Indeterminate Lesions Research Articles

Contrast-enhanced ultrasound of the kidneys and adrenals in children.

Pediatric applications of contrast-enhanced ultrasound (CEUS) are growing. Evaluation of the kidneys and adrenal glands in children using intravenous administration of US contrast agents, however, is still an off-label indication. Pediatric CEUS applications for kidneys are similar to those in adults, including ischemic disorders, pseudo- versus real tumors, indeterminate lesions, complex cystic lesions, complicated pyelonephritis, and abscesses. CEUS applications for evaluation of adrenal glands in children are limited, mainly focusing on the assessment and follow-up of adrenal trauma and the differentiation between an adrenal hemorrhage and a mass. This review addresses the current experience in pediatric CEUS of the kidneys and adrenal glands. By extrapolating the established knowledge for US contrast evaluations in the adult kidney to the pediatric context we can note opportunities for CEUS clinical use in children.

A Case of Paraneoplastic Erythropoietin Secretion Secondary to Medullary Thyroid Cancer

Background: Paraneoplastic erythropoietin (EPO) secretion is a well-described phenomenon that is classically seen in renal cell carcinoma. It has also been described in parathyroid adenoma and in pheochromocytoma. Additionally, follicular thyroid cancer cells, papillary thyroid cancer cells, and anaplastic thyroid cancer cells have all been found to express EPO in vitro. To our knowledge, EPO expression by medullary thyroid cancer has not previously been studied. Here, we describe a case of suspected paraneoplastic EPO secretion in the setting of advanced medullary thyroid cancer.Clinical Case: A 46 year-old woman presented to our clinic with hoarseness and was proven to have a medullary thyroid cancer with enlarged lymph nodes on the right at levels IV, V and VI. Genetic testing was negative for a germline RET mutation. She underwent total thyroidectomy with bilateral lymph node dissection and was subsequently treated with external beam radiation therapy. Pathology confirmed the diagnosis of medullary thyroid cancer, with extension beyond the thyroid capsule and bilateral lymph node involvement. Rising calcitonin and CEA were noted over the following years. A MRI of the abdomen showed indeterminate subcentimetric liver lesions. A Gallium-68 Dotatate PET scan confirmed the suspicion of liver metastases. Five years after the initial surgery, the patient developed rising hemoglobin levels, despite a long-standing history of iron deficiency anemia. JAK2 testing was negative. EPO levels were elevated (43.45 mU/mL, reference range 2.59 - 18.5 mU/mL) suggesting secondary polycythemia. The patient had a negative smoking history and a pulse oximetry of 98%; there was no evidence of hypoxia that could cause an elevation in EPO. Other differential diagnoses including pheochromocytoma, Cushing’s syndrome from ectopic ACTH production, and renal and brain tumors were excluded. Biopsy of the liver lesions is not technically feasible at this time. Since discovery of the erythrocytosis, the patient has undergone repeated therapeutic phlebotomies, to maintain acceptable hematocrit levels.Conclusion: We believe that our patient’s case may be the first reported case of ectopic EPO production from medullary thyroid cancer causing polycythemia. We encourage other clinicians to report similar clinical cases in order to better understand this rare clinical entity.

