Specific Benign Diagnosis Research Articles

CT-guided Transthoracic Lung Biopsy: complications and success in yielding a specific diagnosis

Aim: To present risk factors for common complications of CT-guided transthoracic lung biopsy and to analyse the diagnostic success of the procedure in terms of specific diagnostic rates. Materials & Methods: 461 consecutive procedures retrospectively enrolled. Patient, lesion and technical variables are scrutinized in terms of complications and their severity. Pathology results were evaluated for diagnostic specificity. Results: 27% total complications with %17 alveolar haemorrhage, 7% pneumothorax and 3% developed both. ≤ 15 mm size and ≥ 20 mm distance from pleura significantly increases the risk of both PTX and AH. Perilesional emphysema is a predisposing factor of both severe PTX and extended bleeding. Lateral decubitus position increases the likelihood of pneumothorax. Patients with a needle angle of less than 90±15° had an approximate 2-fold increase risk of PTX (P = 0.034). Semi-solid lesions carry a risk of significant bleeding. The accuracy was 96.9% with a specific malignant diagnosis rate of 83% and a specific benign diagnosis rate of 52%. Conclusion: Perilesional emphysema is risk factor of severe complications. Semi-solid lesions are prone to severe bleeding. Lateral decubitus position and low needle angle are important as preventable predisposing factors of PTX. Although the diagnostic yield is satisfactory, the specific benign diagnosis rates are still below expectations and that larger needle biopsies are more beneficial in this regard.

SHAPE-SENSING ROBOTIC ASSISTED BRONCHOSCOPY FOR THE DIAGNOSIS OF PERIPHERAL PULMONARY LESIONS

TOPIC: Lung Cancer TYPE: Original Investigations PURPOSE: To assess the real-world performance characteristics of a shape-sensing robotic platform for the diagnosis of peripheral pulmonary nodules. METHODS: This is a retrospective, single center, single operator cohort of consecutive cases performed utilizing shape-sensing robotic assisted bronchoscopy (SSRAB) with integrated 3.5mm robotic catheter (Ion Endoluminal System, Intuitive Surgical, Sunnyvale, CA). Cases were performed between January 2020 and April 2021. A specific anesthesia protocol was used in all patients to prevent atelectasis. Radial endobronchial ultrasound (rEBUS) was used in all cases. Cone-beam CT (CBCT, Philips Allura Xper FD20 with Lung Suite, Best, Netherlands) was used at the discretion of the physician. A procedure was considered diagnostic if there was a malignant or specific benign result. Biopsies with inflammation were considered indeterminate, followed with CT imaging and considered diagnostic if there was significant improvement or resolution of the lesion. Specimens noted to be “atypical” were considered non-diagnostic. RESULTS: A total of 230 lesions, biopsied in 192 consecutive patients were included (56% female). Multiple lesions were biopsied (maximum = 3) in a single procedure in 38 patients (20%). Bilateral lesions were biopsied in 13 patients (7%). Most lesions (64%) were in the upper lobes (n= 144, 40% RUL, 24% LUL). Median lesion size was 15mm (IQR: 10, 21). A bronchus sign was present in 38% of lesions. Lesions biopsied were solid (78%), semi-solid (12%), ground glass (7%) or cavitary (3%). Diagnostic yield was 92.2% for all lesions and 89.3% for lesions 10mm or less (n=56, smallest = 5mm). CBCT was used for 75% of lesions (n=174). Malignancy was noted in 74% (n=170) of lesions. A specific benign diagnosis was noted in 16% (n=37), and 8% (n=15) of lesions were non-diagnostic. There were 8 lesions where biopsy results were indeterminate. These patients underwent serial CT scans for follow-up: 5 lesions resolved, improved significantly or were stable for 12 months. Three lesions have follow-up pending and are considered non-diagnostic in this analysis. All indeterminate lesions had tool-in-lesion confirmation on intraprocedural CBCT scan. Sensitivity for malignancy ranges from 90.4% to 91.9% considering pending follow-up of 3 lesions. Pneumothorax was noted in 2 patients (1%), 1 of which required a chest tube (0.5%). There were no episodes of respiratory failure or significant bleeding that required intervention (including removal of the robotic catheter). CONCLUSIONS: This represents the largest cohort of patients to date using any robotic bronchoscopy technology and shows that SSRAB, when combined with CBCT and rEBUS, is safe with a high diagnostic yield. CLINICAL IMPLICATIONS: The use of SSRAB may increase the diagnostic yield for peripheral pulmonary nodules. Larger, prospective multicenter trials are forthcoming. DISCLOSURES: My spouse/partner as a Employee relationship with Medtronic Please note: >$100000 by Michael Pritchett, source=Web Response, value=Salary Consultant relationship with Medtronic Please note: $5001 - $20000 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Johnson & Johnson Please note: $5001 - $20000 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with AstraZeneca Please note: $20001 - $100000 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Intuitive Please note: $20001 - $100000 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with BodyVision Please note: $5001 - $20000 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Michael Pritchett, source=Web Response, value=Consulting fee Research relationship with Philips Please note: $5001 - $20000 by Michael Pritchett, source=Web Response, value=Grant/Research Support Consultant relationship with Biodesix Please note: $5001 - $20000 by Michael Pritchett, source=Web Response, value=Consulting fee Speaker relationship with Intuitive Please note: 2 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Speaking fees Consultant relationship with Medtronic Please note: 5 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Intuitive Please note: 2 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Consulting fee Advisory Committee Member relationship with AstraZeneca Please note: 4 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Honoraria Advisory Committee Member relationship with Pfizer Please note: 4 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Honoraria Advisory Committee Member relationship with Biodesix Please note: 4 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Honoraria Consultant relationship with BodyVision Please note: 3 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Philips Please note: 2 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Consulting fee Consultant relationship with Johnson & Johnson Please note: 3 years Added 06/23/2021 by Michael Pritchett, source=Web Response, value=Consulting fee No relevant relationships by Charles Schirmer, source=Web Response

