resolved despite appropriate therapy. Case: Our patient is 67 year old male with CLL diagnosed incidentally in 2012 for which he was being monitored. In 2015, he developed GERD, bloating, post prandial abdominal pain, early satiety and weight loss. CT imaging revealed a gastric mass. EUS showed thickened gastric body wall and pathology revealed monocytic B-cell population that are CD5, CD19, CD20, CD22 and CD23 positive, consistent with CLL. Bone marrow (BM) biopsy confirmed the diagnosis. He was treated with four cycles of Fludarabine, Cyclophosphamide and Rituximab (FCR). BM biopsy after completion of therapy showed no evidence of CLL, but his symptoms persisted, prompting him to present for a second opinion at our institution. Physical exam was remarkable for mild LUQ tenderness to palpation. Labs revealed mild anemia. Repeat EGD showed diffusely thickened gastric folds throughout stomach and buried biopsies recovered infiltrating poorly differentiated carcinoma of linitis plastic type. Discussion: CLL very rarely affects the stomach, but has been reported by Salek, et. al. (GIE 2006). Given the patient's known diagnosis and initial histopathology results, it was initially thought to be the etiology of his symptoms. Persistence of GI symptoms prompted further investigation and ultimately the diagnosis of LP type gastric adenocarcinoma was made. LP is rare and accounts for only 3.2% of gastric cancers, but it is rarer still to have two malignancies involving the gastrointestinal tract. Nakashima, et. al. (Anticancer Res 2016) reported a case of gastric adenocarcinoma in a patient with underlying CLL. However, our case is the first to describe a dual diagnosis of gastric CLL and LP. While it is not possible to know if gastric CLL was incidental and LP was the underlying reason for the original presenting symptoms, the case underscores the importance of maintaing an elevated index of suspicion and to persevere in obtaining adequate tissue sampling when symptoms suggestive of infiltrative gastric pathology persist.Figure: EGD image showing diffusely thickened and erythematous gastric folds.Figure: EUS image demonstrating gastric wall thickening.

Ultrasound-guided core needle biopsy in salivary glands: A meta-analysis.

Core needle biopsy is an effective diagnostic tool widely used in many oncological diagnostic approaches. It provides an adequate tissue sample for histological evaluation of architecture, which allows tumor grading and classification of malignant and benign tumors. This study aimed to provide an updated meta-analysis and systematic review of core needle biopsy in the salivary glands. A literature search using PubMed, Embase, and the Cochrane Library through December 2016. Data on true positives, true negatives, false positives, and false negatives were extracted from the relevant articles. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. We calculated accuracy, sensitivity, and specificity with 95% confidence intervals (CIs) using random-effects models that considered both within- and between-study variations. Our search included 10 observational studies. For core needle biopsy, the sensitivity and specificity for the diagnosis of salivary glands were 0.94 (95% CI: 0.92-0.96, I2 = 18.7%, χ2 P = .27) and 0.98 (95% CI: 0.97-0.99, I2 = 79.6%, χ2 P = .00), respectively. The area under the summary receiver operating characteristic curve was 0.98 (95% CI: 0.97-0.99). Seven hematomas, one case of temporary facial paralysis caused by local anesthesia, and no tumor seeding were reported from a total of 1,315 procedures. Ultrasound core needle biopsy of salivary glands is an excellent diagnostic tool in terms of accuracy, technical performance, and safety profile. NA. Laryngoscope, 128:118-125, 2018.

Diagnostic use of intramedullary reaming biopsy in metastatic long bone disease.

