CT-guided transthoracic cutting needle biopsy of intrathoracic lesions: comparison between coaxial and single needle technique

Purpose

To evaluate the complication rates and diagnostic accuracy of two different CT-guided transthoracic cutting needle biopsy techniques: coaxial method and single needle method.

Methods

This study involved 198 consecutive subjects with 198 intrathoracic lesions. The first 98 consecutive subjects received a single needle cutting technique and the next 100 consecutive subjects received a coaxial technique. Both groups were compared in relation the diagnostic accuracy and complication rates.

Results

No significant difference was found between the two groups concerning patient characteristics, lesions and procedure variables. There was a borderline statistical difference in the incidence of pneumothorax at within 24-h post biopsy between patients in the single needle group (5%) and the coaxial group (13%) (P = 0.053). Little difference was found in the pneumothorax rate at immediately post biopsy between the two groups, which was 28% in the single needle group and 31% in the coaxial group. There was no significant difference in the hemoptysis rate between the two groups, which was 9.2% in the single needle group and 11% in the coaxial group. Both techniques yielded an overall diagnostic accuracy of 98% for malignant lesions with similar sensitivity (single needle: 96.9% vs. coaxial: 96.4%) and specificity (single needle: 100% vs. coaxial: 100%).

Conclusion

There is little difference in the pneumothorax rates and bleeding complications between patients who either received a single needle or a coaxial transthoracic cutting biopsy. Both techniques produce an overall diagnostic accuracy of 98% for malignant lesions.     

CT fluoroscopy-guided vs. multislice CT biopsy mode-guided lung biopsies: accuracy, complications and radiation dose

Background

The aim of this retrospective study was to compare the diagnostic accuracy, the frequency of complications, the duration of the interventions and the radiation doses of CT fluoroscopy (CTF) guided biopsies of lung lesions with those of multislice CT (MS-CT) biopsy mode-guided biopsies.

Methods

Data and images from 124 consecutive patients undergoing CTF-guided lung biopsy (group A) and 132 MS-CT-biopsy mode-guided lung biopsy (group B) were reviewed. CTF-guided biopsies were performed on a Siemens Emotion 6 CT scanner with intermittent or continuous CT-fluoroscopy, MS-CT biopsy mode-guided biopsies were performed on a Siemens Emotion 16 CT scanner. All biopsies were performed with a coaxial needle technique.

Results

The two groups (A vs. B) did not differ significantly regarding sensitivity (95.5% vs. 95.9%), specificity (96.7% vs. 95.5%), negative predictive value (87.9% vs. 84%) or positive predictive value (98.8% vs. 98.9%). Pneumothorax was observed in 30.0% and 32.5% of the patients, respectively. Chest tube placement was necessary in 4% (group A) and 13% (group B) of the patients. The duration of the intervention was significantly longer in group A (median 37 min vs. 32 min, p = 0.04). The mean CT dose index (CTDI) was 422 in group A and 36.3 in group B (p < 0.001).

Conclusion

Compared to CTF-guided biopsies, chest biopsies using the MS-CT biopsy mode show dramatically lower CTDI levels. Although the diagnostic yield of the procedures do not differ significantly, biopsies using the MS-CT-biopsy mode have a three-fold higher rate of chest tube placement.     

CT-guided core biopsy and percutaneous fiducial seed placement in the lung: Can these procedures be combined without an increase in complication rate or decrease in technical success?

Objective

To determine if concomitant CT-guided biopsy and percutaneous fiducial seed placement in the lung can be performed in a selective patient population without increased complication or decreased success rates compared to either procedure alone.

Materials and methods

An IRB approved retrospective analysis of 285 consecutive patients that underwent CT-guided placement of fiducial seeds in the lung alone (N = 63), with concomitant core biopsy (N = 53) or only core biopsy (N = 169) was performed. Variables compared included: patient demographics, lesion size, depth from pleura, needle size, number of passes through pleura, number and size of core biopsies, number of seeds placed and technical success rates. Statistical analysis was performed using univariate and multivariate pair-wise comparisons.

