Random Biopsies Research Articles

The Use of Multiparametric Magnetic Resonance Imaging for Follow-up of Patients Included in Active Surveillance Protocol. Can PSA Density Discriminate Patients at Different Risk of Reclassification?

The objective of this study was to test Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and MRI-derived prostate-specific antigen density (PSAD) in predicting the risk of reclassification in men in active surveillance (AS), who underwent confirmatory or per-protocol follow-up biopsy. Three hundred eighty-nine patients in AS underwent mpMRI before confirmatory or follow-up biopsy. Patients with negative (-) mpMRI underwent systematic random biopsy. Patients with positive (+) mpMRI underwent targeted fusion prostate biopsies+ systematic random biopsies. Different PSAD cutoff values were tested (< 0.10, 0.10-0.20,≥ 0.20). Multivariable analyses assessed the risk of reclassification, defined as clinically significant prostate cancer of grade group 2 or more, during follow-up according to PSAD, after adjusting for covariates. One hundred twenty-seven (32.6%) patients had mpMRI(-); 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. The rate of reclassification to grade group 2 PCa was 16%, 22%, 31%, and 39% for mpMRI(-) and PI-RADS 3, 4, and 5, respectively, in case of PSAD< 0.10 ng/mL2; 16%, 25%, 36%, and 44%, in case of PSAD 0.10 to 0.19 ng/mL2; and 25%, 42%, 55%, and 67% in case of PSAD≥0.20 ng/mL2. PSAD≥ 0.20 ng/mL2 (odds ratio [OR], 2.45; P= .007), PI-RADS 3 (OR, 2.47; P= .013), PI-RADS 4 (OR, 2.94; P< .001), and PI-RADS 5 (OR, 3.41; P= .004) were associated with a higher risk of reclassification. PSAD≥ 0.20 ng/mL2 may improve predictive accuracy of mpMRI results for reclassification of patients in AS, whereas PSAD< 0.10 ng/mL2 may help selection of patients at lower risk of harboring clinically significant prostate cancer. However, the risk of reclassification is not negligible at any PSAD cutoff value, also in the case of mpMRI(-).

High-Definition Chromoendoscopy Superior to High-Definition White-Light Endoscopy in Surveillance of Inflammatory Bowel Diseases in a Randomized Trial

There is debate over the optimal method for colonoscopic surveillance of patients with inflammatory bowel diseases. Guidelines recommend chromoendoscopy, but the value of chromoendoscopy in high-definition colonoscopy has not been proven. Furthermore, the value of random biopsies is controversial. We performed a prospective study of 305 patients with ulcerative colitis or Crohn's colitis referred for surveillance colonoscopy at a university hospital in Sweden, from March 2011 through April 2016. Patients randomly assigned to a group that received high-definition chromoendoscopy with indigo carmine (HD-CE; n= 152), collection of 32 random biopsies, and targeted biopsies or polypectomies or to a group that received high-definition white light endoscopy (HD-WLE; n= 153), collection of 32 random biopsies, and targeted biopsies or polypectomies. The primary endpoint was number of patients with dysplastic lesions. Dysplastic lesions were detected in 17 patients with HD-CE and 7 patients with HD-WLE (P=.032). Dysplasias in random biopsies (n= 9760) were detected in 9 patients: 6 (3.9%) in the HD-CE group and 3 (2.0%) in the HD-WLE group (P= .72). Of the 9 patients with dysplasia, 3 patients (33%) had primary sclerosing cholangitis-only 18% of patients (54/305) included in the study had primary sclerosing cholangitis. The number of dysplastic lesions per 10 min of withdrawal time was 0.066 with HD-CE and 0.027 with HD-WLE (P= .056). In a randomized trial, we found HD-CE with collection of random biopsies to be superior to HD-WLE with random biopsies for detection of dysplasia per colonoscopy. These results support the use of chromoendoscopy for surveillance of patients with inflammatory bowel diseases. ClinicalTrials.gov no: NCT01505842.

Optical enhancement imaging versus acetic acid for detecting gastric intestinal metaplasia: A randomized, comparative trial

Background and aimsThe diagnosis of gastric intestinal metaplasia (GIM) is still challenging. Optical Enhancement technology (OE) may improve the detection of GIM. We compared detection of GIM with OE, acetic acid and the Sydney biopsy protocol in a surveillance population. MethodsConsecutive patients with atrophic gastritis or known GIM were prospectively included. The stomach was examined with high definition whitelight endoscopy, followed by OE or acetic acid with targeted biopsies (1:1 randomisation). Subsequently, five random biopsies were taken according to the updated Sydney system. ResultsA total of 154 patients were randomized. Higher proportions of patients with GIM were detected by OE and acetic acid versus random biopsy (60.5% vs 35.5%, 67.1% vs 31.5%, respectively; P < 0.0001 for both comparisons). The combined use of targeted biopsies and random biopsies provides high diagnostic yields for GIM (78.9% in OE group and 83.6% in acetic acid group). In addition, the proportion of extensive GIM was significantly increased when image enhanced endoscopy was used instead of white light endoscopy (P = 0.029, P = 0.048, respectively). ConclusionsOE and acetic acid showed comparable results diagnosing GIM in the study. Targeted biopsies plus random biopsies should be used complementary in high risk populations.