Nephrotic Syndrome Following Resection of an Adrenal Incidentaloma:A Case Report

A 69 year old man had a 5 cm right adrenal lesion discovered incidentally while being investigated for a deterioration in previously well-controlled hypertension. Routine investigations including serum albumin were normal. Further investigation confirmed a non-functioning adrenal lesion. MRI revealed a ‘non-fat-containing T1 hyperintense indeterminate adrenal lesion with speckling of T2 hyperintensity, not typical for adenoma, hyperplasia, myelolipoma, haemangioma or pheochromocytoma’. An uncomplicated laparoscopic adrenalectomy was performed. Histology revealed a 118 g adrenal neoplasm, modified Weiss score 0, with abundant hyaline deposits.3 months later the patient complained of peripheral oedema. Investigations revealed a serum albumin of 24 g/L and 14 g of proteinuria in 24 hours. Serum protein electrophoresis revealed a monoclonal IgA type lambda band. Renal biopsy revealed amorphous material displaying apple green birefringence on staining with Congo Red, which stained with antibodies to lambda light chains, confirming AL amyloid. Therefore the patient’s resected adrenal specimen was retrieved and stained with Congo Red, revealing apple green birefringence in the walls of the blood vessels, confirming the presence of amyloidosis. Although adrenal gland involvement in secondary amyloidosis is common, adrenal involvement in primary amyloidosis is less well described. This case illustrates the indolent nature of primary amyloidosis, prior to the development of often catastrophic symptoms. Consideration should be given to Congo Red staining of resected pathologic specimens containing hyaline deposition, to potentially allow for earlier recognition of this devastating disease. A pathophysiologic link between the patient’s incidentaloma, adrenalectomy, and onset of nephrotic syndrome remains a matter for conjecture.

Ovary: MRI characterisation and O-RADS MRI.

Ultrasound has a high specificity for the diagnosis of a benign lesion in cases of classic appearing simple cyst, hemorrhagic cyst, endometrioma and dermoid. However, ultrasound can sometimes be limited for definitive characterisation and risk stratification of other types of lesions, including those with echogenic content that may appear solid, with or without blood flow. Frequently, MRI can be used to further characterise these types of lesions, due to its ability to distinguish solid tissue from non-tissue solid components such as fat, blood, or debris. Incorporating the MR imaging into the evaluation of adnexal lesions can improve diagnostic certainty and guide clinical management potentially avoiding inappropriate surgery for benign lesions and expediting appropriate treatment for malignant lesions, particularly in the females with sonographically indeterminate adnexal lesions.

Accuracy of Breast Fine-Needle Aspiration Biopsy Using the International Academy of Cytology Yokohama System in Clinico-Radiologically Indeterminate Lesions: Initial Findings Demonstrating Value in Lesions of Low Suspicion of Malignancy

Background: Fine-needle aspiration biopsy (FNAB) in breast lesions offers accurate results in differentiating benign and malignant lesions. However, its role is unclear when core-needle biopsy (CNB) is available, the latter providing additional information regarding tumor grade, invasion, and hormone receptor status in malignant lesions. In benign breast lesions, especially in BIRADS category 4a and 4b, FNAB, and CNB provide similar pathological information, whereby FNAB may serve as a more rapid and cost-effective investigation. The study was planned to reevaluate the diagnostic accuracy of FNAB in BIRADS category 4a, 4b, and 4c lesions. Materials and Methods: FNAB and biopsy reports of all patients with breast lesions sent between September 1, 2018, and November 30, 2020, were collected and the International Academy of Cytology (IAC) Yokohama category and BIRADS score were recorded for each case. The rate of malignancy and the accuracy of FNAB in diagnosing malignancy were calculated for each BIRADS 4a, 4b, and 4c subgroup. Results: A total of 249 cases of BIRADS 4 lesions had corresponding cytology and histopathology diagnoses. FNAB showed high diagnostic accuracy in all BIRADS groups. A benign categorization was associated with a very low number of false-negative diagnoses, especially in BIRADS 4a lesions. Conclusion: The study reconfirms the excellent accuracy of breast FNAB using the IAC Yokohama system in diagnosing breast malignancies. Furthermore, BIRADS 4a lesions found to be belonging to the cytological benign category may be excluded from CRB and kept on clinical follow-up.

Limited Clinical and Diagnostic Utility of Circulating Tumor DNA Detection in Patients with Early-Stage Well-Differentiated Thyroid Cancer: Comparison with Benign Thyroid Nodules and Healthy Individuals.