Results

A pathologic diagnosis of malignancy was confirmed in all cases undergoing seed placement alone and seed placement with concurrent biopsy, and in 144 of the biopsy alone lesions. On univariate analysis, major complication rates were similar for all three groups as were lesion size, depth, number of pleural passes, and technical success. Pair-wise comparisons of the remaining variables demonstrated a significant younger age and smaller needle size in the biopsy only group, and less minor complications in the fiducial only group. Overall there were 80/285 (28.1%) minor and 29/285 (10.2%) major complications. All major complications leading to admission consisted of either pneumothorax or hemothorax, while minor complications included asymptomatic stable or resolving pneumothoraces, transient hemoptysis or small hemothoraces.

Conclusions

A combined procedure of percutaneous pulmonary core biopsy and stereotactic seed placement can be performed without additional risk of a major complication when compared to performing these separately.     

Breath-hold after forced expiration before removal of the biopsy needle decreased the rate of pneumothorax in CT-guided transthoracic lung biopsy

Purpose

To assess the effect of a breath-hold after forced expiration on the rate of pneumothorax after computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions.

Materials and methods

Between January 2008 and December 2011, percutaneous CT-guided lung biopsy was performed in 440 patients. Two hundred and twenty-one biopsies were performed without (control group) and two hundred and nineteen biopsies were performed with (study group) the study maneuver – a breath-hold after forced expiratory approach. Multivariate analysis was performed between groups for risk factors for pneumothorax, including patient demographics, lesion characteristics, and biopsy technique.

Results

A reduced number of pneumothoraces (18 [8.2%] vs 35 [15.8%]; P = 0.014) but no significant difference in rate of drainage catheter insertions (2 [0.9%] vs (4 [1.8%]; P = 0.418) were noted in the study group as compared with the control group. By logistic regression analysis, three factors significantly and independently affected the risk for pneumothorax including lesion size (transverse and longitudinal diameter), distance from pleura and utilizing or avoiding the breath-hold after deep expiration maneuver.

Conclusion

Breath-holding after forced expiration before removal of the biopsy needle during the percutaneous CT-guided transthoracic lung biopsy almost halved the rate of overall pneumothorax. Small lesion size (longitudinal diameter) and the distance from pleura were also predictors of pneumothorax in our study.     

How accurate are measurements of skin-lesion depths on prebiopsy supine chest computed tomography for transthoracic needle biopsies?

Aim

To evaluate the accuracy of depth measurements on supine chest computed tomography (CT) for transthoracic needle biopsy (TNB).

Materials and methods

We measured skin-lesion depths from the skin surface to nodules on both prebiopsy supine CT scans and CT scans obtained during cone beam CT-guided TNB in the supine (n = 29) or prone (n = 40) position in 69 patients, and analyzed the differences between the two measurements, based on patient position for the biopsy and lesion location.

Results

Skin-lesion depths measured on prebiopsy supine CT scans were significantly larger than those measured on CT scans obtained during TNB in the prone position (p < 0.001; mean difference ± standard deviation (SD), 6.2 ± 5.7 mm; range, 0–18 mm), but the differences showed marginal significance in the supine position (p = 0.051; 3.5 ± 3.9 mm; 0–13 mm). Additionally, the differences were significantly larger for the upper (mean ± SD, 7.8 ± 5.7 mm) and middle (10.1 ± 6.5 mm) lung zones than for the lower lung zones (3.1 ± 3.3 mm) in the prone position (p = 0.011), and were larger for the upper lung zone (4.6 ± 5.0 mm) than for the middle (2.4 ± 2.0 mm) and lower (2.3 ± 2.3 mm) lung zones in the supine position (p = 0.004).

Conclusions

Skin-lesion depths measured on prebiopsy supine chest CT scans were inaccurate for TNB in the prone position, particularly for nodules in the upper and middle lung zones.     

CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions: diagnostic yield in 83 lesions

Objective

The objective of our study was to retrospectively determine the diagnostic yield of CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions.

Materials and methods

Biopsies were performed using 20-G coaxial cutting needles for 83 focal pure ground-glass opacity lung lesions (mean lesion size, 12.1 mm). After excluding the lesions for which biopsy specimens were unobtainable and final diagnoses were undetermined, the diagnostic yield, including sensitivity and specificity for a diagnosis of malignancy and accuracy, was calculated. The lesions were then divided into 2 groups: the diagnostic failure group, comprising lesions with false-negative results and for which a biopsy specimen was unobtainable; and the diagnostic success group, comprising lesions with true-negative results and true-positive results. Various variables were compared between the 2 groups by univariate analysis.