Transurethral en bloc resection with monopolar current for non-muscle invasive bladder cancer based on TNM system.

BackgroundTo evaluate the surgical safety and quality of transurethral en bloc resection with monopolar current for non-muscle invasive bladder cancer (NMIBC) based on the tumour, node, metastasis (TNM) classification system, and report the midterm oncological outcome.MethodsFrom October 2015 to June 2017, en bloc resection of bladder tumor (ERBT) and transurethral resection of bladder tumor (TURBT) were performed in 96 and 87 patients clinically diagnosed with NMIBC in the prospective case-control trial, respectively. Operative details, intraoperative and postoperative complications regarded as safety outcomes were documented. The quality of ERBT was judged by the histopathological examination of tumor specimens from initial resection and second TURBT, random bladder biopsy and follow-up recurrence rate.ResultsOperative time, obturator nerve reflex, irrigation and catheterization time were similar in the two groups. Bladder perforation was occurred in 2 patients during ERBT and 9 patients during TURBT (2/96 vs. 9/87, P=0.019). Compared with TURBT group, the ratio of detrusor muscle (DM) identified in pathologic T1 tumor specimens was higher (P=0.024), but lower in pathologic Ta tumor specimens in ERBT group (P<0.001). The residual tumor identified in ERBT group was lower than that in TURBT group during second TURBT (2/28 vs. 10/32, P=0.020). The recurrence-free survival rate did not differ significantly between the two groups after 24 months follow-up.ConclusionsERBT based on TNM system is a safe and feasible technique to treat patients with NMIBC. Besides, ERBT may reduce the proportion of bladder perforation and residual tumor during initial resection.

MP13-15 68GA-PSMA-11 PET/MPMRI FOR DETECTION OF PRIMARY PROSTATE CANCER IN PREVIOUSLY NEGATIVE-BIOPSIED MEN

INTRODUCTION AND OBJECTIVE: Multiparametric MRI (mpMRI) represents the current gold standard for detection of primary prostate cancer (PCa) after negative biopsy. PSMA PET imaging has been introduced in the diagnostic work-up of PCa with high specificity, currently mainly utilized in biochemical recurrence. Therefore, the aim of this investigation was to determine the efficacy of combined 68Ga-PSMA-11 PET/mpMRI imaging to detect PCa in patients with previously negative prostate biopsy. METHODS: 57 patients (pts.) who underwent at least one prior negative prostate biopsy were included in this analysis. All pts. underwent 68Ga-PSMA-11 PET/mpMRI imaging of the prostate. Lesions on mpMRI were evaluated according to the PI-RADS classification system and lesions on 68Ga-PSMA-11 PET were rated according to a 5-point scale on a sextant basis (1: PCa highly unlikely; 2: PCa unlikely; 3: presence of PCa is equivocal; 4: PCa likely; 5: PCa highly likely). All pts. received a systematic random biopsy as well as a targeted transrectal biopsy of lesions suspicious on imaging. Results of imaging and histological analysis of prostate biopsies were compared per patient and per prostate sextant. RESULTS: On histological analysis 35/57 (61.4%) of pts. and 75/342 (21.9%) of sextants showed PCa lesions. In patients with biopsy confirmed PCa 21/35 (60.0%) showed a PI-RADS 4 or 5 lesion on mpMRI and 28/35 (80.0%) presented with a PET rating of 4 or 5. 20/75 (26.7%) of sextants with histological confirmed PCa showed a PI-RADS 4 or 5 lesion on mpMRI and 26/75 (34.7%) of sextants presented with a PET rating of 4 or 5. Combined 68Ga-PSMA-11 PET/mpMRI missed only one patient with a Gleason-Score (GS) 7a tumor (rating of 1 or 2 in both, PET and mpMRI). Limitations represent the retrospective analysis as well as possible false negative biopsy results even in a fusion biopsy setting. CONCLUSIONS: In this initial analysis, 68Ga-PSMA-11 PET/mpMRI proved to be a valuable imaging tool to guide prostate biopsies for detection of PCa in patients after prior negative biopsy. Hereby, 68Ga-PSMA-11 PET and mpMRI show complementary findings thus increasing detection of PCa lesions. Source of Funding: none

