Trans-caval trans-jugular liver biopsy—a technical modification of trans-jugular liver biopsy

Objective:

To (a) describe the technical modification of trans-caval TJLB and (b) review our series of nine cases.

Methods:

We performed a retrospective review of all trans-caval TJLBs performed; we assessed indications for the procedure, technical success, complications, adequacy of specimen and histological positivity.

Results:

The technical success rate of the procedure was 9/9 (100%); the minor complication rate was 1/9 (11%), adequate specimen was obtained in all cases and a histological diagnosis was achieved in 8/9 (89%) cases.

Conclusion:

This preliminary report suggests that trans-caval modification of TJLB is a relatively safe procedure that may be useful in cases where conventional TJLB is infeasible.

Advances in knowledge:

(a) We describe the technique of trans-caval TJLBs and report our findings in the largest series of published cases. (b) Trans-caval TJLB is relatively safe and can be used to increase the success rates of conventional TJLB.Trans-jugular liver biopsy (TJLB) is an established technique in patients unsuitable for a percutaneous trans-abdominal liver biopsy. TJLB procedure involves biopsy of the liver parenchyma through trans-jugular venous access, with the biopsy needle placed in the right hepatic vein (commonly described) or the middle or left hepatic veins. However, a TJLB may be not technically feasible in a small subset of cases where hepatic venous cannulation is not possible, owing to unsuitable hepatic venous anatomy, occluded hepatic veins [Budd–Chiari syndrome (BCS)] or markedly shrunken liver. In such cases, a technical modification of TJLB, called a direct trans-caval TJLB, can be performed. In this study, we (a) describe the technical modification of the trans-caval TJLB and (b) review the results of a series of nine cases where the trans-caval TJLB was carried out.     

Targeted MRI-guided prostate biopsy: are two biopsy cores per MRI-lesion required?

Purpose

This study evaluates the feasibility of performing less than two core biopsies per MRI-lesion when performing targeted MR-guided in-bore prostate biopsy.

Methods

Retrospectively evaluated were 1545 biopsy cores of 774 intraprostatic lesions (two cores per lesion) in 290 patients (66?±?7.8 years; median PSA 8.2 ng/ml) regarding prostate cancer (PCa) detection, Gleason score, and tumor infiltration of the first (FBC) compared to the second biopsy core (SBC). Biopsies were acquired under in-bore MR-guidance.

Results

For the biopsy cores, 491 were PCa positive, 239 of 774 (31 %) were FBC and 252 of 771 (33 %) were SBC (p?=?0.4). Patient PCa detection rate based on the FBC vs. SBC were 46 % vs. 48 % (p?=?0.6). For clinically significant PCa (Gleason score ≥4?+?3?=?7) the detection rate was 18 % for both, FBC and SBC (p?=?0.9). Six hundred and eighty-seven SBC (89 %) showed no histologic difference. On the lesion level, 40 SBC detected PCa with negative FBC (7.5 %). Twenty SBC showed a Gleason upgrade from 3?+?3?=?6 to ≥3?+?4?=?7 (2.6 %) and 4 to ≥4?+?3?=?7 (0.5 %).

Conclusion

The benefit of a second targeted biopsy core per suspicious MRI-lesion is likely minor, especially regarding PCa detection rate and significant Gleason upgrading. Therefore, a further reduction of biopsy cores is reasonable when performing a targeted MR-guided in-bore prostate biopsy.

Key Points

? Higher PI-RADS overall score (IV-V) correlated well with PCa detection rate ? In more than 80 % SBC was concordant regarding overall PCa detection ? In almost 90 % there was no Gleason upgrading by the SBC ? Only 2/54 (3.7 %) csPCa was missed when the SBC was omitted ? For IB-GB a further reduction of biopsy cores is reasonable

     

Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary?

PURPOSE: To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB). MATERIALS AND METHODS: Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test). RESULTS: In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88). CONCLUSION: Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.     