Results

Biopsy specimens were obtained from 82 lesions, while specimens could not be obtained from 1 lesion. Final diagnosis was undetermined in 16 lesions. The sensitivity and specificity for a diagnosis of malignancy were 95% (58/61) and 100% (5/5), respectively. Diagnostic accuracy was 95% (63/66). The 4 lesions in diagnostic failure group were smaller, deeper, and more likely to be located in the lower lobe and further, for those lesions, number of specimens obtained was smaller, compared with 63 lesions in diagnostic success group. However, none of the differences were statistically significant.

Conclusion

CT fluoroscopy-guided cutting needle biopsy provided high diagnostic yield for focal pure ground-glass opacity lung lesions.     

Efficacy of CT-guided biopsies of the spine in patients with spondylitis--an analysis of 164 procedures

Objective

To evaluate efficacy of CT-guided spinal biopsy (CTSB) in patients with spondylitis considering patient characteristics, technical issues, antibiotic therapy, histopathological, and microbiological findings.

Materials and methods

All CTSB procedures performed between 1995 and 2009 in patients with proven spondylitis were re-evaluated. Patient sex and age, antibiotic treatment, biopsy approach, number of specimens, length of needle path, laboratory results (CRP, WBC), and histopathological/microbiological findings were documented and compared to the final diagnosis of spondylitis. Statistical analysis was performed using Chi-square test and Student's t-test. The p-value was set to 5%.

Results

164 CTSB procedures were performed in 159 patients (mean age 65 years, 60% men) in which spondylitis was histopathologically verified in 95%. Neither patient sex nor age, positioning, localization of the spinal lesion, bioptic approach, number of specimens, or depth of the needle showed significant impact on the rate of positive histopathological findings. A causative germ was identified in 40/127 biopsies (32%) with Staphylococcus aureus being identified in 50%. Tuberculous spondylitis was diagnosed in ten cases (6%). CRP significantly correlated with bacterial growth (13.3 ± 12.2 mg/dl versus 8.8 ± 7.6 mg/dl; p = .015) whereas administration of antibiotics did not show any significant impact on bacterial growth (29% versus 36% in patients without antibiotics; p = 0.428). Patients with histopathological signs of active spondylitis showed a significantly higher CRP (16.5 ± 15.8 mg/dl versus 8.9 ± 8.0 mg/dl, p < .001). Complication rate was 0.6% (one focal bleeding).

Conclusion

CTSB of the spine in suspected spondylitis is an effective and safe procedure for establishing final histopathological diagnosis. However, microbiological yield is low regardless of technical issues and antibiotic therapy. Other than CRP values, laboratory investigations added little useful information to diagnose infection in our study group. CRP values significantly correlated with bacterial growth and with histopathological signs of active spondylitis.     

Risk factor analysis of pulmonary hemorrhage complicating CT-guided lung biopsy in coaxial and non-coaxial core biopsy techniques in 650 patients

Purpose

To evaluate the risk factors involved in the development of pulmonary hemorrhage complicating CT-guided biopsy of pulmonary lesions in coaxial and non-coaxial techniques.

Materials and methods

Retrospective study included CT-guided percutaneous lung biopsies in 650 consecutive patients (407 males, 243 females; mean age 54.6 years, SD: 5.2) from November 2008 to June 2013. Patients were classified according to lung biopsy technique in coaxial group (318 lesions) and non-coaxial group (332 lesions). Exclusion criteria for biopsy were: lesions <5 mm in diameter, uncorrectable coagulopathy, positive-pressure ventilation, severe respiratory compromise, pulmonary arterial hypertension or refusal of the procedure. Risk factors for pulmonary hemorrhage complicating lung biopsy were classified into: (a) patient's related risk factors, (b) lesion's related risk factors and (d) technical risk factors. Radiological assessments were performed by two radiologists in consensus. Mann–Whitney U test and Fisher's exact tests for statistical analysis. p values <0.05 were considered statistically significant.

