Ultrasound-guided Core Biopsy Research Articles

Évaluation du creux axillaire en 2024 : point de vue du chirurgien et rôle du radiologue

For patients with breast cancer, de-escalation of armpit surgical treatments happened during the last twenty years to reduce the morbidity mainly induced by complete axillary lymph node dissection, with a broadening of sentinel lymph node biopsy indications and, more recently, the development of targeted lymph node excision, with no impact on patient survival. Axillary ultrasound combined with clinical examination can predict the tumour burden in the axilla. At the same time, the radiologist's role has evolved, as they must describe the number of suspicious lymph nodes, which determines surgical management. Patients having fewer than two suspicious lymph nodes are eligible for sentinel lymph node biopsy. Ultrasound-guided fine-needle aspiration or core biopsy will provide proof of lymph node involvement.

Two cases of breast pseudoaneurysm following core biopsy: A very rare complication with different treatment options

Introduction: Breast pseudoaneurysm is a rare complication following breast interventional procedures such as core biopsies and vacuum-assisted biopsies. The occurrence of pseudoaneurysm increases with the conditions of increased breast vascularity like cancer, pregnancy and lactation. Case Report: We present two cases of pseudoaneurysm formation secondary to core biopsies of the breasts. The first patient was an 82-year-old female patient who presented with breast swelling and bruising after multiple clinical core biopsies of the left breast. Our second patient was a 47-year-old lady who presented with a palpable lump following ultrasound-guided core biopsies of the left breast. Ultrasound showed hypoechoic pulsating area with evidence of internal colour flow in connection with a vessel in both cases. Imaging appearances were in keeping with a pseudoaneurysm of the breast. Discussion: Most pseudoaneurysms are secondary to interventional procedures in the breast. Common clinical presentation is a pulsatile, palpable mass at the biopsy site soon after the biopsy or later. On B mode imaging, it presents as a well-circumscribed mass of mixed echogenicity. Typical waveform in spectral Doppler and ‘yin-yang’ sign in colour Doppler is demonstrated with a turbulent internal flow. There are different treatment options to manage pseudoaneurysms of the breast. Conclusion: Pseudoaneurysm of the breast should be considered if a patient presents with a breast mass/lump close to a recent biopsy site. On clinical examination, pulsatility of the mass should raise the suspicion and definite diagnosis can be made with spectral and colour Doppler US scan.

A159 MALIGNANT PERITONEAL MESOTHELIOMA: A CASE OF MISTAKEN IDENTITY

Abstract Background In the Western hemisphere, cirrhosis is the most common cause of ascites. One of the least common causes is malignant peritoneal mesothelioma (MPM), which occurs in one in one million cases. MPM can be a diagnostic challenge due to its rarity and features that mimic other causes of ascites. Aims To describe a complex case of MPM, highlighting the diagnostic dilemma stemming from the subtleties of presentation, confounders in ascites diagnostic criteria, and indeterminate testing. Methods We performed a detailed retrospective chart review of a patient who presented with ascites. He was initially given the diagnosis of decompensated cirrhosis and eventually was diagnosed with MPM. He provided his consent for this case report. Results A 37-year-old male presented with progressive ascites and peripheral edema. He had no known exposure to asbestos and consumed 6 standard drinks a day for 2 years; with a prior history of 10 standard drinks a week for over 3 years. His physical examination was unremarkable for cardiac, renal or liver disease. His transthoracic echocardiogram and urinalysis were normal. Abdominal ultrasound showed features of liver cirrhosis with large-volume ascites and a FIB-4 score of 0.34, excluding advanced fibrosis Laboratory investigations including liver tests were normal; with a platelet count of 568 x 109/L. Viral, metabolic and autoimmune liver disease were excluded. A diagnostic paracentesis demonstrated a serum albumin-ascites gradient (SAAG) of 1.3 g/dL. Due to his history of alcohol misuse, imaging findings and high SAAG, he was diagnosed with alcohol-related cirrhosis. His repeat abdominal ultrasound showed multiple liver nodules. Magnetic resonance imaging was done to investigate for hepatocellular carcinoma; revealing diffuse peritoneal carcinomatosis, cirrhosis and large-volume ascites. Investigations to identify the primary malignancy included a computed tomography chest, colonoscopy and EGD. His EGD was the only positive test; showing a 2cm submucosal gastric lesion with normal gastric mucosa pathology. An endoscopic ultrasound (EUS) with fine needle aspiration was then performed; the lesion appearance in keeping with a gastrointestinal stromal tumor (GIST). Pathology favored a diagnosis of poorly differentiated gastric carcinoma. Cytology was positive for malignancy, with the differential being mesothelioma or adenocarcinoma and a repeat SAAG was 1.0 g/dL. Given the discordances, an ultrasound-guided core biopsy was performed of the peritoneal lesions. Pathology revealed features of poorly differentiated epithelioid mesothelioma. A subsequent review of his gastric biopsies revealed similar cells in retrospect were in keeping with mesothelioma. Conclusions The presentation of MPM is not easily distinguishable from other causes of ascites. There must be a high degree of suspicion for malignant ascites in the face of inconsistent clinical and diagnostic findings. Funding Agencies None

