Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy in cavitary pulmonary lesions

Objective

CT-guided transthoracic biopsy is a well-established method in the cytologic or histologic diagnosis of pulmonary lesions. The knowledge of its diagnostic performance and complications for cavitary pulmonary lesions is limited. The purpose of this study was to determine the diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy (FNAB) in cavitary pulmonary lesions.

Materials and methods

102 consecutive patients with pulmonary cavitary lesions received CT-guided FNAB with use of an 18-gauge (n = 35) or 20-gauge (n = 67) Chiba for histology diagnosis. The sensitivity, specificity, and diagnostic accuracy of FNAB were calculated as compared with the final diagnosis. Complications associated with FNAB were observed. The diagnostic accuracy and complications were compared between patients with different lesion sizes and different cavity wall thickness.

Results

The overall sensitivity, specificity, and accuracy of FNAB were 96.3%, 98.0%, and 96.1%, respectively. The sensitivity, specificity, and diagnosis accuracy in different lesion size (<2 cm vs ≥2 cm), or different cavity wall thickness (<5 mm vs ≥5 mm) were not different (P > 0.05; 0.235). More nondiagnostic sample was found in wall thickness <5 mm lesions (P = 0.017). Associated complications included pneumothorax in 9 (8.8%) patients and alveolar hemorrhage in 14 patients (13.7%) and hemoptysis in 1 patient (1%). No different rate of complications was found with regard to lesion size, wall thickness, length of the needle path and needle size (P > 0.05).

Conclusion

CT-guided FNAB can be effectively ad safely used for patients with pulmonary cavitary lesions.     

Initial CT-guided needle biopsy of extremity skeletal lesions: Diagnostic performance and experience of a tertiary musculoskeletal center

Introduction

Appendicular long bones are the target for a wide spectrum of bony lesions with variable clinical presentations. Biopsy procedures are needed for subsequent proper patient's management. Most of the available literature globally assessed musculoskeletal biopsies with inclusion of repeat biopsy results.We thought to retrospectively assess the diagnostic performance of initial CT-guided percutaneous core needle biopsy (PCNB) of extremity long bone lesions in a tertiary musculoskeletal referral center.

Patients and methods

We retrospectively analyzed the outcome of initial CT-guided PCNB of 49 patients who presented with extremity long bone lesions which were biopsied in our hospital during a 36 months’ time period. The diagnostic performance was assessed in terms of diagnostic yield and accuracy.

Results

There were 34 males and 15 females with a mean age of 33.69 years (range from 4 to 77 years). The overall diagnostic yield of initial biopsies was 87.75% with a diagnostic accuracy of 82.85% derived from the surgically proven cases. The higher diagnostic yield was recorded with malignancy, presence of extra-osseous soft-tissue component as well as mixed and sclerotic lesions. The pathologies of the non-diagnostic biopsies included large-cell lymphoma, giant-cell tumor, langerhans cell histiocytosis, osteoid osteoma and a non-ossifying fibroma.

Conclusion

Initial CT-guided PCNB in extremities’ long bones lesions showed high diagnostic performance in malignant, mixed and/or sclerotic lesions as well as lesions with extra-osseous exophytic tissue growth. Lack of extra-osseous components, benign and lytic lesions all had worse diagnostic performance.     

Percutaneous CT-guided biopsy of the musculoskeletal system: Results of 2027 cases

Introduction

Biopsy of the musculoskeletal system is useful in the management of bone lesions particularly in oncology but they are often challenging procedures with a significant risk of complications. Computed tomography (CT)-guided needle biopsies may decrease these risks but doubts still exist about their diagnostic accuracy. This retrospective analysis of the experience of a single institution with percutaneous CT-guided biopsy of musculoskeletal lesions evaluates the results of these biopsies for bone lesions either in the appendicular skeleton or in the spine, and defines indications.

Materials and methods

We reviewed the results of 2027 core needle biopsies performed over the past 18 years at the authors’ institution. The results obtained are subject of this paper.

Results

In 1567 cases the correct diagnosis was made with the first CT-guided needle biopsy (77.3% accuracy rate), in 408 cases the sample was not diagnostic and in 52 inadequate. Within 30 days these 408 patients underwent another biopsy, which was diagnostic in 340 cases with a final diagnostic accuracy of 94%. Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, flogistic, and systemic pathologies. There were 22 complications (18 transient paresis, 3 haematomas, 1 retroperitoneal haematoma) which had no influence on the treatment strategy, nor on patient outcome.

Conclusion

This technique is reliable and safe and should be considered nowadays the gold standard for biopsies of the musculoskeletal system.     

Stereotactic core biopsy: Comparison of 11 gauge with 8 gauge vacuum assisted breast biopsy

Purpose

The compare the performance and ability to obtain a correct diagnosis on needle biopsy between 11 gauge and 8 gauge vacuum assisted biopsy devices.

