Impact of a Same-Day Breast Biopsy Program on Disparities in Time to Biopsy

BackgroundDisparities in breast cancer diagnosis are established. In usual practice, biopsies are performed days or weeks after recommendation. Our aim was to measure the impact of a same-day biopsy program on disparities in time from biopsy recommendation to performance.MethodsAfter Institutional Review Board approval, we identified all diagnostic examinations leading to biopsy pre- (September 2016 to March 2017) and post- (September 2017 to March 2018) implementation of our same-day biopsy program. We compared demographic characteristics (age, race, language, and insurance) and biopsy information (days from biopsy recommendation to biopsy, and proportion of same-day biopsies in all biopsies) in pre- versus postimplementation groups. Multivariable linear and logistic models in pre- and postimplementation groups assessed if days from biopsy recommendation to biopsy and having a same-day biopsy were associated with patient subgroups.ResultsIn all, 663 and 482 patients underwent biopsy during pre- and postimplementation periods, respectively. Patient subgroups were similar between periods. For all patients, the same-day biopsy program decreased median time from diagnostic examination to biopsy from 8 (interquartile range: 4-13) to 0 (interquartile range: 0-4) days (P < .001). During the pre-implementation period, nonwhite patients and having Medicare insurance were associated with longer days to biopsy (nonwhite Adjusted Coefficient: 2.31, 95% confidence interval [CI]: 0.58-4.03; insurance Adjusted Coefficient: 2.47, 95% CI: 0.58-4.37; P < .05), after adjustment. During the postimplementation period, the previously seen disparities did not persist (nonwhite Adjusted Coefficient: −0.416, 95% CI: −2.16-1.33; insurance Adjusted Coefficient: 0.812, 95% CI: −1.18-2.80; P > .05).ConclusionThere was no evidence of racial/ethnic or insurance disparities in time from biopsy recommendation to performance after implementation of a same-day biopsy program.     

Trends in the Use of Percutaneous Versus Open Surgical Breast Biopsy: An Update

PurposeDespite the emergence of core-needle (percutaneous) biopsy as the standard of breast care, open surgical breast biopsies continue to be performed with variable frequency. The aim of this study was to compare trends in the use of percutaneous and open surgical breast biopsies and the relative roles of radiologists and surgeons in performing them.MethodsThe nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were reviewed, and trends were studied in the total volume of breast biopsies performed in the Medicare fee-for-service population and in volumes of imaging-guided percutaneous biopsies (IGPBs) and open surgical biopsies. Using Medicare’s physician specialty codes, the numbers of procedures performed by different specialties were determined. Trends in the type of imaging used for IGPBs were analyzed using the relevant Current Procedural Terminology codes, introduced in 2014.ResultsBetween 2004 and 2016, utilization of IGPBs increased from 124,423 to 187,914 (+51%), whereas the use of open surgical breast biopsies declined from to 6,605 to 2,373 (−64%). IGPBs performed by radiologists increased from 89,493 to 160,485 (+79%), and IGPBs by surgeons declined from 30,264 to 24,703 (−18%). Among IGPBs from 2014 to 2016, ultrasound-guided and MRI-guided percutaneous biopsies increased, whereas stereotactic biopsies declined.ConclusionsThere is a steady upward trend in the utilization of imaging-guided breast biopsies, and a majority are performed by radiologists. Ultrasound is the primary guidance technique used in percutaneous breast biopsies.     

Ultrasound-Guided Fine-Needle Aspiration Biopsy of the Thyroid: Methods to Decrease the Rate of Unsatisfactory Biopsies in the Absence of an On-Site Pathologist

Purpose

The rate of unsatisfactory samples from ultrasound-guided fine-needle aspirations of thyroid nodules varies widely in the literature. We aimed to evaluate our thyroid ultrasound-guided fine-needle aspiration biopsy technique in the absence of on-site microscopic examination by a pathologist; determine factors that affect the adequacy rate, such as the number of needle passes and needle size; compare our results with the literature; and establish an optimal technique.

