Histological Diagnostic Yield Research Articles

98 Prospective Multicenter Randomized Controlled Trial of Histological Diagnostic Yield Comparing 25G EUS-FNA Needles With and Without a Core Trap in Patients With Solid Pancreatic Masses

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) with 25G needles is safe and easy to handle but have been limited mainly to cytology. The newly developed core biopsy needles may overcome this limitation by providing core specimens for histological analysis.

Introducing a cardiac CT service - ensuring appropriate referrals and overcoming teething problems

s / Clinical Radiology 67 (2012) S11–S20 S18 Transjugular liver biopsy safety and diagnostic yield Authors: Amit Patel, Aman Khan, Pete Thurley, Dominic Clarke, Rajeev Singh Background to the audit: Previous studies have demonstrated transjugular liver biopsy (TJLB) to be an effective procedure in patients not suitable for percutaneous biopsy with high diagnostic yield and low complication rate. Standard, indicator and target: To compare our centres complication rates and outcomes with previously published national studies. Technical success rates previously quoted range from 85 to 91%. Complication rates range from 1.3 to 13%. Methodology: Retrospective review of all TJLB's performed at Royal Derby Hospital between 2009 to 2012. Data gathered from case-note review, CRIS and Isoft medical database. Results of 1st audit round: Number of cases 1⁄4 47. Common indications included alcoholic liver diseasewith ascites/coagulopathy or suspected HCC. Mean age 1⁄4 55 years (range 22-82 years). Mean PT 18, INR 1.6, PLT 177. Large majority required pre-procedural blood products. Technical success rate 1⁄4 45/47 (96%). Mean number of passes 1⁄4 2.4. Mean combined core length 1⁄4 22 mm (range 4-45). Histological diagnostic yield 1⁄4 41/45 (91%). In 4 patients, samples were haemorrhagic precluding definitive histological assessment. Early complication rate 1⁄4 1/47 (2%). One patient developed small subcapsular extravasation identified during procedure and settled spontaneously. Late complication rate 1⁄4 Nil. 1st Action Plan: To disseminate results across department and related clinical specialties. Standardisation of number of cores required for histological diagnosis and continuation of audit cycle. Are CT KUBS being performed with as low a radiation dose as possible? Authors: Adrian A. Pollentine, David Wilson, Alexis Corrigan, Mark Hawkins Background to the audit: We aim to audit whether CTKUB examinations are complying to the principle of keeping radiation exposure ALARP & whether changes to protocol and technique recommended after first round of audit have been effectively implemented. Standard, indicator and target: All CTKUBs performed on the correct CTKUB protocol Cranial extent of the scan should be at the top of the kidneys Meagher T, Sukumar VP, Collingwood J, et al. Low dose computed tomography in suspected acute renal colic. Clin Radiol. 2001 Nov;56(11):873-6 Methodology: All CTKUBs over 3 month periods July-Sept 2010 & AprilJune 2011 were analysed. Age, gender, DLP, kV, scanner used, AP diameter of patient at renal pelvis, distance scanned above kidney w 120kV on CT2 and 100kV on CT1 12% of scans on incorrect protocol Mean examination dose 1⁄4 4.5mSv Mean scan distance above kidney 1⁄4 62mm. 1st action plan: All scans to be performed on correct protocol Top of scan to be top of kidneys – not for repeat if tip of kidney missed 100 kV across both scanners Resultsof 2nd round: Statistically significant reduction inbothdose from4.5 to3.5mSvanddegreeof overestimationof cranial limit of scanfieldby20mm No repeat if top of kidney excluded initially – Compliant All scans performed on correct protocol – Non-compliant but improvement made 6% vs 12% 2nd action plan: Re-audit after introduction of iterative reconstruction software. Introducing a cardiac CT service ensuring appropriate referrals and overcoming teething problems Authors: Adrian A. Pollentine, Anthony Edey, Ladli Chandratreya Background to the audit:We aim to audit appropriateness of referrals for cardiac CT as well as factors contributing towards optimal image production and highlight tips to overcoming initial problems and providing a top notch service. Standard, indicator and target: Cardiac CT referral should adhere to appropriateness criteria published 2010 by the American College of Cardiologists 90% All patients should have on table GTN (unless C/I) 100% Heart rate should be 1000CTPAs annually. It is important to minimise the effective dose of this frequently performed study whilst maintaining diagnostic quality in accordance with IR(ME)R 2000. Standard, indicator and target: Standard 1: All CTPAs should be diagnostic (mean PA HU >200) Standard 2: Dose should be as low as reasonably practicable (mean DLP Methodology: 50 CTPAs performed at 120kVp on 128-slice CT scanner were reviewed. Mean HU in main pulmonary artery (MPA) was measured. Proportion of non-diagnostic CTPAs determined. Effective dose calculated from DLP, using conversion factors. Results of 1st audit round: At 120kVp: Standard 1: 98% CTPAs were diagnostic. Mean attenuation in MPA1⁄4355HU Standard 2: 100% compliance. Mean DLP1⁄4287mGy.cm, Effective dose1⁄44.9mSv 1st action plan: CT tube output is a to kVp squared. Lowering kVp can reduce dose and increase attenuation as more photons approximate to the k-edge of iodine and undergo photoelectric absorption. Perform CTPA at 100kVp rather than 120kVp to lower effective dose without compromising diagnostic quality. Re-audit 50 CTPAs. Results of 2nd round: At 100kVp: Standard 1: 96% CTPAswere diagnostic. Mean attenuation inMPA1⁄4 419HU* Standard 2: 100% compliance. Mean DLP 1⁄4124mGy.cm, Effective dose 1⁄42.0mSv* (*2nd Vs 1st round, P<0.05) 2nd action plan: Perform CTPA at 100kVp as Departmental standard.

