Ultrasound-guided Core Biopsy Research Articles

Diagnostic value of ultrasound guided biopsy in patients with malignant pleural effusion

Aim of workTo study the diagnostic value of ultrasound guided biopsy in patients with malignant pleural effusion. Patients and methodsThis study involved 40 patients with malignant pleural effusion of indeterminate aetiology. All patients had a contrast CT chest performed and were divided into 3 Groups according to their radiologic appearance: GROUP 1: 10 patients having pleural effusion only. GROUP 2: 15 patients having pleural effusion and pleural thickening. GROUP 3: 15 patients having pleural effusion and pleural mass lesions. All 3 groups of patients underwent ultrasound examination in the Radiology department. In patients of Groups 2 and 3, ultrasound fluid aspiration and ultrasound guided core biopsy of the pleura were attempted. Patients of all 3 Groups performed Medical thoracoscopy in the interventional pulmonology unit. ResultsIn Group 1 patients, US guided biopsy was contraindicated and could not be performed due to absence of pleural thickness, nodulation or masses. Thoracoscopy was performed in them all with a sensitivity reaching 90%. In Group 2, a malignant aetiology was reached in 5/10 cases whom had adequate tissue retrieval (sensitivity 50%). In Group 3, 12/15 patients were diagnosed by US guided biopsy (sensitivity 80%). The mean sensitivity of US guided biopsy in both Groups was 65%. Thoracoscopy was then performed successfully in all of patients in Groups 2 and 3 with a diagnostic sensitivity of 100% each. The mean diagnostic sensitivity of thoracoscopy for all 3 Groups was 96.7%. ConclusionThe US guided pleural biopsy with a Tru-cut needle is simple, safe and well tolerated. It is especially useful for patients with pleural tumour, thickened pleura, small amounts of pleural effusion or loculated pleural effusion.

Second-look ultrasound: Only for biopsy or more?

Magnetic resonance imaging (MRI) is a clinically important and increasingly utilized modality in breast imaging. As with any breast imaging modality, there is need for an accurate and well-tolerated biopsy method to establish or exclude malignancy for suspicious lesions detected at breast MRI. When breast MRI was first utilized widely in the clinical setting, the systems needed for direct MRIguided core biopsy was relatively limited. Instead, second-look ultrasound examination (and subsequent ultrasound-guided core biopsy) were performed. Second-look ultrasound is a targeted ultrasound examination of the breast, which may be performed after detection of a breast lesion that is not definitively benign at MRI [1,2]. Information regarding lesion type, morphology, size, and location are obtained from the MRI examination and translated into the ultrasound examination. Second-look ultrasound examination should be performed using high-quality ultrasound equipment and careful technique, taking into account patient (and therefore breast) positional differences during MRI (prone) versus ultrasound (supine or decubitus) examinations [3]. In recent years, sophisticated equipment and software have been developed and marketed for core biopsy using direct MRI guidance. These methods have been shown to be safe and reliable. Nevertheless, second-look ultrasound examination (and subsequent ultrasound-guided core biopsy) remain a clinically relevant approach, as ultrasound-guided biopsy offers some advantages over MRI-guided biopsy. In particular, biopsy guided by ultrasound can be visualized in real-time and is generally less costly, more readily available, and more comfortable for the patient. Additionally, ultrasound-guided biopsy can be performed at the same time as the second-look ultrasound examination, does not require intravenous contrast administration, and certain areas of the breast (e.g. posterior lesions near the chest wall, axillary lesions, lesions near the nipple) are more accessible to ultrasound-guided biopsy than MRI-guided biopsy. However, MRI-guided core biopsy may be indicated if it cannot be established with certainty that the MRI lesion and the finding identified at second-look ultrasound are indeed one and the same [4–6]. Not uncommonly in cases of benign histology, a followup MRI is indicated to evaluate whether or not the clip placed after biopsy at second-look ultrasound correlates with the initial MRI finding, in order to confirm that the finding identified and biopsied at second-look ultrasound is the same finding as the initial MRI finding.

Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy

The objective of this study was to compare the underestimation rate of invasive carcinoma in cases with ductal carcinoma in situ (DCIS) at percutaneous ultrasound-guided core biopsies of breast lesions between 14-gauge automated core-needle biopsy (ACNB) and 8- or 11-gauge vacuum-assisted biopsy (VAB), and to determine the relationship between the lesion type (mass or microcalcification on radiological findings) and the DCIS underestimation rate. We retrospectively reviewed imaging-guided biopsies of breast lesions performed from February 2003 to August 2008. 194 lesions were diagnosed as DCIS at ultrasound-guided core biopsy: 138 lesions in 132 patients by 14-gauge ACNB, and 56 lesions in 56 patients by 8- or 11-gauge VAB. The histological results of the core biopsy samples were correlated with surgical specimens. The clinical and radiological findings were also reviewed. The histological DCIS underestimation rates were compared between the two groups and were analysed for differences according to the clinical and radiological characteristics of the lesions. The DCIS underestimation rate was 47.8% (66/138) for 14-gauge ACNB and 16.1% (9/56) for VAB (p<0.001). According to the lesion type on sonography, DCIS underestimation was 43.4% (63/145) in masses (47.6% using ACNB and 15.8% using VAB; p=0.012) and 24.5% (12/49) in microcalcifications (50.0% using ACNB and 16.2% using VAB; p=0.047). The underestimation rate of invasive carcinoma in cases with DCIS at ultrasound-guided core biopsies was significantly higher for ACNB than for VAB. Furthermore, this difference does not change according to the lesion type on ultrasound. Therefore, ultrasound-guided VAB can be a useful method for the diagnosis of DCIS lesions presented as either mass or microcalcification.

Granular cell tumor in a male breast: Mammographic, sonographic, and pathologic features

Granular cell tumor (myoblastoma) is a rare soft tissue tumor that can present in the breast, producing mammographic and physical exam findings that may be indistinguishable from breast carcinoma. Multifocal lesions in male patients are very unusual. We present a case of a male patient with a granular cell tumor of the breast that was imaged on mammography and sonography. Definitive diagnosis was made with ultrasound-guided core biopsy followed by surgical excision. On clinical examination, the patient demonstrated multiple subcutaneous lesions that were also found to represent granular cell tumor.

Subclinical leishmaniasis associated with infertility and chronic prostatitis in a dog

A stud dog was presented for acquired infertility. Haematospermia and teratozoospermia were found on two ejaculates 2 weeks apart. A presumptive diagnosis of prostatitis was made follo-wing ultrasound examination. An ultrasound-guided needle core biopsy was performed under general anaesthesia, revealing a mild chronic macrophagic and plasma cell prostatitis with intracytoplasmic amastigotes consistent with Leishmania spp. infection. Presence of Leishmania infantum, Leishmania donovani or Leishmania chagasi was confirmed by polymerase chain reaction in seminal plasma. Serology and serum protein electrophoresis confirmed the diagnosis of a subclinical active systemic leishmaniasis. A meglumine antimoniate and allopurinol treatment was given which clearly improved within 3 months both general condition and the quality of sperm. To the authors' knowledge, this is the first reported case of a prostatitis secondary to a Leishmania spp. infection. Subclinical systemic leishmaniasis should be considered in the differential diagnosis of infertility in dogs suffering from semen alterations.

Trastuzumab for Small HER-2+ Breast Cancer: Small Tumor, Big Decision

A 53-year-old postmenopausal woman was found to have a new area of microcalcification at the 10 o'clock position of her right breast during a routine screening mammogram. Ultrasound-guided core biopsy revealed a grade 2 invasive ductal carcinoma, estrogen receptor (ER)+ (90%), progesterone receptor positive (20%), and human epidermal growth factor receptor (HER)-2+ (3+ by immunohistochemistry). A right breast lumpectomy and sentinel node biopsy were performed. The invasive tumor measured 0.7 cm, no lymphovascular space invasion was identified, surgical margins were uninvolved, and the sentinel lymph nodes were negative for tumor. She was evaluated postoperatively in the medical oncology clinic to discuss an adjuvant treatment strategy. The question for our colleagues is: should she be offered adjuvant chemotherapy and trastuzumab prior to adjuvant radiation and 5 years of hormonal therapy?