Head and neck cancers: epidemiology, diagnosis and treatments

Introduction: Head and neck cancers (HNC) affect many subsites in the upper aero-digestive tract. The risk factors include tobacco smoking, chewing betel nut/paan, excessive alcohol consumption, hereditary factors and viruses such as human papillomavirus (HPV) and Epstein–Barr virus (EBV). Early diagnosis, lifestyle changes and HPV vaccination will improve survival. Epidemiology: Globally, recent estimates from GLOBOCAN shows there are 890,000 cases of head and neck cancers annually and 450,000 deaths annually (1). There is an increasing incidence of oral cavity, lip, buccal cancers in the developing world due to higher consumption of tobacco, alcohol and chewing areca nut. There has been an increasing incidence of some HNC due to high-risk strains of human papillomavirus (HPV) (2). Cancers caused by HPV include tonsil cancer, tongue base cancer and unknown primary cancers. The EBV causes nasopharyngeal cancers especially in the Far East. There is a decreasing incidence of some cancers caused by smoking such as laryngeal and hypopharyngeal cancers mainly due to the reduction in smoking rates in some developed countries. Overall, there is a predicted increase in HNC of up to 30% annually by 2030 (2). The HPV-associated cancers affect mainly younger males, who do not necessarily smoke or drink alcohol. The HPV is a strong prognostic factor so patients with HPV positive cancers respond better to treatment as there are less genetic mutations when compared to cancers driven by tobacco smoking. These trends are alarming with socioeconomic impacts. Diagnosis: Symptoms of HNC include difficulty swallowing, persistent sore throat, difficulty breathing, hoarseness, neck lumps, referred pain to the ear, weight loss, and systemic symptoms in advanced disease. A full ENT examination is performed of the oral cavity, oropharynx, neck and ideally flexible nasendoscopy. Ultrasound-guided FNAC or core biopsy of neck lumps are performed. Cross-sectional imaging with CT or MRI scans followed by tumour biopsies either under local or general anaesthetic. Tumour biopsies are assessed using H&E stains, and tests for HPV detection (p. 16 immunohistochemistry, in situ hybridisation or polymerase chain reaction). A PETCT scan is useful for staging cancers, identifying the origin of unknown primary cancers and for surveillance. Treatments: The head and neck cancer multidisciplinary team reviews all investigations and recommends either curative or palliative treatment options that are in every patient’s best interests. Surgery can be open, endoscopic or with the use of a robot. Microvascular reconstruction with flaps is performed as necessary to improve function and quality of life. Oncologic treatments include intensity-modulated radiotherapy (IMRT), which can be combined with chemotherapy. Immunotherapy is a second-line treatment for recurrent HNC currently. Advanced cancers can be treated with palliative intent or best supportive care especially if the patients are frail and have significant comorbidities. There are ongoing clinical trials and research studies exploring better, less-toxic treatments. Multiomics approach and artificial intelligence are exciting developments. Conclusion: There is an increasing incidence of some HNC especially cancers driven by tobacco smoking, alcohol consumption and high-risk human papillomaviruses. Smoking cessation, HPV vaccination, early diagnosis and improvements in treatments are important factors in ensuring good outcomes.

Diagnostic Value of Concurrent Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Fine-Needle Core Biopsy in Cytology Categories of Pancreatic Solid Lesions: An Institutional Experience

