CT-guided Core Biopsy Research Articles

Computed tomography-guided transfacial buccal space core biopsy of deep head and neck space lesions: our experience

Deep head and neck space lesions can present a number of diagnostic challenges due to their deep anatomical position and difficult access for diagnostic tissue sampling. We describe a series of percutaneous ‘transfacial’ buccal space computed tomography (CT)-guided core biopsies of these lesions and subsequent histological findings. Six patients underwent CT-guided core biopsy of deep parotid, parapharyngeal, or masticator space lesions over a 30-month period. We describe our biopsy technique and correlate our histological findings with subsequent surgical resection where performed. Five of six of CT-guided biopsies obtained sufficient tissue for histological interpretation with varying findings, including salivary gland tumours and squamous cell carcinoma confirmed on subsequent resection. One patient was treated palliatively following core biopsy. No biopsy-related complications were observed. In our small series, percutaneous CT-guided transfacial biopsy via the buccal space has proved an excellent option for the minimally invasive tissue acquisition of deep head and neck space lesions.

A case series on the role of 18F-FDG PET/CT-guided biopsy of osseous metastases

PurposeThis case series explores the utility of positron emission tomography (PET)/computed tomography (CT) guidance for biopsy of 18F-fludeoxyglucose (FDG)-avid osseous lesions that are inconspicuous on CT.MethodsPET/CT-guided core biopsies were performed in four patients with suspected malignancies given 18F-FDG-avid osseous lesions that were inconspicuous on CT alone. The final diagnosis for each patient was determined by histopathological and molecular testing.ResultsPET/CT-guided biopsy yielded accurate sampling via core needle biopsy (CNB) with histopathological confirmation of osseous metastases of the primary malignancy as opposed to a secondary malignancy in three patients and ruled-out metastatic spread in the fourth.ConclusionPET/CT-guided biopsy of hypermetabolic osseous lesions that are inconspicuous on CT alone is an effective and safe diagnostic tool in patients with suspected malignancy.

Focal, Symptomatic Bone Marrow Lesions in Waldenström Macroglobulinaemia Characterised By Dense Infiltration with Lymphoplasmacytic Lymphoma: A Newly Defined Indication for Systemic Treatment

BACKGROUND Waldenström Macroglobulinaemia (WM) is an indolent, IgM-producing lymphoplasmacytic lymphoma (LPL) that infiltrates bone marrow (BM) and other tissues. Only symptomatic patients (with IgM-related complications, cytopenias, constitutional symptoms, bulky extramedullary disease) require treatment. Symptomatic BM lesions are not a recognised manifestation of WM and, if present, may raise the possibility of high-grade transformation. AIMS To characterise the clinical, radiological and histological features of focal bone marrow lesions (FBML) identified in WM patients with unrelenting pain in bones and/or joints, and outline implications for treatment. METHODS This study retrospectively reviewed investigations performed at the time of FBMLpresentation, including MRI of the site of pain, total body FDG-PET/CT, review of histology from BM trephine biopsy of the posterior superior iliac spine (PSIS) and CT-guided core biopsy of the identified FBML, and routine blood panels. RESULTS The 6 patients identified (Table 1) presented with localised skeletal pain at different stages of their WM disease course: 1 at initial WM diagnosis, 1 after 10 years of observation, 3 in remission following R-chemotherapy, and 1 during active treatment with R-chemotherapy. Median age at diagnosis of WM was 57 years (41-64 years). Median time from diagnosis to presentation with FBML was 28 months (0-120 months). MRI demonstrated well-defined areas of abnormal signal within the medullae of symptomatic bones and no evidence of cortical or trabecular bone involvement (Fig. 1A), with T1 hypointensity, diffusion restriction and mild STIR hyperintensity in excess of background BM changes. The FBML showed a predilection for the lower limbs (knees, ankles and/or feet involvement in 3 patients, 50%) and periarticular spaces (5 patients, 83%). They were CT-occult and only mildly FDG-avid. In all cases, core biopsies of the FBML showed heavy BM infiltration with diffuse interstitial infiltrate of small, mature lymphocytes (Fig. 1B, 1C) expressing CD20, CD79a and IgM; CD138 staining highlighted scattered interstitial plasma cells (<10%). There was no evidence of infarct or high-grade transformation. When compared to contemporaneous PSIS biopsies (Fig. 1D, 1E), all FBML demonstrated significantly higher proportions of lymphoid infiltration into the haematopoietic space (80-100% vs 0-80%, p=0.03), confirming FBML represent heavier disease infiltrationthan the background BM disease burden. On blood panels, LDH, ALP and platelet count were normal and Hb was >100g/L in all but the 1 patient with active WM (who had Hb 79g/L and ALP 149IU/L). There was no corresponding rise in paraprotein at the time of FBML presentation. In all cases, the detection of FBML prompted initiation/escalation of systemic treatment despite no evidence of progression using conventional criteria; this resulted in resolution of pain and disappearance of the T1 hypointense lesions on MRI in all cases. CONCLUSION Painful, LPL-dense, infiltrative lesions confined to the BM of affected appendicular bones are an unreported manifestation in WM. They are clinicopathologically different from the osteolytic lesions seen in myeloma and the painless, diffuse BM infiltration seen in low-grade lymphomas and can induce unrelenting focal skeletal pain. Based on our findings, such cases should be evaluated for focal bone marrow lesions; MRI is the preferred modality as lesions are CT-occult. They do not necessarily represent high-grade transformation. This small yet comprehensive series suggests they constitute a hitherto undescribed novel indication for systemic therapy irrespective of the general disease status. Disclosures D'Sa: Janssen:Honoraria, Research Funding;BeiGene:Honoraria, Research Funding;Sanofi:Honoraria.