Materials and Methods

We performed a retrospective review of cytopathology reports from 252 consecutive thyroid ultrasound-guided fine-needle aspiration biopsies performed by a radiologist between 2005 and 2010 in our hospital’s radiology department. Sample adequacy, the number of needle passes, and needle size were determined. There was an on-site cytologist who prepared slides immediately after fine-needle aspiration but no on-site microscopic assessment of sample adequacy to guide the number of needle passes that should be performed. Cytopathology biopsy reports were classified as either unsatisfactory or satisfactory samples for diagnosis; the latter consisted of benign, malignant, and undetermined diagnoses.

Results

Seventy-seven biopsies were performed with 1 needle pass, 124 with 2 needle passes, and 51 with 3 needle passes. The rates of unsatisfactory biopsies were 33.8%, 23.4% (odds ratio [OR] 0.599 [95% confidence interval {CI}, 0.319-1.123]; P = .110), and 13.7% (OR 0.312 [95% CI, 0.124-0.788]; P = .014), respectively.

Conclusion

In a hospital in which there is no on-site pathologist, a 3-pass method increases the specimen satisfactory rate by 20% compared with 1 pass, achieves similar rates to the literature, and provides a basis for further improvement of our practice.     

Ultrasound-guided Core Biopsy of Small Renal Masses: Diagnostic Rate and Limitations

PurposeTo evaluate the feasibility and complications of ultrasound (US)-guided biopsy of small renal masses (SRMs) and to determine factors that contribute to nondiagnostic biopsy specimens.Materials and MethodsBetween June 2004 and May 2011, 58 consecutive patients underwent US-guided core biopsy of a SRM (>1 cm and≤4 cm) using an 18-gauge core biopsy device. The diagnostic rate, histologic diagnosis, and complications of US-guided core biopsy were assessed. Mann-Whitney U and Fisher exact tests were used to compare diagnostic and nondiagnostic biopsy specimens. Univariate analysis was performed to determine the predictive factors for nondiagnostic biopsy specimens.ResultsThere were 59 biopsies of SRMs performed, and the diagnostic rate was 81% (48 of 59). The mass size of diagnostic and nondiagnostic biopsy specimens ranged from 1.2–3.9 cm (2.4 cm±0.7) for diagnostic specimens and from 1.1–3.5 cm (1.9 cm±0.7) for nondiagnostic specimens (P= .024). Of the diagnostic biopsy specimens, 77% (37 of 48) were malignant, and 23% (11 of 48) were benign. Minor complications developed in 20.3% (12 of 59) of biopsies. The lesion size or core number threshold for decreasing diagnostic rate was 2 cm or three cores. A cystic mass, fewer cores (three or fewer cores), an upper pole mass, and a small mass (≤2 cm) significantly predicted a nondiagnostic biopsy specimen (P= .007–.046).ConclusionsUS-guided core biopsy is a feasible and safe procedure for histologic diagnosis of a SRM. However, nondiagnostic rates may increase when a cystic mass is biopsied, a mass is located in an upper pole mass, a mass is 2 cm or less, and three cores or fewer are sampled.     

Direction of the Biopsy Needle in Ultrasound-Guided Renal Biopsy Impacts Specimen Adequacy and Risk of Bleeding