Results

Incidence of pulmonary hemorrhage was 19.6% (65/332) in non-coaxial group and 22.3% (71/318) in coaxial group. The difference in incidence between both groups was statistically insignificant (p = 0.27). Hemoptysis developed in 5.4% (18/332) and in 6.3% (20/318) in the non-coaxial and coaxial groups respectively. Traversing pulmonary vessels in the needle biopsy track was a significant risk factor of the development pulmonary hemorrhage (incidence: 55.4% (36/65, p = 0.0003) in the non-coaxial group and 57.7% (41/71, p = 0.0013) in coaxial group). Other significant risk factors included: lesions of less than 2 cm (p value of 0.01 and 0.02 in non-coaxial and coaxial groups respectively), basal and middle zonal lesions in comparison to upper zonal lung lesions (p = 0.002 and 0.03 in non-coaxial and coaxial groups respectively), increased lesion's depth from the pleural surface (p = 0.021 and 0.018 in non-coaxial and coaxial groups respectively), increased distance of traversed lung in the needle track of more than 2.5 cm (p = 0.001 in both groups). Insignificant risk factors were patient's age, gender or emphysema in both groups (p value >0.1 in both groups). Concomitant incidence of pneumothorax was 32.3% (21/65) in non-coaxial group and 36.6% (26/71) in coaxial group. Pulmonary hemorrhage in the majority of cases was treated conservatively.

Conclusion

Pulmonary hemorrhage complicating CT-guided core biopsy of pulmonary lesions, showed insignificant difference between coaxial and non-coaxial techniques. Significant risk factors of pulmonary hemorrhage included small and basal lesions, increased lesion's depth from pleural surface, increased length of aerated lung parenchyma crossed by biopsy needle and passing through vessels within the lung during puncture.     

Application of sonoelastography: comparison of performance between mass and non-mass lesion

Objectives

The purpose of this study was to determine the performance of the conventional ultrasonography (US) and sonoelastography (SE) in three conditions of all lesions, confined to mass, and confined to non-mass lesion and to compare the performance of each modality between mass and non-mass lesion.

Materials and methods

A total 364 patients with 375 lesions were evaluated with US and subsequently SE before performing US-guided biopsy. Two radiologists retrospectively analyzed conventional US and elasticity images by consensus. The US findings were classified as mass or non-mass lesion. With final pathology as reference, in each case of all lesions, masses, and non-mass lesions, areas under the ROC curves (Az) were calculated and compared for the two techniques. The comparison of Az values between the curves for US and SE, and between the curves for mass and non-mass lesion was performed.

Results

Among 375 lesions, 104 (28%) lesions were malignant and 271 (72%) lesions were benign. 36 (9.6%) of 375 lesions were classified as non-mass lesion at US.There were statistically significant difference of performance between US and SE in cases of all lesion (p = 0.003) and mass (p = 0.023). However, there was no statistically significant difference of performance in case of non-mass lesion (p = 0.5). Comparisons of the Az values of US and SE between mass and non-mass lesions were not statistically significant (p = 0.745, p = 0.415, respectively).

Conclusion

There was no statistically significant difference of performance of US and SE between mass and non-mass lesion.     

Interventional bleeding, hematoma and scar-formation after vacuum-biopsy under stereotactic guidance: Mammotome(®)-system 11 g/8 g vs. ATEC(®)-system 12 g/9 g

Purpose

To evaluate prospectively the correlation of scar-formations after vacuum-assisted biopsy with different systems and needle-sizes and interventional bleeding/post-interventional hematoma.

Methods and materials

Between 01/2008 and 12/2009, 479 patients underwent vacuum-assisted biopsy under stereotactic-guidance, using the Mammotome^®-system with 11/8-gauge and ATEC^®-system with 12/9-gauge, whereas in 178 cases with representative benign histology no surgical-biopsy after vacuum-assisted biopsy was performed and at least a 2-plane-follow-up-mammogram after 6 month post-vacuum-assisted biopsy was available. Bleeding during intervention, hematoma post-intervention and scar-tissue was scored as minimal and moderate/severe. Statistical analysis included Chi-Square-trend-test, p-value <0.05 was considered to be significant.

