Indications For Repeat Biopsy Research Articles

PWE-117 The role of repeat liver biopsies in autoimmune hepatitis: clinical practice and outcomes

Introduction The role of repeat liver biopsies in established Autoimmune hepatitis (AIH) is unclear, with limited data on clinical practice and outcomes, and with variation in biopsy practice between physicians. Method We undertook a retrospective review of all patients with AIH who underwent a repeat liver biopsy between 2002–2013 at Frimley Park Hospital (Surrey, England); serving a population 430,000. The indication for repeat biopsy, liver histology and serological markers were recorded, as well as the clinical outcome/management resulting from each procedure. Results 17 patients were identified, all who were on treatment for AIH at the time of repeat biopsy. Clinical indications for repeat biopsy included: disease assessment/staging (34%) clinical deterioration (24%), diagnostic uncertainty (24%), medication withdrawal/remission (12%) and insufficient (Bx) sample (6%). Median time between 1 st and repeat biopsy was 24 months (range 1–108 months). Overall 10/17 (59%) patients had normal LFTs and 12/17 (71%) had normal IgG levels at the time of repeat biopsy. Repeat biopsy led to a change in treatment (dose/regime) in 11/17(65%) patients. Baseline cirrhosis was seen in 3/17 (biopsy/imaging), and developed in a further 2 patients (12%) over 24–48months; both with raised IgG levels at the time of repeat biopsy. 9 patients had a repeat biopsy at ≤ 24months. Within this group 4/9(44%) patients had normal LFTs, and 6/9 (67%) had normal IgG levels. Repeat biopsy led to a change in treatment in 2/4 (50%) patients with normal LFTs and 4/6 (67%) with normal IgG levels. Fibrosis progression was seen in 1/4 (25%) with normal LFTs, and 2/6 (33%) with normal IgG levels. Interface hepatitis/periportal inflammation was present in all repeat biopsies. Conclusion BSG and AASLD guidance suggest the use of repeat biopsies at 12–24 months following normalised transaminases to guide treatment withdrawal/maintenance, with IgG levels also thought predictive of histological response. However, the majority of repeat biopsies in our study were requested due to concerns of disease progression, rather than to assess for treatment withdrawal. Despite normalised LFTs/IgG levels, repeat biopsy led to treatment modification in more than half of this group; as well as demonstrating fibrosis progression and on-going histological activity. Our results support the need to individualise repeat liver biopsies to the needs of each patient. Disclosure of interest None Declared.

Ultrasound and cytological diagnostics of thyroid - its proper application in case of coexisting disturbing clinical signs and symptoms, suggestive of active proliferative lesion

Ultrasound and cytological diagnostics of thyroid - its proper application in case of coexisting disturbing clinical signs and symptoms, suggestive of active proliferative lesion

Imaging and pathology findings after an initial negative MRI-US fusion-guided and 12-core extended sextant prostate biopsy session

A magnetic resonance imaging-ultrasonography (MRI-US) fusion-guided prostate biopsy increases detection rates compared to an extended sextant biopsy. The imaging characteristics and pathology outcomes of subsequent biopsies in patients with initially negative MRI-US fusion biopsies are described in this study. We reviewed 855 biopsy sessions of 751 patients (June 2007 to March 2013). The fusion biopsy consisted of two cores per lesion identified on multiparametric MRI (mpMRI) and a 12-core extended sextant transrectal US (TRUS) biopsy. Inclusion criteria were at least two fusion biopsy sessions, with a negative first biopsy and mpMRI before each. The detection rate on the initial fusion biopsy was 55.3%; 336 patients had negative findings. Forty-one patients had follow-up fusion biopsies, but only 34 of these were preceded by a repeat mpMRI. The median interval between biopsies was 15 months. Fourteen patients (41%) were positive for cancer on the repeat MRI-US fusion biopsy. Age, prostate-specific antigen (PSA), prostate volume, PSA density, digital rectal exam findings, lesion diameter, and changes on imaging were comparable between patients with negative and positive rebiopsies. Of the patients with positive rebiopsies, 79% had a positive TRUS biopsy before referral (P = 0.004). Ten patients had Gleason 3+3 disease, three had 3+4 disease, and one had 4+4 disease. In patients with a negative MRI-US fusion prostate biopsy and indications for repeat biopsy, the detection rate of the follow-up sessions was lower than the initial detection rate. Of the prostate cancers subsequently found, 93% were low grade (≤ 3+4). In this low risk group of patients, increasing the follow-up time interval should be considered in the appropriate clinical setting.