Exogenous Lipoid Pneumonia Presenting as an Enlarging Lung Nodule in a Patient with a Long-standing Usage of Petroleum Jelly

Abstract Introduction/Objective Lipoid pneumonia is an uncommon inflammatory lung lesion resulting from the aspiration of endogenous or exogenous oily substances. It has no age or sex preponderance, and its mode of presentation is non- specific. Radiologic imaging findings may mimic that of a malignant lung lesion. Methods We report a case of a 69-year-old female with a history of chronic obstructive pulmonary disease, rheumatoid arthritis and a 30-pack year smoking. She was being followed for an enlarging PET positive spiculated left upper lung nodule. She underwent a CT-guided core biopsy of the lung nodule. Results Biopsy showed histiocytes and multinucleated giant cells with lipid vacuoles and associated marked fibrosis. Review of a percutaneous lung biopsy performed two years prior showed a chronic inflammatory process with associated fibrosis in the presence of nonpolarizable vacuoles, many of which were intracytoplasmic within multinucleate foreign body type giant cells. A re-assessment of the patient with further history taking revealed a longstanding practice of nighttime application of petroleum jelly to nostrils and lips. Together, these findings are consistent with an exogenous lipoid pneumonia. Conclusion Lipoid pneumonia although an entity with limited literature description, should be considered in patients presenting with enlarging lung nodules. Early diagnosis of this lesion ensures appropriate treatment and prevents unnecessary invasive procedures.

Concordance Rates Between ROSE and Final Diagnosis for Adequacy Only in Touch Imprints Of CT-guided and US-guided Core Biopsies in Liver and Lung Cases

Concordance Rates Between ROSE and Final Diagnosis for Adequacy Only in Touch Imprints Of CT-guided and US-guided Core Biopsies in Liver and Lung Cases