IntroductionAlthough medical factors such as hypertension and coagulopathy have been identified that are associated with hemorrhage after renal biopsy, little is known about the role of technical factors. The purpose of our study was to examine the effects of biopsy needle direction on renal biopsy specimen adequacy and bleeding complications.MethodsTwo hundred and forty-two patients who had undergone ultrasound-guided renal biopsies were included. A printout of the ultrasound picture taken at the time of the biopsy was used to measure the biopsy angle (“angle of attack” [AOA]) and to determine if the biopsy needle was aimed at the upper or lower pole and if the medulla was targeted or avoided.ResultsOf the 3 groups of biopsy angle, an AOA of between 50°-70° yielded the most glomeruli per core (P = .001) and the fewest inadequate specimens (4% vs 15% for > 70°, and 9% for < 50°, P = .038). Biopsy directed at a pole vs an interpolar region resulted in fewer inadequate specimens (8% vs 23%, P = .005), while biopsies that were medulla-avoiding resulted in fewer inadequate specimens (5% vs 16%, P = .004) and markedly reduced bleeding complications (12% vs 46%, P < .001) compared to biopsies where the medulla was entered.DiscussionAn AOA of approximately 60°, aiming at the poles, and avoiding the medulla were each associated with fewer inadequate biopsies and bleeding complications. While biopsy of the medulla is necessary for some diagnoses, the increased bleeding risk emphasizes the need for communication between nephrologist, pathologist, and radiologist.     

Concordance Assessment of Pathology Results with Imaging Findings after Image-Guided Biopsy

PurposeTo assess the impact of radiology review for discordance between pathology results from computed tomography (CT)–guided biopsies versus imaging findings performed before a biopsy.Materials and MethodsIn this retrospective review, which is compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board, 926 consecutive CT-guided biopsies performed between January 2015 and December 2017 were included. In total, 453 patients were presented in radiology review meetings (prospective group), and the results were classified as concordant or discordant. Results from the remaining 473 patients not presented at the radiology review meetings were retrospectively classified. Times to reintervention and to definitive diagnosis were obtained for discordant cases; of these, 49 (11%) of the 453 patients were in the prospective group and 55 (12%) of the 473 patients in the retrospective group.ResultsPathology results from CT-guided biopsies were discordant with imaging in 11% (104/926) of the cases, with 57% (59/104) of these cases proving to be malignant. In discordant cases, reintervention with biopsy and surgery yielded a shorter time to definitive diagnosis (28 and 14 days, respectively) than an imaging follow-up (78 days) (P < .001). The median time to diagnosis was 41 days in the prospective group and 56 days in the retrospective group (P = .46). When radiologists evaluated the concordance between pathology and imaging findings and recommended a repeat biopsy for the discordant cases, more biopsies were performed (50% [11/22] vs 13% [4/31]; P = .005).ConclusionsEleven percent of CT-guided biopsies yielded pathology results that were discordant with imaging findings, with 57% of these proving to be malignant on further workup.     

How to Interpret Thyroid Biopsy Results: A Three-Year Retrospective Interventional Radiology Experience

Results of thyroid biopsy determine whether thyroid nodule resection is appropriate and the extent of thyroid surgery. At our institution we use 20/22-gauge core biopsy (CBx) in conjunction with fine-needle aspiration (FNA) to decrease the number of passes and improve adequacy. Occasionally, both ultrasound (US)-guided FNA and CBx yield unsatisfactory specimens. To justify clinical recommendations for these unsatisfactory thyroid biopsies, we compare rates of malignancy at surgical resection for unsatisfactory biopsy results against definitive biopsy results. We retrospectively reviewed a database of 1979 patients who had a total of 2677 FNA and 663 CBx performed by experienced interventional radiologists under US guidance from 2003 to 2006 at a tertiary-care academic center. In 451 patients who had surgery following biopsy, Fisher’s exact test was used to compare surgical malignancy rates between unsatisfactory and malignant biopsy cohorts as well as between unsatisfactory and benign biopsy cohorts. We defined statistical significance at P = 0.05. We reported an overall unsatisfactory thyroid biopsy rate of 3.7% (100/2677). A statistically significant higher rate of surgically proven malignancies was found in malignant biopsy patients compared to unsatisfactory biopsy patients (P = 0.0001). The incidence of surgically proven malignancy in unsatisfactory biopsy patients was not significantly different from that in benign biopsy patients (P = 0.8625). In conclusion, an extremely low incidence of malignancy was associated with both benign and unsatisfactory thyroid biopsy results. The difference in incidence between these two groups was not statistically significant. Therefore, patients with unsatisfactory biopsy specimens can be reassured and counseled accordingly.     