Limited data are available on the diagnostic utility of circulating tumor DNA (ctDNA) in early-stage thyroid cancers for BRAF, KRAS, NRAS, and TERT promoter mutations, which are known detectable markers for thyroid cancers. Here, we analyzed the above driver mutations in ctDNA and matched neoplastic tissues from patients with early-stage thyroid cancers in order to investigate diagnostic utility of circulating markers in distinguishing from other mimicking thyroid lesions and healthy individuals. In total, 73 matched neoplastic tissue and plasma samples [thyroid cancers (n = 62), benign thyroid disorders (n = 8), and parathyroid lesions (n = 3)] and 54 plasma samples from healthy individuals (as controls) were analyzed for BRAF, KRAS, NRAS, and TERT promoter mutations using peptide nucleic acid clamp real-time PCR. Although only one patient with an indeterminate lesion on thyroid cytology showed KRAS mutation (codon 146) in the preoperative plasma, that KRAS mutation was not identified in the stage I papillary thyroid carcinoma tissue. In the remaining 72 plasma samples, no other mutations were identified in BRAF, NRAS, and TERT promoter genes. The concordance rates of mutational results between the plasma and tumor tissue or metastatic lymph node were very low. One (1.9%) of the 54 healthy individuals harbored a KRAS mutation in the plasma samples. The ctDNA results did not represent the mutational profile of primary or metastatic thyroid cancers, warranting a caution for interpretation. The clinical utility of BRAF, KRAS, NRAS, and TERT promoter mutation analysis on ctDNA appears to be limited to early-stage thyroid cancers.

The impact of vacuum-assisted excision in the management of indeterminate B3 lesions in the NHS Breast Screening Programme in England

To assess the impact of vacuum-assisted excision (VAE) on the management of B3 lesions in the England NHS Breast Screening Programme following an update of national guidance. A secondary aim was to investigate the histological features of malignancies resulting from upgrade of B3 lesions by either VAE or surgery. The study population was all women recalled for assessment after breast screening who had a wide-bore needle biopsy with a B3 result over the period 01/04/2018 to 31/03/2019. Data were extracted from the National Breast Screening Service (NBSS) computer system at unit level. Women with a B3 result were split into those with and without atypia. The upgrade rates and histological features of malignancies in the different groups were analysed. In total, 2,234,514 women attended for screening between 1/4/218 and 31/3/2019, 84,559 women were referred to assessment, and of those 40,037 women had a core biopsy resulting in 3,355 were B3 lesions (8.38%). Within these, 556 cancers were diagnosed, giving an upgrade rate of 16.57% (556/3,355). The upgrade for B3 lesions with atypia was significantly higher than for B3 lesions without atypia (29.1% versus 13.3%, p<0.001). The introduction of the new B3 guidelines has resulted in 73.8% of B3 lesions with atypia and 65.1% of B3 lesions with no atypia having VAE rather than surgery. The data highlights the importance of managing these indeterminate lesions appropriately with an overall upgrade rate of 16.57%.

Role of ultrasonography and magnetic resonance imaging in evaluation of female pelvic masses from reproductive organs with histopathological correlation

Female pelvis houses urological and reproductive organs with perplexing pathologies often because of poor clinical characterization of lesion as it poses overlapping clinical features and difficulty in physical examination. Histopathology is considered gold standard, however the radiological imaging modalities revolutionized the diagnostic and presurgical workup with superior characterization of the lesion, guiding procedures and defining the extensions. In the present study we evaluated different pelvic pathologies using ultrasonography and MRI and these radiological findings were correlated with histopathology findings. This is a prospective study involving 50 female patients with complaints of lower abdominal pain and irregular bleeding were selected. These patients had undergone trans abdominal sonography (transvaginal when needed) and MRI pelvis imaging. Subsequently these findings were correlated with the histopathological findings, whenever needed. Age range of 18-87 were included which showed benign lesions (USG – 43, MRI – 36 and Histopathology – 31) and malignant lesions (USG – 7, MRI – 14 and Histopathology – 19). Most common solid malignant uterocervical lesions are cervical and endometrial cancer and most common malignant cystic adnexial lesions are ovarian neoplasms. The data was statistically analyzed using SPSS software which showed USG (sensitivity – 26.3%, specificity – 93.5%, PPV – 80.3%, NPV – 55.9% & Accuracy – 68%) & MRI (sensitivity – 73.6%, specificity – 100%, PPV – ∞, NPV – 79.1% & Accuracy – 90%). Conclusion: The poor ultrasound sensitivity in the present study can be attributed to the low study population, considering the indeterminate lesions as non-malignant and difficulty in analyzing the small cervical and small adnexial pathologies. MRI showed superior soft tissue resolution, better characterization of lesion compared to Trans abdominal and Trans vaginal sonography. High specificity, high accuracy, low radiation exposure would definitely make MRI pelvis the best imaging modality in diagnostic as well as in presurgical evaluation. On the other hand, ultrasonography with decent specificity and accuracy can be used as first line investigation for its cost efficiency, reproducibility and lack of radiation.

