Need For Routine Biopsy Research Articles

Intradural Melanotic Schwannoma of the Sacral Spine: An Illustrated Case Report of Diagnostic Conundrum

Schwannomas are benign and slow-growing peripheral nerve sheath neoplasms of Schwann cells. These are generally encountered in the neck, head, and flexor areas of the extremities. Even though many schwannomas are easily diagnosable, their variable morphology can occasionally create difficulty in diagnosis. In this study, we present a rare case of melanotic schwannoma of the sacrum, emphasizing the need for routine biopsy to understand the etiology. A 46-year-old man presented to the Department of Neurosurgery, Taipei Medical University Hospital, with buttock pain in the sacrum area for 1 year, which worsened in the last 1–2 months. The patient had no known history of trauma or malignancy. We evidenced an intradural extramedullary neurogenic tumor at the caudal end from S1 to S3. Histologic analysis revealed melanin deposition in the tumor cells. Round to oval tumor cells were positive for HMB-45 and S-100 proteins, suggestive of melanotic Schwannoma, which were removed by laminectomy. After 1 month, the tumor recurred and was further removed surgically. Conclusively, we observed the sacrum as an unusual anatomic site for the possible occurrence of melanotic schwannoma, especially in patients with no known history of trauma and malignancy. The possibility of melanotic schwannoma is very high. We hypothesize that melanotic schwannoma was possible because it occurred in the intradural and extramedullary regions of the spine. Hence, a routine biopsy should be performed to corroborate the exact cause and prevent incorrect presumptions.

Use of Apixaban in Heart Transplant Patients Receiving Biopsies: A Case Series

Purpose The need for routine biopsies poses a challenge in the management of heart transplant recipients with an indication for anticoagulation. Per local institutional protocol, all patients receive at least 7 endomyocardial biopsies within 90 days of transplant to assess for rejection. Apixaban is a direct acting anticoagulant with a short half-life allowing for minimal time off anticoagulation to accommodate a biopsy. To our knowledge, apixaban has never been evaluated in the setting of routine biopsies. The objective of this study was to determine the safety and efficacy of apixaban in heart transplant patients undergoing biopsies. Methods This retrospective case series evaluated patients who received a heart transplant and were treated with apixaban within 90 days post-transplant. This research was approved by the Eastern Virginia Medical School IRB. Per institutional protocol, apixaban was held for 1-2 doses prior to routine biopsy and restarted the night following biopsy. The primary outcome was the occurrence of a bleeding or thrombotic event. Results A total of 13 patients received apixaban within 90 days following heart transplant. The median age was 54 years (IQR 37-59) with a median weight of 96 kg (IQR 72-101). None of the patients had either a bleeding or thromboembolic event while on apixaban. During therapy, patients underwent an average of 8 biopsies. The median time from transplant to initiation of apixaban was 39.5 ± 26.1 days (range 9-77). The number of patients on apixaban for their biopsies during post-op weeks 3-6 are as such: 3, 6, 6, 7. No patients required reversal therapy at any point and patients remained on therapy for a median of 276 (IQR 45-245) days. Indication for apixaban was stroke prevention with atrial fibrillation (15%), acute DVT (70%), and both (15%). Of the DVTs 30% were femoral while 70% were upper extremity. Compliance with the apixaban dosing protocol was excellent. Dosing was adjusted according to indication and renal function. Conclusion Based on the data from this case series, apixaban is safe to use for anticoagulation of heart transplant recipients undergoing routine biopsies in the setting of an established institutional protocol. Using apixaban allows for a short duration off anticoagulation to accommodate a biopsy without any increased risk of bleeding.