Abstract Introduction/Objective Endoscopic ultrasound is the current standard of care in the evaluation of pancreatic solid lesions. Two methods have been employed in obtaining EUS-guided pancreatic specimens; fine needle aspiration (EUS-FNA) and fine needle core biopsy (EUS-FNB). EUS-FNA may have certain limitations, including the inability to assess the histological architecture and a limited sample size for immunohistochemical staining on cell blocks. EUS- FNB, which employs a larger needle for core biopsy, was developed to address these limitations. However, it is still uncertain which method is better suited for specific lesions. In this study, we evaluated the diagnostic efficacy of concurrent EUS-FNA and EUS-FNB from pancreatic solid lesions. Methods/Case Report We reviewed our institutional database for cases that had EUS-FNA from pancreatic solid lesions with a subsequent definitive diagnosis on histology. Similarly, the concurrent EUS-FNB findings were recorded. The cases were categorized based on the World Health Organization pancreaticobiliary cytology reporting system. Furthermore, the absolute risk of malignancy (ARM) of each diagnostic category (defined as the presence of high-grade dysplasia or worse on the histologic follow-up) was calculated. Results (if a Case Study enter NA) A total of 108 cases were reviewed for the study from 1/1/2019 to 6/1/2022. The patients were 47% male and 53% female with an average age of 68. No case was categorized as non-diagnostic or neoplastic high-grade. There were 20 benign, 7 atypical, 3 neoplastic low-grade, 6 suspicious for malignancy, and 72 malignant cases, and the associated ARM related to each category was 40%, 86%, 33%, 33%, and 96% respectively. Concurrent EUS-FNB was performed in 23 cases in total (12 in malignant and 11 in other categories). EUS-FNB exhibited 95% positive and 100% negative predictive values (PPV and NPV) in all categories combined and 89% PPV and 100% NPV in non-malignant and indeterminate categories (categories II, III, IV, VI) for correlating to the histologic follow-up. Conclusion Cases diagnosed in all categories except the malignant category demonstrated ARM rates higher than expected. When approaching a solid pancreatic lesion, EUS-FNB may increase the diagnostic value, especially in cases of non-malignant and indeterminate categories. Moreover, categorizing the cases in the benign category may require additional supporting data, and placing them in the nondiagnostic category may be more appropriate warranting re-sampling if there is a clinical vs pathologic discrepancy.

Ultrason Rehberliğinde Yapılan Meme Biopsi Hakkında Youtube Videoları Yararlı ve Güvenilir Mi?

Background: The aim of this study is to evaluate the usefulness and quality of YouTube videos on ultrasound-guided breast biopsy (UGBB) for patients. Materials and Methods: A video search was undertaken on YouTube on Aug 14, 2020 using the keywords, ‘breast biopsy’, ‘ultrasound-guided core biopsy’, ‘breast ultrasound’, and ‘breast biopsy ultrasound’. Top 100 videos were selected using each keyword (total 400 videos). After applying the exclusion criteria, 51 videos were evaluated by two researchers based on the patient information form of the American Cancer Society and American College of Radiology. According to these criteria, the videos were divided into four categories as very useful, useful, slightly useful, and not useful. Video parameters were compared between the groups by the Kruskal–Wallis test. Results: Of the 51 videos analyzed, 13.7% (n=7) were very useful, and 41.2% (n=21) were useful. Of the very useful videos, 85.7% (n=6) had been uploaded by physicians/hospitals. The DISCERN reliability score was significantly higher in very useful videos (median: 4, range: 2-5, p < 0.001). The length and number of likes and comments were significantly higher for the videos uploaded by civilian individuals (p=0.005, p=0.046, and p=0.013, respectively). Not useful and very useful videos were significantly longer (p = 0.01) Conclusion: Although the primary sources of high-quality and very useful YouTube videos about UGBB were physicians/hospital, a significant portion of low-quality videos had also been uploaded by this group. Thus, medical professionals should take care to upload well-informed videos.

A Rare Case of Sarcoidosis Presenting as an Isolated Breast Mass and Pain: A Case Report and Literature Review.

BACKGROUND Sarcoidosis is a benign systemic granulomatous disorder of unknown etiology that affects multiple organs. Patients diagnosed with sarcoidosis usually present with nonspecific symptoms: fatigue, fever, weight loss, and respiratory symptoms such as cough and dyspnea; 50% of the patients are asymptomatic at the time of diagnosis. In 90% of patients, sarcoidosis targets hilar and mediastinal lymph nodes. In rare cases, it presents solely in the breast with no other symptoms. The diagnosis is established based on compatible clinical and radiological findings and supported by histological evidence in 1 or more organs of non-caseating epithelioid cell granulomas in the absence of organisms or particles. CASE REPORT We herein present a unique case of a 27-year-old woman who presented with pain and swelling in her left breast. On examination, the left breast revealed multiple, firm-hard, and tender masses. Breast ultrasound showed large loculated focally dilated ducts with significant periductal vascularity and inflammation. Fine-needle aspiration (FNA) showed an inflammatory process with granulomatous formation. An ultrasound-guided core biopsy, which was histologically consistent with granulomatous mastitis, and elevated angiotensin-converting enzyme (ACE) levels confirmed a diagnosis of sarcoidosis. The patient was started on IV steroids followed by oral prednisolone and azathioprine. During treatment, the mass size decreased and the pain substantially improved. CONCLUSIONS It is important to consider sarcoidosis in a patient who presents with only pain and swelling in the breast to ensure early diagnosis and initiate treatment, improving the patient's overall prognosis.

