Guided Needle Biopsy Research Articles

Extrapleural locating method in computed tomography-guided needle biopsies of 1,106 lung lesions.

Transthoracic needle biopsy is considered to be safe and effective for the diagnosis of focal lung lesions. The aim of the present study was to evaluate factors affecting the accuracy and safety of automated cutting needle lung biopsy (ACNB) using a new extrapleural locating (EPL) method. Computed tomography (CT)-guided needle biopsies were performed on 1,065 patients between March 2005 and May 2012 using the EPL method. The locating needle remained in the chest following extrapleural positioning, while the radiologist confirmed the puncture angle and distance between the locating needle and lesion. The biopsy instrument was advanced into the lung, and the core needle was subsequently fired into the lesion based on the direction indicated by the locating needle. Univariate and multivariate regression analyses were used to evaluate the diagnostic accuracy and safety of the procedure. The sensitivity, specificity, positive predictive value and negative predictive value of the extrapleural method were 91.9, 100, 100 and 82.9%, respectively, and the overall diagnostic accuracy was 94.2%. Significant risk factors affecting accuracy were younger age, atelectasis, hemoptysis and lesion depth (P<0.03). Multivariate logistic regression analysis revealed that the risk of malignant lesions receiving a false-negative diagnosis decreased for each additional year of subject age [odds ratio (OR), 0.97; P=0.027] and increased with each millimeter increase in lesion depth (OR, 1.03; P=0.008). Among the 1,106 lesions biopsied, 207 were associated with pneumothorax, 251 with hemorrhage and 58 with hemoptysis. Multivariate analysis revealed that lesion size and emphysema affected pneumothorax incidence, while age, lesion location and depth and emphysema significantly affected hemorrhage incidence (P<0.05). In conclusion, low-dose, CT-guided ACNB with the EPL method provides a safe and accurate diagnosis.

Cribriform morphology predicts upstaging after radical prostatectomy in patients with Gleason score 3 + 4 = 7 prostate cancer at transrectal ultrasound (TRUS)-guided needle biopsy.

Selected patients with transrectal ultrasound (TRUS)-guided biopsies containing Gleason score 3 + 4 = 7 prostate cancer (PCa) may be considered candidates for active surveillance (AS). The purpose of this study was to determine if there are features that predict PCa upstaging and/or upgrading after radical prostatectomy (RP) in patients with Gleason score 3 + 4 = 7 PCa diagnosed on TRUS-guided biopsies. We searched our institution's database for patients with Gleason score 3 + 4 = 7 PCa diagnosed on TRUS-guided biopsy who underwent subsequent RP between January 2010 and January 2015. Two blinded genitourinary pathologists independently reviewed and assessed the following on biopsies: (a) nuclear size, nucleolar size and distribution of macronucleoli of PCa, which were subjectively graded using a semi-quantitative scale from 1 to 3, and (b) PCa with cribriform morphology and the size of cribriform disease. Patient age, serum prostate-specific antigen (PSA) and PSA density (PSAD) were also recorded. The Gleason score and stage (presence or absence of organ-confined disease (OCD)) were retrieved from RP reports. Comparisons were performed between groups using the chi-square test and Spearman correlation. One hundred and four patients were identified to have met inclusion criteria. The mean age was 63 (±6.1) years. Mean PSA and PSAD at diagnosis were 7.5 (±4.2) and 0.25 (±0.15) ng/mL, respectively. Gleason scores were upgraded to greater than 3 + 4 = 7 in 26.9 % (28/104) of patients, and 44.2 % (46/104) of patients had no OCD after RP. There was no correlation between age, PSA, PSAD or percent of biopsies with Gleason pattern 4 for either Gleason score upgrading or absence of OCD at the time of RP (p > 0.05). Thirty patients had cribriform morphology on TRUS-guided biopsy of which 60 % (18/30) had no OCD at RP (p = 0.04) while 36.7 % (11/30) were upgraded to Gleason score ≥3 + 4 = 7 after RP (p = 0.15). There was no association between nuclear size, nucleolar size and/or distribution of macronucleoli with upgrading and/or absence of OCD (p > 0.05). The size of cribriform pattern was not associated with the absence of OCD (p = 0.43) or Gleason score upgrade (p = 0.28). A proportion of patients with Gleason score 3 + 4 = 7 PCa at needle biopsy do not have OCD or are upgraded to higher Gleason scores after RP. In our study, patients with Gleason score 3 + 4 = 7 PCa with the presence of cribriform pattern 4 had a significantly increased chance of being found to have no OCD at the time of RP. There were no clinical or pathologic parameters at the time of TRUS-guided biopsy that identified risk factors for Gleason score upgrading at RP in this study. Cribriform morphology detected on biopsy in patients with Gleason score 3 + 4 = 7 PCa is associated with tumour upstaging after RP and may be considered a contraindication to active surveillance.