Development of a narrow-band imaging classification to reduce the need for routine biopsies of gastric polyps

BackgroundMost incidental gastric polyps identified during upper endoscopy are considered low-risk. However, current guidelines recommend sampling all gastric polyps for histopathologic analysis. We aimed to devise a simple narrow-band imaging (NBI) classification to reduce the need for routine biopsies of low-risk gastric polyps.MethodsPairs of NBI and white-light images were collected from 73 gastric polyps for which concurrent histopathologic diagnosis was available. A diagnostic accuracy cohort study was performed. Two blinded endoscopists independently analysed NBI features of each polyp for color, vessel pattern, surface pattern, and any combinations thereof to develop a classification scheme to differentiate low-risk polyps (fundic-gland or hyperplastic) from high-risk polyps (adenomatous or adenocarcinoma) and fundic-gland polyps (FGPs) from non-FGPs.ResultsAn isolated lacy vessel pattern and a homogenous absence of surface pattern successfully differentiated low-risk from high-risk gastric polyps. Combining both descriptors into a single algorithm resulted in a negative predictive value (NPV) of 100% [95% confidence interval (CI): 100%–100%], positive predictive value (PPV) of 13.7% (95% CI: 2.6–24.8), sensitivity of 100% (95% CI: 100%–100%), and specificity of 53.7% (95% CI: 45.3%–62.0%) for high-risk polyps. This would reduce the number of polyps requiring biopsy by 50%, while still capturing all high-risk polyps. Regarding FGPs, using a rule not to biopsy polyps with isolated lacy vessels resulted in a 94.9% NPV (95% CI: 89.2%–100%), 63.2% PPV (95% CI: 47.2%–79.2%), 94.8% sensitivity (95% CI: 89.5%–100%), and 63.6% specificity (95% CI: 51.3%–76.0%) for non-FGPs.ConclusionIn this derivation cohort study, NBI is helpful for differentiating between high-risk and low-risk gastric polyps, thereby reducing the need for routine sampling of low-risk polyps. These results need to be validated in a separate test population.

Oral Leukoplakia and Risk of Progression to Oral Cancer: A Population-Based Cohort Study.

The optimal clinical management of oral precancer remains uncertain. We investigated the natural history of oral leukoplakia, the most common oral precancerous lesion, to estimate the relative and absolute risks of progression to cancer, the predictive accuracy of a clinician's decision to biopsy a leukoplakia vis-à-vis progression, and histopathologic predictors of progression. We conducted a retrospective cohort study (1996-2012) of patients with oral leukoplakia (n = 4886), identified using electronic medical records within Kaiser Permanente Northern California. Among patients with leukoplakia who received a biopsy (n = 1888), we conducted a case-cohort study to investigate histopathologic predictors of progression. Analyses included indirect standardization and unweighted or weighted Cox regression. Compared with the overall Kaiser Permanente Northern California population, oral cancer incidence was substantially elevated in oral leukoplakia patients (standardized incidence ratio = 40.8, 95% confidence interval [CI] = 34.8 to 47.6; n = 161 cancers over 22 582 person-years). Biopsied leukoplakias had a higher oral cancer risk compared with those that were not biopsied (adjusted hazard ratio = 2.38, 95% CI = 1.73 to 3.28). However, to identify a prevalent or incident oral cancer, the biopsy decision had low sensitivity (59.6%), low specificity (62.1%), and moderate positive-predictive value (5.1%). Risk of progression to oral cancer statistically significantly increased with the grade of dysplasia; 5-year competing risk-adjusted absolute risks were: leukoplakia overall = 3.3%, 95% CI = 2.7% to 3.9%; no dysplasia = 2.2%, 95% CI = 1.5% to 3.1%; mild-dysplasia = 11.9%, 95% CI = 7.1% to 18.1%; moderate-dysplasia = 8.7%, 95% CI = 3.2% to 17.9%; and severe dysplasia = 32.2%, 95% CI = 8.1%-60.0%. Yet 39.6% of cancers arose from biopsied leukoplakias without dysplasia. The modest accuracy of the decision to biopsy a leukoplakia vis-à-vis presence or eventual development of oral cancer highlights the need for routine biopsy of all leukoplakias regardless of visual or clinical impression. Leukoplakia patients, particularly those with dysplasia, need to be closely monitored for signs of early cancer.

Right Ventricular Dysfunction as an Echocardiographic Measure of Acute Rejection Following Heart Transplantation in Children.

