Transcatheter Biopsy Research Articles

Transcatheter Biopsy of Primary Cardiac Tumors Guided by Echocardiographic and Fluoroscopic Imaging.

Transcatheter Biopsy of Primary Cardiac Tumors Guided by Echocardiographic and Fluoroscopic Imaging.

Left-sided primary cardiac lymphoma diagnosed by needle biopsy with total endoscopic anterolateral mini-thoracotomy: a case report

Abstract Background Primary cardiac lymphoma (PCL) is an extremely rare tumour that typically affects the right heart chamber. It is a life-threatening tumour presenting with rapid growth; therefore, early diagnosis and treatment are crucial for improving the prognosis of patients with PCL. Case summary An 81-year-old female with a history of dermatomyositis and interstitial pneumonia was referred to the cardiology department for cardiomegaly detected on chest radiography and computed tomography (CT). She experienced shortness of breath on exertion. Electrocardiography revealed negative T-waves in various leads. Transthoracic and transoesophageal echocardiography revealed a large mass on the epicardial free wall of the left atrium and ventricle. Coronary CT angiography showed feeding vessels from the left circumflex artery and the posterolateral branch of the right coronary artery. Positron emission tomography showed elevated mass uptake and no systemic metastasis. Needle biopsy with total endoscopic anterolateral mini-thoracotomy was performed. Histopathological examination revealed diffuse large B-cell lymphoma. She received systemic chemotherapy and achieved a complete metabolic response. Discussion Herein, we report an extremely rare case of PCL located on the left side of the heart. Owing to the location of the tumour, percutaneous or transcatheter biopsy could not be performed. Early diagnosis with needle biopsy via anterolateral mini-thoracotomy and systemic chemotherapy resulted in good outcomes.

Abstract 17852: A Right Atrial Mass(querader) Causing Complete Heart Block in an Otherwise Healthy Female

Introduction: Right atrial masses are ominous and have a broad differential including thrombus, primary cardiac tumors such as myxoma vs sarcoma, metastatic processes like lymphoma, and, rarely, autoimmune etiologies. In this case, an apple watch notification of bradycardia was a simple start to a complicated course of rapidly progressive conduction disease arising from an unusual presentation of cardiac sarcoidosis. Case Presentation: A 45-year-old previously healthy female originally presented to clinic with a one-month history of exertional dyspnea and palpitations with bradycardia noted on her Apple Watch and an ongoing event monitor revealing transient type II second-degree atrioventricular block. In the office, she was normotensive but bradycardic at 33 beats per minute with electrocardiogram revealing complete heart block with junctional escape. She was admitted for additional work-up with transesophageal echocardiogram (TEE) which was unrevealing. Cardiac magnetic resonance imaging (cMRI) identified two 2 x 2 cm right atrial masses that appeared hypermetabolic on cardiac fluorodeoxyglucose positron emission tomography (FDG cPET) in addition to bilateral hilar lymph nodes. A temporary-permanent pacemaker equipped with a lead capable of floating atrial bipolar sensing was placed while biopsy plans were arranged. Transbronchial ultrasound guided biopsy of the hilar lymph node returned benign. She then underwent two different attempts at transcatheter biopsy of the right atrial masses - one TEE guided, another intracardiac echo (ICE) guided - with most samples unrevealing except one with an inconclusive amount of spindle cells raising concerns for sarcoma. The decision was made to pursue cardiothoracic surgical resection of the right atrial masses with pathology returning with granulomatous lesions consistent with sarcoidosis. Discussion: Cardiac involvement is present in 25% of cases of sarcoidosis and most commonly manifests as conduction abnormalities, ventricular arrhythmia, and/or heart failure. Only a few cases of atrial masses are reported in the literature and its presence in this woman with heart block confounded the picture before a diagnostic biopsy of this treatable condition could be obtained.