Holder design for robotic assisted ultrasound and MRI imaging guided needle biopsy

Ultrasound and MRI imaging guiding system for Robotic assisted interventional procedures such as needle biopsy and FUS ablation have to be improved to allow a one stop shop multimodality image guidance. A specific holder which has the capability for connecting the application module of the interventional robotic system “INNOMOTION” (IBSmm, CZ) with SIEMENS wireless ultrasound probe (Acuson Freestyle) was designed and manufactured in order to achieve the desired function. The work is a subproject in FUTURA an EU FP7 funded project for the development of robotic assisted Ultrasound guided focused ultrasound.

Non-invasive and repeatable EGFR analysis using novel enrichment method for circulating tumor cells.

e22033 Non-invasive and repeatable EGFR analysis using novel enrichment method for circulating tumor cells Background: The first-line treatment in confirmed NSCLC (non-small cell lung cancer) patients harboring EGFR mutation is the epidermal growth factor receptor inhibitors (EGFR-TKIs) therapy. A bronchoscopy with transbronchial biopsy or CT guided needle biopsy for EGFR mutation screening may accompany complication, such as infection, bleeding or pneumothorax. However, use of enriched circulating tumor cells (CTCs) from patients’ blood might overcome these risks by means of non-invasive and repeated EGFR mutation analysis. Methods: The blood samples (10 ml) were obtained from NSCLC patients harboring EGFR mutation, and processed through Cytogen Protocolto enrich CTCs. In brief, peripheral blood mononuclear cell fraction was passed through micro fabricated porous filter (CytoGen), and EpCAM antibody was used for positive selection. The identification of enriched CTC was performed by immunofluorescent staining for EpCAM, CD45 and DAPI. The DNAs were extracted from enriched CTCs and used as templates for multi-step real-time PCR. The LOD (limit of detection) values were optimized in spike-in experiments. And, the mutation was identified by both EGFR dependent Real-time PCR and sequencing. Results: The recovery rate by micro fabricated porous filters was about 80% in spike-in experiments for establishing platform. The EGFR mutations were detected by multi-step Real-time PCR method in as low as 10~20 cells per ml of blood. The DNAs ( > 350 ng) were obtained from enriched CTCs through micro fabricated porous filter, pre-amplified, and analyzed for at least 7 mutations using real-time PCR. Among other EGFR mutations, deletion of exon 19 and L858R point mutation are commonly detected. However, the mutation relevant to exon 18 was not detected. Conclusions: In this study, we showed that CTCs enriched using micro fabricated porous filter can be used for EGFR mutation analysis. This new approach may provide insight establishing the personalized cancer therapeutic strategies based on them to molecular profiles in NSCLC. Background: Methods: Results: Conclusions:

CARS 2015-Computer Assisted Radiology and Surgery Proceedings of the 29th International Congress and Exhibition Barcelona, Spain, June 24-27, 2015.