Sonographically Guided Core Biopsy of the Breast: Comparison of 14-Gauge Automated Gun and 11-Gauge Directional Vacuum-Assisted Biopsy Methods

Objective

To compare the outcomes of 14-gauge automated biopsy and 11-gauge vacuum-assisted biopsy for the sonographically guided core biopsies of breast lesions.

Materials and Methods

We retrospectively reviewed all sonographically guided core biopsies performed from January 2002 to February 2004. The sonographically guided core biopsies were performed with using a 14-gauge automated gun on 562 breast lesions or with using an 11-gauge vacuum-assisted device on 417 lesions. The histologic findings were compared with the surgical, imaging and follow-up findings. The histologic underestimation rate, the repeat biopsy rate and the false negative rates were compared between the two groups.

Results

A repeat biopsy was performed on 49 benign lesions because of the core biopsy results of the high-risk lesions (n = 24), the imaging-histologic discordance (n = 5), and the imaging findings showing disease progression (n = 20). The total underestimation rates, according to the biopsy device, were 55% (12/22) for the 14-gauge automated gun biopsies and 36% (8/22) for the 11-gauge vacuum-assisted device (p = 0.226). The atypical ductal hyperplasia (ADH) underestimation (i.e., atypical ductal hyperplasia at core biopsy and carcinoma at surgery) was 58% (7/12) for the 14-gauge automated gun biopsies and 20% (1/5) for the 11-gauge vacuum-assisted biopsies. The ductal carcinoma in situ (DCIS) underestimation rate (i.e., ductal carcinoma in situ upon core biopsy and invasive carcinoma found at surgery) was 50% (5/10) for the 14-gauge automated gun biopsies and 41% (7/17) for the 11-gauge vacuum-assisted biopsies. The repeat biopsy rates were 6% (33/562) for the 14-gauge automated gun biopsies and 3.5% (16/417) for the 11-gauge vacuum-assisted biopsies. Only 5 (0.5%) of the 979 core biopsies were believed to have missed the malignant lesions. The false-negative rate was 3% (4 of 128 cancers) for the 14-gauge automated gun biopsies and 1% (1 of 69 cancers) for the 11-gauge vacuum-assisted biopsies.

Conclusion

The outcomes of the sonographically guided core biopsies performed with the 11-gauge vacuum-assisted device were better than those outcomes of the biopsies performed with the 14-gauge automated gun in terms of underestimation, rebiopsy and the false negative rate, although these differences were not statistically significant.     

Diagnostic Performance of the Modified Korean Thyroid Imaging Reporting and Data System for Thyroid Malignancy: A Multicenter Validation Study

ObjectiveTo evaluate the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System (K-TIRADS), and compare it with the 2016 version of K-TIRADS using the Thyroid Imaging Network of Korea.Materials and MethodsBetween June and September 2015, 5708 thyroid nodules (≥ 1.0 cm) from 5081 consecutive patients who had undergone thyroid ultrasonography at 26 institutions were retrospectively evaluated. We used a biopsy size threshold of 2 cm for K-TIRADS 3 and 1 cm for K-TIRADS 4 (modified K-TIRADS 1) or 1.5 cm for K-TIRADS 4 (modified K-TIRADS 3). The modified K-TIRADS 2 subcategorized the K-TIRADS 4 into 4A and 4B, and the cutoff sizes for the biopsies were defined as 1 cm for K-TIRADS 4B and 1.5 cm for K-TIRADS 4A. The diagnostic performance and the rate of unnecessary biopsies of the modified K-TIRADS for detecting malignancy were compared with those of the 2016 K-TIRAD, which were stratified by nodule size (with a threshold of 2 cm).ResultsA total of 1111 malignant nodules and 4597 benign nodules were included. The sensitivity, specificity, and unnecessary biopsy rate of the benign nodules were 94.9%, 24.4%, and 60.9% for the 2016 K-TIRADS; 91.0%, 39.7%, and 48.6% for the modified K-TIRADS 1; 84.9%, 45.9%, and 43.5% for the modified K-TIRADS 2; and 76.1%, 50.2%, and 40.1% for the modified K-TIRADS 3. For small nodules (1–2 cm), the diagnostic sensitivity of the modified K-TIRADS decreased by 5.2–25.6% and the rate of unnecessary biopsies reduced by 19.2–32.8% compared with those of the 2016 K-TIRADS (p < 0.001). For large nodules (> 2 cm), the modified K-TIRADSs maintained a very high sensitivity for detecting malignancy (98%).ConclusionThe modified K-TIRADSs significantly reduced the rate of unnecessary biopsies for small (1–2 cm) nodules while maintaining a very high sensitivity for malignancy for large (> 2 cm) nodules.     