Cancelled stereotactic biopsy of calcifications not seen using the stereotactic technique: do we still need to biopsy?

Objective

To determine the frequency of cancelled stereotactic biopsy due to non-visualisation of calcifications, and assess associated features and outcome data.

Methods

A retrospective review was performed on 1,874 patients scheduled for stereotactic-guided breast biopsy from 2009 to 2011. Medical records and imaging studies were reviewed.

Results

Of 1,874 stereotactic biopsies, 76 (4 %) were cancelled because of non-visualisation of calcifications. Prompt histological confirmation was obtained in 42/76 (55 %). In 28/76 (37 %) follow-up mammography was performed, and 7/28 subsequently underwent biopsy. Of 27 without biopsy, 21 (78 %) had follow-up. Nine cancers (9/49, 18 %) were found: 6 ductal carcinoma in situ (DCIS), 3 infiltrating ductal carcinoma (IDC). Of 54 patients with either biopsy or at least 2 years’ follow-up, 9 (17 %) had cancer (95 % CI 8–29). Cancer was present in 7/42 (17 %, 95 % CI 7–31 %) lesions that had prompt histological confirmation (DCIS?=?5, IDC?=?2) and in 2/28 (7 %, 95 % CI 0.8–24 %) lesions referred for follow-up (DCIS?=?1, IDC?=?1). Neither calcification morphology (P?=?0.2), patient age (P?=?0.7), breast density (P?=?1.0), personal history (P?=?1.0) nor family history of breast cancer (P?=?0.5) had a significant association with cancer.

Conclusion

Calcifications not visualised on the stereotactic unit are not definitely benign and require surgical biopsy or follow-up. No patient or morphological features were predictive of cancer.

Key points

? Half of cancelled stereotactic biopsies were due to non-visualisation of calcified foci. ? This reflects the improved detection of calcifications by digital mammography. ? Calcifications too faint for the stereotactic technique require alternative biopsy or follow-up ? 17?% of patients with biopsy or at least 2 years’ follow-up had cancer. ? No patient/morphological features were found to aid selection for re-biopsy vs. follow-up.     

Add-on device for stereotactic core-needle breast biopsy: how many biopsy specimens are needed for a reliable diagnosis?

PURPOSE: To prospectively determine whether there is a minimum number of cores required for histopathologic diagnosis of mammographically detected nonpalpable breast lesions with an add-on 14-gauge stereotactic core-needle biopsy device. MATERIALS AND METHODS: The study was approved by the ethics committee of the hospital; informed consent was obtained. Biopsy was performed in 197 patients with 205 lesions (97 masses, 108 microcalcifications). The first sample (from the center) was collected in container A; second and third samples (2 mm from center), in container B; and additional samples, in container C. Malignancies, atypical ductal hyperplasia (ADH), and radial scars were excised. Benign lesions were followed up mammographically (mean, 24 months). Strict sensitivity and working sensitivity were calculated separately. Stereotactic biopsy with diagnosis of a nonmalignant lesion that, after surgery, proved to be malignant was considered false-negative when strict sensitivity was calculated. Stereotactic biopsy with diagnosis of ADH or radial scar was considered true-positive if the findings at surgery corresponded to the results at biopsy or indicated malignancy and was considered false-positive if the findings at surgery were benign when working sensitivity was calculated. Sensitivity, specificity, and overall accuracy of stereotactic biopsy were determined for masses and microcalcifications in all three containers by using surgical samples and findings at mammographic follow-up as reference. At chi2 analysis, P < .05 was considered to indicate significant difference. RESULTS: Strict sensitivity of the first sample was 77% (66 of 86) (90% [35 of 39] for masses, 66% [31 of 47] for microcalcifications). Results of the first sample were false-negative significantly more often in microcalcifications (n = 16) than in masses (n = 4) (P = .010). Combined results of containers A and B (ie, three samples) yielded higher strict sensitivity than those with first sample alone (95% [37 of 39] for masses [P = .196], 91% [43 of 47] for microcalcifications [P < .001]). With multiple samples, strict and working sensitivity were both 100% (39 of 39) for masses and 91% (43 of 47) and 98% (46 of 47), respectively, for microcalcifications. Four false-negative diagnoses (ADH, three cases; lesion with discordant mammographic and stereotactic biopsy findings, one case) were microcalcifications. CONCLUSION: More than three samples are needed (a minimum number was not determined) for a histologic diagnosis of a mass lesion by using an add-on stereotactic biopsy device.     