Ultrasound-Guided Core Biopsy in the Diagnosis of Lymphoma of the Head and Neck. A 9-Year Experience

Ultrasound Quarterly: March 2012 - Volume 28 - Issue 1 - p 44 doi: 10.1097/01.RUQ.0000412981.87812.b8

Analysis by MRI of Residual Tumor After Radiofrequency Ablation for Early Stage Breast Cancer

The objective of our study was to evaluate the effectiveness of MRI in the detection of possible residual lesions after radiofrequency ablation (RFA) in the treatment of breast cancer. We prospectively evaluated 14 patients who had undergone ultrasound-guided core biopsies diagnostic of invasive ductal carcinoma (IDC; range of diameters, 1.0-3.0 cm) and then ultrasound-guided percutaneous RFA with sentinel node biopsy as the primary treatment. Breast MRI was performed 1 week before RFA to evaluate tumor extension and again 3 weeks after RFA to verify the presence of possible residual lesions. Conventional surgical resection of the tumors was performed 1 week after RFA. The MRI findings were compared with histopathologic analyses to confirm the presence or absence of residual tumor. There was no residual enhancement in seven lesions on the postablation breast MRI scans. These findings were confirmed by negative histopathologic findings in the surgical specimens. The MRI scans of five patients showed small areas of irregular enhancement that corresponded to residual lesions. In the two remaining patients, we observed enhancement of almost the entire lesion, indicating that RFA had failed. Breast MRI is effective in detecting residual lesions after RFA in patients with IDC.

Ultrasound-Guided Percutaneous Thyroid Nodule Core Biopsy: Clinical Utility in Patients with Prior Nondiagnostic Fine-Needle Aspirate

Five percent to 20% of thyroid nodule fine-needle aspiration (FNA) samples are nondiagnostic. The objective of this study was to determine whether a combination of FNA and core biopsy (CFNACB) would yield a higher proportion of diagnostic readings compared with FNA alone in patients with a history of one or more prior nondiagnostic FNA readings. We conducted a retrospective study of 90 core biopsies (CBs) performed in 82 subjects (55 women and 27 men) between 2006 and 2008 in an outpatient clinic. CFNACB yielded a diagnostic reading in 87%. The diagnostic reading yield of the CB component of CFNACB was significantly superior to the concurrent FNA component, with CB yielding a diagnosis in 77% of cases and FNA yielding a diagnosis in 47% (p<0.0001). The combination of CB and FNA had a higher diagnostic reading yield than either alone. In 69 nodules that had only one prior nondiagnostic FNA, CB was diagnostic in 74%, FNA was diagnostic in 52%, CFNACB was diagnostic in 87%, and CB performed significantly better than FNA (p=0.0135). In 21 nodules with two or more prior nondiagnostic FNAs, CFNACB and CB were diagnostic in 86%, FNA was diagnostic in 29%, and CB was significantly better than FNA (p=0.0005). Clinical, ultrasound, or histopathologic follow-up was available for 81% (73/90) of the CFNACB procedures. No subject with a benign CFNACB reading was diagnosed with thyroid malignancy in the follow-up period (range 4-37 months, mean 18 months), although one subject had minimal increase in nodule size and was awaiting repeat sonography at study conclusion. Thyroid nodule CFNACB is safe and clinically useful in selected patients when a prior FNA reading is nondiagnostic. CFNACB is superior to either CB or FNA alone. CFNACB should be strongly considered as an alternative to surgery in individuals with two prior nondiagnostic FNAs.

Endoscopic ultrasound-guided fine needle core biopsy versus aspiration for gastrointestinal mass lesions: A randomized trial.

161 Background: Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract (GIT). However, the amount of tissue obtained with a regular aspirating needle is not always satisfactory. A newly developed Coo Pro-Core 22G needle has been proposed to obtain core tissue and may improve diagnostic yield. This study aimed to compare the performance of two EUS guided biopsy systems, Coo 22G fine needle aspiration (FNA) versus Coo 22G Pro-Core (PC) needle, in the evaluation of mass lesions within or adjacent to the GIT. Methods: 61 consecutive patients, who were referred for EUS guided biopsy of mass lesions within or adjacent to the upper GIT, were randomized to either the use of 22G FNA or 22G PC needle. The procedures were performed by a single experienced EUS-endoscopist. Four needle passes were taken from each lesion and all specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were diagnostic yield and complication. Results: EUS guided biopsy was performed with 22G FNA needle in 31patients and with 22G PC needle in 30 patients. There were no differences in age, gender, site or size of biopsied lesion between the groups. Diagnostic yield from the PC group was significantly higher than that of the FNA groups (27/30 vs. 22/31, P=0.04). The ability to obtain core-like tissue and provide “histological” detail were also higher in the PC group (16/30 vs. 0/31, P&lt;0.001). Although no patients with FNA biopsy had complications, the first 4 cases of PC needle biopsy had abdominal pain (with 1 proven pancreatitis), requiring overnight admission. No further complications occurred after the number of PC passes was reduced to 2 per lesion. Conclusions: EUS guided biopsy with Pro-Core needles had a substantially higher diagnostic yield than that with FNA needles, with the ability to provide "histological" information in the majority of cases. Initial use of the Pro-Core needle, however, is associated with an increased risk of abdominal pain, which is reduced with fewer passes and more experience.