Biopsy is commonly used to confirm cancer diagnosis when radiologically indicated. Given the ability of PET to localize malignancies in heterogeneous tumors and tumors that do not have a CT correlate, PET/CT guided biopsy may improve the diagnostic yield of biopsies. To facilitate PET/CT guided needle biopsy, we developed a workflow that allows us to bring PET image guidance into the interventional CT suite. In this abstract, we present SlicerPET, a user-friendly workflow based module developed using open source software libraries to guide needle biopsy in the interventional suite.

Reliability of Small Biopsy Samples Compared With Resected Specimens for the Determination of Programmed Death-Ligand 1 Expression in Non–Small-Cell Lung Cancer

BackgroundSeveral studies have assessed the expression of programmed death-ligand 1 (PD-L1) in resected surgical specimens of non–small-cell lung cancer (NSCLC). However, the expression of PD-L1 in smaller biopsy samples of advanced NSCLC has not been reported. Patients and MethodsA total of 79 patients with NSCLC at our institution with available biopsy samples and resected specimens were retrospectively enrolled in the present study. PD-L1 expression was assessed by immunohistochemistry and scored using the hybrid scoring method. The concordance rates for the expression of PD-L1 between the 2 samples were analyzed. ResultsThe pathologic stage of the patients (51 men, 28 women; median age, 68 years) was stage I in 37, stage II in 18, and stage III in 24. The diagnostic procedures included transbronchial biopsy in 59, transbronchial needle aspiration biopsy in 14, and computed tomography (CT)-guided needle biopsy in 6. The positivity rate of PD-L1 in these samples was 38.0% (27 transbronchial biopsies, 6 transbronchial needle aspiration biopsies, 3 CT-guided needle biopsies) versus 35.4% in the resected specimens. The median hybrid score was 0 (range, 0-170), and the mean score was 28.7 ± 43.4. Comparing the biopsy samples and resected specimens with a score of ≥ 1 as positive for PD-L1 staining, 6 tumors were discordant for PD-L1 expression and 73 were concordant, for a concordance rate of 92.4% and κ value of 0.8366. ConclusionPD-L1 status showed good concordance between the biopsy samples and resected specimens. These small samples, even those derived from transbronchial needle aspiration biopsies, appear adequate for the assessment of PD-L1 expression.