Noninvasive biomarkers of acute allograft rejection (AAR) following orthotopic heart transplantation (OHT) are needed. The aim of this study was to investigate the accuracy of echocardiographic (ECHO) right ventricular (RV) global functional and resistance indices in the detection of AAR. This retrospective chart review included children with biopsy-proven AAR (grade≥2R cellular or CD4+antibody-mediated rejection) following OHT and an ECHO within 12h of the biopsy. ECHO measures: (a) ratio of systolic to diastolic duration (S/D), (b) RV myocardial performance index (MPI) and (c) tricuspid regurgitant gradient to RV outflow tract velocity time integral ratio (TRG/VTI), were derived at baseline, during AAR and at two follow-ups. Sixteen patients [56% male, mean (SD) age at OHT 3.5 (4.3)years] had 16 AAR episodes. S/D (1.15 vs. 1.60, p<0.01), RV MPI (0.19 vs. 0.39, p<0.01) and TRG/VTI (1.05 vs. 1.7, p=0.01) deteriorated during AAR and, except for diastolic duration, improved significantly at first follow-up. The negative predictive values for S/D, RV MPI and TRG/VTI at cutoffs of 1.3, 0.31 and 1.3 were 97, 97 and 87%, respectively. RV S/D, MPI and TRG/VTI deteriorated during AAR. Their excellent negative predictive values suggest that their incorporation in surveillance may obviate the need for routine biopsies.

Cancer surveillance strategies in ulcerative colitis

The risk of colorectal cancer is increased in patients with long-standing ulcerative colitis. Traditional surveillance has centered around regular standard white-light colonoscopy, with multiple biopsies aimed at detecting dysplasia or the identification of early cancer. This has resulted in only a modest reduction in cancer incidence and mortality. A better understanding of disease risk factors may allow endoscopic resources to be more focused on patients at higher risk. In addition, advanced endoscopic techniques have the potential to improve dysplasia detection, minimize the need for routine biopsies, and allow for the removal of dysplastic lesions, avoiding the need for surgery. Techniques such as magnification colonoscopy, chromoendoscopy, narrow band imaging, autofluorescence, and confocal endomicroscopy may all have a role to play in improving the benefits of endoscopic surveillance. Revised endoscopic surveillance strategies are proposed, incorporating aspects of risk stratification, a well-established practice in noncolitis-related colorectal cancer screening, and some of these new technologies.

Histological, CT, and Intraoperative Ultrasound Appearance of Hepatic Tumors Previously Treated by Laparoscopic Radiofrequency Ablation

PurposeThe purpose of this paper is to compare intraoperative biopsy results of previously ablated liver tumors with their preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound (LUS) appearances in patients undergoing repeat radiofrequency ablation (RFA). MethodsSeventy repeat RFA procedures were performed in 59 (13%) patients. Laparoscopically, suspected recurrent and stable appearing foci were biopsied using an 18 G biopsy gun. Preoperative CT and LUS appearances of the previously ablated lesions were compared with core biopsy results. ResultsThere were 33 patients with colorectal cancer, 11 with hepatocellular cancer, 8 with neuroendocrine tumors, and 7 with other tumor types. Two hundred lesions were treated by RFA in these 70 repeat ablations. Suspected recurrent tumor foci were enhanced on CT and produced a more finely stippled echo pattern on LUS. Biopsy confirmed recurrent tumor in 72 of 84 such lesions. Previously ablated foci had a CT appearance of a hypodense, nonenhancing lesion without evidence of adjacent enhancing foci. Laparoscopic ultrasound appearance was of a hypoechoic lesion with a coarse internal pattern with the tracks of the ablation catheter probes often still visible. Biopsy found necrotic tissue in 21 of 22 such lesions appearing radiologically to be without recurrence. Biopsy of an ablated focus adjacent to an area of suspected recurrence showed necrotic tissue in 17 of 22 lesions and viable cancer in 5. ConclusionCT and LUS appearance of previously ablated foci showed good correlation with core biopsies. CT scan is reliable in following RFA lesions, without the need for routine biopsy. LUS reliably distinguished recurrent from ablated lesions in patients undergoing repeat ablation.