Ultrasound Practice Redesign to Improve Image Quality: Implementation of a Quality Control Sonographer

PurposeThe aim of this study was to systematically improve ultrasound image quality via the implementation of a quality control (QC) sonographer.MethodsThe position of a QC sonographer was created, whose responsibility was to preview ultrasound examinations performed by other sonographers and audit ultrasound examinations for image quality and protocol adherence. Retrospective audits of examinations performed before and after the implementation of the QC sonographer position were performed. Examinations from 17 sonographers were audited (16 examinations per sonographer), with a sample size of 272 examinations per audit. The QC sonographer graded the following imaging quality parameters (IQPs) as acceptable or needing improvement: gain, depth, color Doppler, spectral Doppler, and protocol adherence. Statistical comparisons were performed by a biostatistician using a χ² test, with P < .05 used as the threshold for significance.ResultsThe baseline audit (September 1, 2015 to November 30, 2015) revealed 439 instances of IQPs that required improvement. A second audit after establishing the QC sonographer role (August 1, 2016 to October 31, 2016) found 176 instances of IQPs that required improvement. A third, follow-up audit (May 1, 2018 to September 30, 2018) found 172 instances of IQPs that required improvement.ConclusionsRemoving a sonographer from the clinical line to work as a QC sonographer resulted in a 60% decrease in parameter errors that was maintained over time. Another benefit of the QC sonographer role is improved sonographer education.     

Radiofrequency Ablation to Treat Loco-Regional Recurrence of Well-Differentiated Thyroid Carcinoma

Objective

To evaluate the efficacy of radiofrequency ablation (RFA) in the treatment of loco-regional, recurrent, and well-differentiated thyroid carcinoma.

Materials and Methods

Thirty-five recurrent well-differentiated thyroid carcinomas (RTC) in 32 patients were treated with RFA, between March 2008 and October 2011. RTCs were detected by regular follow-up ultrasound and confirmed by biopsy. All patients had fewer than 3 RTCs in the neck and were at high surgical risk or refused to undergo repeated surgery. Average number of RFA sessions were 1.3 (range 1-3). Post-RFA biopsy and ultrasound were performed. The mean follow-up period was 30 months. Pre- and post-RFA serum thyroglobulin values were evaluated.

Results

Thirty-one patients with 33 RTCs were treated with RFA only, whereas 1 patient with 2 RTCs was treated with RFA followed by surgery. At the last follow-up ultrasound, 31 (94%) of the 33 RTCs treated with RFA alone completely disappeared and the remaining 2 (6%) RTCs showed decreased volume. The largest diameter and volume of the 33 RTCs were markedly decreased by 93.2% (from 8.1 ± 3.4 mm to 0.6 ± 1.8 mm, p < 0.001) and 96.4% (from 173.9 ± 198.7 mm³ to 6.2 ± 27.9 mm³, p < 0.001), respectively. Twenty of the 21 RTCs evaluated with post-RFA biopsies (95%) were negative for malignancy. One (5%) showed remaining tumor that was removed surgically. The serum thyroglobulin was decreased in 19 of 26 patients (73%). Voice change developed immediately after RFA in 6 patients (19%) and was spontaneously recovered in 5 patients (83%).