2091088 Detection And Characterization of Focal Lesions Of The Prostate Using Shear Wave Elastography (SWE)

ObjectivesThe purpose of this study is the access to the role of Shear Wave Elastography (SWE) in the detection and characterization of focal lesions of the prostate.MethodsWe prospectively examined 150 consecutive patients in a 6-month period with TRUS, SWE and TRUS-guided biopsies. The median patient age was 59 years (range 45-88 years), the median serum PSA level was 8.5 ng/ml (range 1,9-47 ng/ml) and the median prostate volume was 55 ml (range 25-180 ml). All examinations were performed on an Aixplorer/Supersonic system with an end-fire transrectal probe (SE 12-3). Additionally, in cases where no TRUS or SWE visible lesions were present, 20 systematic biopsies were performed in all prostate segments.ResultsProstate cancer (PRCA) was found in 60/140 patients (43%). A total number of 69 PRCAs were proved by TRUS-guided biopsies. The SWE findings were positive in 50 (73%) of PRCAs. In particular, 12 (17.4%) PRCAs were positive only on SWE, including 6 in the peripheral zone (PZ) and 7 in the transitional zone (TZ) lesions. The SWE findings were negative in 17 (25%) lesions, all in the PZ. SWE findings in these cases showed disagreement with tumor location or undetectable lesion. 15 of these lesions were judged as positive on TRUS.ConclusionsSWE in conjunction with TRUS shows promising results in the detection of PRCA. Meticulous technique and strict protocol are necessary. SWE helps guiding needle biopsy and proving PRCA in atypical lesions in the PZ and the TZ. ObjectivesThe purpose of this study is the access to the role of Shear Wave Elastography (SWE) in the detection and characterization of focal lesions of the prostate. The purpose of this study is the access to the role of Shear Wave Elastography (SWE) in the detection and characterization of focal lesions of the prostate. MethodsWe prospectively examined 150 consecutive patients in a 6-month period with TRUS, SWE and TRUS-guided biopsies. The median patient age was 59 years (range 45-88 years), the median serum PSA level was 8.5 ng/ml (range 1,9-47 ng/ml) and the median prostate volume was 55 ml (range 25-180 ml). All examinations were performed on an Aixplorer/Supersonic system with an end-fire transrectal probe (SE 12-3). Additionally, in cases where no TRUS or SWE visible lesions were present, 20 systematic biopsies were performed in all prostate segments. We prospectively examined 150 consecutive patients in a 6-month period with TRUS, SWE and TRUS-guided biopsies. The median patient age was 59 years (range 45-88 years), the median serum PSA level was 8.5 ng/ml (range 1,9-47 ng/ml) and the median prostate volume was 55 ml (range 25-180 ml). All examinations were performed on an Aixplorer/Supersonic system with an end-fire transrectal probe (SE 12-3). Additionally, in cases where no TRUS or SWE visible lesions were present, 20 systematic biopsies were performed in all prostate segments. ResultsProstate cancer (PRCA) was found in 60/140 patients (43%). A total number of 69 PRCAs were proved by TRUS-guided biopsies. The SWE findings were positive in 50 (73%) of PRCAs. In particular, 12 (17.4%) PRCAs were positive only on SWE, including 6 in the peripheral zone (PZ) and 7 in the transitional zone (TZ) lesions. The SWE findings were negative in 17 (25%) lesions, all in the PZ. SWE findings in these cases showed disagreement with tumor location or undetectable lesion. 15 of these lesions were judged as positive on TRUS. Prostate cancer (PRCA) was found in 60/140 patients (43%). A total number of 69 PRCAs were proved by TRUS-guided biopsies. The SWE findings were positive in 50 (73%) of PRCAs. In particular, 12 (17.4%) PRCAs were positive only on SWE, including 6 in the peripheral zone (PZ) and 7 in the transitional zone (TZ) lesions. The SWE findings were negative in 17 (25%) lesions, all in the PZ. SWE findings in these cases showed disagreement with tumor location or undetectable lesion. 15 of these lesions were judged as positive on TRUS. ConclusionsSWE in conjunction with TRUS shows promising results in the detection of PRCA. Meticulous technique and strict protocol are necessary. SWE helps guiding needle biopsy and proving PRCA in atypical lesions in the PZ and the TZ. SWE in conjunction with TRUS shows promising results in the detection of PRCA. Meticulous technique and strict protocol are necessary. SWE helps guiding needle biopsy and proving PRCA in atypical lesions in the PZ and the TZ.

Multiattribute probabilistic prostate elastic registration (MAPPER): application to fusion of ultrasound and magnetic resonance imaging.