Thyroid and Molecular Testing. Advances in Thyroid Molecular Cytopathology

Thyroid nodules are a common finding in the adult population including the fact that more than 50% of individuals, over the age of 60, have thyroid nodules. The majority have been mostly detected with ultrasonography and 10% by palpation. The majority of these nodules are benign, whereas 5–15% of them are malignant. The pre-operative diagnosis of cancer is a critical challenge in order to ensure that each patient can be treated with the best tailored management with a reduction of unnecessary surgery for benign lesions. Fine needle aspiration cytology (FNAC) represents the first and most important diagnostic tool for the evaluation of thyroid lesions. According to the literature, FNAC is able to render a conclusive diagnosis in up to 70–80% of all cases. For the remaining 20–30% of nodules, cytological diagnoses fall into the category of indeterminate lesions mostly due to the lack of specific morphological features. According to the Bethesda system for reporting thyroid cytopathology (TBSRTC), indeterminate lesions can be sub-stratified into three different subcategories including “atypia of undetermined significance/follicular lesion of undetermined significance-AUS/FLUS”; “follicular or Hürthle cell neoplasm/suspicious for follicular or Hürthle cell neoplasm-FN/SFN”; and “suspicious for malignancy-SFM”. Many of these indeterminate lesions undergo repetition or diagnostic lobectomy. Nonetheless, the majority of these cases will have a benign diagnosis due to the fact that the rate of cancer ranges between 6 and 30%. It stands to reason that the application of ancillary technique, mostly molecular testing, emerged as a critical additional tool for those thyroid indeterminate lesions. Since the early 1990s, material collected from cytological samples yields sufficient and adequate cells for the detection of point mutation or gene fusions. Nonetheless, the further availability of new sequencing technologies such as next-generation sequencing (NGS) has led to more comprehensive molecular applications adopted now in clinical use. The current review investigates the multiple advances in the field of molecular testing applied in thyroid cytology.

Diagnostic algorithm of solid kidney lesions with contrast-enhanced ultrasound

Most often any kidney lesions are primary renal, but sometimes they can be secondary (metastases, lymphoma). Every year renal cell carcinoma tends to a significant increase in the incidence. Today there are many available methods of examination, however difficulties often remain in the differential diagnosis of kidney lesions. The article discusses about the modern possibilities of methods in the identification and assessment of kidney lesions, their role in determining the tactics of patient management and key approaches in imaging characterization of these masses using CT and PET, MRI and CEUS. The analysis of the modern literature has shown that the currently existing radiation diagnostic methods do not provide an absolute opportunity for differential diagnosis of rare kidney tumors. CEUS, according to various authors, demonstrates high efficiency indicators, but does not exceed these indicators in comparison with CT and MRI. Contrast-enhanced ultrasound is a potentially safe method and can be used as a method for additional examination to characterize indeterminate renal lesions.