CUA guidelines on prostate biopsy methodology

Transrectal ultrasound prostate biopsy (TRUS Bx) is increasingly performed by urologists. Lee and colleagues reported on the diversity in TRUS Bx practice and training in United Kingdom.1 Fifty-six percent of the surveyed urologists were actively involved in TRUS Bx and 68% of them did not think they received enough training. There is a wide variation in patient preparation (antibiotic prophylaxis regimens and analgesia used), biopsy schemes and indications for repeat biopsy. The lack of standardized guidelines for TRUS Bx highlights the necessity of a structured program for training the new generation of urologists.

Predictors of Cancer on Repeat Prostate Biopsy: A Contemporary UK Series

Objective: The aim of our study was to review current rebiopsy practice across our cancer network and to develop evidence-based guidelines to assist clinicians and patients in taking the decision when to proceed to repeat prostate biopsy in a UK healthcare setting. Methods: We conducted case note review of patients who underwent more than one prostate biopsy over a 5-year period (2000–2005) within a single cancer network. Results: Multivariate logistic regression analysis demonstrated that the factors from the first biopsy associated with the diagnosis of cancer at rebiopsy were PINATYP (RR = 4.1, p < 0.05), ASAP (RR= 3.9, p< 0.05), HGPIN (RR= 3.8, p< 0.05), abnormal DRE (RR = 2.2, p< 0.05). Histological evidence of inflammation reduced the risk of cancer on rebiopsy in comparison with benign prostatic tissue. Age below 70 also resulted in a reduced risk. PSA doubling time correlated with a final diagnosis of cancer on Pearson correlation test (coefficient -.011). Only 43 patients (21.5%) had the average PSA measurement frequency within 6 months; however, the average PSA measurement frequency was not predictive of cancer diagnosis (between groups ANOVA, p> 0.05). 61 patients were diagnosed with prostate cancer. 38 patients (62%) received definitive local therapy with 13 patients (21%) receiving no immediate treatment. Conclusions: Our retrospective series has defined predictors of a cancer diagnosis on repeat biopsy in a UK population. The findings of this study will form the basis of our local guidelines for the time-being, but there is scope for a large prospective study utilizing the 10 or 12 core protocol recommended by NICE to ascertain the most appropriate frequency of PSA testing and the indications for repeat biopsy.

Lesions predictive for prostate cancer in a screened population: first and second screening round findings.

We evaluated the incidence of prostate cancer, high-grade prostatic intraepithelial neoplasia (PIN) and lesions suspicious for prostate cancer (LSPC) in sextant biopsies in two subsequent screening rounds at a 4-year interval and their predictive value for subsequent prostate cancer detection. In the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC), 4,117 men underwent sextant biopsy in the 1st screening round. The 2nd round was performed at a 4-year interval and biopsies were taken in 1,840 men. The incidences of prostate cancer, LSPC and PIN in the 1st, respectively 2nd round were 24.6, resp. 19.9% (P = 0.001), 2.7, resp. 2.8% and 0.8, resp. 2.5% (P < 0.0001). Prostate cancer incidence after repeat biopsy for LSPC in the 1st, respectively 2nd round was 36.7 and 17.0%, and after repeat biopsy for PIN 13.3% in both rounds, respectively. Men with a benign biopsy in the 1st round had a significantly lower prostate cancer incidence in the 2nd round compared to men who did not undergo biopsy in the 1st round (10.7 vs. 22.7%, P < 0.0001). The decrease of prostate cancer detection in the 2nd round was associated with an increase in the incidence of PIN. Strikingly, LSPC diagnosed during the 1st round, but not during the 2nd round were predictive for prostate cancer, while isolated PIN was never predictive for prostate cancer. PIN should not be an indication for repeat biopsy in a screening population. Importantly a 1st round benign biopsy outcome proved to be a negative predictor of subsequent prostate cancer detection.