Results

Significantly more bleedings and post-interventional hematomas for 8-gauge-Mammotome^®-system vs. 11-gauge-Mammotome^®-system (41.9% vs. 8.4%, p < 0.001/35.5% vs. 16.7%, p = 0.029), no significant-differences for the ATEC^®-systems 9-gauge vs. 12-gauge (26.9% vs. 29.7%, p = 0.799/42.3% vs. 43.2%, p = 0.596). 11-gauge-Mammotome^®-system vs. ATEC^®-12-gauge-system revealed significantly less bleedings/hematomas (8.4% vs. 29.7%, p = 0.015/16.7% vs. 43.2%, p = 0.001), no significant differences for the large-systems (p = 0.135/p = 0.352). Follow-up of Mammotome^®-11/8-gauge-system system has shown 13.1/16.1% minimal scar-formation and 1.2/3.2% moderate/severe scars, whereas ATEC^®-12/9-gauge-system has shown 10.8/3.8% minimal scar-formation and 0/11.5% moderate/severe scars, no significant differences. No significant difference was found when comparing Mammotome^®-11/8-g-systems vs. ATEC^®-12/9-g-systems (p = 0.609/p = 0.823). There was also no correlation between risk of scar-formation after occurrence of bleeding or hematoma with any examined VAB-system or any needle size in this study (p = 0.800).

Conclusion

Using larger needle-sizes significantly (Mammotome^®)/not significant for ATEC^®) more interventional bleedings and post-interventional hematomas were detected, only a tendency concerning scar-formation.     

Malignant spiculated breast masses: dynamic contrast enhanced MR (DCE-MR) imaging enhancement characteristics and histopathological correlation

Aim

Spiculation of breast masses is usually the result of significant desmoplastic reaction. Diminished neovascularization is expected due to sparsely dispersed tumor cells within the lesion. This feature can cause differences in enhancement patterns which can cause pitfalls while evaluating MR images as well. Aim of this study is to explore the enhancement characteristics of malignant spiculated masses and to correlate these findings with histopathological features.

Materials and methods

Eighteen spiculated and seventeen non-spiculated masses depicted with mammography were included in the study. MR imaging was performed with 1.5 T magnet with breast coil. In MR imaging, T2-weighted turbo spin echo (TSE) with fat suppression sequence followed by pre- and post-contrast T1-weighted 3D-fast low angle shot (FLASH) sequences were used. Lesions were evaluated according to enhancement characteristics: early phase enhancement (first 2 min; less than 50%, 50–100% and more than 100%), late phase enhancement (2–6 min; persistent, plateau and washout) and inner enhancement pattern (homogenous, heterogenous and rim). Desmoplasia and lymphocyte infiltration was classified as mild, moderate and severe. MR images and histopathological findings (desmoplasia, lymphocyte infiltration and grade) of both groups were compared.

Results

Mean ages of patients in spiculated and non-spiculated-mass groups were 55.07 (41–71) and 47.35 (31–62), respectively. Mean diameter of lesions was 17.3 mm (10–31 mm) for spiculated masses while non spiculated masses were 15.8 mm (6–40 mm). There were statistically significant differences between late phase enhancement, persistent enhancement, plateau and washout (p < 0.05). Intergroup comparison of desmoplasia revealed significant difference between severe versus and mild, moderate (p < 0.05).

Conclusion

Spiculated malignant lesions are supposed to contain intense desmoplastic reaction. On DCE-MR images they can show persistent enhancement pattern more often than non-spiculated lesions.     

Elastography ultrasound and questionable breast lesions: Does it count?

Objective

To check possible additional value of using elastography ultrasound in the specification of questionable breast lesions.

Subjects and methods

Questionable breast lesions on gray scale ultrasound examination had been further evaluated by elastography ultrasound in 97 cases with median age of 42 years. The studied lesions were pathologically proven (58 benign and 39 malignant) using true cut tissue/surgical excision biopsy that was considered the gold standard of reference.