Application of pathological diagnosis by using ultrasound-guided percutaneous biopsy for cervical lymph lesions

Objective To evaluate the clinical application value of pathological diagnosis by using ultrasound-guided percutaneous needle core biopsy (PNCB) for cervical lymph lesions.Methods Two hundred and ten patients with cervical lymph lesions underwent ultrasound-guided PNCB,and pathological diagnosis were made based on core biopsy material.The results of study were concluded by comparing the pathological diagnosis from core biopsy of the lymph nodes with those from excision biopsy. Results There were 210 patients underwent ultrasound- guided PNCB,98.6％ (207/210) cases of core biopsies yielded adequate material at first time and 92.9％ (195/210) cases of those had pathologic diagnosis.The accuracy of ultrasound-guided PNCB in differentiating benign from malignant lymphadenopathy was 99.4％ ( 194/195 ).The diagnostic accuracy of metastatic tumor and lymphoma by ultrasound-guided PNCB was 96.4％ (135/140) and 86.1％ (31/36),respectively.Only 67.7％ (21/31) patients with lymphoma could be classified by ultrasound-guided PNCB.Conclusion Ultrasound-guided PNCB in patients with neck lymph lesions is a safe,convenient and quick procedure that has a high diagnosis accuracy.Ultrasound-guided PNCB can replace the open surgery for neck lymph node diagnostic method.Due to the complicated and diverse pathologic performance,lymphoma should be cut by open surgery to confirm the diagnosis and classification. Key words: Diagnostic techniques and procedures; Biopsy; Cervical lymph lesions

Noncirrhotic Portal Hypertension due to Nodular Regenerative Hyperplasia Treated with Surgical Portacaval Shunt

Nodular regenerative hyperplasia (NRH) is an uncommon condition, but an important cause of noncirrhotic intrahepatic portal hypertension (NCIPH), characterized by micronodules of regenerative hepatocytes throughout the liver without intervening fibrous septae. Herein, we present a case of a thirty-seven-year-old female with systemic lupus erythematosus (SLE) who was discovered to have significant esophageal varices on endoscopy for dyspepsia. Her labs revealed a slight elevation in the alkaline phosphatase and mild thrombocytopenia. Abdominal MRI revealed seven focal hepatic masses, splenomegaly, no ascites, and a patent portal vein. Ultrasound-guided core biopsy was reported as focal nodular hyperplasia. However, her varices persisted despite treatment with beta-blockers and four additional upper endoscopies with banding. She was subsequently referred for a surgical opinion. At that time, given her history of SLE, azathioprine use, and portal hypertension, suspicion for NRH was raised. Given her normal synthetic function and lack of parenchymal liver disease, the patient was offered surgical shunting. During shunt surgery, a liver wedge biopsy was also performed and this confirmed NRH. An upper endoscopy six weeks after shunting verified complete resolution of varices. Currently, fifteen months after surgery duplex ultrasonography demonstrates shunt patency and the patient is without recurrence of her portal hypertension.

A Case of Enzootic Nasal Adenocarcinoma in a Ewe

An approximately 2-year-old open Suffolk ewe presented to the North Carolina State University College of Veterinary Medicine Veterinary Health Complex for evaluation of a left nasal mass. An ultrasound-guided aspirate and core biopsies were performed. An epithelial neoplasia with mild mixed inflammation (neutrophils and plasma cells) was diagnosed on cytology and confirmed on histopathology. Immunohistochemistry (IHC), reverse transcriptase polymerase chain reaction (RT-PCR), and transmission electron microscopy were also performed. IHC and RT-PCR identified the presence of enzootic nasal tumor virus and confirmed the final diagnosis of enzootic nasal adenocarcinoma.