Transrectal ultrasound-guided punch biopsies of the prostate. Indication, technique, results, and complications

The golden standard for diagnosis of prostate cancer is transrectal ultrasound-guided systematic biopsy (TRUS-Bx). The optimal number of cylinders, sampling design, and indications for repeat biopsy are still in a state of flux. At the beginning of the 1980s, considerable doubts persisted regarding the benefit of ultrasound-guided punch biopsy for the diagnosis of prostate cancer. The examination on a chair with a fixed ultrasound head caused the patient substantial discomfort. Besides, in the pre-PSA era, most prostate carcinomas were detected by palpation and digitally guided biopsies were easily obtained. Indeed, the DRU procedure alone exhibited low sensitivity. Keetch et al. found that in only 25% of patients with abnormal palpatory findings and PSA between 4 and 20 ng/ml was a carcinoma revealed upon biopsy. On the other hand, patients with suspicious palpatory findings and proven malignancy suffered more frequently from locally advanced and systemic metastasizing tumors. As a result of restaging based on PSA, in most series more than half of the detected carcinomas presented normal palpatory findings. Ultrasound examination made precise imaging of zonal structures possible and thus offered the advantage of precision guidance for tissue biopsy despite lower sensitivity and specificity for diagnosis of suspicious lesions. Furthermore, calculation of prostate volume was possible. At the end of the 1980s, Hodge defined the systematic sextant biopsy as the first golden standard for early detection of prostate cancer. This meant the systematic removal of three punch cylinders from both lateral lobes of the prostate in the parasagittal midline at various levels (apex, middle, and base).

EXTENSIVE REPEAT TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY IN PATIENTS WITH PREVIOUS BENIGN SEXTANT BIOPSIES

Standard sextant prostate biopsy may underestimate cancer in men in whom clinical findings are suspicious for localized prostate cancer. We describe our experience with extensive transrectal ultrasound guided prostate biopsy in men in whom previous sextant biopsy was negative. Between November 1997 and March 1999, 57 men 47 to 72 years old (mean age 61.4) underwent extensive transrectal ultrasound guided biopsy of the prostate using intravenous sedation at our institution. An average of 22.5 cores (range 15 to 31) were obtained depending on prostate size. Biopsies were obtained from each of 6 sagittal regions, including samples from the far lateral and mid transitional zones. Each patient had undergone at least 1 previous benign transrectal ultrasound guided sextant biopsy (mean 2.1, range 1 to 4). Indications for repeat biopsy were persistently elevated prostate specific antigen (PSA) in 89% of the cases, increased PSA velocity in 63%, suspicious free-to-total PSA in 39% and a previous suspicious biopsy finding in 32%. Clinical factors (PSA, PSA velocity, free-to-total PSA and previous suspicious biopsy) were analyzed for the ability to predict positive biopsy, and tumor parameters were assessed pathologically in patients undergoing radical prostatectomy. Adenocarcinoma was identified in 17 of the 57 men (30%). Biopsy revealed a Gleason score of 6 to 8 (mean 6.4). In 7 of the 17 patients (41%) in whom cancer was identified only 1 biopsy core was positive. Of the 15 patients in whom previous sextant biopsy had demonstrated high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation extensive biopsy revealed cancer in 7 (47%). Although serum PSA was higher and free-to-total PSA was lower in those with cancer, the only statistically significant predictor of positive biopsy was PSA velocity (p <0.001). Prostate cancer was noted in 64% of the men with PSA velocity 1 ng./ml. or greater. Of the 13 patients undergoing radical prostatectomy pathologically significant disease was identified in all but 1 (92%). Complications of extensive biopsy included urinary retention in 6 patients and limited rectal bleeding in 1. Extensive prostate biopsy identifies significant prostate cancer in many men in whom previous sextant biopsy was benign. This procedure should be considered when findings are suspicious for adenocarcinoma despite previously negative sextant biopsy.

Clinical evaluation of the histochemical diagnosis of Hirschsprung's disease.

The histochemical staining of suction rectal biopsies for acetylcholinesterase (AChE) activity is a safe and accurate diagnostic tool in the management of patients with symptoms and signs of Hirschsprung's disease. In this study 101 patients who have undergone AChE analysis of suction rectal biopsies are presented in order to correlate histochemical findings with subsequent clinical course after a minimum of 18 months follow up. There were no false positive results, but the limitations and problems associated with the technique which we have encountered are discussed. Equivocal, atypical, or negative results when contradicting clinical features are indications for repeat biopsy or full thickness biopsy, and awareness of the situations in which false negative results may occur is essential.