PD50-07 SYSTEMATIC ENDOSCOPIC EVALUATION FALLS SHORT IN PREDICTING PT0 BLADDER CANCER

INTRODUCTION AND OBJECTIVE: Concern for discordance between endoscopic evaluation and final pathology drives current clinical management of patients deemed appropriate candidates for radical cystectomy (RC). Yet, > 30% of patients (pts) who undergo neoadjuvant chemotherapy (NAC) prior to RC do not harbor detectable malignancy within the bladder at the time of extirpative surgery. Our objective was to prospectively assess the reliability of cystoscopic evaluation in RC candidates. METHODS: Pts undergoing RC for urothelial carcinoma (UC) at our institution were enrolled in a prospective single-arm study to evaluate reliability of Systematic Endoscopic Evaluation (SEE) in predicting pT0 UC. SEE consisted of rigid cystoscopy with targeted biopsy (and transurethral resection with loop after protocol amendment) of visible tumor and/or tumor bed/scar, plus two additional random biopsies performed at the time of RC. A standardized bladder map was used to index cystoscopic findings. SEE and biopsy results were compared to RC pathology. Comparisons were considered congruent if both SEE and RC were T0, or if any level of disease seen at both SEE and RC (exception, cT0 with pTis at RC called congruent). This trial design included early stopping rules for futility based on the primary endpoint of a negative predictive value (NPV) less than 70%. RESULTS: In total, 61 pts underwent SEE and RC as part of this trial. The final population included MIBC in 41 pts (67%) and high-risk NMIBC in 20 pts (33%). 38 pts (62%) received platinum-based neoadjuvant chemotherapy. Based on RC final pathology, 16 pts (26%) were pT0 and 28 pts (46%) harbored residual ≥pT2 disease. For detecting any disease, the positive predictive value was 96.7%, but the NPV was 48.4%, necessitating study closure based on pre-specified boundaries for futility. The sensitivity for detecting pT2 at RC disease was 71%. CONCLUSIONS: To our knowledge, this was the first prospective study exploring whether a standardized SEE could sufficiently predict the presence of residual malignancy. The NPV was below the pre-specified threshold, triggering study closure. pT2 or higher disease was missed nearly 30% of the time. This study definitively demonstrates that current cystoscopic techniques are inadequate to guide decisions on bladder preservation.Source of Funding: None

SAGES TAVAC safety and efficacy analysis WATS3D (CDx Diagnostics, Suffern, NY).

Wide-area transepithelial sampling of the esophagus with computer-assisted three-dimensional analysis (WATS3D, CDx Diagnostics, Suffern, NY) is an adjunctive technique to random biopsies for early detection of Barrett's esophagus. The aim of the SAGES Technology and Value Assessment Committee aims is to evaluate the efficacy, value, and safety of WATS3D. Clinical studies involving WATS3D were identified via a search of the PubMed/Medline databases ( www.ncbi.nlm.nih.gov/pubmed ) conducted in March of 2019 using search terms, such as wide-area transepithelial sampling, three-dimensional (3D) computer-assisted analysis, WATS-3D, Barrett's esophagus and WATS-3D, Barrett's esophagus and wide-area transepithelial sampling with three-dimensional computer-assisted analysis, Barrett's esophagus, and emerging technology. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. No significant morbidity or mortality was reported within the literature associated with the WATS3D technology. WATS3D increases diagnostic yield by 38-150% for Barrett's Esophagus, by 40-150% for Low Grade Dysplasia; and by 420% for High Grade Dysplasia; when compared to forceps biopsy alone. WATS3D technique has very high inter-observer agreement for the pathological diagnosis of non-dysplastic and dysplastic Barrett's Esophagus. Increased detection of pre-malignant diseases of the esophagus by the adjunctive use of WATS3D supports screening and surveillance by the adjunctive use of WATS3D during upper endoscopy in appropriate patients. Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D, CDx Diagnostics) is a safe and effective adjunct to forcep biopsies in the evaluation of Barrett's Esophagus, Low Grade Dysplasia, and High Grade Dysplasia.

Accuracy of colposcopy-directed biopsy vs dynamic spectral imaging directed biopsy in correctly identifying the grade of cervical dysplasia in women undergoing conization: A methodological study.