Materials and methods

Hospital records of all consecutive stereotactic core biopsies performed over five years were retrospectively reviewed in compliance Health Insurance Portability and Accountability Act (HIPPA) policy and with approval from the hospital institutional review board (IRB). Pathology from core biopsy was compared with surgical pathology and/or imaging follow-up. A histological underestimation was defined if the surgical excision yielded a higher grade on pathology which changed management.

Results

828 needle core biopsies (47.5%, 393/828 with 11 gauge and 52.5%, 435/828 with 8 gauge) yielded 471 benign, 153 high risk and 204 malignant lesions. 30/193 (15.5%) 11 gauge lesions and 16/185 (8.6%) 8 gauge lesions demonstrated higher grade pathology on surgical excision. The difference in the rates of the number of correct diagnoses on core needle biopsy between 11 gauge (363/393, 92.4%) and 8 gauge (419/435, 96.3%) based on either surgical or clinical/imaging follow up and the difference in the number of discordant benign core biopsies between 11 (17/217, 7.8%) and 8 gauge (4/254, 1.6%) necessitating a surgical biopsy was significant (P = 0.013; P = 0.001). Although there were more underestimations with the 11 gauge (25/193, 13.0%) than 8 gauge (15/185, 8.1%) needle, this was not significant.

Conclusion

Our study demonstrates improved performance and increased diagnostic ability of 8 gauge needle over 11 gauge in obtaining a correct diagnosis on needle biopsy.     

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.     

Comparison of fully automated and semi-automated biopsy needles for lung biopsy under CT fluoroscopic guidance

Objective

The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for lung biopsy.

Methods

50 consecutive percutaneous lung biopsies using the Monopty needle between June 2006 and January 2007 and 66 consecutive lung biopsies for 1 nodule in each session using the Temno needle between February 2007 and August 2008 were performed under CT fluoroscopic guidance followed by histopathological evaluation.

Results

In 42/50 lung biopsies performed with the Monopty needle and 54/66 lung biopsies performed with the Temno needle, the final diagnosis was confirmed by independent surgical pathological findings or clinical follow-up. Sufficient samples for histopathological evaluation were obtained in all 50 (100%) biopsies using the Monopty needle and in 55 (83.3%) of the 66 biopsies using the Temno needle (p<0.01). Accurate diagnosis was achieved in 41 (97.6%) of 42 biopsies using the Monopty needle and in 45 (83.3%) of 54 biopsies using the Temno needle (p=0.04). Biopsy-induced complications were pneumothorax, haemoptysis and haemothorax in 44.0%, 10.0% and 6.0% of biopsies, respectively, using the Monopty needle and in 48.3%, 8.3% and 3.3%, respectively, using the Temno needle.

Conclusion

There is a possibility that a fully automated biopsy needle such as the Monopty is more useful for CT scan-guided lung biopsy than semi-automated biopsy needles.CT scan-guided needle biopsy of lung nodules has become a well-established diagnostic technique [1]. Most CT scan-guided lung biopsies cited in earlier reports [2,3] were performed with fine-needle aspiration for cytology and were useful in differentiating malignant from benign lesions. In addition, a tissue-core biopsy using a cutting needle, which enables histopathological evaluation of the samples obtained [4], has been implemented to enhance diagnostic ability. Owing to the development of the automated cutting needle, tissue-core biopsy can now be performed more easily and higher quality core specimens can be obtained for histopathological analysis [5-11].There are two types of automated cutting needles: the fully automated biopsy needle and the semi-automated biopsy needle. Comparisons have been made of the use of these needles for autopsy [12] or breast tissue biopsy [13]. To our knowledge, no investigation has been carried out to compare these two types of automated cutting needles for lung biopsy. The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for use in CT scan-guided lung biopsy.     

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 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.     

Diagnostic performance of breast MRI with and without the addition of quantitative diffusion weighted imaging

Objective

The purpose of our study was to investigate whether adding diffusion weighted imaging to dynamic contrast-enhanced MRI could improve the diagnostic performance of breast MRI.

Materials and methods

This retrospective study included 86 women with 93 primary and postoperative breast lesions detected on DCE-MRI who underwent subsequent biopsy. The diagnostic performance was calculated for DCE-MRI alone, combined DCE-MRI and quantitative DWI, and for quantitative DWI alone.

Results

Of the 93 lesions, 42 were benign and 51 malignant (5 DCIS, 41 IDC, 2 ILC, 3 NOS). Both DCIS (mean ADC = 1.17 ± 0.12 × 10⁻³ mm²/s) and IDC (mean ADC, 0.98 ± 0.14) exhibited lower mean ADC values than benign lesions (ADC value = 1.72 ± 0.36). Applying an ADC cutoff value of 1.33 increased the specificity and PPV of DCE-breast MRI from 59.5% and 75% to 78.5% and 83.3%, respectively. The specificity and PPV for quantitative DW-MRI alone (73.5% and 83.3%) were close to those broken out from the combined use of DCE and quantitative DW-MRI. However, the sensitivity and NPV of DWI remains lower than that of DCE-MRI.