CT-guided percutaneous lung biopsy: Correlation between diagnostic yield, lung lesion size, and lobar distribution

Objectives: The aim of this retrospective study was to investigate the relationship between lung lesion lobar distribution, lesion size, and lung biopsy diagnostic yield. Material and Methods: This retrospective study was performed between January 1, 2013, and April 30, 2019, on CT-guided percutaneous transthoracic needle biopsies of 1522 lung lesions, median size 3.65 cm (range: 0.5– 15.5 cm). Lung lesions were localized as follows: upper lobes, right middle lobe and lingual, lower lobes superior segments, and lower lobes basal segments. Biopsies were classified as either diagnostic or non-diagnostic based on final cytology and/or pathology reports. Results were considered diagnostic if malignancy or a specific benign diagnosis was established, whereas atypical cells, non-specific benignity, or insufficient specimen were considered non-diagnostic. Results: The positive predictive value (PPV) of a diagnostic yield was 85%, regardless of lobar distribution. Because all PPVs were relatively high across locations (84–87%), we failed to find statistically significant difference in PPV between locations (P = 0.79). Furthermore, for every 1 cm increase in target size, the odds of a diagnostic yield increased by 1.42-fold or 42% above 85%. Although target size increased the diagnostic yield differently by location (between 1.4- and 1.8-fold across locations), these differences failed to be statistically significant, P = 0.55. Conclusion: Percutaneous transthoracic needle biopsy of lung lesions achieved high diagnostic yield (PPV: 84– 87%) across all lobes. A 42% odds increase in yield was achieved for every 1 cm increase in target size. However, this increase in size failed to be statistically significant between lobes.

CT-guided biopsy of pulmonary nodules ≤10 mm: Diagnostic yield based on nodules' lobar and segmental distribution

PurposeThe aim of our study is to evaluate the diagnostic performance of CT-guided biopsy of lung nodules ≤10 mm based on their lobar and segmental location. Materials and methodsThis was a retrospective study performed on 193 CT-guided percutaneous transthoracic needle biopsies of lung nodules ≤10 mm in greatest dimension, between January 1, 2013 and April 30, 2019. Biopsies were classified as either diagnostic or non-diagnostic based on final cytology and surgical pathology reports. Diagnostic results were those that met parameters for malignancy or a specific benign diagnosis, whereas atypical cells, non-specific benignity, or insufficient specimen were considered non-diagnostic. ResultsA total of 1577 CT-guided percutaneous transthoracic needle biopsies were reviewed. Of these, 193 nodules (12.24%) measured ≤10 mm and were selected for further analysis. Of the 193 biopsies, 138 yielded diagnostic results while 56 yielded nondiagnostic results (71% vs 29%, respectively). When analyzed by nodule location, the superior segments of the lower lobes boasted the highest diagnostic yield compared to nodules located in the basal segments of the lower lobes which had the lowest diagnostic yield (84.2% vs 64.7%, respectively). Nodules in the upper lobes and in the middle lobes had a diagnostic yield of 70% and 66.7%, respectively. ConclusionThe diagnostic performance of CT-guided biopsy of lung nodules ≤10 mm in diameter may be affected by lobar and segmental location. While the overall performance was good (diagnostic yield of 71%), the yield varied nearly 20% depending on location.