Efficacy of Periprostatic Anesthesia according to Lidocaine Dose during Transrectal Ultrasound-Guided Biopsy of the Prostate

PurposeThe aim of this study was to evaluate the efficacy of periprostatic lidocaine injection according to lidocaine dose during transrectal ultrasound-guided prostate biopsy.Materials and MethodsThe subjects of this study were 92 patients who had undergone transrectal ultrasound-guided 12-core biopsy of the prostate. The patients were randomly assigned to three groups: group 1 (n=31, no lidocaine injection), group 2 (n=30, periprostatic injection of 10 ml 1% lidocaine), and group 3 (n=31, periprostatic injection of 20 ml 1% lidocaine). The patients were assessed for pain by use of a 10-point visual analogue scale (VAS) and for other complications after the procedure.ResultsThe mean VAS scores of groups 1 through 3 were 0.93±0.89, 1.32±1.37, and 1.13±1.10, respectively. There were no statistically significant differences between the three groups. However, the mean VAS score of the biopsy pain was 5.0±1.48, 3.93±1.94, and 3.60±2.15, in the same groups, respectively, with statistically significant differences between group 1 and the other groups. Patients in groups 2 and 3 reported significantly less biopsy pain than did group 1 patients (p=0.004, 0.021), with no statistically significant difference in VAS score between groups 2 and 3 (p=0.533). With respect to post-biopsy complications, there were no significant differences in the incidence of hematuria, hematospermia, rectal bleeding, or infection among the three groups.ConclusionsPeriprostatic injection of local anesthesia with lidocaine was associated with significantly less pain than in the absence of anesthesia. Furthermore, a 20-ml dose of lidocaine produced no better pain control than did a 10-ml lidocaine dose for prostate biopsy.

P5-09-01: Breast Cancer Annual Screening Program Núcleo Mama Porto Alegre (NMPOA): Imaging Results after Seven Years.

Abstract Introduction: The NMPOA cohort started in 2004 with the purpose of testing a breast screening model for underserved women in limited resource countries. In the city of Porto Alegre (South Brazil with 1.5 million population), breast cancer incidence rate is 127/100.000 (Brazilian NCI,2010) with increasing mortality due to 45% of Stage III and IV and no public health care early detection program, it was mandatory to test the feasibility of an organized screening program for women with very low income and level of education (64% under 6 years of schooling). In this scenario, there was always a concern of over diagnosis that will increase costs (more biopsies and surgeries) and under diagnosis by the radiologists involved in the program. We present here the results of all breast biopsies performed in this period, and its correlation with the attributed BI-RADS classification in order to optimize care and costs. Also, this study has a long term proposal and other results have been published concerned to the baseline profile of the population (Cancer Epidemiol Biomarkers Prev. 2010 Oct;19(10):2673–9. Epub 2010 Aug 17). Methods:Since April 2004, 5592 women from 40 to 69 years were enrolled in the program and underwent to clinical breast exam and annual mammography screening at NMPOA. Initially, lesions were classified as B1, B2 or B0. After complementary views or exams, B0 was classified as B3, B4 (A, B or C) or B5. B4 and B5 were considered positive tests and immediately submitted to biopsy (open surgical or ultrasound guided core biopsy). B3 was followed according to recommended in BI-RADS fourth edition, and subsequently classified as benign (annual follow up) or suspicious findings (biopsy performed). The evaluation included histological analysis of breast biopsy specimens by two independent pathologists. Predictive positive value (PPV), predictive negative value (PNV) and accuracy (Acc) were calculated. Results: A total of 259 breast lesions were initially classified as BI-RADS 0 (recall rate of 2.8%), and further classification of these was: 166 B3 (64.1%), 60 B4 (23.2%) and 33 B5 (12.7%). Thirty seven B3 (14.3%) were considered suspicious after 6 months and submitted to biopsy. Correlation results of the 130 biopsies performed are summarized on [Table1]. PPV of 63.4% (52.8%-73.1%), PNV of 97.3% (85.8%-99.9%) and an Acc of 73.1% were observed. In this sample, 71.7% of BC were ductal invasive carcinoma, 11.7% ductal carcinoma in situ, 5% lobular invasive carcinoma and 11.6% were other types of neoplasia. Conclusion: Recall rate is in accordance with the medical audit benchmarks recommended of less than 10% published in BI-RADS fourth edition. NMPOA is model for limited resource countries in breast cancer imaging diagnosis. The radiologists involved in the program are classifying breast lesions in accordance with the established parameters, with a high accuracy in diagnosis. Even though we are dealing with a poorly educated cohort not used to any form of screening, our adherence is 57% in 12 months and 71% in 24 months. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-09-01.