S2125 Short Time Recurrence of Retroperitoneal Desmoid Tumor in Patient With Familial Adenomatous Polyposis

Introduction: A Desmoid Tumor (DT) is a locally invasive, non-metastatic mesenchymal stem cell tumor that typically manifests as a soft tissue mass occurring in muscles, fasciae and aponeuroses. We present a case of a patient with recurrence of a retroperitoneal DT shortly after resection. Case Description/Methods: A 34-year-old male presented with abdominal pain found to have a large (11 × 14.4 * 14 cm) intrabdominal mass. IR transcatheter biopsy of the mass confirmed DT. He underwent bidirectional endoscopy and found to have more than hundred adenomatous colon polyps. Genetic testing confirmed APC mutation. Patient was diagnosed with DT associate with Familial Adenomatous Polyposis (FAP). He underwent radical resection of mesenteric mass and small bowel (20 cm of terminal ileum), omentectomy as well as total colectomy with ileorectal anastomosis. There was no evidence of lymphoid involvement. About 3 months later, he was re-admitted for increased abdominal girth with abdominal pain. MRI scans demonstrated a new, extensive, lobulated soft tissue mass occupying the entire abdominal cavity measuring 23.4 × 12.5 × 24.2 cm. Biopsy of the mass confirmed recurrent DT. Given the large size and proximity to the superior mesenteric artery, the mass was deemed to be unresectable. Patient was initially started on palliative systemic treatment with liposomal Doxorubicin. Due to lack of response, he was then switched to weekly methotrexate and Vinblastine (Figure). Discussion: DTs are rare neoplasms, making up only 0.03% of all neoplasms and 3% of soft tissue tumors. They typically include the abdominal wall, extremities, and mesentery. Although the etiology of DTs is not well known, there are several risk factors that are associated with their occurrence. Genetic syndromes such as FAP and Gardner syndrome have a well-known association with DTs. Other associations include antecedent trauma to the site of the lesion, pregnancy, and female sex. Numerous studies have been done assessing the efficacy of surgery, radiotherapy, and chemotherapy in managing DTs. However, none have shown conclusive benefit. The recurrence rate, particularly following surgical management, has been found to be as high as 77%. Given the lack of definitive management and high recurrence rates, treatment options should likely include combination of both surgical intervention and systemic treatment after discussing options and adverse effects of treatment with the patient.Figure 1.: A, Contrast enhanced CT axial through the lower abdomen demonstrating recurrence of large mass now occupying the majority of the abdominal cavity (black star); B, Spindle cell lesion, with fascicular and loose storiform growth patterns (H&E, 40×) prior to resection; C, Recurrent tumor with pathology demonstrating spindle cell lesion with more edema and/or myxoid stroma.

Cardiac metastasis after esophagogastrectomy for esophageal adenocarcinoma with an antemortem diagnosis

Cardiac metastasis is uncommon and rarely diagnosed antemortem. Here, we describe a case of symptomatic cardiac metastasis from esophageal adenocarcinoma. A 64-year-old man developed chest symptoms 26months after curative esophagogastrectomy for esophageal adenocarcinoma. Initially, ischemic cardiac disease was suspected based on electrocardiography findings, but an infiltrative tumor was seen morphologically in the wall of the interventricular septum and apex. No other lesions were detected. Histological examination of a transcatheter biopsy specimen indicated that the cardiac tumor was metastasis from esophageal adenocarcinoma. Chemoradiotherapy with cisplatin relieved his symptoms, and he had resumed normal activities. However, he opted not to undergo further aggressive treatment due to severe adverse effects from cisplatin. Seventeen months after completion of chemoradiotherapy, metastases to the right ventricle and the left thighbone were detected and he died 27 and 24months after the diagnosis of cardiac metastasis and completion of chemoradiotherapy, respectively.

Percutaneous transcatheter biopsy for intracardiac mass diagnosis.