PERIODIC FEVERS WITH LYMPHADENOPATHY: RARE DIAGNOSIS OF KIKUCHI-FUJIMOTO DISEASE

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Patients who present with a periodic fevers represent a clinical puzzle to the clinician. Histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease (KFD) is a rare inflammatory condition that can be confused with lymphoma or tuberculous lymphadenitis. It mostly affects young females and presents with fever, fatigue, joint pain, lymphadenopathy, hepatosplenomegaly, and rashes. High ESR and anemia are common lab findings. Additionally, it is associated with lupus, infectious, inflammatory, or viral diseases. The disease course is self-limiting; however, it requires early diagnosis to avoid unnecessary testing and treatment due to its shared characteristics with more malignant pathologies. METHODS: A review of the literature was conducted. RESULTS: A 25-year-old African American woman with a history of fibroids was referred from an outpatient clinic for daily fevers of 102°F for the past month. There was an associated painful left-sided axillary lump without redness or discharge. She was given a course of Bactrim and Keflex by an urgent care clinic for presumed hidradenitis suppurativa without any improvement. She presented to the emergency department, where the initial workup was unremarkable. Admission was recommended but the patient left against medical advice but was given clindamycin for 7 days. Three weeks later, the patient presented to the ED for the same symptoms. She complained of generalized fatigue, bilateral upper extremity and abdominal rash and a 10-pound weight loss for the past month, attributed to a poor appetite. Vital signs were significant for temp 100.9°F and HR 108. Physical exam was notable for diaphoresis and a 2 x 2 cm left axillary node that was mobile and tend. Lab results were notable for ESR of 40, CRP of 74.56, and LDH of 431. A rheumatic workup was negative. CT scan of the Chest Abdomen and Pelvis showed a soft tissue mass next to the left pectoralis minor measuring 2.7 x 2.1 x 3.7 cm, possibly representing a cluster of pathologically enlarged lymph nodes. It also showed ground-glass and tree-in-bud opacities bilaterally. The patient underwent CT-guided core biopsy of the axillary mass which showed limited lymph node tissue with faintly preserved nodular pattern and necrotic areas, confirming necrotizing lymphadenitis. CONCLUSIONS: Like many clinicians who may encounter a young female presenting with periodic fevers and constitutional symptoms, malignancy, or common autoimmune diseases like sarcoid are likely high on the differential. KFD's rarity risks its confusion with malignant lymphoma. For example, one case series reviewed the lymph node biopsies of 27 patients with confirmed KFD. Only three of these were suggested by the pathologists to be KFD, while the rest were incorrectly diagnosed as non-Hodgkin’s lymphoma. CLINICAL IMPLICATIONS: Unnecessary diagnostic testing and workup are avoidable if the physician is well informed of rare diagnoses that may present. DISCLOSURES: No relevant relationships by Raheel Anwar, source=Web Response No relevant relationships by Namrita Prasad, source=Web Response

S3029 Unexpected Diagnosis of Worsening Abdominal Distension

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) constitute about 1% of primary gastrointestinal cancers. Primary omental GIST without gastrointestinal involvement (extra-gastrointestinal stromal tumor or EGIST) is extremely rare. We present a case of EGIST with peritoneal metastases and partial response to Imatinib. CASE DESCRIPTION/METHODS: A 68-year-old Caucasian male with a history of coronary artery disease and chronic obstructive lung disease presented with shortness of breath and progressively worsening abdominal distension for several months. Labs were significant for hemoglobin of 10.8 g/dL and positive fecal occult blood test. Computed tomography (CT) of the abdomen and pelvis revealed innumerable masses in the peritoneum and omentum (Figure 1), with no solid visceral abnormality. CT-guided core biopsy of an omental mass revealed cluster spindle cells diffusely positive for c-kit (CD117) (Figure 2) and CD34, with negative stains for cytokeratin 5/6, D2-40, calretinin, cytokeratin AE1/3, Melan-A, S-100, and actin, consistent with EGIST. Subsequent esophagogastroduodenoscopy and colonoscopy with biopsy did not reveal any neoplastic lesion. His symptoms dramatically improved with Imatinib. Follow-up CT scan 3 months later showed partial remission (Figure 3). DISCUSSION: Primary omental stromal tumors without GI tract involvement or attachment are exceedingly rare. Classic GISTs originate from the interstitial cells of Cajal (ICCs) or their stem cells. EGISTs share the same immunophenotype despite arising outside of GI tract, as the tumors either lose their original connection with GI tract or originate from ICC-like precursor cells dispersed during fetal development. The most common symptoms associated with omental stromal tumors are abdominal distension and pain. The tumors are often found as large masses as they tend not to cause obstruction and associated symptoms at earlier stages. CT is the preferred imaging modality for identification of the primary tumors and metastases. Endoscopy can be used to obtain additional information and biopsy. There are no established treatment guidelines for EGIST, and the guidelines developed for GIST are typically used for management of EGIST. Surgery is the primary treatment for localized disease. In our case, Imatinib was utilized due to numerous non-resectable masses, leading to partial remission. More studies are needed to better understand the pathophysiology and evaluate treatment options for EGIST.Figure 1.: Initial abdominal CT revealed extensive lymphadenopathy and multiple soft tissue masses in the peritoneum and omentum.Figure 2.: The biopsied mass was mostly made of cluster spindle cells with high cellularity and frequent mitotic activity, with diffusely positive stain for CD117/c-KIT, a key proto-oncogene activated in GISTs.Figure 3.: A repeat abdominal CT, in 3 months after the diagnosis, showed partial response to Imatinib.

Induction and characterization of pancreatic cancer in a transgenic pig model.