Is it necessary to biopsy the obvious?

OBJECTIVE: The radiologist and oncologist are often confident that biopsy will confirm their suspicion of recurrent disease, but a biopsy is performed to confirm the histologic diagnosis before beginning or altering therapy. We have examined data to determine how often the biopsied lesion represents recurrent disease from the primary tumor or is an instance of new cancer, and whether recurrent disease can be predicted. MATERIALS AND METHODS: We reviewed the medical and imaging records of 253 patients who underwent CT-guided biopsy of an abdominal or pelvic lesion between 1993 and 1996. Sixty-nine of the 253 patients had a previously diagnosed primary tumor and were being examined for possible tumor recurrence or metastasis. The images of these 69 patients were analyzed to determine if the pattern of disease was typical of recurrence or metastasis. RESULTS: In 55 of the 69 patients, the pattern was judged to be typical of metastatic or recurrent disease. Biopsy confirmed this suspicion in all 55 patients. In 14 of the 69 patients, the pattern of spread was judged not to be typical of recurrence or metastasis. These 14 patients were found to have a new primary tumor (n = 4), benign processes (n = 2), and recurrences (n = 8). CONCLUSION: Of the patients for whom radiographic findings suggested recurrence, we found no patients in whom a new primary tumor would have been missed if biopsy had been avoided. Data should now be acquired prospectively to determine whether it may be prudent to make treatment decisions on the basis of imaging findings alone, without histologic confirmation.     

Does biopsy needle traversing through central portion of lesion increase the risk of hemoptysis during percutaneous transthoracic needle biopsy?

Purpose

To evaluate whether traversal through the central part of a pulmonary lesion by a biopsy needle, and other factors, increases the risk of hemoptysis in patients undergoing CT-guided percutaneous transthoracic needle biopsy (PTNB).

Materials and methods

From July 2012 to November 2016, 227 patients undergoing 233 procedures were recruited as our study population. Patients were classified according to the occurrence of hemoptysis. Radiological assessments were performed by reviewing multiplanar reconstructed CT images. Other factors complicating PTNB-related hemoptysis were classified into (1) patient-related variables: age, gender, presence of emphysema; (2) lesion-related variables: size, location, distance to pleura, characteristics, presence of and degree of enhancement, histopathology of biopsy results; and (3) procedure-related variables: lesion depth, patient’s body position.

Results

Twenty-two cases (9.4%) experienced hemoptysis. Univariate analysis revealed that subsolid lesions (p = 0.031) and lesion depth > 1 cm (p = 0.049) were risk factors. Traversal through the central part of the lesion by the biopsy needle was not a risk factor.

Conclusion

Traversal through the central part of the lesion by the biopsy needle is not a risk factor of PTNB-related hemoptysis, but subsolid lesions and lesion depth > 1 cm increase the risk of hemoptysis.

     

Can galactography-guided stereotactic, 11-gauge, vacuum-assisted breast biopsy of intraductal lesions serve as an alternative to surgical biopsy?