Dynamic spectral imaging (DSI) colposcopy has previously been found to improve sensitivity of CIN2+ detection. The aim of this study was to compare the histological diagnosis of colposcopic-directed biopsies (CDB) with that of DSI-directed biopsies in women undergoing conization, using the histological diagnosis of the conization specimen as gold standard. Women referred for colposcopy were included in a prospective cohort study at Randers Regional Hospital, Denmark, from January 2016 to February 2019. All women had four cervical punch biopsies taken. The first biopsy was taken from the area that appeared most abnormal by conventional colposcopy (ie, CDB) and the second biopsy from the area that appeared most abnormal using the DSI map. An additional two biopsies were taken either from other visible lesions or as random biopsies. Biopsies were analyzed separately. If any biopsies revealed cervical dysplasia of such a degree that excisional treatment was recommended, the patient was referred for conization. Subsequently, we compared the histological diagnosis of CDB and DSI-directed biopsies with that of the cone biopsy. A total of 573 women were enrolled, 170 of which underwent conization. In women with an adequate colposcopy and representative biopsies (n=124) there was an overall agreement rate between the worst biopsy diagnosis (of any four) and the conization diagnosis in 95.2% (95% CI 89.8-98.2) of women. CDB diagnosis agreed with the cone diagnosis in 80.6% (95% CI 72.6-87.2) of women. DSI-directed biopsy agreed with the cone diagnosis in 83.9% (95% CI 76.2-89.9) of women. The difference in detection rate between the CDB and the DSI-directed biopsy was, however, not significant (P=.54). Taking four biopsies increases the detection rate of cervical dysplasia to 95.2%, which was a significant increase from both CDB alone (P=.0008) and DSI-directed biopsy alone (P=.0053). We found no significant difference in the ability to identify the cervical dysplasia grade between CDB and DSI-directed biopsies. A higher detection rate of cervical dysplasia was achieved with four biopsies than with one CDB biopsy or one DSI-directed biopsy.

Aneuploidy in Targeted Endoscopic Biopsies Outperforms Other Tissue Biomarkers in the Prediction of Histologic Progression of Barrett's Oesophagus: A Multi-Centre Prospective Cohort Study

Introduction: The cancer risk in Barrett’s oesophagus (BO) is difficult to estimate. Confirmed histologic dysplasia has strong predictive power, but can be missed by random biopsies, while other clinical parameters have limited utility for risk stratification. We aimed to assess the utility of a large panel of molecular biomarkers on targeted biopsies to predict neoplastic progression of BO. Methods: In a prospective study in three tertiary centres, 203 patients with BO were tested for 9 biomarkers (p53 and cyclin A expression; aneuploidy and tetraploidy; CDKN2A (encoding for p16), RUNX3 and HPP1 hypermethylation; 9p and 17p loss of heterozygosity) on autofluorescence-targeted biopsies taken at index endoscopy and followed-up as per clinical standard. Data comparing progressors to non-progressors were evaluated by univariate and multivariate analyses using survival curves, Cox-proportional hazards and logistic regression models. Findings: 127 patients with no high-grade dysplasia (HGD) or early oesophageal adenocarcinoma (OAC) were included, of which 42 had evidence of any histologic progression over time. Aneuploidy was the only predictor of progression from non-dysplastic BO (NDBO) to any grade of neoplasia (p=0.013) and HGD/OAC (p=0.002). Aberrant p53 expression correlated with the risk of short-term progression within 12 months, with an odds ratio for histologically missed dysplasia of 6.0 (95% CI: 3.1-11.2). A biomarker panel comprising aneuploidy and p53 had an area under the ROC curve of 0.68 (95% CI: 0.59-0.77) for prediction of any histologic progression. Interpretation: In our study, aneuploidy is the only biomarker that predicts neoplastic progression of NDBO. Aberrant p53 expression suggests prevalent dysplasia, which might have been missed by random biopsies, and warrants early follow up. Funding Statement: This study was funded by a Medical Research Council Program Grant to RCF and by a Lister Institute for Preventive Medicine prize to RCF, with additional clinical research infrastructure support from the Experimental Cancer Medicine Centre and the Cambridge Biomedical Research Centre. Declaration of Interests: KR reports grants, personal fees and non-financial support from Olympus, outside the submitted work. JJGHMB reports grants from Olympus Endoscopy, outside the submitted work. Other authors declare no conflicts of interest. Ethics Approval Statement: This was a prospective study approved by the Cambridgeshire 2 Research Ethics Committee (09/H0308/118) and the Amsterdam University Medical Centre (AUMC) Medical Ethics Committee (MEC 09/073). This was a National Institute of Health research (NIHR) portfolio study (UKCRN ID 7561).

Positive surgical margin during radical prostatectomy: overview of sampling methods for frozen sections and techniques for the secondary resection of the neurovascular bundles.