Are CT KUBS being performed with as low a radiation dose as possible?

s / Clinical Radiology 67 (2012) S11–S20 S18 Transjugular liver biopsy safety and diagnostic yield Authors: Amit Patel, Aman Khan, Pete Thurley, Dominic Clarke, Rajeev Singh Background to the audit: Previous studies have demonstrated transjugular liver biopsy (TJLB) to be an effective procedure in patients not suitable for percutaneous biopsy with high diagnostic yield and low complication rate. Standard, indicator and target: To compare our centres complication rates and outcomes with previously published national studies. Technical success rates previously quoted range from 85 to 91%. Complication rates range from 1.3 to 13%. Methodology: Retrospective review of all TJLB's performed at Royal Derby Hospital between 2009 to 2012. Data gathered from case-note review, CRIS and Isoft medical database. Results of 1st audit round: Number of cases 1⁄4 47. Common indications included alcoholic liver diseasewith ascites/coagulopathy or suspected HCC. Mean age 1⁄4 55 years (range 22-82 years). Mean PT 18, INR 1.6, PLT 177. Large majority required pre-procedural blood products. Technical success rate 1⁄4 45/47 (96%). Mean number of passes 1⁄4 2.4. Mean combined core length 1⁄4 22 mm (range 4-45). Histological diagnostic yield 1⁄4 41/45 (91%). In 4 patients, samples were haemorrhagic precluding definitive histological assessment. Early complication rate 1⁄4 1/47 (2%). One patient developed small subcapsular extravasation identified during procedure and settled spontaneously. Late complication rate 1⁄4 Nil. 1st Action Plan: To disseminate results across department and related clinical specialties. Standardisation of number of cores required for histological diagnosis and continuation of audit cycle. Are CT KUBS being performed with as low a radiation dose as possible? Authors: Adrian A. Pollentine, David Wilson, Alexis Corrigan, Mark Hawkins Background to the audit: We aim to audit whether CTKUB examinations are complying to the principle of keeping radiation exposure ALARP & whether changes to protocol and technique recommended after first round of audit have been effectively implemented. Standard, indicator and target: All CTKUBs performed on the correct CTKUB protocol Cranial extent of the scan should be at the top of the kidneys Meagher T, Sukumar VP, Collingwood J, et al. Low dose computed tomography in suspected acute renal colic. Clin Radiol. 2001 Nov;56(11):873-6 Methodology: All CTKUBs over 3 month periods July-Sept 2010 & AprilJune 2011 were analysed. Age, gender, DLP, kV, scanner used, AP diameter of patient at renal pelvis, distance scanned above kidney w 120kV on CT2 and 100kV on CT1 12% of scans on incorrect protocol Mean examination dose 1⁄4 4.5mSv Mean scan distance above kidney 1⁄4 62mm. 1st action plan: All scans to be performed on correct protocol Top of scan to be top of kidneys – not for repeat if tip of kidney missed 100 kV across both scanners Resultsof 2nd round: Statistically significant reduction inbothdose from4.5 to3.5mSvanddegreeof overestimationof cranial limit of scanfieldby20mm No repeat if top of kidney excluded initially – Compliant All scans performed on correct protocol – Non-compliant but improvement made 6% vs 12% 2nd action plan: Re-audit after introduction of iterative reconstruction software. Introducing a cardiac CT service ensuring appropriate referrals and overcoming teething problems Authors: Adrian A. Pollentine, Anthony Edey, Ladli Chandratreya Background to the audit:We aim to audit appropriateness of referrals for cardiac CT as well as factors contributing towards optimal image production and highlight tips to overcoming initial problems and providing a top notch service. Standard, indicator and target: Cardiac CT referral should adhere to appropriateness criteria published 2010 by the American College of Cardiologists 90% All patients should have on table GTN (unless C/I) 100% Heart rate should be 1000CTPAs annually. It is important to minimise the effective dose of this frequently performed study whilst maintaining diagnostic quality in accordance with IR(ME)R 2000. Standard, indicator and target: Standard 1: All CTPAs should be diagnostic (mean PA HU >200) Standard 2: Dose should be as low as reasonably practicable (mean DLP Methodology: 50 CTPAs performed at 120kVp on 128-slice CT scanner were reviewed. Mean HU in main pulmonary artery (MPA) was measured. Proportion of non-diagnostic CTPAs determined. Effective dose calculated from DLP, using conversion factors. Results of 1st audit round: At 120kVp: Standard 1: 98% CTPAs were diagnostic. Mean attenuation in MPA1⁄4355HU Standard 2: 100% compliance. Mean DLP1⁄4287mGy.cm, Effective dose1⁄44.9mSv 1st action plan: CT tube output is a to kVp squared. Lowering kVp can reduce dose and increase attenuation as more photons approximate to the k-edge of iodine and undergo photoelectric absorption. Perform CTPA at 100kVp rather than 120kVp to lower effective dose without compromising diagnostic quality. Re-audit 50 CTPAs. Results of 2nd round: At 100kVp: Standard 1: 96% CTPAswere diagnostic. Mean attenuation inMPA1⁄4 419HU* Standard 2: 100% compliance. Mean DLP 1⁄4124mGy.cm, Effective dose 1⁄42.0mSv* (*2nd Vs 1st round, P<0.05) 2nd action plan: Perform CTPA at 100kVp as Departmental standard.