The differential diagnosis of intracardiac masses (ICM) is wide. While imaging modalities can suggest a diagnosis, clinical decision making usually requires histopathologic diagnosis. The aim of this study was to describe the procedural technique, safety outcomes, diagnostic accuracy and clinical utility of percutaneous transcatheter biopsy (TCB) for histopathologic diagnosis of ICM. The records of all patients undergoing TCB of ICM at the Mayo Clinic catheterisation laboratories in Rochester, Minnesota, between 2002 and 2017 were retrieved and reviewed. TCB of ICM to establish histopathologic diagnosis was performed in 29 patients. Masses were located in the right-sided chambers in 93% of cases. Echocardiographic guidance was used. Ventricular arrhythmias requiring immediate cardioversion occurred in 7% of patients. No other complications were noted. The average number of samples retrieved per procedure was 7±3.6. A histopathologic diagnosis was made by TCB in 72% and altered clinical decision making in 52% of patients overall. Eleven patients (38%) who would otherwise have required excisional biopsy were able to avoid cardiovascular surgery. Each additional biopsy sample was associated with an increase in the likelihood of making a histopathologic diagnosis (OR 1.74, 95% CI: 1.05-2.87, p=0.032). Echo-guided percutaneous TCB of ICM provides an accurate diagnosis and alters clinical management in the majority of cases. The procedural complication rate is low. An increase in the number of samples retrieved markedly improves the ability to render a diagnosis. TCB may therefore be considered as a first-line approach for the histopathologic diagnosis of ICM.

Solitary cardiac metastasis of uterine cervical cancer with antemortem diagnosis: A case report and literature review.

Cardiac metastasis of uterine cervical cancer with antemortem diagnosis is extremely rare. Therefore, its landscape epidemiology has not been well elucidated to date. In the present study, a case of solitary cardiac metastasis of uterine cervical cancer diagnosed antemortem is reported, and a review of the currently available literature (which includes 18 cases of cardiac metastasis of uterine cervical cancer) is conducted. In January 2013, a 78-year-old woman with squamous cell carcinoma (SCC) of the uterine cervix (International Federation of Gynecology and Obstetrics stage IIIb) underwent definitive radiotherapy at Gunma University Hospital (Gunma, Japan). Follow-up examination at 5 months after completion of the treatment indicated no evidence of recurrence or metastasis. In April 2014, the patient reported epigastric discomfort and general malaise. Electrocardiogram suggested myocardial dysfunction. Transthoracic echocardiography revealed the presence of a mass occupying the right ventricle and pericardial effusion. Cine magnetic resonance imaging demonstrated a filling defect in the right ventricle, and transcatheter biopsy confirmed SCC. The patient was diagnosed with a solitary cardiac metastasis of uterine cervical cancer. Despite aggressive medical therapy, the patient succumbed to disease 31 days after admission to hospital. A review of the current literature revealed that 84% of cases of cardiac metastasis develop within 2 years of completion of the initial treatment, and that electrocardiogram and echocardiography reveal findings of myocardial dysfunction and the presence of a mass in the right ventricle, respectively. A treatment strategy for cardiac metastasis of uterine cervical cancer has not been standardized thus far, and the prognosis is very poor, as the majority of patients succumbed to disease within 1 year. In summary, the current case and the literature review conducted in the present study suggest that: i) Cardiac metastasis should be included in the differential diagnosis in cases with nonspecific complaints such as epigastric discomfort and general malaise when patients have a history of uterine cervical cancer, particularly within the previous 2 years; and ii) electrocardiogram and echocardiography are convenient and effective modalities for the diagnosis of cardiac metastasis of uterine cervical cancer.