Role of ultrasound in the assessment of benignity and malignancy of parotid masses

This study aimed to investigate the value of ultrasound in the identification of benign and malignant parotid masses. Data of 189 patients with parotid gland masses undergoing ultrasound-guided fine-needle aspiration (FNA), core biopsy or surgery were reviewed retrospectively and the presumed sonographic diagnoses were compared with the histopathology. The sensitivity, specificity and accuracy of sonographic diagnoses were assessed and the sonographic characteristics of those lesions, including shape, margin, echogenicity, echotexture and vascularization, were studied. Of the 189 patients, the final pathological diagnosis included 18 malignant tumours and 171 benign masses; the presumed sonographic diagnoses showed 165 cases as benign and probably benign masses (11 cases were confirmed malignant, 154 cases benign) and 24 cases were diagnosed as probably malignant and malignant masses (7 cases were confirmed malignant, 17 cases benign). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound for the diagnosis of parotid gland masses were 38.9%, 90.1%, 29.2%, 93.3% and 85.2%, respectively, and accuracy for malignant masses was 20%. The sonographic characteristics of parotid masses between benign and malignant lesions had no significant differences. The parotid gland masses in this study included pleomorphic adenoma, Warthin's tumour, retention cyst, haemangiomas, chronic granuloma, lymphoma, fibrolipoma, abscess, basal cell adenoma, oncocytoma, lymphatic tuberculosis, myoepithelioma, neurilemmoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, alveolar soft part sarcoma and retinal blastoma (metastasis). It is challenging to use sonography for differentiating between benign and malignant parotid gland masses. To make a definite diagnosis, ultrasound-guided FNA or core biopsy is advocated.

Ultrasound-Guided Core Biopsy: An Effective Method of Detecting Axillary Nodal Metastases

Axillary nodal status is an important prognostic predictor in patients with breast cancer. This study evaluated the sensitivity and specificity of ultrasound-guided core biopsy (Ax US-CB) at detecting axillary nodal metastases in patients with primary breast cancer, thereby determining how often sentinel lymph node biopsy could be avoided in node positive patients. Records of patients presenting to a breast unit between January 2007 and June 2010 were reviewed retrospectively. Patients who underwent axillary ultrasonography with or without preoperative core biopsy were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography and percutaneous biopsy were evaluated. Records of 718 patients were reviewed, with 445 fulfilling inclusion criteria. Forty-seven percent (n = 210/445) had nodal metastases, with 110 detected by Ax US-CB (sensitivity 52.4%, specificity 100%, positive predictive value 100%, negative predictive value 70.1%). Axillary ultrasonography without biopsy had sensitivity and specificity of 54.3% and 97%, respectively. Lymphovascular invasion was an independent predictor of nodal metastases (sensitivity 60.8%, specificity 80%). Ultrasound-guided core biopsy detected more than half of all nodal metastases, sparing more than one-quarter of all breast cancer patients an unnecessary sentinel lymph node biopsy. Axillary ultrasonography, when combined with core biopsy, is a valuable component of the management of patients with primary breast cancer. Its ability to definitively identify nodal metastases before surgical intervention can greatly facilitate a patient's preoperative integrated treatment plan. In this regard, we believe our study adds considerably to the increasing data, which indicate the benefit of Ax US-CB in the preoperative detection of nodal metastases.

Audit of accuracy of ultrasound-guided axillary core biopsy

Sentinel lymph node biopsy (SLNB) is the preferred method of axillary staging in breast cancer. If metastases are detected, axillary node clearance (ANC) is necessary. Preoperative detection of nodal metastases using ultrasound-guided core biopsy (USCB) allows the surgeon to proceed directly to ANC. Negative CBs do not exclude metastases. All patients still need SLNB. However, by minimising false negatives, unnecessary SLNBs can be minimised. We compared our USCB results with the results of subsequent SLNB + axillary node sampling (ANS) or ANC to assess our accuracy.