Enteroscopic and radiologic diagnoses, treatment, and prognoses of small-bowel tumors

Small-bowel tumors (SBTs) represent a diagnostic challenge. To evaluate the usefulness of contrast-enhanced CT (CECT), fluoroscopic enteroclysis (FE), videocapsule endoscopy (VCE), and double-balloon endoscopy (DBE) and the outcome after treatment. Single-center, retrospective study. Tertiary-care referral hospital. Between June 2003 and May 2011, 159 consecutive patients with SBTs (93 malignant and 66 benign) were enrolled. Comparison of diagnostic yields among CECT, FE, VCE, and DBE and the prognosis. CECT and FE had significantly lower diagnostic yields of SBTs ≤ 10 mm, but VCE and DBE had high yields of SBTs regardless of size. CECT had a significantly lower diagnostic yield of epithelial tumors compared with subepithelial tumors. When stratified by the site, the diagnostic yield of VCE for SBTs located only in the distal duodenum/the proximal jejunum (73%) was significantly lower than that for SBTs located in other areas (90%). Comparisons among the 4 methods revealed that VCE and DBE had significantly higher diagnostic yields than CECT, and DBE had significantly higher diagnostic yields than VCE, but a combination of CECT and VCE had a diagnostic yield similar to that of DBE. The histologic diagnostic yield of SBTs by DBE was 92%, and 25% of SBTs were enteroscopically treated. Metastatic tumors had the poorest overall survival, followed by adenocarcinomas and malignant lymphomas. Retrospective comparative study. For the detection of SBTs, a combination screening method by using VCE and CECT is recommended. DBE is useful for histologic diagnosis and endoscopic treatment.