Tall Cell Variant of Invasive Papillary Breast Carcinoma.

Tall cell variant of invasive papillary breast carcinoma is exceedingly rare, with only 30 cases reported in the literature. This report describes a case of a 47-year-old woman who presented to the clinic with bilateral breast masses on a screening mammogram. The patient was lost to follow-up, but she presented again after 4 years when the right breast mass significantly grew in size over several months. Mammography showed a 1.9 cm right breast mass and a 2.3 cm left breast mass. Ultrasound-guided core biopsy revealed right breast triple negative invasive carcinoma of the tall cell papillary variant and left breast fibroadenomatoid nodules. She underwent bilateral lumpectomies with a right sentinel lymph node biopsy and was started on chemotherapy after surgical excision.

Contrast-Enhanced Ultrasound of Fibrolamellar Hepatocellular Carcinoma

We present the case of a 24-year-old male patient, who was admitted for endoscopy due to sustained pain in the upper abdomen with nausea and postprandial fullness without vomiting for more than 5 months. In the physical examination, an epigastric induration was found. Endoscopy revealed an external impression of the proximal duodenum. Beyond that, normal findings could be ascertained in gastroscopy and ileo-colonoscopy. Abdominal ultrasound identified a large hypoechoic lesion in the left liver lobe with a sharp delineation. Along the upper mesenteric vessels, enlarged lymphnodes were visible with contact to the proximal duodenum. Contrast-enhanced ultrasound (CE-US) was conducted and revealed the typical perfusion pattern of hepatocellular carcinoma. For further assessment, an ultrasound-guided core-biopsy of the lesion was performed. The histopathological evaluations resulted in the diagnosis of a hepatocellular carcinoma of fibrolamellar subtype.With the present case, we want to illustrate the perfusion pattern of a fibrolamellar hepatocellular carcinoma in contrast-enhanced ultrasound. Even though the tumor tissue is surrounded by lamellar bands of fibrosis with collagen-rich fibers, the perfusion pattern is consistent with the previously known appearance of HCC in CE-US.

Comparison of Transrectal Prostate Digital and Ultrasound-Guided Core Biopsies in 400 Men in a Low-and-Middle Income Country

Comparison of Transrectal Prostate Digital and Ultrasound-Guided Core Biopsies in 400 Men in a Low-and-Middle Income Country

Accuracy of core biopsy image-guided post-neoadjuvant chemotherapy breast to predict pathologic complete response

Background. Achieving a pathologic complete response (pCR) after neoadjuvant systemic therapy (NST) is a predictive factor for improving disease free and overall survival. In triple negative (TN) and HER2-positive breast cancer (BC), the pCR rate exceeds 60 %. Patients with TN and HER2-positive BC who demonstrate an excellent response to NST are like­ly ideal candidates for downsizing surgery. The condition for reducing the volume of surgical intervention is a reliable determination of pathologic complete response using instrumental imaging and biopsy methods.Aim. To further assess the accuracy of post-NST image-guided biopsy to predict pCR.Materials and methods. Sixty one patients with T1-3N0-3 triple negative or HER2-positive BC receiving NST in the Department of Breast Tumors of the NMRC of Oncology named after N.N. Petrov in the period from 2017 to 2019 were enrolled in this single-center retrospective trial. Patients underwent ultrasound-guided core-biopsy of the initial breast tumor region before surgery. Findings were compared with findings on pathologic evaluation of surgical specimens to determine the performance of biopsy in predicting pCR after NST.Results. After neoadjuvant systemic therapy, clinical partial response (cPR) was diagnosed in 47 (77 %) patients, clinical complete response (cCR) in 14 (23 %) patients. pCR in the core-biopsy tissue and surgical material was achieved in 46 (75.4 %) and 37 (60.7 %), respectively. Performance of image-guided core-biopsy: sensitivity 100 % (95 % confldence interval (CI) 90.51-100), specificity 62.5 % (95 % CI 40.59-81.20), false-negative rate (FNR) 0 %, positive-pre­dictive value (PPV) 75.00 % (95 % CI 59.46-85.99), negative predictive value (NPV) 100.00 %.Conclusion. This retrospective trial showed that ultrasound-guided core biopsies are accurate enough to identify breast pCR in patients with triple-negative or HER2-positive BC with good response after NST (FNR 0 %). Based on these results, a prospective clinical trial has commenced in which breast surgery is omitted in patients with a breast pCR after NST according to image-guided biopsy.