Results

Conventional ultrasound categorization before biopsy included: category 3 (probably benign) in 42.3% (n = 41), category 4a (low suspicion of malignancy) in 13.4% (n = 13), category 4b (intermediate suspicion of malignancy) in 16.5% (n = 16) and category 4c (moderate suspicion of malignancy) in 27.8% (n = 27). We had evaluated elastography ultrasound regarding elastography strain scoring and quantitative strain ratio.Sensitivity, specificity and accuracy were 89.7%, 86.2% and 87.6% for conventional ultrasound, 92.3%, 74.1% and 81.4% for elastogram 5-point scoring method and 87.1%, 89.6% and 88.6% for the calculated strain ratios respectively in the assessment of the examined breast lesions.

Conclusion

Ultrasound elastography, using both qualitative and quantitative methods can improve the performance of conventional B-mode ultrasound and enhance its specificity and accuracy in the diagnosis of questionable (BI-RADS categories 3 and 4) breast lesions.     

Usual interstitial pneumonia and nonspecific interstitial pneumonia: correlation between CT findings at the site of biopsy with pathological diagnoses

Objectives

The aim of this study was to correlate high-resolution CT (HRCT) findings at the site of biopsy with the whole lung CT and pathologic diagnoses in usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP).

Methods

The study included 35 patients (25 UIP and 10 NSIP) diagnosed both pathologically and clinically. 81 surgical biopsy specimens (54 UIP, and 27 NSIP) and extracted areas corresponding to biopsy sites on HRCT were analyzed. CT interpretations were compared with pathological diagnoses in both extracted images and the whole lung. Concordant and discordant cases in multiple extracted images were divided and analyzed. Then the whole cases were categorized by including or not at least one UIP diagnosis of extracted images and evaluated.

Results

The diagnoses in extracted sites significantly correlated with pathological diagnoses (p = 0.047). There were significant differences in the concordances of extracted images compared with the diagnosis of whole lung and pathology (p = 0.008, 0.003, respectively). All 7 cases that were not concordant were diagnosed as radiological UIP with whole lung CT. The cases with at least one UIP diagnosis of extracted CT images were diagnosed as UIP in pathology more frequently (18 in 25) (p = 0.007).

Conclusions

Radiological UIP in whole CT had more frequently discordant diagnoses from multiple extracted images than NSIP. And there were more cases in pathological UIP that included at least one UIP diagnosis of extracted images compared with pathological NSIP.     

Percutaneous excisional biopsy of clinically benign breast lesions with vacuum-assisted system: comparison of three devices

Purpose

The aim of this study was to compare three devices in percutaneous excisional biopsy of clinically benign breast lesions in terms of complete excision rate, duration of procedure and complications.

Materials and methods

In a retrospective study from March 2005 to May 2009, 983 lesions underwent ultrasound-guided excisional biopsy with three vacuum-assisted systems, respectively. The lesions were category 3 lesions as determined by ultrasound imaging according to Breast Imaging Reporting and Data System (BI-RADS) (n = 951) or had been confirmed as benign by a previous core needle biopsy (n = 32). The completely excision rate, duration of procedure and complications (hematoma, pain and ecchymosis) were recorded.

Results

99.7% (980/983) lesions were demonstrated to be benign by pathology after percutaneous excisional biopsy. The overall complete excision rate was 94.8% (932/983). In lesions whose largest diameter equal to or larger than 1.5 cm, the complete excision rates of EnCor^® group (97.8%, 348/356) and Mammotome^® group (97.2%, 139/143) were significantly higher than that of Vacora^® group (91.9%, 445/484) (P < 0.05). The EnCor^® group (6.6 ± 6.5 min) had a significant less duration than Mammotome^® (10.6 ± 9.3 min) and Vacora^® group (25.6 ± 23.3 min) (P < 0.05). Hematoma occurred more in EnCor^® group and Mammotome^® group than in Vacora^® group (P < 0.05).

Conclusions

All these three vacuum-assisted systems are highly successful for excisional biopsy of benign breast lesions.     

Predictive factors for complete excision and underestimation of one-pass en bloc excision of non-palpable breast lesions with the Intact(®) breast lesion excision system

Objective

Image-guided percutaneous biopsy is the recommended initial diagnostic procedure for suspicious mammographic lesions. This study was conducted to determine the accuracy of the Intact^® breast lesion excision system (BLES) and to identify predictive factors for complete excision and underestimation.

Material and methods

A prospective study was conducted between January 28, 2008 and April 30, 2009 on 166 biopsy procedures using Intact^® biopsy device. Diagnoses obtained from biopsy specimen were compared with to final diagnosis on surgical excision specimen.