BackgroundPreclinical testing of new locoregional therapies for pancreatic cancer has been challenging, due to the lack of a suitable large animal model.PurposeTo develop and characterize a porcine model of pancreatic cancer. Unlike small animals, pigs have similar physiology, drug dosing, and immune response to humans. Locoregional therapy in pigs can be performed using the same size catheters and devices as in humans.MethodsThe Oncopig is a transgenic pig with Cre-inducible TP53R167H and KRASG12D mutations. In 12 Oncopigs, CT-guided core biopsy of the pancreas was performed. The core biopsy was incubated with an adenoviral vector carrying the Cre recombinase gene. The transformed core biopsy was injected back into the pancreas (head, tail, or both). The resulting tumors (n = 19) were characterized on multi-phase contrast-enhanced CT, and on pathology, including immunohistochemistry. Angiographic characterization of the tumors was performed in 3 pigs.ResultsPancreatic tumors developed at 19 out of 22 sites (86%) that were inoculated. Average tumor size was 3.0 cm at 1 week (range: 0.5–5.1 cm). H&E and immunohistochemical stains revealed undifferentiated carcinomas, similar to those of the pancreatobiliary system in humans. Neoplastic cells were accompanied by a major inflammatory component. 1 of 12 pigs only had inflammatory nodules without evidence of neoplasia. On multiphase CT, tumors were hypovascular compared to the normal pancreas. There was no pancreatic duct dilation. In 3 pigs, angiography was performed, and in all 3 cases, the artery supplying the pancreatic tumor could be catheterized using a 2.4 F microcatheter. Selective angiography showed the pancreatic tumor, without extra-pancreatic perfusion.ConclusionPancreatic cancer can be induced in a transgenic pig. Intra-arterial procedures using catheters designed for human interventions were technically feasible in this large animal model.

SUN-928 Adrenal Plasmacytoma in Multiple Myeloma Patient-An Unusual Presentation

Introduction:Extramedullary plasmacytomas are plasma cell tumors that arise outside of the bone marrow. They are solitary lesions, and are most often located in the head and neck region, mainly in the upper aerodigestive tract. However, involvement of adrenal gland is extremely rare, with only nine case reports published to date. A mass in the adrenal gland carries a broad differential, and identification is important, as diagnosis drives treatment options. CT imaging with attenuation, timing of contrast medium washout, size, and shape, with biopsy is necessary for diagnosis of a high Hounsfield unit mass. Ruling out pheochromocytoma before biopsy of the adrenal glands is crucial.Clinical Case:A 64-year-old female was diagnosed with multiple myeloma after presenting with back pain and altered mental status. Imaging revealed diffuse lytic lesions in clavicles, pelvis, calvarium, long bones, ribs, and compression fractures of T8, T10, and T12 vertebral bodies. A 1.5 cm left adrenal nodule was also noted. She was treated with bortezemib, cyclophosphamide, lenalidomide, and dexamethasone, and clinically improved. Four months after initial presentation, patient was to undergo chemotherapy with melphalan and autologous stem cell transplantation. Further imaging was performed, and CT Chest revealed an enlarging left adrenal mass measuring 3.0 x 3.2 cm with increased attenuation at 37 Hounsfield units and lobulated borders with no invasion of adjacent structures. The endocrinology team was consulted for evaluation of the adrenal mass, as patient’s disease from multiple myeloma was presumed to be in remission. Differential for the adrenal mass included pheochromocytoma, primary adrenal carcinoma, and metastatic disease from multiple myeloma vs other primary. Plasma fractionated metanephrines and DHEAS were within normal range. CT guided core biopsy was performed. Cytology revealed diffuse infiltrate of atypical plasma cells. IHC studies were positive for CD138, CD56, and showed lambda light chain restriction. Cyclin D1 stain was negative, consistent with plasmacytoma. Clinically, the patient started developing progressive disease, including cutaneous plasmacytomas, and she was treated with additional chemotherapy.Conclusion:Adrenal plasmacytoma is extremely rare, and in a patient with multiple myeloma, should be considered in the differential diagnosis of a rapidly enlarging adrenal mass with high CT attenuation. CT guided biopsy is the definitive test for diagnosis.

CT-Guided Core Biopsy for Peripheral Sub-solid Pulmonary Nodules to Predict Predominant Histological and Aggressive Subtypes of Lung Adenocarcinoma.