A Scalp Metastatic Follicular Thyroid Carcinoma with a Silent Thyroid History and Normal Thyroid Uptake by PET-CT

Abstract Introduction/Objective Follicular thyroid carcinoma (FTC) accounts for 10%-15% of all primary thyroid cancers. Follicular thyroid cancer is known to metastasize hematogenously, with distant metastasis occurring in 6-20% of cases. Scalp metastasis with an underlying thyroid carcinoma is an exceedingly rare clinical entity; there are less than 15 case reports in the literature. 1-2. Here, we present a case of widely invasive FTC with skull metastases located on the parietal calvarium. The scalp mass was confirmed as follicular thyroid carcinoma via microscopic morphology and positive immunoreactivity for Vimentin, TTF1, thyroglobulin, and PAX8. We present this case not only because of the diagnostic challenge and rare scalp metastasis, but also because of the patient’s unusual “silent” thyroid medical history and no abnormal thyroid uptake by PET-CT. Methods/Case Report 81-year-old female presenting 2-year history of right parietal scalp mass, which was previously suspected for lipoma with attempted resection in Mexico but interrupted due to severe hemorrhage. No palpable thyroid nodule was noted. PET-CT showed avid lesions of the right breast with nipple retraction, as well as avid suspicious lesions of bilateral lungs, calvarium, xiphoid process, right acetabulum, T spine most c/f widely metastatic cancer, most likely a breast primary; evaluation of the neck demonstrates physiologic FDG-activity in the thyroid. Thyroid studies showed hyperthyroidism: TSH (L) <0.010 uIU/mL; Free T3 (H) 4.7 pg/mL and Free T4 1.00 ng/d. The patient was performed Ultrasound-guided FNA and core biopsy of the large parietal scalp lesion, however, FNA of the cystic component was nondiagnostic (no malignant cells seen). Results (if a Case Study enter NA) NA. Conclusion Core biopsy of the large parietal mass the tumor cells tend to form follicular or microfollicular architecture with colloid present, but no papillary nuclear features. Rare mitotic figures are seen. IHC stain of tumor cells are positive for AE1/AE3, Cam5.2, CK7, TTF1, thyroglobulin, PAX8, and Vimentin, which show strong evidence for metastatic follicular thyroid carcinoma (FTC) origin. Tumor cells are negative for Napsin-A, P63, Synaptophysin, Ck5/6, Ck20, EMA, WT1, CDX2, GATA3, Mammaglobin, ER, PR, and BRST2, which helps rule out the primary malignancy from lung, breast, neuroendocrine or other adenocarcinomas.

Incorporation of ultrasound-guided core biopsy with flow cytometry to assist the diagnosis of cervical lymphoma.

The main purpose of surgery for cervical lymphoma is only for tissue sampling. To establish a patient-friendly diagnostic approach, we investigated the feasibility of ultrasound-guided core biopsy with flow cytometry in the patients with suspected cervical lymphoma. We prospectively recruited patients with suspected cervical lymphoma from Nov 2017 till Jan 2021 in a referral medical center and performed retrospective interpretation of the prospectively acquired data. Ultrasound-guided core biopsy as the tissue sampling approach for the targeted lesions was performed in all patients. The ultrasound-guided core biopsy samples were analyzed by immunohistochemical stains and flow cytometry. The sample quality and therate of definite and decisive diagnosis obtainedby ultrasound-guided core biopsy alone and ultrasound-guided core biopsy with flow cytometry were evaluated. Total 81 consecutive patients were recruited for analysis. All ultrasound-guided core biopsy samples were qualified for analysis of pathology and flow cytometry. Pathologically, the diagnoses were definite and compatible with their flow cytometry results in 70 patients (86.42%). Either newly-diagnosed or recurrent cervical lymphoma/lymphoproliferative disorders with histologic transformation could be diagnosed by ultrasound-guided core biopsy with flow cytometry. Nine of the 11 patients with pathologically indefinite diagnosis became clinically decisive when flow cytometry was incorporated into the process, which improved the rate of decisive diagnosis to 98.77% (Odds ratio [95% CI]: 6.21 [1.28, 58.96]). Ultrasound-guided core biopsy combined with flow cytometry is suggested to serve as the first-line and patient-friendly diagnostic approach for the patients with suspected cervical lymphoma.