The purpose of this study was to determine the value of galactography-guided, stereotactic, vacuum-assisted breast biopsy (VABB) for the assessment of intraductal breast lesions and its potential as a therapeutic tool that could eliminate the need for surgical excision. Eighteen patients (median age 64 years, range 37–80) with nipple discharge and galactography-verified intraductal lesions underwent galactography-guided, stereotactic, 11-gauge VABB followed by surgery. Histopathology findings from VABB and subsequent surgery were compared. Underestimation and false-negative rates were assessed. After VABB, histopathology revealed invasive ductal carcinoma (IDC) in three (17%), ductal carcinoma in situ (DCIS) in six (33%), high-risk lesions in six (33%) and benign lesions in three (17%) cases. After surgical biopsy, histopathology confirmed the previously established diagnosis in 11 lesions (61%). The underestimation rate for high-risk lesions and DCIS was 50% (6/12). The false-negative rate was 7% (1/14). Histopathology examination after surgery showed that not a single lesion had been completely removed at VABB. Galactography-guided VABB is a feasible diagnostic tool. However, its value as a therapeutic procedure is limited because of the high number of underestimated and missed lesions and because of the histopathological detection of lesions’ remnants in every case. Surgical excision should be the therapeutic gold standard in cases of pathological nipple discharge and galactography abnormalities.     

MR-guided vacuum-assisted breast biopsy with a handheld biopsy system: clinical experience and results in postinterventional MR mammography after 24 h

This prospective study evaluates the feasibility of the magnetic resonance (MR)-guided vacuum-assisted breast biopsy with a handheld vacuum-biopsy system and documents the biopsy results with MR mammography 24 h after the procedure. MR-guided biopsy was undertaken in 33 patients with 34 lesions on dynamic MR mammography. The interventions were performed with the handheld 10-gauge Vacora vacuum-biopsy system. In all cases, dynamic MR mammography was performed 24 h after the procedure to determine the extent of the lesion removal and to identify the lesions that were missed. In 5/34 (14.7%) lesions, biopsy was not performed because no suspicious lesion was identified on the day of biopsy. In 25/29 (86.2%) lesions, the biopsy was successfully performed with a complete removal in 4/29 (13.8%) and a partial removal of 21/29 (72.4%) lesions. In 4/29 (13.8%) interventions the lesion was missed with the biopsy. In one case, histopathology after surgical excision revealed ductal carcinoma in situ. Histopathology revealed 9/29 (31%) malignant and 20/29 (68.9%) benign lesions. MR-guided vacuum-assisted breast biopsy with the handheld Vacora vacuum-biopsy system is technically feasible in most cases. MR mammography 24 h after the biopsy should be performed in those cases in which the biopsy success is unclear immediately after the procedure.     

Ultrasound diagnosis of fibroadenoma — is biopsy always necessary?

AIM: To review the ultrasound characteristics of fibroadenoma and the necessity to biopsy all fibroadenomas in the under 25 years age group. MATERIALS AND METHODS: The details of all patients under 25 years of age who attended a large district general hospital in the UK between 1995 and 2005 with a clinical diagnosis of fibroadenoma and subsequently, underwent a breast biopsy were obtained. The report of the targeted ultrasound for these patients was reviewed and this was correlated with the histopathology report (n=447). If there was a significant discrepancy between the ultrasound and the pathology report, the ultrasound images were reviewed. RESULTS: Out of 447 patients 357 had an ultrasound diagnosis of fibroadenoma. This was histologically proven in 281 (78.8%) cases. In 75 (21.5%) of these patients the final histology was either another benign pathology or normal. One patient (0.3%) had an invasive carcinoma. CONCLUSION: The majority of patients in the 25 years and under age group have benign breast pathology, most commonly fibroadenoma. Modern ultrasound is a reliable technique to diagnose fibroadenoma in the hands of experienced breast radiologists. Therefore, in this age group, it is proposed that a palpable lump that has the ultrasound characteristics entirely consistent with a fibroadenoma need not be biopsied unless there is overriding clinical concern. The patients should be reassured, discharged, and advised to return for further evaluation only if they detect a change in the palpable abnormality.