Adenocarcinoma is the most common type of lung cancer, and pre-operative biopsy plays an important role to determine its major subtypes. As proposed by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS), and European Respiratory Society (ERS) in 2011, the predominant histological subtype of adenocarcinoma is an indicator of outcomes and recurrence rate. However, the value of CT-guided core biopsy in predicting the predominant subtype and detecting the presence of an aggressive subtype of adenocarcinoma, peripheral sub-solid nodule, has less been discussed. We retrospectively reviewed 318 consecutive peripheral sub-solid nodules that underwent percutaneous CT-guided lung biopsy and surgical resection, between October 2015 and December 2018 and were diagnosed as adenocarcinoma with histological subtype. The subtyping results from biopsy and surgical pathology were compared to evaluate the concordance rate. The overall concordance rate between biopsy and surgical pathology in determining the predominant histological subtype was 64%. Better concordance was found in small tumors (≤ 2cm), in predicting either predominant histology (χ2 = 7.091, P = 0.008) or high grade adenocarcinoma, micropapillary and/or solid subtype, MIP-SOL (χ2 = 22.301, P < 0.001). The analysis of ground glass opacity (GGO) component (C/T ratio) obtained significantly higher accuracy in the pure GGO group than in the other two groups in predicting predominant histology or high grade adenocarcinoma (χ2 = 17.560, P < 0.001 and χ2 = 61.938, P < 0.001, respectively). CT-guided core biopsies provide additional value in predicting the histological subtype of lung adenocarcinoma after surgical resection, especially in small tumors (≤ 2cm) or an initially pure GGO group.

Primary biliary neuroendocrine carcinoma: A rare presentation

Presenter: Frances McCarron MD | St. Elizabeth Youngstown Hospital Background: Biliary neuroendocrine carcinomas make up approximately 0.2% of neuroendocrine neoplasm cases per the most recent WHO classification. Previous reports document tumors in the gallbladder and extra-hepatic bile ducts. There has been very little documentation of hepatic involvement of biliary NECs and even fewer reports of intra-hepatic biliary NENs. Given the rarity of these tumors, diagnosis can be mistaken for other malignancies such as cholangiocarcinoma, hepatocellular carcinoma or metastasis. Formal diagnosis, and thus targeted treatment, is usually delayed until post-operative pathology identifies the tumor. We present a rare case of poorly differentiated biliary neuroendocrine carcinoma (G3) with extensive hepatic involvement without evidence of distant metastasis. Methods: A 59-year-old female presented to her primary care office with symptoms of diverticulitis which was confirmed by CT of the abdomen and pelvis. An incidental 9.1cm lesion was identified involving segments 4B, 5, and 8 of the liver. The mass appearing hypodense on non-contrasted phase, with peripheral enhancement in the portal venous phase, was initially concerning for a pyogenic liver abscess secondary to diverticulitis. Differential diagnosis also included intra-hepatic cholangiocarcinoma, and less likely hepatocellular carcinoma or metastasis. A CT guided core biopsy of the lesion suggested a moderately differentiated adenocarcinoma of unknown primary. PET-CT scan showed hypermetabolic uptake of the mass without additional activity to suggest metastatic disease or alternate primary malignancy. Preoperative tumor markers were: CEA = 1.6, Ca 19-9 = 65, AFP = 6. The patient was referred to hepatobiliary surgery for resection. She underwent an en bloc cholecystectomy with central hepatectomy and intra-operative cholangiogram. Total operative time was 346 minutes, estimated blood loss = 600mL, pringle time = 15 minutes with a length of stay of 6 days. Her drain was removed on postoperative day 6. Results: Final pathology revealed a 12.5cm large cell neuroendocrine carcinoma involving the liver of biliary origin. Ki-67 uptake was present in 90% of tumor cells with 25 mitoses per 10 high power fields. An R0 resection was obtained. Pathology was also sent to University of Pittsburgh Medical Center whom concurred with our pathologists. She completed 4 cycles of adjuvant cisplatin and etoposide with no evidence for Conclusion: Biliary tract neuroendocrine neoplasms are exceedingly rare entities. It is estimated that approximately 0.5% of all NENs are of primary gallbladder origin and NEC make up 0.5% of all gallbladder carcinomas. Minimal reports of these tumors, make it difficult to identify the proper treatment modalities. In general, a poor survival rate and increased incidence of metastasis has been associated with G3 biliary NEC. We introduce a case of a rare presentation of a 12.5 cm large cell neuroendocrine carcinoma (G3) of biliary origin with hepatic involvement, no distant metastasis and good response to an R0 resection with 4 cycles of adjuvant chemotherapy. Further research, with long term follow up is needed to identify the optimal treatment plan for these rare tumors. However, this case poses a potential benefit for R0 resection with adjuvant chemotherapy.

PET/CT-guided versus CT-guided percutaneous core biopsies in the diagnosis of bone tumors and tumor-like lesions: which is the better choice?