Results

Of the 166 patients, 15 (9%) displayed lesions with cell atypia, 28 (17%) had an intra ductal carcinoma (IDC) and 9 (5%) had an invasive carcinoma. Eight of 15 patients with cell atypia had open surgical excision, and none showed underestimation. All patients with IDC underwent surgical excision: we found an invasive carcinoma in 6 cases (21.4% underestimation) and a complete removal of the lesion by the Intact^® BLES in 11 cases (39%). All 9 patients with invasive carcinoma had a surgical excision, with 1 complete removal of the lesion by Intact^® BLES. Multivariate analyses did not identify predictive factors for underestimation; clear margins ≥1 mm on biopsy specimen was the only independent predictive factor of complete excision (OR = 8.51, p = 0.02).

Conclusions

Intact^® BLES provides a safe alternative to vacuum assisted core needle biopsy (VACNB) with an underestimation rate comparable to those previously reported for VACNB. The high rate of complete removal of the lesions, particularly ISC, offers an interesting perspective of avoiding subsequent excisional surgery for small lesions and thus requires further confirmational study.     

Extrapleural paravertebral CT guided fine needle biopsy of subcarinal lymph nodes

Purpose

To report our experience in CT guided extrapleural paravertebral subcarinal lymph biopsy using a thin 25 gauge (25 G) thin needle without the need of injection of saline to widen the mediastinum.

Materials and methods

Biopsy was performed using a 25 G needle which was advanced lateral to the vertebral body between the endothoracic fascia and the parietal pleura to gain access to subcarinal lymph nodes. One hundred and forty one patients were included in the study (74 females, 57 males). No artificial widening of the mediastinum using saline injection was required. The study was performed in the presence of a cytopathologist; sensitivity and specificity rates were calculated. Complications were documented for each case especially for pneumothorax and haemorrhage.

Results

Cytopathological diagnosis was reached in all cases. All re-aspirations were done in the same session to reach a primary diagnosis at the time of the biopsy. Imunophenotyping study was done in 94 cases to confirm the primary diagnosis and to classify the malignant lesions. No pneumothorax was encountered. Small haematomas were noted in 5 cases (3.5%). Cytopathology showed a sensitivity of 97.2% and specificity of 100%. By adding immunophenotyping a 100% sensitivity and specificity was achieved.

Conclusion

Fine needle aspiration cytology (FNAC) using a 25 gauge needle for subcarinal lymph nodes via a percutaneous extrapleural paravertebral CT guided approach is a safe, minimally invasive, and tolerable procedure yielding a high sensitivity and specificity rates without the need of artificial widening.     

A systematic comparison of two pulse sequences for edema assessment in MR-mammography

Objective

Perifocal edema, defined as high T2w signal intensity around an enhancing lesion has been described as a specific feature of malignancy. In clinical MR-mammography (MRM), both fatsat and non-fatsat T2w sequences are available. However, there is no consensus on which technique should be used for edema assessment. Consequently, this investigation was performed to compare two commonly used pulse sequences for edema assessment in MRM.

Materials and methods

321 consecutive patients from a 22 month period were included in this investigation. Further selection criteria were histopathological verification of enhancing lesions and absence of presurgical chemotherapy or biopsy, resulting in 108 malignant and 107 benign lesions. All underwent MRM according to international guidelines including a non-fatsat T2w-TSE sequence (TR/TE: 8900/207 ms) and a short tau inversion recovery fatsat sequence (STIR, TR/TE: 8420/70 ms). All images were acquired in the same orientation (axial) and slice thickness. Two experienced radiologists in consensus rated presence of perifocal edema according to an ordinal scale: 0 = not present, 1 = little, 2 = intermediate, and 3 = distinct. Data analysis was performed using crosstabs and Visual Grading Characteristics (VGC) analysis.

Results

Overall sensitivity/specificity was calculated with 53.7%/94.4% (T2w-TSE) and 52.8%/95.3% (STIR). VGC revealed an area under the VGC curve of 0.502 (standard error 0.026), P = 0.814.