Colonoscopic Findings and Histologic Diagnostic Yield of Colorectal Endometriosis

No study has systematically investigated the colonoscopic findings and histologic diagnostic yield in the diagnosis of colorectal endometriosis. We classified the colonoscopic features of colorectal endometriosis and determined the diagnostic yield of endoscopic biopsy in relation to endoscopic subtypes of colorectal endometriosis. A total of 17 patients with colorectal endometriosis were assessed. The data from the colonoscopic and histologic assessments made between November 1994 and October 2009 were retrospectively analyzed in single tertiary referral teaching hospital. Colonoscopy showed eccentric wall thickening in 14 patients (82%) and polypoid lesions in 3 patients (18%). Surface nodularities were noted in 11 of the 14 patients (79%) with eccentric wall thickening, and in 1 of the 3 patients (33%) with polypoid lesions. The overall histologic diagnostic yield was 47% (8 of the 17 patients). The rate of histologic confirmation was higher in patients with surface nodularities (8 of the 12 patients, 67%) versus those without (0 of the 5 patients, 0%) surface nodularities (P=0.02). Eccentric wall thickening is the most common colonoscopic finding of colorectal endometriosis, and the histologic diagnostic yield of endoscopic biopsy is high when lesions are accompanied by surface nodularities.

Navigation-Guided Endoscopic Biopsy for Intraparenchymal Brain Tumor

To evaluate the efficacy of intraparenchymal brain tumor biopsy using endoscopy and a navigation system (navigation-guided endoscopic biopsy) as a diagnostic tool, a case series of intraparenchymal tumor biopsies was reviewed. Navigation-guided endoscopic biopsy was applied in 9 cases, stereotactic needle biopsy in 16 cases, and open biopsy with or without navigation system in 34 cases. In all biopsy cases, 84.7% of biopsy points were sampled accurately, and 93.2% of diagnoses by biopsy were correct. Comparison of each type of biopsy showed that the resected volumes in navigation-guided endoscopic biopsy and open biopsy tended to be larger than those in stereotactic biopsy, and the mean operation time for the open biopsy procedure was the longest. To define the most applicable device or examination method to increase sampling accuracy, various factors were analyzed in 59 procedures. Navigation-guided endoscopic biopsy was the most accurate of the three types of biopsy, although the statistical difference was not significant. Older patients, histological diagnosis of high-grade glioma or malignant lymphoma, positive photodynamic diagnosis, and positive intraoperative pathology were significant factors in improving the sampling accuracy. Navigation-guided endoscopic biopsy could provide a larger sample volume within a relatively short operation time. The biopsy can be easily combined with both photodynamic diagnosis and intraoperative pathology, significantly improving the histological diagnostic yield.

A study of serial vertical sectioning of scalp biopsies to increase the histological diagnostic yield in alopecias

This study was performed to determine whether serial vertical sectioning of scalp biopsies increases the histological diagnostic yield in alopecias. The study group included 100 consecutively referred patients with scalp alopecias. The formalin-fixed paraffin-embedded specimens of the scalp alopecias were completely serially sectioned in a vertical orientation and stained with haematoxylin and eosin. The histological diagnosis rendered in the initial slide harbouring three to six sections was compared with the diagnosis in the following vertical serial sections (30-116 serial sections per specimen, mean 53). A total of 55 scalp biopsies were classified histologically as non-cicatricial alopecia, 35 as cicatricial alopecia and 10 as 'others'. Diagnostic histological findings were present in the initial sections of 50 (50%) cases of alopecia, and only in the following serial sections in 48 (48%) cases. Two cases (2%) lacked differentiating diagnostic histological features in all of the vertical sections. The diagnostic yield of the serial vertical sections compared with the initial sections was higher in the non-cicatricial alopecias (52.7%) than in the cicatricial alopecias (48.5%) and the 'others' category (10%). Serial vertical sectioning of scalp alopecias increases the histological diagnostic yield, substantially.