ObjectiveThe present study aimed to evaluate the diagnostic performance and safety of PET/CT-guided percutaneous core bone biopsy and to compare the PET/CT-guided method to conventional CT-guided percutaneous core biopsies to diagnose Chinese patients with bone tumors and tumor-like lesions.MethodsData for 97 patients with bone tumors and tumor-like lesions diagnosed by percutaneous core bone biopsy from February 2013 to November 2018 were retrospectively analyzed. The study included 42 cases in the PET/CT group and 55 cases in the CT alone group. The diagnostic performance, cost and complications associated with the intervention were compared between the two groups. All patients were eventually confirmed to have bone tumors and tumor-like lesions according to surgical pathology findings.ResultsThere were no significant differences in patient characteristics (P > 0.05). For the patients in the PET/CT group, the overall diagnostic yield of the initial biopsies and the diagnostic accuracy derived from the surgically proven cases were both 97.62%, which was significantly higher than the values in the CT group during the same period (P < 0.05). No major biopsy-related complications (e.g., serious bleeding or tumor dissemination) occurred before, during, or after the intervention. Therefore, no significant difference was observed between the two groups with regard to the complication rate (P > 0.05).ConclusionCompared with CT-guided percutaneous bone biopsy, PET/CT-guided percutaneous bone biopsy is an effective and safe alternative with high diagnostic performance in the evaluation of hypermetabolic bone lesions to diagnose bone tumors and tumor-like lesions.

CT-guided core biopsy for retroperitoneal lesions. Experience in 136 procedures

CT-guided core biopsy is a widely used diagnostic technique for retroperitoneal lesions. To evaluate the diagnostic yield and safety of this procedure. Review of medical records of 136 patients aged 57 ± 16 years (55% males) subjected to core biopsies performed between 2006 and 2016. Procedure images, biopsy reports and patients' medical charts were reviewed. Diagnostic yield was calculated in those patients whose final diagnosis was confirmed using strict criteria for malignancy. A final diagnosis was confirmed in 122/136 patients. Of these, 110 had malignant lesions. The sensitivity and global accuracy of the procedure for malignancy were 93%. In only 4 of 13 benign lesions (31%), a specific diagnosis was obtained with the biopsy. Only minor complications were reported (6 small, self-contained hematomas). There were no major complications. CT-guided core biopsy of retroperitoneal lesions is a safe procedure, with an excellent diagnostic yield.

SPINDLE CELL CARCINOMA OF THE LUNG: A RARE, AGGRESSIVE TUMOR ELUSIVE TO TYPICAL DIAGNOSTIC METHODS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Spindle cell carcinoma is a subtype of sarcomatoid carcinoma, which encompasses a rare group of non-small cell lung carcinomas (NSCLC) that contain true sarcoma or sarcoma-like elements. Less than one percent of all lung cancers are sarcomatoid carcinomas. Here we present a case of spindle cell carcinoma that proved difficult to diagnose in the absence of surgical lobectomy. CASE PRESENTATION: A previously healthy 73-year-old female non-smoker presented to her primary care physician for a persistent non-productive cough. A chest radiograph revealed a large left upper lobe (LUL) mass. A computed tomography (CT) scan of the chest was performed, which demonstrated a 7.5cm LUL mass with a necrotic-appearing center and mediastinal lymphadenopathy. A subsequent positron emission tomography (PET)-CT scan showed uptake around the rim of the mass, sparing the center. She underwent bronchoscopy with endobronchial ultrasound-transbronchial needle aspirations of the mediastinal lymph nodes as well as radial probe ultrasound-guided transbronchial biopsies of the mass, with pathology showing inflammation and no evidence of malignancy. Shortly after the bronchoscopy, she became febrile with shaking chills. She was started on amoxicillin-clavulanate for possible lung abscess. A three-week follow-up CT scan showed no improvement in the size of the mass, so she underwent a CT-guided core biopsy, the pathology from which revealed extensive necrosis but was again negative for malignancy. A thoracentesis was also performed for a small left pleural effusion, during which 470ml of hemorrhagic fluid was drained. Fluid cytology and cultures were negative. Antibiotics were discontinued and she was referred for a lobectomy for definitive diagnosis. She underwent a left upper lobectomy, with pathology revealing an 8.5cm spindle cell carcinoma with visceral pleural invasion and involvement of the internal mammary and levels 5 and 6 lymph nodes, consistent with stage IV disease. A PET-CT performed three weeks post-operatively was highly concerning for residual or recurrent neoplasm in the left anterior chest wall. Radiation therapy was initiated. Genetic testing revealed a MET exon 14 deletion as well as a high expression of PD-L1. The patient is planning to start chemotherapy with pembrolizumab and crizotinib in the near future. DISCUSSION: This case highlights a rare form of lung cancer that was very difficult to diagnose, with false negative bronchoscopic biopsies and CT-guided percutaneous core needle biopsy. Such biopsy methods may not be capable of detecting epithelial and sarcomatous components, which could lead to a missed diagnosis. CONCLUSIONS: Given the high clinical suspicion for malignancy in this patient with a persistent and enlarging lung mass, a surgical biopsy was necessary to obtain a definitive diagnosis. Reference #1: Franks TJ, Galvin JR. Sarcomatoid carcinoma of the lung: histologic criteria and common lesions in the differential diagnosis. Arch Pathol Lab Med. 2010;134(1):49-54. Reference #2: Girard N, Cadranel J, Brambilla E, Cordier J-F. Rare primary lung tumors. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. United States: Elsevier; 2016:965-980. Reference #3: Tazelaar, HD. Pathology of lung malignancies. UpToDate. https://www.uptodate.com/contents/pathology-of-lung-malignancies?search=sarcomatoid%20carcinoma&source=search_result&selectedTitle=1∼29&usage_type=default&display_rank=1. Updated November 16, 2018. Accessed March 13, 2019. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by Leah Lande, source=Web Response No relevant relationships by Kriti Pathak, source=Web Response