Prenatal Imaging Diagnosis of Suprarenal Lesions

Introduction: Prenatal suprarenal lesions represent diverse pathologies. This study investigated prenatal imaging features and regression patterns associated with specific lesion diagnoses. Methods: This is a multicenter retrospective review of fetuses with prenatally diagnosed suprarenal lesions between 2001 and 2019. Prenatal ultrasound and MRI characteristics, postnatal imaging, and clinical course were reviewed. Prenatal imaging findings were compared by the most common diagnoses and regression patterns. Results: Forty-four fetuses were prenatally diagnosed with suprarenal lesions. Diagnoses included pulmonary sequestration (n = 12; 27.3%), adrenal hemorrhage (n = 12; 27.3%), upper quadrant cyst (including 2 duplication cysts, 1 splenic cyst, and 3 indeterminate cysts), neuroblastoma (n = 4), adrenal hyperplasia (n = 3), bilateral adrenal calcifications (n = 1), and indeterminate lesions (n = 6). Sequestrations were uniformly left-sided (100 vs. 50%; p = 0.014) and diagnosed earlier in gestation than adrenal hemorrhages (p = 0.025). Sequestrations were also significantly more likely to have a prenatal feeding vessel (p = 0.005), low T1 MRI signal (p = 0.015), and no MRI blood products (p = 0.018) compared to adrenal hemorrhages. When comparing all 44 patients, a prenatal feeding vessel and low T1 signal on prenatal MRI were significantly associated with lesion persistence (p = 0.003; p = 0.044). Discussion/Conclusion: Imaging findings on prenatal ultrasound and MRI aid in the diagnosis of suprarenal lesions, including differentiating pulmonary sequestrations and adrenal hemorrhages.

Handcrafted MRI radiomics and machine learning: Classification of indeterminate solid adrenal lesions

PurposeTo assess a radiomic machine learning (ML) model in classifying solid adrenal lesions (ALs) without fat signal drop on chemical shift (CS) as benign or malignant. Method55 indeterminate ALs (21 lipid poor adenomas, 15 benign pheocromocytomas, 1 oncocytoma, 12 metastases, 6 primary tumors) showing no fat signal drop on CS were retrospectively included. Manual 3D segmentation on T2-weighted and CS images was performed for subsequent radiomic feature extraction. After feature stability testing and an 80–20% train-test split, the train set was balanced via oversampling. Following a multi-step feature selection, an Extra Trees model was tuned with 5-fold stratified cross-validation in the train set and then tested on the hold-out test set. ResultsA total of 3396 features were extracted from each AL, of which 133 resulted unstable while none had low variance (< 0.01). Highly correlated (r > 0.8) features were also excluded, leaving 440 parameters. Among these, Support Vector Machine 5-fold stratified cross-validated recursive feature elimination selected a subset of 6 features. ML obtained a cross-validation accuracy of 0.94 on the train and 0.91 on the test sets. Precision, recall and F1 score were respectively 0.92, 0.91 and 0.91. ConclusionsOur MRI handcrafted radiomics and ML pipeline proved useful to characterize benign and malignant solid indeterminate adrenal lesions.

Can endoscopic ultrasonography (EUS) improve the accuracy of clinical T staging by computed tomography (CT) for gastric cancer?

IntroductionWith the introduction of new therapeutic options for gastric cancer treatment, more precise preoperative staging of gastric cancer is needed. The purpose of this study was to evaluate the role of endoscopic ultrasonography (EUS) for improving the accuracy of clinical T staging by computed tomography (CT) for gastric cancer. Materials and methodsA total of 2636 patients underwent stomach protocol CT (S-CT) and EUS, followed by gastrectomy for primary gastric adenocarcinoma between September 2012 and February 2018 at Seoul National University Hospital. The results of preoperative S-CT and EUS were compared to the postoperative pathologic staging. ResultsThe overall accuracy of S-CT and EUS for T staging were 69.4% and 70.4%, respectively. When T staging was divided into T1-2 and T3-4 for clinically advanced gastric cancer (AGC), the positive predictive value for T3-4 using S-CT, EUS, and a combination of both modalities was 73.8%, 79.3%, and 85.6%, respectively. In 114 cases of indeterminate lesions between cT1 and cT2 by S-CT, EUS had a better prediction rate than the final decision based on endoscopy or the agreement between the two experts (Match rate: EUS vs. final decision, 69.3% vs. 58.8%). ConclusionEUS can be a complementary diagnostic tool to clinical T staging of gastric cancer by CT for selecting T3-4 lesion.