Transrectal ultrasound (TRUS)-guided needle biopsy is the current gold standard for prostate cancer diagnosis. However, up to 40% of prostate cancer lesions appears isoechoic on TRUS. Hence, TRUS-guided biopsy has a high false negative rate for prostate cancer diagnosis. Magnetic resonance imaging (MRI) is better able to distinguish prostate cancer from benign tissue. However, MRI-guided biopsy requires special equipment and training and a longer procedure time. MRI-TRUS fusion, where MRI is acquired preoperatively and then aligned to TRUS, allows for advantages of both modalities to be leveraged during biopsy. MRI-TRUS-guided biopsy increases the yield of cancer positive biopsies. In this work, the authors present multiattribute probabilistic postate elastic registration (MAPPER) to align prostate MRI and TRUS imagery. MAPPER involves (1) segmenting the prostate on MRI, (2) calculating a multiattribute probabilistic map of prostate location on TRUS, and (3) maximizing overlap between the prostate segmentation on MRI and the multiattribute probabilistic map on TRUS, thereby driving registration of MRI onto TRUS. MAPPER represents a significant advancement over the current state-of-the-art as it requires no user interaction during the biopsy procedure by leveraging texture and spatial information to determine the prostate location on TRUS. Although MAPPER requires manual interaction to segment the prostate on MRI, this step is performed prior to biopsy and will not substantially increase biopsy procedure time. MAPPER was evaluated on 13 patient studies from two independent datasets—Dataset 1 has 6 studies acquired with a side-firing TRUS probe and a 1.5 T pelvic phased-array coil MRI; Dataset 2 has 7 studies acquired with a volumetric end-firing TRUS probe and a 3.0 T endorectal coil MRI. MAPPER has a root-mean-square error (RMSE) for expert selected fiducials of 3.36 ± 1.10 mm for Dataset 1 and 3.14 ± 0.75 mm for Dataset 2. State-of-the-art MRI-TRUS fusion methods report RMSE of 3.06-2.07 mm. MAPPER aligns MRI and TRUS imagery without manual intervention ensuring efficient, reproducible registration. MAPPER has a similar RMSE to state-of-the-art methods that require manual intervention.

5:27 PM, Abstract No. 331 - Comparison analysis pre and post implementation of a BioSentry tract sealant system after percutaneous transthoracic CT guided needle biopsy

5:27 PM, Abstract No. 331 - Comparison analysis pre and post implementation of a BioSentry tract sealant system after percutaneous transthoracic CT guided needle biopsy

A proven case of cutaneous rhizopus infection presenting with severe limb pain very soon after induction treatment in a patient with acute lymphoblastic leukemia.

Objective and Importance. Invasive mucormycosis may complicate the course of patients with hematologic malignancies and has a very high mortality rate. Early diagnosis and aggressive approach combined with surgical and medical treatment have paramount importance for cure. Clinical Presentation. We report here a case of a patient with acute lymphoblastic leukemia presenting with a subcutaneous mass lesion which was sampled by an ultrasound guided needle biopsy. The pathology showed microorganisms with aseptate hyphae with wide, irregular walls and more or less branching with highly vertical angles which suggested a mold infection. The specimen was also cultured where Rhizopus spp. grew. Conclusion. Posaconazole 200 mg QID was commenced. She recovered from neutropenia and pain on day 20 of treatment. After 4 courses of hyper-CVAD chemotherapy, the remaining soft tissue mass was removed surgically and she underwent allogeneic HSCT from a full matched sibling donor under secondary prophylaxis.

Practice of percutaneous needle autopsy; a descriptive study reporting experiences from Uganda.

BackgroundPercutaneous needle autopsy can overcome a number of barriers that limit the use of complete autopsies. We performed blind-and ultrasound guided needle autopsies in HIV-infected adults in Uganda. In this study we describe in detail the methods we used, the ability of both procedures to obtain sufficient tissue for further examination and the learning curve of the operators over time.MethodsIf written informed consent was granted from the next of kin, we first performed a blind needle autopsy, puncturing brain, heart, lungs, liver, spleen and kidneys using predefined surface marking points. We then performed an ultrasound guided needle autopsy puncturing heart, liver, spleen and kidneys. The number of attempts, expected success and duration of the procedure were noted. A pathologist read the slides and indicated if the target tissue was present and of sufficient quality for pathological review. We report the predicted and true success rates, compare the yield of blind to ultrasound guided needle biopsies and evaluate the failure rate over time.ResultsTwo operators performed 96 blind needle autopsies and 95 ultrasound guided needle autopsies. For blind needle biopsies true success rates varied from 56-99% and predicted success rates from 89-99%. For ultrasound guided needle biopsies true success rates varied from 72-100% and predicted success rates from 84-98%. Ultrasound guidance led to a significantly higher success rate in heart and left kidney. A learning curve was observed over time with decreasing failure rates with increasing experience and a shorter duration of the needle autopsy.ConclusionNeedle autopsy can successfully obtain tissue for further pathological review in the vast majority of cases, with a decrease in failure rate with increasing experience of the operator. The benefit of ultrasound guidance will depend on the population, the disease and organ of interest and the local circumstances. Our results justify further evaluation of needle autopsies as a method to establish a cause of death.