Accuracy and complications of CT-guided pulmonary core biopsy in small nodules: a single-center experience

BackgroundComputed tomography (CT)-guided pulmonary core biopsies of small pulmonary nodules less than 15 millimeters (mm) are challenging for radiologists, and their diagnostic accuracy has been shown to be variable in previous studies. Common complications after the procedure include pneumothorax and pulmonary hemorrhage. The present study compared the diagnostic accuracy of small and large lesions using CT-guided core biopsies and identified the risk factors associated with post-procedure complications.MethodsBetween January 1, 2016, and December 31, 2017, 198 CT-guided core biopsies performed on 195 patients at our institution were retrospectively enrolled. The lesions were separated into group A (< or = 15 mm) and group B (> 15 mm) according to the longest diameter of the target lesions on CT. Seventeen-gauge introducer needles and 18-gauge automated biopsy instruments were coaxially used for the biopsy procedures. The accuracy and complications, including pneumothorax and pulmonary hemorrhage, of the procedures of each group were recorded. The risk factors for pneumothorax and pulmonary hemorrhage were determined using univariate analysis of variables.ResultsThe diagnostic accuracies of group A (n = 43) and group B (n = 155) were 83.7 % and 96.8 %, respectively (p = 0.005). The risk factors associated with post-biopsy pneumothorax were longer needle path length from the pleura to the lesion (p = 0.020), lesion location in lower lobes (p = 0.002), and patients with obstructive lung function tests (p = 0.034). The risk factors associated with post-biopsy pulmonary hemorrhage were longer needle path length from the pleura to the lesion (p < 0.001), smaller lesions (p < 0.001), non-pleural contact lesions (p < 0.001), patients without restrictive lung function tests (p = 0.034), and patients in supine positions (p < 0.003).ConclusionCT-guided biopsies of small nodules equal to or less than 15 mm using 17-gauge guiding needles and 18-gauge biopsy guns were accurate and safe. The biopsy results of small lesions were less accurate than those of large lesions, but the results were a reliable reference for clinical decision-making. Understanding the risk factors associated with the complications of CT-guided biopsies is necessary for pre-procedural planning and communication.

Chest wall implantation of lung cancer following percutaneous transthoracic biopsy

A 75-year-old man had an incidental finding of a 1.7 cm spiculated lung nodule over the left lower lobe on thoracic CT scan (figure 1). He underwent CT-guided percutaneous thoracic...

The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung

PurposeTo assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung. Materials and methodsWe performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1–3 versus ≥4 samples), and experience of the performing physician. ResultsThe rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001). ConclusionsIBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.