An abbreviated MRI protocol for surveillance of cystic pancreatic lesions.

Cystic pancreatic lesions (CPLs) are common and increasingly encountered in clinical radiology practice. The appropriate imaging surveillance strategy for lower-risk CPLs (branch duct-intraductal papillary mucinous neoplasms and indeterminant small cystic lesions) has been a topic of intense study and debate in recent years. MRI is considered the investigation of choice for initial characterisation and follow-up of CPLs. Follow-up intervals for CPLs vary from 6months to 2years and surveillance may be lifelong or until the patient is no longer considered fit for potential surgical intervention. This creates a significant burden on MRI resources as a standard protocol pancreatic MRI may have an acquisition time of up to 35-50min. However, the necessity of contrast-enhanced sequences and diffusion weighted imaging (DWI) for routine follow-up of CPLs has been questioned in recent years. We reviewed the available evidence to determine whether an abbreviated MRI (A-MRI) protocol may be safely adopted for surveillance of CPLs, as has been implemented in other clinical scenarios. A number of recent retrospective studies have indicated that an A-MRI, omitting contrast-enhanced and DWI, may be used for CPL surveillance without any suspicious features or cases of malignancy being missed. Although small number of cases may need to be recalled for additional MR sequences based on the A-MRI findings, there is still a significant overall timesaving. The best available evidence currently suggests that an A-MRI protocol should be considered for routine surveillance of CPLs. Prospective studies are required to ensure the findings reported in these retrospective case studies are backed up in ongoing clinical practice.

Diagnostic Accuracy and Therapeutic Efficacy of Digital Single-Operator Cholangioscopy for Biliary Lesions and Stenosis

Background/Aims: Digital single-operator cholangioscopy (dSOC) has revolutionized bile duct visualization. Interventions like electrohydraulic or laser lithotripsy, inspection of suspicious areas, and targeted biopsies have become possible quick and easy. One main indication for dSOC remains the evaluation of indeterminate biliary strictures. Objective and Methods: We analyzed 180 consecutive dSOCs procedures performed in a high-volume tertiary center to evaluate sensitivity, specificity as well as positive and negative predictive values (PPV and NPV) for indeterminate strictures. Furthermore, technical success and complications were analyzed. Results: In 92–97%, the region of interest was reached and successfully visualized. In 83–100%, targeted biopsies were obtained from the suspicious area. Only the distal bile duct was less successful with only 84 and 62%, respectively. In general, dSOC procedures were safe. Cholangitis was the main complication. Regarding the diagnostic accuracy of dSOC of indeterminate biliary strictures, we found a sensitivity of 0.87 and specificity of 0.88, over all. Within the whole cohort, the investigators’ assessment directly after dSOC had a PPV of 0.63 and a NPV of 0.97. In patients with biliary lesions or stenosis suspicious for malignancy, the dSOC-based visual diagnosis revealed a very high diagnostic accuracy with sensitivity and specificity of 1.0 (95% CI 0.86–1.0) and 0.76 (95% CI 0.56–0.9) with a PPV of 0.77 (95% CI 0.59–0.9) and a high NPV of 1.0 (95% CI 0.85–1.0). Conclusions: Our study demonstrates that dSOC has a high diagnostic accuracy as well as a favorable safety profile. Therefore, dSOC should be discussed as standard of care during endoscopic retrograde cholangiography for indeterminate biliary lesions.

Photoacoustic Computed Tomography of Breast Cancer in Response to Neoadjuvant Chemotherapy.