INTRODUCTION Bone is the third most common site of metastasis. A histological diagnosis is important in guiding therapy and prognosis. In up to 15% of cases of metastatic disease, the primary tumour remains unknown. This emphasises the importance of adequate, reliable and accurate sampling when performing any type of biopsy. Reaming biopsy is commonly performed during intramedullary nailing of metastatic long-bone disease but there is little published evidence on the diagnostic use and reliability of this technique. AIMS AND METHODS We reviewed 49 cases of confirmed metastatic bone disease to determine adequacy for analysis, diagnostic accuracy and factors affecting reliability. RESULTS Adequate tissue for histopathological analysis was obtained in 96% of cases but metastasis was confirmed in only 51% of cases. The presence of a pathological fracture had no effect on accuracy of the results but metastasis was more likely to be missed in the presence of tissue crushing and or necrosis (P = 0.015). DISCUSSION This study determines the use and accuracy of bone reaming biopsy in metastatic disease and, to the best of our knowledge, is the only study determining the effect of additional factors such as the presence of a pathological fracture and tissue necrosis or crushing on the diagnostic accuracy of this technique. CONCLUSIONS In spite of adequate tissue sampling, the diagnostic accuracy and, hence, reliability of intramedullary reaming biopsy in metastatic bone disease is less than optimal. A reaming histopathology report suggesting no evident metastasis should always be taken in clinical context.

Pediatric renal transplant biopsy with ultrasound guidance: the 'core' essentials.

This review provides a comprehensive and practical approach to pediatric percutaneous renal transplant biopsies, highlighting techniques and strategies to optimize adequate sample yield and ensure patient safety. In children with end-stage renal disease, transplantation is the preferred choice of therapy, providing for overall lower long-term morbidity and mortality compared with dialysis. In the ongoing management of renal transplant patients, core tissue sampling via a percutaneous renal biopsy remains the gold standard when transplant dysfunction is suspected. Indications for renal transplant biopsy and techniques/tools for adequate sample yield are discussed. Strategies for common challenges such as poor visualization and renal transplant mobility are addressed. We discuss the clinical signs, techniques and imaging findings for common complications including hematomas, arteriovenous fistulas and pseudoaneurysms. Although the percutaneous renal transplant biopsy procedure is generally safe with rare complications, care must be taken to ensure major complications are promptly recognized and treated. Adequate tissue samples obtained via renal biopsy are imperative to promptly identify transplant rejection to provide valuable information for patient diagnosis, treatment and outcomes. Radiologist and nephrologist attention to proper ultrasound techniques and optimal biopsy tools are critical to ensure tissue adequacy and minimize complications.

Electromagnetic Navigation Bronchoscopy

OBJECTIVE: Suspicious pulmonary nodules have become a more common finding since the advent of CT scans as a screening method for lung cancer. The challenge is to find a safer, practical and more accurate way to diagnose peripheral nodules and lesions while minimizing harm to the patient. Electromagnetic Navigation Bronchoscopy (ENB) is a cutting edge technology that enables pulmonologists to precisely target small and difficult to reach peripheral pulmonary nodules by using technology similar to a global positioning system (GPS).This study describes our experience in using ENB with Endobronchial ultrasound (EBUS) as a diagnostic tool on patients suspected of lung malignancy. MATERIALS AND METHODS: A retrospective analysis was conducted for 33 patients between November 2014 and November 2015 at our institution. Yield was determined by attaining final diagnosis from tissue analysis of every patient who underwent the ENB and EBUS procedure for suspected lung malignancy. Patients with no definite diagnosis were referred to surgery for further examination. Intraoperative and postoperative complications were recorded. RESULTS: The ENB and EBUS procedure was completed in all 33 subjects on lung nodules measuring from 2 to 108mm. The patients were 67% (22) male, 33% (11) female, 88% (29) Asian, with a mean age of 61 years old. Lung nodules were located in the upper lobe (52%), lower lobe (43%) and middle lobe (5%). Lymph node involvement was present in 33% of cases. Of the patients in the study, 26 cases (79%) were accurately diagnosed using ENB and EBUS, 6 cases (18%) were referred to surgery and 1 patient (3%) refused further investigation. No bleeding or pneumothorax complications were reported. CONCLUSION: ENB is an effective, accurate and a novel method that provides real time directions toward lung lesions and nodules. This tool allows flexibility that aids biopsy of hard to reach areas, and attains adequate tissue samples. This instrument compliments other bronchoscopic methods such as EBUS.

Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

1 ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.) 2 ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.) 3 ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.) 4 ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.) 5 ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.) 6 ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size >40mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.) 7 For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1).