R0 resection and reconstruction for a large, rapidly progressive chest wall sarcoma

BackgroundChest wall sarcomas are a rare group of soft tissue malignancies with variable presentations. Here we describe the definitive management of a large, rapidly progressing chest wall sarcoma arising from the pectoralis major muscle.Case reportAn obese 42-year-old African American male with multiple medical comorbidities presented with new onset right-sided chest pain and a palpable right chest mass. Initial CT chest demonstrated a 9x9x9cm necrotic mass arising from the pectoralis major. CT-guided core biopsy was positive for high-grade spindle cell neoplasm (positive for smooth muscle actin, desmin, S100, and CD31; negative for CD34, PAX8, and beta-catenin). Staging imaging 2 months later demonstrated growth of the mass to 21.4 × 17.8 × 13.7 cm. The patient underwent neoadjuvant chemoradiation with surveillance CT imaging demonstrating a stable tumor. Then he underwent wide local excision of the mass followed by delayed local myocutaneous flap reconstruction and skin grafting. Final pathology was R0 resection, 38x20x18 cm tumor with 70% gross necrosis. Microscopic examination confirmed high-grade sarcoma with smooth muscle differentiation. Final pathologic staging was Stage III G3 pT2bNxMx.ConclusionsThis patient presented with a rare, rapidly enlarging high-grade leiomyosarcoma of the chest wall without metastases or violation of the thorax. We describe the definitive management including a multidisciplinary team to manage a complex and rapidly progressive sarcoma of the chest wall.

MS09.02 Cases Prepared by Drs. Edell/Murgu

Lung cancer remains the leading cause of cancer-related mortality worldwide. In order to provide adequate and appropriate treatment, staging is crucial. The TNM staging system is the established uniform method of staging lung cancer, both non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). The revised classification of the most recent edition (TNM-8) of the TNM staging system, proposed by the International Association for the Study of Lung Cancer (IASLC) and introduced in 2016, is based on detailed analysis of a new large international database of almost 78000 lung cancer cases from 16 countries. The first part of this talk will focus on tissue diagnosis, specifically CT-guided core biopsy. In the era of targeted therapies and customized treatment, the acquisition of an adequate and representative sample, especially in non-surgical patients, is pivotal. Complications, pitfalls and pearls of CT-guided lung biopsies will be addressed. The second part of the talk will be focussing on the changes between TNM-7 and TNM-8 – downstaging of lung atelectasis and pneumonitis, upstaging of diaphragmatic invasion, reclassification of extra-thoracic metastatic disease; the IASLC recommends that radiologists should document the number of metastatic lesions, the diameter of individual metastatic lesions and the number of involved organs at staging examinations. The conundrum relating to nodal staging with CT and FDG-PET imaging will be explored. Lung cancer with multiple sites of pulmonary involvement – multiple primary lung cancers, lung cancer with separate tumour nodules, multiple ground glass/lepidic lesions and lung cancer manifesting as consolidation - will be discussed.

Bronchovascular injury associated with clinically significant hemoptysis after CT-guided core biopsy of the lung: Radiologic and histopathologic analysis.

ObjectiveTo evaluate bronchovascular injuries as the causative occurrence for clinically significant hemoptysis after percutaneous transthoracic needle biopsy (PTNB).Materials and methodsWe included 111 consecutive patients who experienced hemoptysis after cone beam CT (CBCT)-guided PTNB from January 2014 through January 2017. Clinically significant hemoptysis was defined as hemoptysis causing hemodynamic instability or oxygen desaturation greater than 10% of baseline. The lesion characteristics were evaluated on CT images. The penetration of bronchovascular structures along the trajectory of the introducer needle and potential penetration at the firing of the biopsy gun were assessed on CBCT images. The cutting injury of bronchovascular structures was histopathologically assessed in biopsy specimens. The associated factors for clinically significant hemoptysis were assessed using logistic regression analyses.ResultsSeventeen patients (15.3%; 95%CI, 9.7%-23.2%) had clinically significant hemoptysis. On univariate analysis, the open bronchus sign (P = .004), nodule consistency (P = .012), potential penetration of a pulmonary vessel or bronchus 1 mm or larger at firing (P = .008 and P = .038, respectively), and a cutting injury of a pulmonary vessel 1 mm or larger (P = .007) or a bronchial structure (P = .041) were associated with clinically significant hemoptysis. Multivariate analysis found the following significant associated factors: potential penetration of a pulmonary vessel 1 mm or larger at firing (OR, 3.874; 95%CI, 1.072–13.997; P = .039) and cutting injury of a pulmonary vessel 1 mm or larger (OR, 6.920; 95%CI, 1.728–27.711; P = .006) or a bronchial structure (OR 4.604; 95%CI, 1.194–17.755; P = .027).ConclusionPotential penetration and cutting injury of bronchovascular structures 1mm or larger at firing were independently associated with clinically significant hemoptysis after PTNB.