Conclusion

Radiofrequency ablation can be effective in treating loco-regional, recurrent, and well-differentiated thyroid carcinoma in patients at high surgical risk.     

Safety and Utility of Transjugular Liver Biopsy in Hematopoietic Stem Cell Transplant Recipients

PurposeHematopoietic stem cell transplant (HSCT) recipients are at high risk in the setting of percutaneous liver biopsy as a result of comorbid coagulopathy and ascites, and are commonly referred to undergo transjugular liver biopsy. The present study was performed to assess the safety and utility of transjugular liver biopsy in HSCT recipients and to analyze the correlation between corrected hepatic sinusoidal pressure gradient (CHSPG) and pathologic diagnoses.Materials and MethodsData from reports of transjugular liver biopsy procedures, pathology reports, and laboratory values of 141 consecutive HSCT recipients who underwent transjugular liver biopsy with pressure measurement between January 2005 and August 2011 in a single institution were retrospectively reviewed and analyzed.ResultsA total of 166 biopsy procedures were performed in 141 patients. Technical success rate was 98.8%. Biopsy was diagnostic in 95.7% of patients. There were three major complications (1.8%), including one death. CHSPG in patients with venoocclusive disease (VOD) was significantly higher (P<.001) than in those without VOD (16.2 mm Hg±9.2 vs 5.6 mm Hg±3.7). A CHSPG of 10 mm Hg or higher was 90.8% specific and 77.3% sensitive for VOD.ConclusionsThe present data show that transjugular liver biopsy is a relatively safe procedure that provides important information for the clinical management of patients with HSCT. Measurement of CHSPG during the procedure can support the diagnosis of VOD.     

Risk Factors of Pneumothorax after CT-Guided Coaxial Cutting Needle Lung Biopsy through Aerated versus Nonaerated Lung

PurposeTo compare the risk factors of developing a pneumothorax after computed tomography–guided lung biopsy in cases in which aerated lung is traversed and in cases in which aerated lung is not traversed.Materials and MethodsThe records of 381 patients from July 2005–December 2009 were retrospectively reviewed. Multivariable analysis of patient demographic characteristics, lung lesion characteristics, and biopsy procedure details was performed with respect to the development of pneumothorax.ResultsAmong 381 patients, 249 biopsies traversed aerated lung tissue, and 132 biopsies did not traverse aerated lung tissue. Patients in whom aerated lung tissue was traversed had a significantly higher rate of pneumothorax. When aerated lung was not traversed, lesion size (≤ 2 cm vs > 2 cm; P = .025) and pleural-lesion angle (odds ratio = 1.033/degree; P = .004) were associated with pneumothorax. When aerated lung was traversed, location (middle vs upper; P = .009) and a transfissure approach (yes vs no; P = .001) were associated with pneumothorax.ConclusionsWhen aerated lung was not traversed, lesion size and pleural-lesion angle were associated with pneumothorax, and when aerated lung was traversed, location and a transfissure approach were associated with pneumothorax.     

Percutaneous Image-Guided Core Needle Biopsy of Neuroendocrine Tumors: How Common Is Intraprocedural Carcinoid Crisis?