The aim of the paper is to provide an overview of intraoperative sampling methods for frozen section (FS) analysis and of surgical techniques for a secondary neurovascular bundle (NVB) resection, as the method of surgical margin (SM) sampling and the management of a positive SM (PSM) at the nerve-sparing (NS) area are under evaluated issues. FS analysis during radical prostatectomy (RP) can help to tailor the plane of dissection based on cancer extension and thus extend the indications for NS surgery. We performed a PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, Cochrane Library, and Elton B. Stephens Co. (EBSCO)host search to include articles published in the last decade, evaluating FS analysis in the NS area and surgical attempts to convert a PSM to a negative status. Overall, 19 papers met our inclusion criteria. The ways to collect samples for FS analysis included: systematic (analysing the whole posterolateral aspect of the prostate specimen, i.e., neurovascular structure-adjacent frozen-section examination [NeuroSAFE]); magnetic resonance imaging (MRI)-guided (biopsies from MRI-suspicious areas, retrieved by the surgeon in a cognitive way); and random biopsies from the soft periprostatic tissues. Techniques to address a PSM in the NS area included: full resection of the spared NVB, from its caudal to cranial aspect, often including the rectolateral part of the Denonvilliers' fascia; partial resection of the NVB, in cases where sampling attempts to localise a PSM; incremental approach, meaning a partial or full resection that extends until no prostate tissue is found in the soft periprostatic environment. There is no homogeneity in prostate sampling for FS analysis, although most recent evidence is moving toward a systematic sampling of the entire NS area. The management of a PSM is variable and can be affected by the sampling strategy (difficult localisation of the persisting tumour at the NVB). The difficult identification of the exact soft tissue location contiguous to a PSM could be considered as the critical point of FS analysis and of spared-NVB management.

A84 LINITIS PLASTICA FROM A NON-GASTROINTESTINAL PRIMARY TUMOR: A CASE REPORT

Abstract Background Infiltrative malignancies to the stomach are unusual and are difficult to detect. Linitis Plastic is a syndrome caused by submucosal invasion of the gastric wall. It represents Bormann type III or IV of gastric adenocarcinoma. Uncommonly, the latter can be a manifestation of lobular breast cancer. Aims To present a case report of lobular breast cancer that manifested primarily as Linitis Plastica (LP). We review the literature of LP as a clinical syndrome and the diagnostic challenges associated with this condition. We aim to increase the awareness of LP as a non-gastric tumor and its endoscopic features. Methods - Results A seventy-two-year-old female patient, previously healthy, presented with general deconditioning and distended abdomen. Basic laboratory testing such as complete blood count, electrolytes and kidney function were normal. Computed tomography of the abdomen and pelvis revealed moderately sized peritoneal carcinomatosis deposits on the abdominal wall. Her family history was non-contributary for any gastrointestinal or gynecological malignancies. On review of system, the patient noted a history of successful eradication of Helicobacter pylori infection remotely. Additionally, no preceding age-appropriate malignancy screening tests were reported. A gastroscopy was done looking for a primary gastrointestinal tumor exhibited abnormally stiff gastric wall, erythematous thickened mucosal folds, and non-distensible stomach. No clear lesions, submucosal masses or ulcers were visualized. The duodenal mucosa was noted to be normal. Twelve deep random biopsies were retrieved from the mucosal body and fundus. Following immunohistochemistry, the histological diagnosis revealed lobular adenocarcinoma of the breast. Conclusions Linitis Plastica (leather bottle stomach) or Brinton disease is a rare entity of diffuse gastric mucosa infiltrating tumor. LP depicts 3–10% of primary gastric carcinoma, whilst less than 10% are secondary breast cancer. Endoscopically, breast cancer-related LP can be divided into two morphologies: nodular pattern with ulceration, which is the typical presentation of ductal breast carcinoma and diffuse mural pattern in lobular breast carcinoma. LP is a unique condition with challenging diagnostic features. Many biopsies can result in negative histopathological diagnoses. This can be explained partially by 1. The scirrhous and fibrous stroma that forms LP tumors. 2. The deep location in the submucosa and muscular layer of the gastric wall. 3. Inability to identify this entity endoscopically. In one case report, Endoscopic Ultrasound-Fine Needle Aspirate (EUS-FNA) was incorporated after negative obtained biopsies. There are no standardized diagnostic approaches for LP. Further studies inquiring rates of missed malignant diagnoses and optimum diagnostic assessments in the setting of LP are needed. Funding Agencies None

Biopsies From Ascending and Descending Colon Are Sufficient for Diagnosis of Microscopic Colitis