Diagnosis of a primary cardiac B-cell lymphoma

A 56-year-old man with acute onset of sepsis and ventricular fibrillation was successfully resuscitated after his wife had noticed him breathing heavily in the night. The arrhythmia did not persist after curing the sepsis. However, during the diagnostic workup, echocardiography detected a right-ventricular mass (Image 1A). Cardiac magnetic resonance imaging identified the mass being a perfused tumor without attached thrombus (Image 1B; arrowheads). The tumor's gadolinium-enhancement was somewhat heterogeneous with a small central hypointensity shown in Image 1B (arrow). A biopsy was taken during right-heart catheterization that depicted the tumor well (Image 1C). Histologically, the tumor consisted of multiple atypical lymphoid cells with large nuclei (Image 1D; Giemsa staining). Additional immunostaining revealed a CD20-positive B-cell lymphoma (Image 1E) with a high proliferation rate. The staging revealed no other malignancies, leading to the diagnosis of a primary cardiac diffuse large B-cell lymphoma (DLBCL). The patient received dose-dense chemotherapy according to the R-CHOP-14 protocol, consisting of six cycles of cyclosphosphamide, doxorubicin, vincristine, and prednisone given at 14-day intervals. Each cycle was preceded by immunotherapy with the monoclonal antibody rituximab that is targeted against CD20-positive B-cells (Image 1E). The cardiac lymphoma resolved, and the patient is now in remission since more than 3 years. Diagnosis of a primary cardiac B-cell lymphoma: (A) echocardiography identified a mass in the right ventricle; (B) cardiac magnetic resonance imaging showed that this mass was gadolinium-enhancing and thus a perfused vital tumor (arrowheads), the contrast-enhancement was somewhat inhomogeneous with a central hypointensity (arrow), the tumor had contact to the trabeculae of the right ventricle (T), and some pericardial effusion was visible at the apex of the heart (*); (C) a minimally invasive transcatheter biopsy was obtained during right-ventricular catheter angiography; (D) Giemsa staining showed atypical lymphoid cells with large nuclei; and (E) the CD-20 immunostaining was positive. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] In persons without immunodeficiency, a primary cardiac lymphoma is a rare malignancy, accounting for about 1.3% of primary cardiac tumors [1]. Histologically, most cases are DLBCLs [1, 2]. Echocardiography generally is the initial imaging modality. Magnetic resonance imaging is well suitable for obtaining more detailed information about the tumor's localization, mobility, vitality, infiltration of cardiac or pericardial structures, and attached thrombus that might embolize. For the differential diagnosis of magnetic resonance imaging, isointensity of the tumor to the normal myocardium on T1- and T2-weighted images and heterogeneity of gadolinium-enhancement have been described for primary cardiac lymphoma and not for other cardiac neoplasms; however, histology is required for definite diagnosis [3]. Modern therapy, such as chemotherapy with the addition of immunotherapy, has improved the individual prognosis [2, 4].

Hypertrophic Cardiomyopathy With Restrictive Phenotype and Myocardial Crypts

This report describes a 22-year-old woman who has clinical and physiologic features of a restrictive cardiomyopathy. Magnetic resonance imaging showed myocardial delayed enhancement and interventricular septal crypts characteristic of hypertrophic cardiomyopathy (HCM). Transcatheter biopsy confirmed the diagnosis, revealing marked myocyte hypertrophy, interstitial fibrosis, and fiber disarray, which are findings consistent with HCM. A review of the literature suggests that this is the first case of HCM reported with a restrictive pattern and myocardial crypts.

Endomyocardial Biopsy of Right Atrial Angiosarcoma Guided by Intracardiac Echocardiography

We report a case of a 22-year-old female who presented with pericardial effusion and cardiac tamponade. She was diagnosed with a right atrial mass by computed tomography and was referred to our institution for biopsy of this mass. Transcatheter biopsy was performed with intracardiac echocardiography (ICE) guidance, avoiding the need for transesophageal echocardiography or surgery to obtain the biopsy. ICE for transcatheter biopsy of an intracardiac mass is an attractive modality which provides precise localization of the cardiac structures.

Transcatheter biopsy of lesions obstructing the bile ducts.