Routine bladder biopsy after bacille Calmette-Guérin treatment: is it necessary?

Objectives. To evaluate the need for routine biopsy at first follow-up after intravesical bacille Calmette-Guérin (BCG) therapy for superficial transitional cell cancer of the bladder (TCCB). We examined the potential role of voided urine cytology and cystoscopy as screening tools to determine which patients should undergo biopsy. Methods. The records of 71 patients with TCCB who received a total of 95 courses of BCG were reviewed. The pathology findings before BCG and the cystoscopic, voided cytologic, and biopsy results after BCG were recorded. Results. In 54 cases, the cystoscopic and/or cytologic findings were abnormal. In 19 (35%) of these 54 cases, TCCB was found on biopsy after BCG. In 41 cases, both cystoscopy and cytology were normal. In 1 of these 41 cases, a small superficial low-grade TCCB was found on biopsy. An abnormality on voided cytology or cystoscopy was more likely to occur after treatment for carcinoma in situ. Conclusions. Patients with papillary TCCB who have negative cystoscopic and negative urine cytologic results can safely be spared routine transurethral bladder biopsy with its associated cost and morbidity. However, patients with carcinoma in situ are very likely to have persistent abnormal cytologic or abnormal cystoscopic findings warranting investigation with biopsy and may benefit from routine scheduled biopsy.

Predicting the liver histology in chronic hepatitis C: how good is the clinician?

OBJECTIVE:Liver biopsy is believed to be necessary before antiviral treatment in hepatitis C. Studies have found symptoms and biochemistry poorly predictive of grade and stage. In practice, a combination of factors is used to anticipate histology. The aim of this study is to evaluate the ability of global clinical assessment to predict histology in hepatitis C.METHODS:Fifty-four consecutive patients referred to a university center for consideration of antiviral therapy were enrolled. Clinical and laboratory data were recorded as was a prediction of the inflammatory grade (0–3) and fibrotic stage (0–3), with fibrotic stage 3 referring to cirrhosis. Liver biopsies were read by a blinded pathologist. The predictive value of the clinical assessment and individual parameters was assessed.RESULTS:All predictions were ≤1 point off the actual grade and stage. Thirty-six (66.7%) patients’ grades and 41 (75.9%) patients’ stages were exactly predicted. All four cirrhotic patients (sensitivity 100%, specificity 94%) and one case of hemochromatosis were correctly predicted. Spider nevi, organomegaly, white blood cell count ≤ 4 × 109/L, ALT > 120 U/L, bilirubin > 20 μmol/L, albumin ≤ 35 g/L, and ferritin > 200 μg/L predicted grade ≥2. Stage ≥2 was associated with age > 40 yr, previous decompensation, spider nevi, organomegaly, white blood cell count ≤ 4 × 109/L, albumin ≤ 35 g/L, platelets ≤ 150 × 109/L, and international normalized ratio > 1.2. Grade correlated with stage (Spearman coefficient = 0.54, p < 0.001). By multivariate analysis, ferritin plus spider nevi or hypoalbuminemia was independently predictive of inflammation. Spider nevi and thrombocytopenia, with either splenomegaly or hypoalbuminemia, were useful three-variable models for predicting fibrosis. The corresponding scoring systems produced useful likelihood ratios.CONCLUSIONS:Global clinical assessment mirroring clinical practice in a tertiary liver transplant center is moderately accurate in predicting grade and stage in hepatitis C. Liver biopsy is the current gold standard; however, the amount of new information gleaned is less than was perceived. The need for routine biopsy before antiviral treatment in hepatitis C should be reevaluated in a multicenter study.

Large-cell carcinoma metastatic to the jaw: Report of a case

A case of two metastatic lesions of the oral mucosa simulating odontogenic infections is presented. One lesion mimicked chronic pericoronitis, and the other lesion mimicked a dental abscess. The case stresses the need for routine biopsy and pathology examination of conditions found in the oral cavity.