PurposeTo retrospectively evaluate the incidence of carcinoid crisis, other complications, and physiologic disturbances during percutaneous image-guided core needle biopsy of neuroendocrine tumors (NETs) in the lung and the liver.Materials and MethodsBetween January 2010 and January 2020, 106 computed tomography (CT) or ultrasound (US)-guided core needle biopsies of lung and liver NETs were performed in 95 consecutive adult patients. The mean age was 64 ± 13 years, and 48% were female. The small bowel was the most common primary site (33%, 31/95), and 32 (34%) patients had pre-existing symptoms of carcinoid syndrome. The mean tumor size was 3.2 ± 2.6 cm, and mean number of passes was 3.4 ± 1.6. A 17/18-gauge needle was used in 91% (96/106) of the biopsies. Thirteen (12%) patients received either outpatient or prophylactic octreotide.ResultsNo patients experienced carcinoid crisis or needed octreotide, inotropes, vasopressors, or resuscitation. A single biopsy procedure (0.9%, 1/106) was complicated by bleeding that required angiographic hepatic artery embolization. Changes in pre-biopsy- versus post-biopsy systolic blood pressure and heart rate were -1.6 mm Hg (P = .390) and 0.6 beat/min (P = .431), respectively. Tumor functional status, overall tumor burden, and the elevation of neuroendocrine markers were not associated with intraprocedural physiologic disturbances. There were 4 minor complications (0.4%, 4/106) associated with the biopsy procedure that were not attributed to hormone excretion from tumor manipulation.ConclusionsPercutaneous image-guided core biopsy of NETs is safe, with low complication rate and no definite carcinoid crisis in the current cohort.     

Image-Guided Percutaneous Omental and Mesenteric Biopsy: Assessment of Technical Success Rate and Diagnostic Yield

Purpose

To assess biopsy technique, technical success rate, and diagnostic yield of image-guided percutaneous biopsy of omental and mesenteric lesions.

Effectiveness and Safety of Percutaneous CT-Guided Rib Biopsy

Purpose

To retrospectively evaluate effectiveness and safety of percutaneous CT-guided rib biopsy.

Reducing Variability of Radiation Dose in CT: The New Frontier in Patient Safety

PurposeAlthough reducing radiation dose in CT examinations is an important goal, also important in the management of radiation dose is ensuring consistency of dose administered for a given type of examination. We have implemented an approach to reducing variance in CT radiation dose by standardizing protocols and implementing software that decreases variance.MethodsA multifaceted approach to reducing variance in CT radiation dose was utilized: (1) establishment of the Radiation Dose Optimization Committee, (2) standardization of protocols, and (3) implementation of scanner software. Two periods of data were collected: pre-intervention (January 1, 2013, to July 31, 2014) and postintervention (January 1, 2016, to December 31, 2016). The period from August 1, 2014, to December 31, 2015, represented the time the major interventions were performed.ResultsThe average radiation dose for all CT exams performed during the pre-intervention period (n = 39,314) was 22.3 CTDIvol with an SD of 17.0. The average radiation dose for all CT exams performed during the postintervention period (n = 49,863) was 13.6 CTDIvol with an SD of 9.01. The postintervention variance was significantly decreased (P < .0001).ConclusionsA significant decrease in the variability of our network CT radiation dose was achieved as a result of a combination of standardizing protocols across the network and implementation of advanced software that effectively managed radiation dose, all overseen by the Radiation Dose Optimization Committee.     

Modified Core Biopsy Technique to Increase Diagnostic Yields for Well-Circumscribed Indeterminate Thyroid Nodules: A Retrospective Analysis