Lymphocytic and collagenous colitis are types of microscopic colitis (MC) that commonly cause chronic watery diarrhea, but there are no macroscopic features of MC that can be detected during colonoscopy. Endoscopists therefore often collect multiple random colonic biopsies, potentially oversampling, increasing times of colonoscopy and slide review. We sought to identify sites from which biopsies could be taken and analyzed to identify patients with MC with a high level of sensitivity and determine the appropriate number of biopsies to take at these sites. We performed a retrospective study using biopsies from 101 consecutive patients with MC (52 cases of collagenous colitis, 42 cases of lymphocytic colitis, 7 combined cases), without comorbidities, from 2017 through 2018. Slides were reviewed, and the proportion of biopsies that were diagnostic of MC were calculated at each biopsy site. The proportions of biopsy fragments from each site of the colon found to be positive for MC were as follows: cecum, 90.0%; ascending colon, 96.9%; hepatic flexure, 77.8%; transverse colon, 95.7%; splenic flexure, 75.0%; descending colon, 85.0%; sigmoid colon, 90.9%; and rectum, 82.2%. For biopsies labeled random, 95.7% were positive for MC. When findings from ascending and descending colon biopsies were combined, 100% of MC cases were detected. MC can be detected with certainty by analyzing biopsies from the ascending and descending colon. Fewer biopsies than were collected from our cases are sufficient for diagnosis. We propose a Western protocol (taking 2 biopsies from each of the ascending and descending colon) in evaluation of patients for MC.

4:03 PM Abstract No. 206 The risk factors for major bleeding following ultrasound-guided native renal biopsy: what is the “core” of the problem? A case-control study

To identify risk factors for major bleeding following ultrasound (US)-guided random renal biopsy by microscopic analysis and comparison of the cores obtained in patients with and without bleeding. A retrospective review identified 17 of 179 patients (9.50%) with major bleeding complications (per criteria determined by the Society of Interventional Radiology guidelines) post-US-guided native renal biopsy between July 2014 and June 2019. Case-control matching was accomplished by propensity score based on sex, age, body mass index (BMI), blood pressure (BP), international normalized ratio (INR), platelet (PLT), blood urea nitrogen (BUN), and creatinine (Cr) concentration, estimated glomerular filtration rate (eGFR), needle size, and core number. The cores obtained in the bleed and non-bleed patients were analyzed for total length, medullary length, cortical thickness, and number of arcuate/interlobular vessels by the pathologist. 26 controls were matched to 17 cases (with and without major hemorrhage, respectively). Conditional logistic regression was used to explore the statistical significance between core characteristics obtained from random renal biopsies and the probability of a major bleed. Analysis revealed that arcuate artery (AA) quantity per specimen exhibits a significant association with a major bleed (P = 0.0006). When 0, 1, or ≥ 2 AA were identified, the frequency of major bleeding was 13.04%, 66.67%, and 75.00%, respectively. The odds of major bleed are 6 times higher with 1 AA (95% CI, 1.28 – 32.30) and 15 times higher with ≥ 2 AAs (95% CI, 1.41 – 169.57). Despite lacking statistical significance, correlations between medullary length (P = 0.228), medulla-cortex (MC) (P = 0.089), medulla-total (MT) (P = 0.108), and cortex-total (CT) (P = 0.112) length ratios to major bleeding may require a larger population study. A strong and incremental correlation between major renal hemorrhage following native renal biopsy and the number of arcuate arteries per core specimen exists. Identification of arcuate arteries by the pathologist while assessing sample adequacy in the US suite can help predict major hemorrhage in patients undergoing random renal biopsies.

Abstract No. 599 Transfemoral transcaval liver mass biopsy

Transfemoral transcaval approach for liver mass biopsy under fluoroscopic guidance with ultrasound assistance in target confirmation demonstrates similar efficacy when compared to a percutaneous approach with a safer risk profile in patients with bleeding diathesis. Image-guided liver biopsies are one of the most common procedures performed by interventional radiologists. The majority of these are performed percutaneously via CT scan or ultrasound however this method is not always feasible in patients with coagulopathies or difficult anatomy. Transjugular transcaval approach is used as an alternative most commonly for random liver biopsies. This approach mitigates some risk of bleeding complications however requires device manipulation through the right heart. With these risks in mind we purpose a select group of patients may benefit from transfemoral transcaval hepatic lesion biopsy. We selected 5 patients with masses in proximity of the inferior vena cava and performed transfemoral transcaval biopsies with US target confirmation to determine its effectiveness in diagnostic sampling of masses and complication rate. All five patients selected for transfemoral transcaval liver biopsies demonstrated masses that were thought to be accessible from a transcaval approach. Fluoroscopic guidance with US target confirmation achieved a positive diagnostic biopsy in all 5 patients without any complication. Transfemoral transcaval liver biopsy is an effective method of obtaining pathologic specimens when masses are located in proximity to the inferior vena cava. This can be done using fluoroscopy with ultrasound or fluoroscopy alone and should be considered when appropriate, especially in patients with increased bleeding risk.