How safe is curettage of low-grade cartilaginous neoplasms diagnosed by imaging with or without pre-operative needle biopsy?

The pre-operative differentiation between enchondroma, low-grade chondrosarcoma and high-grade chondrosarcoma remains a diagnostic challenge. We reviewed the accuracy and safety of the radiological grading of cartilaginous tumours through the assessment of, first, pre-operative radiological and post-operative histological agreement, and second the rate of recurrence in lesions confirmed as high-grade on histology. We performed a retrospective review of major long bone cartilaginous tumours managed by curettage as low grade between 2001 and 2012. A total of 53 patients with a mean age of 47.6 years (8 to 71) were included. There were 23 men and 30 women. The tumours involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula (n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses resulted from multidisciplinary consensus following radiological review alone for 35 tumours, or with the addition of pre-operative image guided needle biopsy for 18. The histologically confirmed diagnosis was enchondroma for two (3.7%), low-grade chondrosarcoma for 49 (92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients with a low-grade tumour developed a local recurrence at a mean of 15 months (12 to 17) post-operatively. A single high-grade recurrence (grade II) was treated with tibial diaphyseal replacement. The overall recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to 12.3). Cartilaginous tumours identified as low-grade on pre-operative imaging with or without additional image-guided needle biopsy can safely be managed as low-grade without pre-operative histological diagnosis. A few tumours may demonstrate high-grade features histologically, but the rates of recurrence are not affected.

Open versus needle biopsy in diagnosing neuroblastoma

BackgroundOpen surgical biopsy is traditionally advocated prior to initiating therapy in UKCCLG neuroblastoma protocols. We report a single centre experience comparing the utility of open biopsy vs image guided needle biopsy in aiding the definitive diagnosis and risk stratification of neuroblastoma – (Shimada classification, MYCN expression, cytogenetics – 1p 11q, 17 q). MethodsMedical records of all new cases of neuroblastoma presenting to a single UKCCLG centre during January 2002–July 2013 were examined. ResultsThirty nine patients underwent a biopsy of primary tumour for neuroblastoma during the study. Twenty one children had open biopsy and eighteen cases had a needle biopsy. Staging of neuroblastoma revealed - stage 4 (n=26), stage 3 (n=7), stage 2 (n=3) and stage 4S (n=3). Sites of primary tumour were adrenal gland (n=20), abdomen (n=12), thoracic (n=4), abdomino-thoracic (n=2) and abdomino pelvic regions (n=1). All patients (open vs needle) had adequate tissue retrieved for histological diagnosis of neuroblastoma. One needle and one open biopsy case did not have MYCN status determined despite adequate tissue sampling. Seventeen patients (7 open and 10 needle biopsies) had 1p and 17q status reported in MLPA testing (Multiplex Ligation-dependent Probe Amplification). No single patient required a repeat tumour biopsy. Morbidity in the series was minimal with only one child – open biopsy group, requiring emergent laparotomy to control bleeding from an abdominal primary tumour. No complications were recorded with needle biopsy. ConclusionsOpen and image guided needle biopsy appear to yield adequate tissue sampling for diagnosis, risk classification and staging of neuroblastoma. Further larger co-operative studies may usefully guide national and international protocols.