Colonoscopic Findings and Histologic Diagnostic Yield in Patients with Colorectal Endometriosis

Background and Aim: There is no study that systematically addresses colonoscopic findings and histologicdiagnostic yield in the diagnosis of colorectal endometriosis. A retrospective study was therefore performed todescribe the colonoscopic features and diagnostic yield of endoscopic biopsy of endometriosis. Methods: A total of 13, 237 patients whose final diagnosis was endometriosis were enrolled from November 1994 to October 2008 at the Asan Medical Center. Among them, we only selected 357 patients who had undergone colonoscopy, or sigmoidoscopy. Of 357 patients, endoscopic and histologic reports for procedures performed during the same period were reviewed to find patients with endometriosis based on their typical cyclic symptoms such as rectal bleeding, abdominal pain or histologic diagnosis was endometriosis. Finally we studied 14 patients with colorectal endometriosis. Endoscopic finding were divided into three categories: 1) eccentric wall thickening without surface nodularitis; 2) eccentric wall thickening with surface nodularities; 3) polypoid lesion. Results: The most common colonoscopic findings were eccentric wall thickening with surface nodularities, seen in 71% (10/14), followed by both eccentric wall thickening without surface nodularities and polypoid lesion in 14.2% (2/14). With regard to histologic diagnostic yield, the median number of obtained specimens was 4, with a range 1 to 9, and the diagnostic yield was no association with the number of specimens. Overall histologic diagnostic yield was 57% (8/14). Histologic confirmation of endometriosis in eccentric wall thickening with surface nodularity was in 80% (8/10), 0% (0/2) in both eccentric wall thickening withous surface nodularity and polypoid lesion. Conclusion: Even though colonic endometriosis is often difficult to diagnose owing to the rare nature of disease, about two thirds of all patients can be diagnosed with endoscopic and histologic findings only.

Frameless Stereotactic Surgery Using Intraoperative High-Field Magnetic Resonance Imaging

This study evaluated the clinical validity of frameless stereotaxy using high-field intraoperative magnetic resonance (iMR) imaging combined with an in-room neuronavigation system. A 1.5 Tesla MR scanner in conjunction with a ceiling-mounted neuronavigation system was used during 32 frameless stereotaxy procedures consisting of 19 brain biopsies and 13 catheter placements between April 2002 and mid-October 2003. Evaluation of the procedure was based on either the rate of histological diagnostic yield or the ability to accurately position the catheter in the target region. This technique allowed successful registration with a mean error of 1.2 +/- 0.8 mm and resulted in successful placement of the instrument within the target tissue. Intraoperatively, frozen section analysis showed all biopsy samples contained pathological tissue and locations of sampling points were confirmed by iMR imaging. Specific final diagnosis was made in all 19 brain biopsies. The tip of the catheter was successfully placed into the target in all 13 patients confirmed by iMR imaging. The catheter was repositioned based on iMR imaging in four of 13 patients, increasing the rate of successful placement. There were no procedure-related neurological deficits or mortality, but we encountered two cases of wound infection, one needing surgical revision. Total additional procedure time related to the induction of iMR imaging was 76.7 +/- 23.3 minutes. This initial experience of the combination of conventional frameless stereotaxy and high-field iMR imaging improved the quality of frameless stereotaxy with low morbidity and mortality, but did not translate into a significant reduction of procedure-related time.

Computer-assisted brain surgery (neuronavigation) in Abuja, North Central Nigeria: A 3-year retrospective review and practical challenges.

Neuronavigation has become a standard of care in contemporary neurosurgery since more than two decades and is gradually being embraced in our local practice. It is, therefore, important to share our local experience, including practical challenges encountered with this technology. The aim of this study is to review and present our early experience with stealth neuronavigation and to discuss the practical challenges encountered with the application of this technology in this environment. Retrospective review of all consecutive cases over a 3-year period (January 2016-December 2018). Admitting diagnosis, operations, histological diagnosis, adjuvant treatments and 6 months outcome were the major study parameters. Procedural challenges were also highlighted. Data were analysed using simple descriptive statistics, and results were presented in tables and figures. A total of 30 procedures were conducted. Nineteen males and 11 females (male: female = 1.7:1). Youngest was 8 months, oldest was 71 years, mean = 39 and standard deviation (SD) = 19.3. Operations performed were resection of mass lesion 18/30 (60%) and biopsy of mass lesion in 12/30 (40%) cases. Histological diagnostic yield was 100%. Mean duration of hospital stay was 2 days (SD = 0.25) for the biopsy group and 8 days (SD = 1.7) for the resection group. At 6 months review, 10/30 (33.3%) have died following progression and/or complications of their primary pathology. Wide spectrum of brain lesions were approached confidently with precision and minimal morbidity. No procedure-related mortality was recorded. Adjuvant treatments were easily deployed in line with a precise histological diagnosis. Practical challenges did not compromise the navigation process.