Endoscopic medial maxillectomy in patients treated at the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008-2018.

<b>Introduction:</b> Endoscopic medial maxillectomy (EMM) refers to surgical resection of the medial wall of the maxillary antrum. The primary indications for EMM are recalcitrant maxillary sinusitis, ablation of malignant and specific benign diagnoses such as Schneiderian Papilloma. Maxillectomy is potentially complicated by injuries to the orbital contents, lacrimal apparatus, optic nerve, ethmoidal arteries that may be accompanied by brisk bleeding. <br><b>Aim:</b> The purpose of this paper is to conduct a retrospective analysis of patients treated with EMM surgery at the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008-2018. <br><b>Material and methods:</b> The retrospective analysis was conducted on patients who underwent EMM treated at the the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008-2018. The research included 18 patients aged 15-94; 8 women and 10 men. <br><b>Results:</b> Out of 18 patients, 8 had been operated before EMM. 16 of them presented with histological examinations, though 5 of which were not confirmed with postoperative histological result. The most common indication for the operation was inverted papilloma. <br><b>Conclusion:</b> Endoscopic surgical approach is effective and precious way to manage tumors which involve the neighboring structures especially medial maxillary sinus. EMM itself is a safe surgical method in managing maxillary sinus disorders and is favored for its decreased invasiveness and avoidance of the deformity of face.

Detection Rates for Benign and Malignant Diagnoses on Breast Cancer Screening With Digital Breast Tomosynthesis in a Statewide Mammography Registry Study.

The objective of our study was to determine whether detection rates of specific benign and malignant diagnoses differ for breast cancer screening with digital breast tomosynthesis (DBT) versus full-field digital mammography (FFDM) alone. We analyzed observational data from the Vermont Breast Cancer Surveillance System, including 86,349 DBT screening examinations and 97,378 FFDM screening examinations performed at eight radiology facilities in Vermont that adopted DBT screening during 2012-2016. We determined the most severe diagnosis made within 6 months after positive screening examinations. Multivariable-adjusted logistic regression was used to compare detection rates for specific diagnoses on DBT versus FFDM. Compared with FFDM, DBT had a lower recall rate (adjusted odds ratio [OR], 0.81; 95% CI, 0.77-0.85) but comparable biopsy rate (OR = 1.05; 95% CI, 0.93-1.17), benign biopsy rate (OR = 1.12; 95% CI, 0.97-1.29), and cancer detection rate (OR = 0.94; 95% CI, 0.78-1.14). Among benign diagnoses, DBT and FFDM had comparable detection rates for nonproliferative lesions (OR = 1.19; 95% CI, 0.92-1.53), fibroepithelial proliferations (OR = 1.24; 95% CI, 0.85-1.81), proliferative lesions without atypia (OR = 1.13; 95% CI, 0.90-1.42), atypical lesions (OR = 0.77; 95% CI, 0.43-1.38), and lobular carcinoma in situ (LCIS) (OR = 0.92; 95% CI, 0.53-1.61). Among malignant diagnoses, DBT and FFDM had comparable detection rates for ductal carcinoma in situ (OR = 1.05; 95% CI, 0.70-1.57) and invasive breast cancer (OR = 0.92; 95% CI, 0.74-1.13), with no statistically significant differences in detection of invasive ductal carcinoma (OR = 0.83; 95% CI, 0.66-1.06), invasive lobular carcinoma (OR = 1.11; 95% CI, 0.59-2.07), or invasive mixed ductal-lobular carcinoma (OR = 1.49; 95% CI, 0.65-3.39). Compared with FFDM, breast cancer screening with DBT has a lower recall rate while detecting a similar distribution of benign and malignant diagnoses.

Non-Diagnostic CT-Guided Percutaneous Needle Biopsy of the Lung: Predictive Factors and Final Diagnoses.