Complications From Computed Tomography–Guided Core Needle Biopsy for Patients Receiving Stereotactic Body Radiation Therapy for Early-Stage Lesions of the Lung

BackgroundObtaining a tissue diagnosis has traditionally been standard practice before initiating therapy for early-stage non–small-cell lung cancer (NSCLC). In several recent studies from Europe and Asia, a substantial proportion of patients have received stereotactic body radiation therapy (SBRT) based only on the imaging characteristics of the suspicious lesion. The underlying assumption is that the risk of percutaneous needle biopsy may outweigh the benefits in a population that generally has underlying pulmonary dysfunction and other medical comorbidity. Nevertheless, there is limited information regarding biopsy-related complication rates in high-risk patients with early-stage NSCLC who are treated with SBRT. Materials and MethodsThis was a retrospective review of outcomes after biopsy in patients treated with SBRT. Complications of percutaneous core needle biopsy were analyzed in relation to patient and tumor characteristics. Each biopsy event was analyzed independently for patients with multiple biopsies. ResultsA total of 112 percutaneous biopsies were performed in 103 patients. Pneumothorax of any degree was observed in 40 patients (35%) (95% CI, 27%-45%), and 12 patients (10.7%) had a clinically significant pneumothorax requiring chest tube placement (95% CI, 6%-18%). The time to first fraction of SBRT was not different in patients who had a pneumothorax or placement of a chest tube. On multivariate analysis, age, performance status, smoking history, pack-years of smoking, chronic obstructive pulmonary disease history, and forced expiratory volume in the first second of expiration were not statistically significantly associated with chest tube placement. ConclusionComputed tomography–guided needle biopsy in a primarily medically inoperable patient population is safe, with an acceptable degree of complications.

Lean Six Sigma Applied to Ultrasound Guided Needle Biopsy in the Head and Neck

(1) Confirm the positive value stream of office-based ultrasound using Lean Six Sigma; (2) demonstrate how ultrasound reduces time to diagnosis, costs, patient inconvenience and travel, exposure to ionizing radiation, intravenous contrast, and laboratory tests. Case series with historical controls using chart review. Tertiary Veterans Administration Hospital (university-affiliated). Patients with a consult request or decision for ultrasound guided fine needle aspiration (USFNA) from 2006 to 2012. Process evaluation using Lean Six Sigma methodologies; years study conducted: 2006-2012; outcome measurements: type of diagnostic tests and imaging studies including CT scans with associated radiation exposure, time to preliminary and final cytopathologic diagnosis, episodes of patient travel. Value stream mapping prior to and after implementing office-based ultrasound confirmed the time from consult request or decision for USFNA to completion of the USFNA was reduced from a range of 0 to 286 days requiring a maximum 17 steps to a range of 0 to 48 days, necessitating only a maximum of 9 steps. Office-based USFNA for evaluation of head and neck lesions reduced costs, time to diagnosis, risks and inconvenience to patients, radiation exposure, unnecessary laboratory, and patient complaints while increasing staff satisfaction. In addition, office-based ultrasound also changed the clinical management of specific patients. Lean Six Sigma reduces waste and optimizes quality and accuracy in manufacturing. This is the first known application of Lean Six Sigma to office-based USFNA in the evaluation of head and neck lesions. The literature supports the value of office-based ultrasound to patients and health care systems.

Ethical Case Studies in Uroradiology

: Today, radiologists are more than ever in need of current knowledge and skills to make use of moderm technologies. Radiologists need to be considerate of patients values and wishes in addition to observing technical guidelines. Such conduct is a sign of respect for patient autonomy and is the basis for informed consent before every medical procedure. Doctors are obligated to inform their patients at a level that they can understand about the procedures, its expected outcomes and its potential harms and benefits of. In the field of uroradiology especially when some sort of interventions are going to be done, disregarding informed consent as a simple but important step can impair the relationship between patient and radiologist. For example, in the cases of ultrasound guided needle biopsy of prostate, misinforming the patient on some important adverse effect of the procedure including infection, pain and injury of adjacent organs may result in serious legal action. Radiologist negligence for taking consent from patient for prostate needle biopsy is a case that will be discussed in this lecture.