Neoadjuvant chemotherapy (NAC) has contributed to improving breast cancer outcomes, and it would ideally reduce the need for definitive breast surgery in patients who have no residual cancer after NAC treatment. However, there is no reliable noninvasive imaging modality accepted as the routine method to assess response to NAC. Because of the inability to detect complete response, post‐NAC surgery remains the standard of care. To overcome this limitation, a single‐breath‐hold photoacoustic computed tomography (SBH‐PACT) system is developed to provide contrast similar to that of contrast‐enhanced magnetic resonance imaging, but with much higher spatial and temporal resolution and without injection of contrast chemicals. SBH‐PACT images breast cancer patients at three time points: before, during, and after NAC. The analysis of tumor size, blood vascular density, and irregularity in the distribution and morphology of the blood vessels on SBH‐PACT accurately identifies response to NAC as confirmed by the histopathological diagnosis. SBH‐PACT shows its near‐term potential as a diagnostic tool for assessing breast cancer response to systemic treatment by noninvasively measuring the changes in cancer‐associated angiogenesis. Further development of SBH‐PACT may also enable serial imaging, rather than the use of current invasive biopsies, to diagnose and follow indeterminate breast lesions.

Use of 18F-fluciclovine PET/CT (FluPET) for prostate cancer (PC): Initial results from a prospective registry at a tertiary academic center.

29 Background: FluPET, a next-generation imaging modality approved in 2016 for suspected PC recurrence with elevated PSA after prior therapy, is becoming more widely available; however, practice patterns and impact on outcomes is unknown. We hypothesize FluPET is ordered for a variety of reasons, with findings often leading to changes in treatment plan. Methods: In this prospective registry, providers are surveyed before, 1-2 weeks after, and 1 year after FluPET to assess reasons for obtaining FluPET, projected treatment plan, changes in plan due to FluPET findings, and toxicity potentially attributable to change in treatment plan. Baseline patient characteristics, FluPET results, and longitudinal outcomes are collected. We report early descriptive findings with χ2 and student’s t-test used for univariate analyses. Results: 50 patients enrolled 12/2018-08/2020 had baseline characteristics described in Table; 46 underwent FluPET. Rationale for ordering included initial staging prior to definitive local therapy (6.1%), guidance of salvage local therapy for 1st biochemical recurrence (BCR) (46.9%), guidance of additional salvage after ≥2 local therapies and 2nd BCR (36.7%), and confirmation of equivocal metastatic disease (10.2%). When queried on next steps, providers considered observation (67.3%), androgen deprivation therapy (ADT) (26.5%), ADT + docetaxel or novel anti-androgens (AA) (20.4%), and salvage therapy with surgery, radiation, or cryotherapy (26.5%), often selecting ≥1 option. FluPET found ≥1 PC lesion in 73.9% of cases, ≥1 indeterminate lesion in 8.7%, and no lesions in 17.4%. 45.5% of providers reported changing treatment plan based on FluPET results; 6.8% changed to observation, 20.5% to systemic therapy, 13.6% to local salvage therapy, and 4.5% to a combination of local and systemic therapies. Change in therapy was associated with positive FluPET (54.5% vs. 18.2%, p=0.044), and within those cases, with higher SUVMax (mean 7.7 vs. 5.2, p=0.021) but not number of lesions (p=0.804). Conclusions: FluPET is often obtained to guide salvage therapy after BCR but is also used for initial staging or resolving equivocal findings of metastases. Many providers changed intended treatment based on FluPET findings, especially if positive; de-escalation to observation was rare. [Table: see text]

Current molecular and clinical insights into uveal melanoma (Review).

Uveal melanoma (UM) represents the most prominent primary eye cancer in adults. With an incidence of approximately 5 cases per million individuals annually in the United States, UM could be considered a relatively rare cancer. The 90-95% of UM cases arise from the choroid. Diagnosis is based mainly on a clinical examination and ancillary tests, with ocular ultrasonography being of greatest value. Differential diagnosis can prove challenging in the case of indeterminate choroidal lesions and, sometimes, monitoring for documented growth may be the proper approach. Fine needle aspiration biopsy tends to be performed with a prognostic purpose, often in combination with radiotherapy. Gene expression profiling has allowed for the grading of UMs into two classes, which feature different metastatic risks. Patients with UM require a specialized multidisciplinary management. Primary tumor treatment can be either enucleation or globe preserving. Usually, enucleation is reserved for larger tumors, while radiotherapy is preferred for small/medium melanomas. The prognosis is unfavorable due to the high mortality rate and high tendency to metastasize. Following the development of metastatic disease, the mortality rate increases to 80% within one year, due to both the absence of an effective treatment and the aggressiveness of the condition. Novel molecular studies have allowed for a better understanding of the genetic and epigenetic mechanisms involved in UM biological activity, which differs compared to skin melanomas. The most commonly mutated genes are GNAQ, GNA11 and BAP1. Research in this field could help to identify effective diagnostic and prognostic biomarkers, as well as novel therapeutic targets.