ObjectiveTo investigate the predictive factors for a non-diagnostic result and the final diagnosis of pulmonary lesions with an initial non-diagnostic result on CT-guided percutaneous transthoracic needle biopsy.Materials and MethodsAll percutaneous transthoracic needle biopsies performed over a 4-year period were retrospectively reviewed. The initial pathological results were classified into three categories—malignant, benign, and non-diagnostic. A non-diagnostic result was defined when no malignant cells were seen and a specific benign diagnosis could not be made. The demographic data of patients, lesions' characteristics, technique, complications, initial pathological results, and final diagnosis were reviewed. Statistical analysis was performed using binary logistic regression.ResultsOf 894 biopsies in 861 patients (male:female, 398:463; mean age 67, range 18–92 years), 690 (77.2%) were positive for malignancy, 55 (6.2%) were specific benign, and 149 (16.7%) were non-diagnostic. Of the 149 non-diagnostic biopsies, excluding 27 cases in which the final diagnosis could not be confirmed, 36% revealed malignant lesions and 64% revealed benign lesions. Predictive factors for a non-diagnostic biopsy included the size ≤ 15 mm, needle tract traversing emphysematous lung parenchyma, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Non-diagnostic biopsies with a history of malignancy or atypical cells on pathology were more likely to be malignant (p = 0.043 and p = 0.001).ConclusionThe predictive factors for a non-diagnostic biopsy were lesion size ≤ 15 mm, needle tract traversing emphysema, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Thirty-six percent of the non-diagnostic biopsies yielded a malignant diagnosis. In cases with a history of malignancy or the presence of atypical cells in the biopsy sample, a repeat biopsy or surgical intervention should be considered.

Abstract No. 352 - Lung biopsy and management of pneumothorax in an outpatient center

This study evaluates CT guided core biopsy of the lung and management of pneumothorax (PTX) in a freestanding IR center. This retrospective study included 651 consecutive CT guided lung biopsies from March 2010 to June 2012 in 613 patients (273 male, 340 female, mean age 69) by IR physicians in an outpatient center. Biopsy was performed with sedation using the Achieve 20 gauge coaxial biopsy system (Cardinal,Dublin,Ohio). PTX was treated on site with a 14 fr Thal-Quick chest tube (n=37), or 10.5 fr multipurpose drain (n=6) attached to a Heimlich valve (Cook Medical, Bloomington, IN). Mean lesion size was 2.6 cm (range .5 - 9.5 cm) and depth was 1.7 cm (range 0-11.3 cm). 95% of patients received 2 or less CXR’s after biopsy, and the mean time to pre-discharge CXR was 1.7 hr (range 0 - 6hr). Samples showed malignancy in 416(64%), and 43(7%) had a specific benign diagnosis. No malignancy with concordant follow-up imaging was seen in 87(13%), and incomplete follow-up was found in 91(14%). 14(2%) of samples were falsely negative. Pneumothorax occurred in 95(15%) of cases. Chest tubes were placed for enlarging or symptomatic PTX in 43(6.6% of total biopsies) 0-72 hr (mean 6 hr) after biopsy. Of three delayed PTX’s at 24-72 hrs, two received chest tubes; one was aspirated. Hospitalization occurred in 7(16%) receiving chest tubes, either for suction or pain management. All but one hospitalized patient was transferred from the IR center. Apical positioned 14 fr tubes required a single tube exchange to control the PTX in 2 of 24 patients. Smaller tubes or 14 fr tubes not in the apex needed a single exchange in 7 of 19 patients (odds ratio 5.9 p<.05). Tube removal was delayed 24hrs if placed in late afternoon, and 7 patients had tubes through the weekend. All patients had successful tube removal 18 to 216 hrs (mean 52hr) after biopsy, 36(84%) as outpatients. Self limited hemoptysis occurred in 60 (9.2%) of patients. Two patients died after urgent transfer to the hospital; one death from massive hemoptysis, and one from complications of hemothorax. Core biopsy of the lung in an IR center is feasible, and pneumothorax can be safely managed as an outpatient.

Granulomatous inflammation and organizing pneumonia: Role of computed tomography-guided lung fine needle aspirations, touch preparations and core biopsies in the evaluation of common non-neoplastic diagnoses