Combination of Multiparametric Magnetic Resonance Imaging With Elastic-fusion Biopsy Has a High Sensitivity in Detecting Clinically Significant Prostate Cancer in Daily Practice.

The index lesion (IL) is the largest cancer focus, usually harbors the highest grade, and might drive the history of prostate cancer (PCA). Multiparametric magnetic resonance imaging (mp-MRI) has a high negative predictive value in ruling out clinically significant (cs)PCA. We aimed evaluating the efficiency of mp-MRI and targeted biopsy in detecting csPCA and the concordance between the MRI index lesion (MRI-IL) and the presence of csPCA inside it. We retrospectively evaluated 158 men who underwent prostate biopsy after a positive pre-biopsy mp-MRI scan. All mp-MRI lesions were biopsied using a transrectal ultrasound elastic-fusion approach (2-4 targeted plus 10-12 random systematic biopsies). csPCA was defined as grading group≥ 2 or > 3 cores with cancer or≥ 50% of core involved by tumor. mp-MRI detected 158 ILs and 46 non-ILs. One hundred were Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score 3, 84 score 4, and 20 score 5. csPCA was found in 63.9% of the MRI-ILs. Eighty percent of detected cancer using mp-MRI and targeted biopsy was clinically significant. Eighty-seven percent of the transitional zone lesions were clinically non-significant or negative for cancer. The probability of detecting csPCA increases with increasing size of MRI-IL, and every extra millimeter raises the odds of detecting csPCA of 12.2%. All PI-RADS v2 score lesions showed a strong association with csPCA. The risk of matching between MRI-IL and csPCA inside it increases by 36.2% as the total percentage of cancer in all cores increases. mp-MRI showed high sensitivity in detecting csPCA in the peripheral zone, with concordance between MRI-IL and csPCA.

Reports of prostate needle biopsies-what pathologists provide and urologists want

The prostate biopsy report is key for risk stratification of prostate cancer patients and subsequent therapeutic decision-making. However, due to the inclusion of amultitude of additional parameters its interpretation is becoming more challenging. We aimed to determine how urologists currently interpret prostate biopsy reports, in particular how they consider different histopathological parameters for therapy decision-making. Asurvey was sent to all urology practices in Germany with the help of the BDU (Berufsverband der Deutschen Urologen e. V.). In total, there were 106 complete responses that could be included for further analyses. Most urologists consider the number of positive cores and relative tumor burden (%) per core as crucial for the assessment of tumor extension. In case of targeted biopsies, the majority of urologists prefers aseparate statement of positive cores per random biopsy scheme and per region of interest, respectively. The core with the highest Gleason score is mostly the basis for therapy decision-making (versus the overall Gleason score). Proportion of Gleason4 pattern also seems to be critical for prostate cancer management. Only half of the urologists demand reporting of the new ISUP/WHO (International Society of Urological Pathology/World Health Organization) grade groups. Additional parameters claimed are Ki67, prostate-specific membrane antigen status, presence of intraductal or neuroendocrine component of the tumor. Our survey shows that there is no standardized reporting for prostate biopsies and that the interpretation of prostate biopsy reports varies among urologists. Further studies and guideline recommendations are necessary to establish astandardized reporting scheme for prostate biopsies.

Detection of DNA mismatch repair deficient crypts in random colonoscopic biopsies identifies Lynch syndrome patients.

The hallmark of Lynch syndrome (LS)-associated neoplasia is DNA mismatch repair protein (MMR) deficiency. Recent studies have demonstrated that histologically normal colonic crypts in patients with LS can exhibit deficient MMR expression. The aim of this study was to determine the feasibility of detecting MMR deficient crypts in random colonoscopic biopsies of normal mucosa in patients with and without LS. Forty-nine patients, including 33 with LS, 12 without LS, and 4 with germline MMR gene variants of uncertain significance (VUS), were prospectively and blindly evaluated by immunohistochemistry for MMR deficient crypts within random normal-appearing mucosal biopsies obtained during surveillance colonoscopy. MMR deficient crypts were identified in 70% (23/33) of patients with LS and in no patients without LS (0/12) (p < 0.001). MMR deficient crypts were identified with nearly equal frequency in both LS patients with and without a cancer history and were associated with germline variants in all four MMR genes and EPCAM. MMR deficient crypts were also identified in LS patients with a history of non-colorectal cancer types, including patients with endometrial cancer, skin sebaceous neoplasms, and renal cancer. Two of the four patients with germline MMR gene VUS had MMR deficient crypts. In conclusion, MMR deficient crypts are a specific biomarker of LS and can be identified in random normal mucosal biopsies in LS patients. Evaluation for MMR deficient crypts in colonoscopic biopsies of normal mucosa can help identify LS patients.