308 Fine Needle Aspiration Cytology vs Ultrasound Guided Core Biopsy in the Diagnosis of Parotid Neoplasia: An Up-to-Date Review

Abstract Aim Parotid tumours account for 80% of salivary neoplasms. Regarding diagnostic techniques, fine needle aspiration cytology (FNAC) has long been the technique for tissue sampling and can be optimised with ultrasound or presence of a cytopathologist. USCB differs in that it obtains a core of tissue which allows preservation of the tissue architecture. The authors performed a literature review to provide an update on current practice and outcomes of both techniques Method A literature review of EMBASE, Medline, PubMed and Google Scholar were conducted. Regarding USCB, four systematic reviews and meta-analyses were identified, alongside three other studies that were not included within these papers. Regarding FNAC, three systematic reviews and meta-analyses were identified, alongside seven other studies, not included within these papers, using optimised FNAC in sample sizes of over fifty. Results USCB has higher sensitivity, specificity, and lower non-diagnostic rates than optimised fine needle aspiration cytology (FNAC). It also has a significantly higher sensitivity for the detection of malignancy. Complications post-USCB are uncommon, with only one reported case of tumour seeding and no cases of permanent facial nerve dysfunction. The technique is less operator dependent than FNAC, with less variation in results between institutions. Conclusions USCB can be considered as the optimum tool of choice for diagnosis of parotid neoplasia. This would particularly be the case in centres utilising FNAC with high non-diagnostic rates or reduced diagnostic accuracy when compared to USCB published data or in centres establishing a new service.

Promoting simulation-based training in radiology: a homemade phantom for the practice of ultrasound-guided procedures.

Ultrasound-guided intervention is an essential skill for many radiologists and critical for accurate diagnosis and treatment in many radiology subspecialties. Simulation using phantoms have demonstrated statistically significant benefits for trainees within the literature. We propose a novel phantom model which the authors feel is ideal for training clinical radiology trainees in the performance of ultrasound-guided procedures. The recipe to prepare a homemade phantom is described. Results of a local survey from trainees preparing and using the phantom are also presented. This realistic training simulation model can be adapted to suit a variety of biopsy devices and procedures including soft tissue biopsy and cyst aspiration. The phantom mimics the sonographic appearances of soft tissue and biopsy targets can be concealed within. The phantom was easily prepared by 22 trainees (Likert score 4.5) and it functioned well (Likert score of 4.7). In summary, our phantom model is ideal for training clinical radiology trainees in the performance of ultrasound-guided core biopsy. The availability and low cost of the model, combined with the ease of preparation and reproducibility, make this an efficient and effective addition to the training process. A low cost easily handmade phantom recipe is described that could be easily implemented in training schemes.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings

ObjectivesTo determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings. Material and methodsThis retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity. ResultsCore-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%. ConclusionsCore-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

The efficacy of incorporating ultrasound-guided core biopsy into the clinical workflow of indeterminate thyroid tumors

Ultrasound-guided core biopsy (USCB) is a minimally invasive sampling procedure which may help to confirm the diagnoses of the thyroid tumors with indeterminate results of ultrasound-guided fine-needle aspiration (USFNA). Although with potential advantages, the working protocol of introducing USCB in the routine practice has not been established yet. This study aims to evaluate the efficacy of USCB when it is included in the clinical workflow of assessing the thyroid tumors with indeterminate USFNA results after a long-term follow up. Between 2009 and 2016, consecutive patients receiving thyroid USFNA were reviewed retrospectively in the tertiary referral hospital. The patients, who finally received USCB for their thyroid tumors after repeated indeterminate USFNA results, were recruited. The important sonographic features in facilitating specific diagnoses by USCB, differentiating malignancy from benignity, and confirming origins of thyroid tumors were analyzed and the role of USCB was investigated. Thirty-nine patients met the inclusion criteria were analyzed. The specific diagnoses were confirmed in 23 patients (59%) by USCB. Taller than wide, ill-defined margin and hypoechogenicity helped in differentiating malignant tumors and the latter two features were pertinent to the success of applying USCB for specific diagnosis. No sonographic features were able to differentiate the thyroid malignancy from extra-thyroid origins exclusively. Thyroid USCB facilitated clinical decision making in 37 of the 39 patients (94.9%) with indeterminate USFNA results. The USCB is a cost-effective sampling procedure for confirming the diagnosis of indeterminate thyroid tumors and their clinical management, especially for those malignancies from extra-thyroid origins.