Background:Fine-needle aspirations (FNAs) and core biopsies (CBs), with or without touch preparations (TPs), are performed to characterize pulmonary lesions. Although a positive (P) or suspicious report is sufficient for further management, the significance of unsatisfactory (U), negative (N) and atypical (A) cytological diagnoses remains uncertain. The aims of the study were to correlate U, N and A cytological diagnoses with histological and/or clinical/radiological follow-up and evaluate the utility of FNAs, TPs and CBs.Materials and Methods:We performed a retrospective search and examined 30 consecutive computed tomography-guided transthoracic U, N and A lung FNAs (n = 23) and TPs (n = 7) with surgical pathology (SP) (n = 17) and/or clinical/radiological follow-up (n = 13) and compared them to 10 SP-confirmed P FNAs, which served as controls.Results:The 30 FNAs and TPs were from 29 patients. All 6 U specimens were scantly cellular. Granulomas, the most common specific benign cytological diagnosis, were evident in 8 (of 13) and 7 (of 11) N and A cytology cases, respectively. Histology corroborated the presence of granulomas identified on cytology. Organizing pneumonia was the second leading benign specific diagnosis (5/17), but it was rendered on histology (n = 5) and not FNAs or TPs. Evaluation of the A cases revealed that type II pneumocytes were the source of “atypical”, diagnoses often associated with granulomas or organizing pneumonia and lacked 3-D clusters evident in all P cases.Discussion:U, N and A FNAs and TPs lacked 3-D clusters seen in carcinomas and were negative on follow-up. Granulomas and organizing pneumonia were the most common specific benign diagnoses, but the latter was recognized on histology only. In the absence of a definitive FNA result at the time of on-site assessment, a CB with a TP containing type II pneumocytes increases the likelihood of a specific benign diagnosis.

Prediction without Pigment: a decision algorithm for non-pigmented skin malignancy

While there are several published comprehensive stepwise algorithmic methods for diagnosing pigmented skin malignancy, only limited material has been published for the stepwise assessment of non-pigmented lesions. We present a method based on pattern analysis, with a stepwise assessment, first, for ulceration, second, for white clues (defined as white lines, or in the case of a raised lesion any of the keratin clues: dermatoscopic white circles, dermatoscopic white structureless areas or surface keratin), and third, if no ulceration or white clues are present, proceed to vessel pattern analysis.This is a novel method, and apart from the assessment of white clues in raised lesions, it has not been formally tested. The priority of keratin clues in raised lesions over vessel pattern analysis has, however, been verified.It is conceded that this method is less specific than methods which have clues of pigmented structures, and accepting these limitations, Prediction without Pigment is a decision algorithm intended to guide the clinician in the decision as to whether to perform a biopsy rather than consistently leading to a specific diagnosis. Reaching a more specific diagnosis at the end of our flowchart can be achieved by weighing of clues both clinical and dermatoscopic, and that ability can be expected to improve with both knowledge and experience, but no diagnostic method, including this one, can be 100% sensitive in diagnosing malignancy, in particular, melanoma. Taking these limitations into account, any non-pigmented lesion, regardless of pattern analysis, which is raised and firm (nodular) and for which a confident, specific benign diagnosis cannot be made, should be excised to exclude the nodular variant of amelanotic melanoma.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is increasingly used to sample mediastinal and hilar lymph nodes and has excellent diagnostic test characteristics. The determinants of sampling adequacy, however, have not been extensively examined. We set out to determine which procedural variables were associated with acquisition of tissue sufficient for pathologic analysis during EBUS-TBNA. A retrospective analysis of all EBUS-TBNA cases performed over 32 months by 10 proceduralists at our institution was completed. Variables potentially associated with sampling adequacy were analyzed. A total of 1304 procedures performed by 10 proceduralists while the patient received conscious sedation were included for analysis. Sampling adequacy was 94.2% overall and varied with the primary proceduralist (87% to 99.2%; P<0.001). Diagnostic yield per procedure for malignancy or a specific benign diagnosis was 43.2% overall. Proceduralists with a higher average number of lymph node stations sampled per procedure had improved sampling adequacy (parameter estimate=1.32; P=0.007). Sampling adequacy was lower with lymph nodes smaller than 10 mm (parameter estimate=-0.7; P=0.002) but was not associated with procedural environment (hospital procedural suite vs. clinic-based procedural suite) (P=0.08), lymph node station (P=0.69), propofol use (P=0.90), or average annual proceduralist cases performed (P=0.21). Only 6/216 (2.8%) patients had subsequent procedures (EBUS-TBNA or surgery) that indicated the initial EBUS-TBNA had inadequate sampling potentially leading to a missed cancer diagnosis. Excellent EBUS-TBNA sampling adequacy can be achieved by pulmonologists in a large group setting, who are not exclusively dedicated to interventional pulmonary medicine, using only moderate conscious sedation.