Conclusion

Perifocal edema is a specific feature of malignancy with moderate sensitivity. VGC analysis did not reveal significant differences between both pulse sequences analysed. Consequently, both T2w-TSE and STIR images are suitable for assessment of perifocal edema.     

Intraobserver and interobserver agreement of volume perfusion CT (VPCT) measurements in patients with lung lesions

Objectives

To evaluate intraobserver and interobserver agreement of manually encompassed lung lesions for perfusion measurements using volume-perfusion computed tomography (VPCT).

Materials and methods

Institutional review board approval and informed consent were obtained. HIPAA guidelines were followed. A 65-s dynamic study was acquired with scan parameters 80 kV, 60 mA s (80 mA s for patients ≥70 kg), 128 × 0.6 mm collimation. Blood flow (BF), blood volume (BV) and K^trans parameters were determined by syngo volume perfusion CT body with 88 lesions analyzed retrospectively.

Results

Within-subject coefficients of variation for intraobserver agreement (range 6.59–12.82%) were superior to those for interobserver agreement (range 21.75–38.30%). Size-dependent analysis revealed lower agreements for lesions <4 cm as compared to larger lesions. Additionally, agreements of the upper, middle and lower lung zones were different.

Conclusions

Intraobserver agreement was substantial for VPCT lung cancer perfusion measurements encouraging the use for tumor characterization and therapy response monitoring. Interobserver agreement is limited and unexperienced readers should be trained before using this new method.     

Should breast MRI be performed with adjustment for the phase in patients’ menstrual cycle? Correlation between mammographic density,age, and background enhancement on breast MRI without adjusting for the phase in patients’ menstrual cycle

Purpose

The purpose of this study was to assess the correlation between mammographic density, age, and background enhancement on breast MRI without adjusting for the phase in patients’ menstrual cycle.

Material and methods

The background enhancement of bilateral breast MRI and the breast density of mammography in 146 consecutive women without adjusting for the phase in patients’ menstrual cycle were reviewed. The breast density was classified into four categories according to the American College of Radiology the Breast Imaging Reporting and Data System lexicon. The background enhancement was classified into four categories: minimal, mild, moderate, and marked. The correlations of mammographic breast density as well as age with background enhancement on breast MRI were examined.

Results

There was a significant correlation between mammographic breast density and background enhancement (p = 0.011). All nine cases with almost completely fat mammographic breast density showed minimal (78%) or mild (12%) background enhancement on breast MRI. There was a significant inverse correlation between age and background enhancement (p < 0.0001). Younger patients with dense breasts were more likely to demonstrate moderate/marked background enhancement.

Conclusion

When no adjusting for the phase in patients’ menstrual cycle, a significant correlation was observed between background enhancement and mammographic density. A significant inverse correlation was also observed between age and background enhancement.     

Patterns of pulmonary tuberculosis on FDG-PET/CT

Objective

This study aims to describe patterns of pulmonary tuberculosis (TB) on FDG-PET/CT.

Methods

All patients with a diagnosis of TB and who underwent FDG-PET/CT between January 2009 and June 2010 were included. Clinical, biological and imaging data were reviewed. TB was proven either on bacteriological or histopathological studies (n = 13) or on a clinical and imaging basis (n = 3).

Results

Sixteen patients (11 men; median age 56, range 22–84 years) were included. Two distinct patterns were identified. In the lung pattern (9/16), patients had predominantly pulmonary symptoms (6/9 patients, 67%) with a parenchymal involvement: uptakes on lung consolidation ± cavitation surrounded by micronodules. Mediastino-hilar lymph nodes were slightly enlarged (15 mm, 10–27) with moderate uptake (3.9, 2.5–13.4). In the lymphatic pattern (7/16), patients had predominantly systemic symptoms (5/7 cases, 71%) and all had extra-thoracic involvement. Mediastino-hilar lymph nodes were more enlarged (30 mm, 18–35, p = 0.03) and with higher uptake (6.8, 5.7–16.8, p = 0.034) than in the lung pattern.

Conclusion

We identified two distinct patterns of pulmonary TB on FDG-PET/CT. The lung pattern related to a restricted and slight hypermetabolic infection and the lymphatic pattern related to a systemic and intense infection. Combined interpretation of PET and CT findings improves the specificity of images, especially for the lung pattern.