Performance of Ultrasound-Guided Core Biopsy Driven by FDG-avid Supraclavicular Lymph Nodes in Patients With Suspected Lung Cancer.

ObjectivesUltrasound-guided core biopsy (UGCB) for supraclavicular lymph nodes (SLNs) represents an attractive procedure to obtain tissues for lung cancer confirmation. The aim of the present study is to evaluate the performance of UGCB driven by FDG-avid SLNs, as performed by nuclear medicine physicians, in patients with suspected lung cancer.MethodsInstitutional database in our hospital was searched for eligible patients between September 2019 and March 2021. A 3-12 MHz linear probe was used to guide the biopsy process and to ensure that the needle tip was being directed at the metabolically active area that had been indicated by side-by-side PET/CT images. Diagnostic yield, malignancy rate, molecular testing results, and complications were reviewed.ResultsAmong the 54 patients included in this study, definite pathological diagnosis from UGCB specimens was achieved in 53 patients, reaching a diagnostic yield of 98.1% (53/54) and a malignancy rate of 96.2% (51/53). Among the 50 patients confirmed as lung cancer, thirty-eight were spared from further invasive procedures which had been planned. Molecular analyses were adequately performed on all the 38 specimens obtained from non-small cell lung cancer (NSCLS). The positive rate was 36.8% (14/38) for epidermal growth receptor (EGFR) mutation and 31.6% (12/38) for anaplastic lymphoma kinase (ALK) translocation. 28.9% (11/38) of the patients had a tumor proportion score (TPS) ≥ 50% for PD-L1 expression. No complication was observed and the average biopsy time was 15 min.ConclusionsNuclear medicine physicians-performed UGCB driven by FDG-avid SLNs in suspected lung cancer patients could produce a high performance in terms of diagnostic yield, malignancy rate, and molecular analysis, which may obliviate more invasive interventional procedures and lead to fast decisions on subsequent management.

Liver Tumor Post Liver Transplantation for Hepatitis C Cirrhosis: An Unusual Cause

Question: A 60-year-old African American man with a history of hepatitis C virus (HCV) cirrhosis underwent orthotopic liver transplantation in 2009. The explant showed chronic HCV with mild activity and cirrhosis (grade 2, stage 4) without evidence of malignancy. The post-transplant course was complicated by recurrent HCV treated 5 years later with simeprevir and sofosbuvir with a sustained viral response. However, the patient developed fibrosing cholestatic hepatitis with rapid progression to fibrosis and portal hypertension demonstrated by small varices and ascites. A liver biopsy in August 2010 revealed mild to moderated inflammatory activity and incipient bridging fibrosis grades 2–3, stages 2–3. Due to worsening renal function and new-onset proteinuria, the dose of the calcineurin inhibitor was reduced and mycophenolate mofetil was added. He was lost to follow-up from 2014 to 2016. Magnetic resonance imaging in February 2017 for screening showed numerous masses in the liver with arterial enhancement and incomplete but progressive washout, some with an enhancing capsule (Figure A–C). At the time, his laboratory tests showed excellent graft function. What is the diagnosis and strategy for treatment? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Given the history of HCV infection and transplantation, there was concern for hepatocellular carcinoma. An ultrasound-guided core biopsy showed a vascular tumor positive for CD34 and negative for pancytokeratin and CK7, consistent with epithelioid hemangioendothelioma (HEHE) (Figure D-F). Low-power image on with hematoxylin and eosin staining (Figure D) shows upper core with normal liver, and lower core with replacement by vascular lesion (black arrow) with hemorrhage (thick black arrows). Figure E shows high power image with multiple diminutive vascular channels replacing liver parenchyma (black arrowheads), and Figure F with vascular channels replacing liver parenchyma on CD34 stain (black arrows). Figures A-C demonstrate HEHE lesions as target shaped lesion on a T1-weighted volumetric interpolated breath-hold examination sequence (Figure A), with largest lesion in a postcontrast sequence (Figure B), and multiple lesions seen on venous phase sequence (Figure C). Retransplantation was considered; however, given the indolent nature of the lesions, he was referred to oncology and interventional radiology for treatment. He did not make those appointments, and the latest blood tests in August 2020 showed stable graft function with no decompensation. He developed dementia and has not been able to follow-up with further imaging. HEHE was first described in 1984 and is a rare indolent malignant tumor with unclear etiology with vague presentations including abdominal discomfort, nausea, and vomitting.1Ishak K.G. Sesterhenn I.A. Goodman M.Z.D. et al.Epithelioid hemangioendothelioma of the liver: A clinicopathologic and follow-up study of 32 cases.Hum Pathol. 1984; 15: 839-852Crossref PubMed Scopus (382) Google Scholar HEHE rarely involves the vasculature, causing Budd–Chiari Syndrome, veno-occlusive disease, and portal hypertension. At diagnosis, extrahepatic involvement is reported in 36.6% of patients involving lungs, regional lymph nodes, and peritoneum.2Mehrabi A. Kashfi A. Fonouni H. et al.Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy.Cancer. 2006; 107: 2108-2121Crossref PubMed Scopus (343) Google Scholar Although the etiology is unknown, reported associations include oral contraceptive use, alcohol consumption, liver trauma, sarcoidosis, Crohn’s disease, viral hepatitis, and vinyl chloride or asbestos exposure.2Mehrabi A. Kashfi A. Fonouni H. et al.Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy.Cancer. 2006; 107: 2108-2121Crossref PubMed Scopus (343) Google Scholar Treatment options include a combination of liver resection, transarterial chemoembolization, liver transplantation, and the possible addition of chemotherapy.2Mehrabi A. Kashfi A. Fonouni H. et al.Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy.Cancer. 2006; 107: 2108-2121Crossref PubMed Scopus (343) Google Scholar,3Brahmbhatt M. Prenner S. Bittermann T. Liver transplantation for hepatic epithelioid hemangioendothelioma is facilitated by exception points with acceptable long-term outcomes.Transplantation. 2020; 104: 1187-1192Crossref PubMed Scopus (13) Google Scholar HEHE should be considered in the differential diagnosis of de novo liver masses after liver transplantation.