Primary pulmonary peripheral T-cell lymphoma: A case report and review of the literature.

Primary pulmonary T-cell lymphoma is a rare condition characterized by fever, cough, dyspnea, and bilateral pulmonary nodules, usually diagnosed by transbronchial biopsy or computed tomography (CT) guided needle biopsy and pathology. In view of its poor prognosis, it is critical to distinguish and diagnose this disease as early as possible. We report here a case of a 39-year-old man who presented with fever, cough, expectoration with multiple nodules, and patch shadow in both lungs by chest CT. Tissue samples were taken by CT guided needle biopsy. The histological sample and immunohistochemistry showed peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS). After the patient was treated by chemotherapy for two courses, his condition deteriorated rapidly and he died 2.3 months after the onset of the disease.

Digital rectal examination in a simulated environment using sweeping palpation and mechanical localization

Computerized palpation systems have been studied for the quantitative characterization of prostate properties. The aim of this study was to evaluate the reliability of mechanical tumor localization maps by estimating correlation with pathological maps. A total of 120 indentations were performed on 10 specimens by using a sweeping palpation system in simulated environment conditions. Suspicious tumor lesions from the mechanical localization were compared to those of the pathological maps. The concordance rate between the mechanical localization maps and pathological maps was 81.7% (98/120). The positive predictive value (PPV) and the negative predictive value (NPV) of the proposed localization system were 78.6% (59/75) and 86.7% (39/45), respectively. Based on these data, the suspicious tumor lesions of mechanical localization maps were in close agreement with those from the pathological maps. The findings suggest that the high compatibility and detection rate of prostate tumor could be enhanced if computerized palpation and the conventional diagnosis are used synergistically. This study may contribute to technological progress in overcoming diagnostic limitations, which include many complications from digital rectal examination (DRE) and transrectal ultrasound (TRUS) guided needle biopsy.

Pulmonary cryptococcosis that mimicked rheumatoid nodule in rheumatoid arthritis lesion.

Recently, the incidence of pulmonary cryptococcosis is gradually increasing in rheumatoid arthritis (RA) patients. Pulmonary rheumatoid nodules (PRN) are rare manifestations of RA. Eighteen months ago, a 65-year old woman was admitted to hospital due to multiple nodules (2.5×2.1×2 cm) with cavitations in the right lower lobe. She was diagnosed with RA three year ago. She had been taking methotrexate, leflunomide, and triamcinolone. A video-assisted thoracoscopic surgery biopsy was performed and PRN was diagnosed. However, a newly growing huge opacity with cavitation was detected in the same site. Pulmonary cryptococcal infection was diagnosed through a transthoracic computed tomograpy guided needle biopsy. Cryptococcus antigen was detected in serum but not in cerebrospinal fluid. The patient was treated with oral fluconazole which resulted clinical improvement and regression of the nodule on a series of radiography. Herein, we report the case of pulmonary cryptococcosis occurring in the same location as that of the PRN.

FhSPECT-US guided needle biopsy of sentinel lymph nodes in the axilla: is it feasible?

Until now, core needle biopsy of the axillary sentinel lymph nodes in early stage breast cancer patients is not possible, due to the lack of a proper combination of functional and anatomical information. In this work we present the first fully 3D freehand SPECT--ultrasound fusion, combining the advantages of both modalities. By using spatial positioning either with optical or with electromagnetic tracking for the ultrasound probe, and a mini gamma camera as radiation detector for freehand SPECT reconstructions, we investigate the capability of the introduced multi-model imaging system, where we compare both 3D freehand SPECT and 3D ultrasound to ground truth for a realistic breast mimicking phantom and further analyze the effect of tissue deformation by ultrasound. Finally, we also show its application in a real clinical setting.