Parotid cancer treatment with surgery followed by radiotherapy

We read with interest the paper by Shah et al looking at the 15-year experience of parotid cancer in their centre. The review highlights the criticisms frequently aimed at fine needle aspiration (FNA), which often performs poorly outside specialist centres with high non-diagnostic rates. The diagnostic performance of FNA can be improved when undertaken by a cytologist, who can re-aspirate if needed, and with the use of imaging guidance1 and ancillary techniques, which are expensive and not widely available. We would suggest that all patients undergoing parotid surgery should ideally have an accurate preoperative cytological/histological diagnosis. We would agree with the authors that preoperative diagnosis is important for operative planning and informed consent of the patients. A non-diagnostic FNA is as unhelpful as a false negative or false positive result. In this paper an accurate preoperative diagnosis was obtained in only 18 of 27 patients. Four patients had a false positive and five patients had non-diagnostic FNA; these results seem high. Twenty-three patients had no preoperative diagnosis at all although this may to some extent reflect the changing trends in preoperative diagnosis. The authors do not mention the use of ultrasound guided core biopsy (USCB), which has recently been described in the diagnosis of parotid tumours.2,3 The procedure is safe, requiring only local anaesthetic, and can be performed on an outpatient basis. This technique utilises a spring loaded biopsy automated device to obtain a core of tissue, usually via an 18G or 20G needle inserted into the parotid lesion. USCB provides a diagnostic accuracy approaching 100% with the advantage over FNA that it provides a core of tissue that can be used for immuno/histochemical analysis, which will allow grading and typing of parotid malignancy (as well as lymphoma). As recognised by Shah et al, this ability is a crucial aspect of surgical management, allowing the operation to be tailored according to the tumour. Only 12 of 27 patients (44.4%) who had FNA were accurately subtyped in the study by Shah et al. USCB can be combined with diagnostic ultrasonography to facilitate lesion characterisation and also compartmentalisation (superficial vs deep lobe). Additionally, it can be used to obtain biopsies from the solid parts of necrotic lesions. We would suggest that USCB is the technique of choice for the diagnosis of parotid tumours. It not only informs the choice of operative intervention but also provides an accurate preoperative diagnosis for the vast majority of patients, which, combined with further staging investigations, should be a baseline requirement for the multidisciplinary team.

Non-cirrhotic Portal Hypertension Due to Nodular Regenerative Hyperplasia Treated with Surgical Portacaval Shunt

Purpose: A 37 year-old female with systemic lupus erythematosus (SLE) was discovered to have incidental esophageal varices during an endoscopy for dyspepsia. Her labs were normal, except alkaline phosphatase 135(U/L) and platelet count 137,000 (BIL/L). An abdominal MRI revealed seven focal hepatic masses, splenomegaly, no ascites and a patent portal vein. An ultrasound-guided core biopsy of the largest liver lesion was consistent with focal nodular hyperplasia without surrounding cirrhosis. However, given the patient's history of SLE, azathioprine use, and portal hypertension, suspicion for co-existent nodular regenerative hyperplasia (NRH) was raised. Her rheumatologist agreed to discontinue azathioprine. Her varices persisted despite three surveillance endoscopies with banding. To better manage her portal hypertension she underwent a surgical portacaval shunt (Fig 1). During surgery, portal vein pressure measurements and a liver wedge biopsy were performed. The pre-shunt portal vein gradient measured 20 mmHg. The wedge specimen demonstrated multiple hypercellular nodules centered around portal triads without fibrosis, confirming NRH (Fig 2). An endoscopy six weeks after shunting verified complete resolution of varices. NRH is an uncommon condition, but an important cause of non-cirrhotic portal hypertension. A core biopsy can be insufficient, therefore diagnosis of NRH may require a surgical biopsy. In this case, the etiology is likely due to underlying SLE and azathioprine use. Management includes treating underlying disorders and discontinuing offending agents. Patients with NRH have preserved liver function, thus morbidity is due to portal hypertension. In this case, portal hypertension was successfully managed with a surgical portacaval shunt.Figure 1: No Caption available.Figure 2: No Caption available.