BACKGROUND AND PURPOSE:The results of conventional core biopsy for some thyroid nodules with indeterminate cytology have still remained indeterminate. The aim of this study was to evaluate whether the ultrasonography-guided core needle biopsy technique containing the nodule, capsular portion, and surrounding parenchyma was more effective than a conventional method in enhancing diagnostic yield for circumscribed solid thyroid nodules without malignant sonographic features.MATERIALS AND METHODS:This retrospective comparative study evaluated 26 thyroid nodules in 26 consecutive patients between 2006 and 2010. They were biopsied by using a conventional method, and 61 nodules from 60 patients were biopsied by using a modified ultrasonography-guided core needle biopsy technique in 2013. The patients enrolled in this study presented with circumscribed solid thyroid nodules without malignant sonographic features, classified as nondiagnostic or atypia/follicular lesions of undetermined significance at previous cytology. The ultrasonography-guided core needle biopsy results of the 2 groups were compared.RESULTS:The rate of inconclusive ultrasonography-guided core needle biopsy results was 34.6% (9/26) in the conventional group and 11.4% (7/61) in the modified technique group (P = .018). There was no significant difference in the mean size of the nodules between the 2 groups (P = .134). The malignancy rate was 33% (3/9) for the conventional group and 52% (27/52) for the modified technique group (P = .473). The most common malignant pathology was a follicular variant of papillary thyroid carcinoma and follicular adenoma was the most common benign lesion.CONCLUSIONS:For circumscribed solid nodules without malignant sonographic features with indeterminate cytology, the ultrasonography-guided core needle biopsy technique containing the nodule, capsular portion, and surrounding parenchyma is more effective in diagnostic yield compared with a conventional method that biopsies the intranodular portion.

Despite the lack of definite malignant sonographic features, solid thyroid nodules showing nondiagnostic or atypia or follicular lesions of undetermined significance (AUS/FLUS) in fine-needle aspiration (FNA) readings by using the Bethesda System for Reporting Thyroid Cytopathology have raised concerns about the diagnosis of malignancy.^1–4 The management of nodules with nondiagnostic lesions or AUS/FLUS has been a matter of debate.^2,3 Several studies have suggested that sonography-guided core needle biopsy (US-CNB) helps decrease the frequency of inconclusive diagnostic results and improves the rate of accurate diagnoses.^5–9US-CNB is safe and well-tolerated, yields a low incidence of complications, and serves as an alternative to FNA for obtaining tissues for diagnosis.^7,10 However, its results have remained indeterminate for up to 36% of the nodules whose cytology is insufficient to differentiate nodular hyperplasia from follicular neoplasm, even after US-CNB.⁵ On ultrasonography (US), circumscribed solid nodules without malignant features are frequently confirmed histologically as nodular hyperplasia, a follicular neoplasm (follicular/Hürthle adenoma or carcinoma), a follicular variant of papillary thyroid carcinoma (PTC), or a classic type of PTC.^11–14The preoperative diagnosis of PTC would usually be sufficient with FNA because nuclear features are the key to diagnosis.⁴ “Follicular neoplasm” is defined as an encapsulated lesion whose growth pattern (microfollicular, macrofollicular, trabecular, or another growth pattern) is distinct from that of the surrounding thyroid parenchyma. Nodular hyperplasia is one of the most common pathologies in benign thyroid disease and is characterized by a densely cellular follicular proliferation that lacks a capsule on histology.^4,15,16 Because nodular hyperplasia may sometimes be considered normal thyroid tissue after core needle biopsy diagnosis, the presence of a capsule and normal parenchyma in the thyroid nodule can be meaningful for the differentiation of a follicular neoplasm from nodular hyperplasia. Nodules with circumscribed solid features only identified on US are diagnosed as indeterminate because they have neither malignant nor benign features.¹⁷ Moreover, indeterminate FNA of these lesions may lead to an unnecessary diagnostic operation. Thus, circumscribed solid thyroid nodules not associated with other malignant features require the use of CNB techniques under US guidance other than a conventional method that biopsies the internal portion of the thyroid nodule. One recent study suggested that the use of a CNB technique that biopsied the capsule of the thyroid nodule and the surrounding parenchyma was useful for the diagnosis of cytologically indeterminate nodules.¹⁸ However, the authors did not compare the results of the conventional method with those of the modified method or focus on the diagnosis of problematic nodules by using a conventional CNB method. We evaluated whether the modified CNB technique was more effective in the diagnostic yield of circumscribed solid nodules without malignant sonographic features with indeterminate cytology compared with a conventional method. Therefore, we compared the inconclusive rate (nondiagnostic or AUS/FLUS rate) and malignant rate of CNB results between the conventional and the modified technique groups.