Fine-needle aspiration biopsy versus core-needle biopsy in diagnosing lung cancer: a systematic review

Background: Lung cancer leads cancer-related mortality in the world. The objective of the present systematic review was to compare fine-needle aspiration biopsy (FNAB) with core-needle biopsy (CNB) for diagnostic characteristics and yields for diagnosing lung cancer in patients with lung lesions. Methods: The MEDLINE and EMBASA databases (from January 1, 1990, to September 14, 2009), the Cochrane Library (to Issue 4, 2009), and selected guideline Web sites were searched for relevant articles. Results: For overall diagnostic characteristics (benign vs. malignant) of FNAB and CNB, the ranges of sensitivity were 81.3%–90.8% and 85.7–97.4% respectively; of specificity, 75.4%–100.0% and 88.6%–100.0%; and of accuracy, 79.7%–91.8% and 89.0%–96.9%. For specific diagnostic characteristics of FNAB and CNB (identifying the histologic subtype of malignancies or the specific benign diagnoses), the ranges of sensitivity were 56.3%–86.5% and 56.5–88.7% respectively; of specificity, 6.7%–57.1% and 52.4%–100.0%; and of accuracy, 40.4%–81.2% and 66.7%–93.2%. Compared with FNAB, CNB did not result in a higher complication rate (pneumothorax or hemoptysis). No study has yet compared the diagnostic yields of FNAB and of CNB for molecular predictive-marker studies in patients with lung lesions. Discussion and Conclusions: The evidence is currently insufficient to support a difference between FNAB and CNB in identifying lung malignancies in patients with lung lesions. Compared with FNAB, CNB m ight h ave a h igher s pecificity t o diagnose specific benign lesions. Well-designed, good-quality studies comparing FNAB with CNB for diagnostic characteristics and yields in diagnosing lung cancer should be encouraged.

Fine-Needle Sspiration Biopsy versus Core-Needle Biopsy in Diagnosing Lung Cancer: A Systematic Review

Lung cancer leads cancer-related mortality in the world. The objective of the present systematic review was to compare fine-needle aspiration biopsy (fnab) with core-needle biopsy (cnb) for diagnostic characteristics and yields for diagnosing lung cancer in patients with lung lesions. The medline and embase databases (from January 1, 1990, to September 14, 2009), the Cochrane Library (to Issue 4, 2009), and selected guideline Web sites were searched for relevant articles. For overall diagnostic characteristics (benign vs. malignant) of fnab and cnb, the ranges of sensitivity were 81.3%-90.8% and 85.7-97.4% respectively; of specificity, 75.4%-100.0% and 88.6%-100.0%; and of accuracy, 79.7%-91.8% and 89.0%-96.9%. For specific diagnostic characteristics of fnab and cnb (identifying the histologic subtype of malignancies or the specific benign diagnoses), the ranges of sensitivity were 56.3%-86.5% and 56.5-88.7% respectively; of specificity, 6.7%-57.1% and 52.4%-100.0%; and of accuracy, 40.4%-81.2% and 66.7%-93.2%. Compared with fnab, cnb did not result in a higher complication rate (pneumothorax or hemoptysis). No study has yet compared the diagnostic yields of fnab and of cnb for molecular predictive-marker studies in patients with lung lesions. The evidence is currently insufficient to support a difference between fnab and cnb in identifying lung malignancies in patients with lung lesions. Compared with fnab, cnb might have a higher specificity to diagnose specific benign lesions. Well-designed, good-quality studies comparing fnab with cnb for diagnostic characteristics and yields in diagnosing lung cancer should be encouraged.

Utility of small biopsies for diagnosis of lung nodules: doing more with less

Small biopsies obtained by core needle or bronchoscopy are commonly used for diagnosis of lung nodules. This review provides guidance in two key areas of interpretation of small lung biopsies. The first part answers common questions regarding the immunohistochemical subclassification of non-small cell lung carcinomas that cannot be classified by standard criteria on hematoxylin–eosin-stained sections of small lung biopsies. The second part discusses common benign entities that can be diagnosed in core needle biopsies of lung nodules, such as granulomatous inflammation, parenchymal scars and organizing pneumonia. The approach to cases in which malignant cells are absent and features of a specific benign diagnosis are lacking is also addressed.