Comparison of contrast-enhanced versus conventional EUS-guided FNA/fine-needle biopsy in diagnosis of solid pancreatic lesions: a randomized controlled trial

Contrast-enhanced harmonic EUS (CEH-EUS) is useful in the differential diagnosis of solid pancreatic lesions (SPLs). However, there is lack of verification about the usefulness of CEH-EUS-guided FNA/fine-needle biopsy (FNB) sampling. This study aimed to investigate the usefulness of CEH-EUS-guided FNA/FNB sampling without on-site cytopathology. Patients with SPLs were prospectively enrolled and randomly assigned (1:1) to 2 parallel groups, the interventional group (CEH-EUS) or the control group (conventional EUS). The diagnostic sensitivity and optimal number of needle passes for pathologic diagnosis were investigated and compared between groups. Two hundred forty patients were enrolled from March 2016 to September 2019, with 120 patients assigned to each group. Pancreatic malignancies and neuroendocrine tumors were found in 202 (90.83%) and 9 (3.75%) patients, respectively. There was no statistically significant difference between the groups in terms of age, sex, lesion size (30.96 ± 12.09mm in the CEH-EUS group vs 33.09 ± 16.39mm in the conventional EUS group; P= .252), lesion location, adverse event rate, and disease distribution. The diagnostic sensitivity values in the CEH-EUS and conventional EUS groups were 85.8% and 88.3%, respectively (P= .564). All patients in the conventional EUS group and most in the CEH-EUS group received a pathologic diagnosis within 3 needle passes. Diagnostic sensitivity for SPLs was not different between the CEH-EUS and conventional EUS groups, and no independent factors were found that could improve diagnostic sensitivity. CEH-EUS-guided FNA/FNB sampling does not need to be used routinely and may be selectively considered for small, indeterminate lesions. (Clinical trial registration number: KCT 0001840.).

Vacuum-Assisted Breast Biopsy System: No Innovation Without Evaluation.

BackgroundVacuum-assisted breast biopsy (VABB) has recently been gaining more popularity as a modality to reach the final diagnosis, especially in indeterminate breast lesions, resulting in a decreased number of surgical interventions and unnecessary follow-ups.ObjectiveWhile our primary aim was to look into the outcomes of the VABB technique, our secondary aim was to assess the impact of the method on changes in patients’ management.Patients and methodsThis study was a retrospective database analysis of vacuum-assisted biopsies (VABs) carried out at our breast unit during the period between January 2011 and January 2018. All our cases were image-guided; the caliber of vacuum-assisted needles used was 8 gauge (G) and 11 G. Patient demographics, lesion characteristics, and outcomes were retrieved from patients’ notes and the hospital database.ResultsA total of 122 female patients were included in the analysis, out of whom 41.8% (51 patients) were screen-detected, and 58.1% (71 patients) were symptomatic presentations. The mean lesion size on imaging was 14.8 mm (SD: 12.6); 50% (61 patients) had stereotactic vacuum-assisted breast biopsy (SVAB), and 50% (61 patients) had ultrasound-guided vacuum-assisted breast biopsy (US-VAB). Post-procedure histology was upgraded in 19.6% (24 patients), downgraded in 18.8% (23 patients), and remained unchanged in 61.4% (75 patients).ConclusionVABB is a safe and efficient procedure for the diagnosis and management of indeterminate and suspicious breast lesions. It provides an adequate amount of tissue, which can help in upgrading or downgrading histopathologically diagnosed patients, thereby decreasing the need for surgery.