12-year review of MRI-detected breast cancers. How often was a diagnosis of malignancy established using targeted ultrasound and standard 14-gauge core biopsy?

This retrospective study aimed to determine the percentage of MRI-detected breast cancers diagnosed using targeted ultrasound and standard 14-gauge (14g) biopsy in the setting of an Australian breast MRI service. This is of clinical relevance because malignancies not identifiable on mammography or by ultrasound may then require more invasive, technically demanding and costly MRI-guided interventional procedures, usually by large-core vacuum-assisted biopsy (VAB) or hook-wire localisation with open surgical biopsy. On review of the 12-year period 2006-2018, we identified 67 new breast cancer events in 64 women where the diagnosis was made on the basis of the MRI scan findings either alone (n = 60) or in combination with a concurrent mammogram (n = 7), with no recorded clinical abnormality. The percentage in which malignancy was confirmed on histopathology using targeted ultrasound in combination with 14g biopsy was determined versus other biopsy methods, for both invasive cancer and insitu disease. Ultrasound-guided 14g biopsy was successful in establishing the presence of malignancy in 42/46 (91%) of events with a final diagnosis of invasive cancer, with 2 more proven by MRI-guided interventional procedures (1 VAB and 1 hook-wire) and 1 by open surgical biopsy. In the final case, a 5 mm focus on MRI with no sonographic correlate at the initial presentation was only identified and biopsied by ultrasound at 12-month follow-up. For events with a final diagnosis of DCIS/pLCIS (pleomorphic LCIS, n = 2), US-guided 14g biopsy was successful in 10/21 (48%), while 4/7 events with corresponding mammographic microcalcifications were proven by x-ray stereotactic interventions. A further 5 events had MRI-guided interventions (3 VAB and 2 hook-wires) and 1 an open surgical biopsy to confirm malignancy. In the final case (a woman with a 30 × 20 mm focal area of non-mass enhancement with corresponding microcalcifications consistent with DCIS), a pathologic diagnosis was not made until the patient presented 5 years later with invasive disease. There were also 3 instances of upgrades to invasion on final surgical pathology, one from pLCIS to microinvasion and 2 others from DCIS to IDC. Among the DCIS/pLCIS events, semi-random 14g core biopsy (sampling at the expected location of the MRI abnormality without a specific sonographic correlate) proved to be successful in 3 women. Ultrasound-guided 14g core biopsy established a malignant diagnosis in 91% of invasive cancers and in 48% of DCIS/pLCIS cases. This relatively non-invasive, technically easy to perform and low-cost biopsy procedure can be used immediately when targeted ultrasound shows a correlate for a suspicious MRI scan finding. Careful imaging-pathologic correlation is required after 14g biopsy, and a discordant result will usually prompt recourse to an MRI-guided VAB or hook-wire localisation.