Diagnostic yield of percutaneous image‐guided tissue biopsy of focal hepatic lesions in cancer patients

The diagnostic yield was evaluated of percutaneous image-guided tissue biopsy of hepatic lesions identified on computed tomography performed for staging of a primary malignancy, and it was determined how often the biopsy result was unexpectedly negative, benign, or secondary to a second unknown malignancy. In a retrospective investigation from 1998 through 2008, 580 patients with primary malignancies had indeterminate focal hepatic lesions and underwent percutaneous image-guided biopsy; 369 patients had lesions in their liver at first cross-sectional imaging, performed for staging; 211 patients had a negative liver imaging study, followed by the subsequent appearance of at least 1 indeterminate suspicious lesion. The results of percutaneous image-guided tissue biopsies were compared with the histology of the primary malignancy. Liver biopsies were performed in 580 patients (288 men and 292 women; age, 25-92 years; mean age, 61 years). The most common primary malignancies were pancreatic (n = 96), breast (n = 85), melanoma (n = 57), esophageal (n = 51), lung (n = 47), colorectal (n = 37), and urothelial tumors (n = 26). Biopsy results were positive for malignancy in 528 (91%) cases. Among the positive biopsies, 29 (5%) cases had pathology results different from the primary tumor. Of the 52 biopsies negative for malignancy, 20 yielded a specific benign diagnosis, and 32 were nondiagnostic. If all liver lesions had been assumed to be metastases, as expected secondary to the known primary tumor, then the true or presumed alternate diagnosis would have been missed in 60 (10.3%) of the 580 cases. The authors did not attempt to determine whether actual clinical management changed based on these 60 liver biopsy results, so this number is an upper bound on management change. On the basis of these results, and given the minimal complication rate of liver biopsy, the authors suggest that liver biopsy should still be performed in the types of cases studied here, despite the finding that the vast majority of biopsies produced the expected result and presumably did not change patient management.

Inconclusive Result from CT Guided Transthoracic Needle Aspiration and Biopsy: Affecting Factors and Final Outcome

Purpose: Inconclusive results from computed tomography (CT)-guided transthoracic needle aspiration and biopsy (TNAB) performed for lung lesions presents a clinical dilemma. The purpose of this study was to determine the factors affecting an inconclusive result from a CT guided TNAB, and to evaluate the final outcomes of these inconclusive results. Materials and Methods: The medical records and radiologic features of 331 patients with lung lesion who received CT guided TNAB were analyzed retrospectively. The results of the TNAB were classified as conclusive (malignancy or specific benign diagnosis) or inconclusive (nonspecific benign or nondiagnostic). Results: Of the 331 cases, 269 (81.3% ) were diagnosed as a m alignancy (210) or a specific benign lesion (59) after the first TNAB. The remaining 62 (18.7%) were inconclusive. Benign disease, a lesion size ≤15 mm, and morphology of the consolidation type were features significantly correlated with inconclusive results. Of these 62 inconclusive cases a second TNAB was performed in 23, and conclusive diagnoses were obtained in 19 (82.6%). Surgery or radiographic follow up was done in other cases. Finally, among the 62 inconclusive results on the first CT guided TNAB, 16 lesions were diagnosed as malignant, 26 were classified as specific benign disease, and the remaining 20 were defined as nonspecific inflammation. Age over 50 and morphology of a nodule or a mass type were significantly correlated with a m alignancy in these 62 cases with inconclusive results on the first TNAB. Conclusion: A final diagnosis of benign disease was significantly higher after the CT guided TNAB was inconclusive for lesions ≤15 mm that had consolidation type morphology. Despite the application of core biopsy procedures, there continue to be appreciable numbers of inconclusive results after the first CT guided TNAB. A repeat CT guided TNAB had a high diagnostic yield in these cases and therefore should be considered for cases with inconclusive results.

Improved Resolution of Diagnostic Problems in Selected Prostate Needle Biopsy Specimens by Using the ASAP Workup

This study assessed the value of an atypical small acinar proliferation (ASAP) workup consisting of preparing new recut sections from the paraffin block and performing H&E-stained sections and immunostains (using the antibody cocktail for p63, cytokeratins 5 and 14, and alpha-methylacyl coenzyme A racemase) on the slides. We compared the ASAP workup with the interval workup, the common practice of performing the same immunostains on the saved interval sections, in 105 cases because of focal glandular atypia on the original H&E-stained sections. There were no specimens in which only the interval workup showed a changed diagnosis, but there were 23 specimens (21.9%) in which the preliminary diagnosis was changed to a definitive diagnosis of carcinoma (10 specimens) or a specific benign diagnosis (13 specimens) based solely on the findings of the ASAP workup. The ASAP workup is recommended as a very useful histologic tool for resolving diagnostic problems in prostate needle biopsy specimens.