A method was developed for biopsy sampling of masses obstructing the biliary system in patients with a biliary drainage catheter. The biopsy needle is inserted through the drainage catheter, with fluoroscopic guidance, to the site of the lesion. The technique has been used without complication in more than 30 patients with cancer of the pancreas and bile ducts.

BIOPSY TECHNIQUES IN THE INVESTIGATION OF DISEASES OF THE LUNG, MEDIASTINUM, AND CHEST WALL

Closed biopsy techniques are available for the investigation of diseases of the mediastinum, hilus, and chest wall as well as for pulmonary and pleural disease. Biopsy via the bronchoscope is of greatest value in the diagnosis of endobronchial lesions, especially those that are centrally sited, and of diffuse pulmonary disease including opportunistic infections. Fluoroscopically controlled fiberoptic bronchoscopy is beginning to replace the transcatheter biopsy technique. In general, the use of large needles for biopsy should be avoided. Percutaneous fine needle biopsy is an effective means of sampling lesions of the mediastinum, hilus, and chest wall. However, this mode of biopsy is most widely used as a safe and highly accurate means of diagnosing localized pulmonary disease.

Transcatheter biopsy in the diagnosis of diseases of the respiratory tract. An evaluation of seven years' experience with 693 patients.

Between 1965 and 1972, 693 patients underwent transcatheter biopsy. In most cases, biopsy was performed because of the presence of a pulmonary lesion of suspected malignancy, and bronchoscopy and sputum examination had failed to establish a diagnosis. The method proved highly successful in the diagnosis of primary lung cancer but was less successful in diagnosing metastatic carcinoma. Opportunistic infections of the lungs such as Pneumocystis carinii and aspergillosis were frequently detected when other methods had failed. Complications are rare but may be catastrophic if the technique is undertaken in a patient with active hemoptysis or bleeding diathesis.

Diagnosis of Busulfan Lung by Transcatheter Biopsy

A 58-year-old woman, treated with busulfan for chronic myelogenous leukemia, developed diffuse interstitial pulmonary infiltrates. Histopathologic changes seen in busulfan lung were demonstrated by transcatheter biopsy, and later confirmed at autopsy. This case further illustrates the diagnostic usefulness of transcatheter pulmonary biopsy.

BRONCHOGRAPHIC CRITERIA OF INFLAMMATORY DISEASE AND RADIOLOGIC LUNG BIOPSY TECHNIQUES

The techniques of bronchography, percutaneous needle biopsy, and transcatheter biopsy enable one to determine the etiology of pulmonary lesions without the necessity for thoracotomy in the majority of patients subjected to biopsy. Of the three techniques --- bronchography, transcatheter and needle biopsy --- bronchography is of the least value since evidence for the cause of the abnormal pulmonary density is revealed by bronchography is indirect. Percutaneous aspiration needle biopsy offers the most direct approach to the diagnosis of pulmonary lesions. This method does however expose a significant number of patients to the hazards of pneumothorax and the largely theoretical hazards of tumor dissemination in the pleura or along the needle track. Transcatheter biopsy is more time-consuming than needle biopsy but the likelihood of significant complications occurring is low and the integrity of the pleura and chest wall is preserved. It is not possible to state that one or the other biopsy technique is "best." The decision as to which technique to adopt is sometimes made logically --- e.g., one fears tumor dissemination and therefore advocates transcatheter biopsy, or one is unskilled at catheter manipulation and finding the procedure time-consuming utilizes needle biopsy. We believe that both needle biopsy and transcatheter biopsy techniques have a valid place in the diagnostic armamentarium of radiologists and that every radiologist concerned with the diagnosis of chest diseases of obscure etiology should be familiar with and competent to perform biopsy by both methods.

Transcatheter biopsy of esophageal lesions.

Endoscopic biopsy of esophageal lesions is sometimes impossible, for a variety of reasons. In such cases, a simple technique of transcatheter biopsy has proved to be reliable, simple, and readily tolerated by even the most debilitated patients.