A Color Flow Tract in Ultrasound‐Guided Random Renal Core Biopsy Predicts Complications

To determine patient and procedural risk factors for major complications in ultrasound (US)-guided random renal core biopsy. Random renal biopsies performed by radiologists in the US department at a single institution between 2014 and 2018 were retrospectively reviewed. The patient's age, sex, race, and estimated glomerular filtration rate (eGFR) were recorded. The biopsy approach, needle gauge, length of cores, number of throws, and presence of a color flow tract were recorded. Outcome data included minor and major complications. Associations between variables were tested with χ2 analyses and univariable/multivariable logistic regression models. A total of 231 biopsies (167 native and 64 allografts) were reviewed. There was no significant difference in the sex, age, race, or eGFR between native and allograft groups. The overall rate for any complication was 18.2%, with a 4.3% rate of major complications, which was significantly greater in native compared to allograft biopsies (6% versus 0%; P = .045). A risk analysis in native biopsies only showed that major complications were significantly associated with a low eGFR such that patients with stage 4 or 5 kidney disease had higher odds of complications (odds ratio [95% confidence interval]: stage 4, 9.405 [1.995-44.338]; P = .0393; stage 5, 10.749 [2.218-52.080]; P = .0203) than patients with normal function (eGFR >60 mL/min). The presence of a color flow tract portended a 10.7 times greater risk of having any complication (95% confidence interval, 4.595-24.994; P < .001). Other procedural factors were not significantly associated with complications. There is an increased risk of major complications in US-guided random native kidney biopsy in patients with a low eGFR (<30 mL/min) and a patent color flow tract in the immediate postbiopsy setting.

How Can We Optimize Tools and Techniques for Endoscopic Ultrasound–Guided Liver Biopsy?

How Can We Optimize Tools and Techniques for Endoscopic Ultrasound–Guided Liver Biopsy?

P005 A SURVEY STUDY OF GASTROENTEROLOGISTS’ VIEWS ON DYSPLASIA SURVEILLANCE AND CHROMOENDOSCOPY IN IBD

Abstract Background Patients with inflammatory bowel disease (IBD) have an increased risk of colon cancer. Current guidelines are equivocal in their recommendations for chromoendoscopy. The objective of this study is to assess gastroenterologists’ current attitudes and barriers toward chromoendoscopy in IBD. Methods A 23 question survey was distributed to members of the Crohn’s &amp; Colitis Foundation via email. We collected physician characteristics, practice demographics, and data regarding chromoendoscopy use and barriers to chromoendoscopy. Results A total of 57 gastroenterologists from 22 US states [male, n=42 (74%); practicing in an academic university n=44 (77%)] met inclusion criteria. All respondents agree that patients with IBD involving more than 1/3 of the colon have increased risk of colon cancer. Most gastroenterologists agree that patients with extensive UC (100%), left-sided UC (80%), or Crohn’s involving more than 1/3 of the colon (98%) should be in a surveillance protocol, however, 37%, 9%, and 2% also believe that patients with distal ulcerative proctosigmoiditis, ulcerative proctitis, and ileal Crohn’s disease should be in a surveillance protocol respectively. All gastroenterologists perform surveillance in patients without other risk factors within 3 years, however the interval varies: 28% every year, 47% every 2 years, and 25% every 3 years. 61% believe that chromoendoscopy is the preferred method for dysplasia surveillance, but 72% use white light endoscopy most often for surveillance in their clinical practice. Two-thirds (38/57) of gastroenterologists reported ever performing chromoendoscopy. The most common reasons to use chromoendoscopy were history of dysplasia found on random biopsy (89%), history of nonpolypoid dysplasia (76%), or history of primary sclerosing cholangitis (76%). Only 8 gastroenterologists reported using chromoendoscopy for all IBD surveillance. Physicians agree that the top barriers to chromoendoscopy use include longer procedure time (43), lack of standardized training in chromoendoscopy (42), and lack of reimbursement for chromoendoscopy (36); however, most would be likely or very likely to use chromoendoscopy if data showed which patients would benefit most from chromoendoscopy (95%) and if data showed benefits of chromoendoscopy compared to other techniques (93%). Conclusion Most gastroenterologists believe that chromoendoscopy is the ideal method for IBD surveillance, yet white light endoscopy is used most often. Physicians agree that longer procedure times and lack of reimbursement deter chromoendoscopy use, but the majority would be willing to use chromoendoscopy if data showed superiority of chromoendoscopy compared to other techniques and identified patients that would benefit the most.