Fine-Needle Aspiration Biopsy of the Distal Extremities

We reviewed our cytopathology databases for an 11-year period to identify all fine-needle aspiration biopsy (FNAB) cases of palpable masses of the hand, wrist, ankle, or foot. Cases were included only if there was a subsequent tissue biopsy or a minimum 1-year clinical follow-up. Of 141 aspirates, 41, 23, 34, and 43 were from the hand, wrist, ankle, and foot, respectively. Specific benign or malignant diagnoses were achievable in 71.6% of cases, whereas the remaining cases were given a descriptive diagnosis (26.2%) or, infrequently, a "suspicious for" diagnosis (2.1%). Overall sensitivity and specificity for distinguishing a benign from malignant entity from all 4 sites were 100% and 96%, respectively, whereas positive and negative predictive values were 88% and 100%, respectively. The most common lesion was a ganglion. Of the benign neoplasms, giant cell tumor of tendon sheath (17) and desmoid-type fibromatosis (7) were most common. Of 31 malignancies, 24 were sarcomas: sarcoma not otherwise specified (6), high-grade pleomorphic sarcoma (5), and Ewing sarcoma (3) were most common. Seven nonsarcomas included melanoma (3), metastatic squamous carcinoma (2), and malignant lymphoma (2). An FNAB-procured cytopathologic diagnosis is clinically reliable in a high percentage of distal extremity mass lesions.

Nodules in the Thickened Greater Omentum

In patients with unclear ascites, a thickened greater omentum with variable nodules is usually encountered with high-frequency insonation. The purpose of our study was to assess the importance of nodules in indicating the origin of ascites. In patients suggested for a biopsy of the greater omentum, if nodules were found in the omentum, sonograms of the nodules were recorded, and during the biopsy, 2 passes were made for each procedure in the nodule and the thickest region without nodules, respectively. A biopsy was considered successful if a specific benign or malignant diagnosis was made. In the 258 patients undergoing sonographically guided biopsies of the greater omentum from November 2001 to November 2008, the percentage of definitive diagnoses was 94.57% (244 of 258), and sonography showed nodules in 62 patients. Nodules were found more often by a 10-MHz transducer (62 cases) than by a 3.5-MHz transducer (15 cases). The percentage of definitive diagnoses by sonographically guided biopsies was 100% (62 of 62) at the sites of the nodules and decreased to 87.1% (54 of 62) at the sites without nodules. According to the pathologic results, 48 cases were peritoneal carcinomatosis, and 14 cases were tuberculous peritonitis. The sensitivity and specificity of nodules for indicating malignant ascites were 77.42% and 75.27%, respectively. Nodules in the greater omentum were good indicators of lesions and were well shown by a high-frequency transducer. A biopsy at the site of a nodule could substantially increase the positive biopsy result rate.

Ultrasound-guided biopsy of greater omentum: An effective method to trace the origin of unclear ascites

Objectives Thickened greater omentum is encountered with high frequency in patients with ascites. The purpose of our study was to assess the utility of greater omentum biopsy under the guidance of ultrasound (US) in tracing the origin of unclear ascites and differentiating benign and malignant ascites. Materials and methods We retrospectively reviewed our institutional database for all records of greater omentum biopsy cases. One hundred and ninety-four patients with unclear ascites and thickened greater omentum were included in the study. The sonograms of greater omentum were evaluated before undergoing the ultrasound-guided biopsy and a biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist. Results Successful biopsy was rendered for 182 biopsy procedures (93.8%, 182/194) including tuberculosis ( n = 114), chronic inflammation ( n = 3), metastases ( n = 58), malignant mesothelioma ( n = 6) and pseudomyxoma peritonei ( n = 1). Twelve biopsies were non-diagnostic. According to the results of biopsy and follow-up, the sensitivity and specificity of biopsy in distinguishing malignant ascites from benign ascities were respectively 95.6% (65/68) and 92.9% (117/126). The greater omentum of 84 cases of tuberculous peritonitis showed “cerebral fissure” sign and was well seen as an omental cake infiltrated with irregular nodules when involved by carcinomatosis. No “cerebral fissure” sign was observed in peritoneal carcinomatosis. The sensitivity and specificity of this sign in indicating the existence of tuberculous peritonitis were 73.5% (89/121) and 100% (73/73). Moreover, if the specific “cerebral fissure” sign was combined with the biopsy results, the specificity of biopsy in distinguishing malignant ascites from benign ascits increased to 96.8% (122/126). Conclusion Ultrasound-guided biopsy of greater omentum is an important and effective method to diagnose the unclear ascites for patients with thickened omentum if certain techniques could be paid attention to. “Cerebral fissure” sign of greater omentum was a specific sign in indicating the tuberculous peritonitis and could increase the specificity of biopsy in distinguishing malignant ascites from benign ascits if combined with the biopsy results.