Conclusion

DWI shows potential for improving the diagnostic performance of breast MRI and may reduce the number of unnecessary biopsies.     

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.     

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.     

Multidetector computed tomography arthrography of the knee: diagnostic accuracy and indications

Purpose

To evaluate the diagnostic accuracy and indications of arthrography with multidetector computed tomography (arthro-MDCT) of the knee, in patients with absolute or relative contraindications to MRI and in patients with periarticular metal implants using diagnostic arthroscopy as the gold standard.

Materials and methods

After intra-articular injection of iodixanol and volumetric acquisition, 68 knees in patients of both sexes (30 females, 38 males, age range 32–60 years) were examined with a 16-detector-row CT scanner. The patients had arthralgia but no radiologically detected fractures. They could not be studied by MRI either because of absolute contraindications (subcutaneous electronic implants), surgical metal implants or claustrophobia. In 37 of 68 patients who had had previous knee surgery, the arthro-CT examination was preceded by an MRI on the same day.All examinations were interpreted by two experienced musculoskeletal radiologists.The findings were compared with arthroscopic findings carried out within 28 days of the CT study.

Results

In non-operated patients the comparison between arthro-MDCT and arthroscopy showed sensitivity and specificity ranging between 86% and 100%. In the 37 operated knees, arthro-MDCT had an accuracy of 95% compared with 53% of the MRI.Inter-observer agreement was almost perfect (K = 0.97) in the evaluation of all types lesions, both on MDCT and MRI.When arthro-MDCT was compared with MRI in post-operative patients by a McNemar test, a significant difference (p < 0.05) was found between these two techniques.

Conclusions

Arthro-MDCT of the knee is a safe technique that provides accurate diagnosis in identifying chondral, fibrocartilaginous and intra-articular ligamentous lesions, in patients that cannot be evaluated by MRI, and in patients after surgical.     

Use of magnetic resonance imaging to detect neoplastic meningitis: limited use in leukemia and lymphoma but convincing results in solid tumors

Background

An early diagnosis of meningitis is important to improve patients’ survival. Data about a direct comparison of cerebrospinal fluid cytology (CSF-cytology) and MRI are very limited. Therefore, the aim of this study was to compare these two diagnostic modalities in diagnosing meningitis in patients with hematopoietic and solid malignancies.

Methods

In 68 patients suspicious for neoplastic meningitis, cytology and MRI (1.5 T) was performed. The meningeal, pial or intraparenchymal hyperintense signal or contrast enhancement was correlated to the final CNS diagnosis and to cytology.

Results

44 patients (64.7%) had neoplastic meningitis, 21 patients (30.9%) had non-neoplastic meningitis. The sensitivity to diagnose meningeal disease was 49.2% for MRI and 95.4% for cytology (p < 0.001). In patients with neoplastic meningitis, sensitivity was 45.5% for MRI and 93.2% for cytology (p < 0.001). In patients with infectious meningitis, sensitivity was 57.1% for MRI and 100% for cytology (p = 0.0013). In patients with solid tumors, the sensitivity was 84.6% for both diagnostic methods. The sensitivity for MRI was low in patients with leukemia (20.0%) and lymphoma (37.5%). The positive predictive value (PPV) for MRI to differentiate infectious from neoplastic meningitis was high in patients with infectious meningitis (75.0%), in patients with lymphoma (83.3%), and in patients with solid tumors (72.7%). Ppv was low in patients with leukemia (33.3%).

Conclusion

Diagnostic value of MRI for diagnosing meningitis is especially limited in patients with hematopoietic malignancies. MRI better detected leptomeningeal involvement caused by solid tumors than by leukemia or lymphoma. The ppv to specify neoplastic meningitis depends on tumor subtype.     

Diagnostic accuracy and complication rates of percutaneous CT-guided coaxial needle biopsy of pulmonary lesions

PURPOSEThe aim of this retrospective study was to evaluate and compare diagnostic accuracy and complication rates of percutaneous computed tomography (CT)-guided biopsies of pulmonary lesions 10–35 mm, 35–50 mm, and >50 mm, using the coaxial biopsy technique.METHODSOver a 4-year period, 235 lung biopsies were performed using the coaxial biopsy technique with 18G semi-automated true-cut needle. There were 163 (69.4%) male and 72 (30.6%) female patients, with a mean age of 64.01±9.18 years (18–85 years). The mean lesion size was 59.6±29.3 mm. The lesions were stratified into three groups according to size: lesions <35 mm (n=42, 17.9%), lesions 35–50 mm (n=53, 22.5%), and lesions >50 mm (n=140, 59.6%). Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for all biopsies, and for each group separately, as well as the incidence of complications.RESULTSThe overall diagnostic accuracy was 95.4%, with 95.52% sensitivity, 100% specificity, 100% PPV, and 47.37% NPV. For lesions <35 mm, diagnostic accuracy, sensitivity, and PPV were 100%. The lowest diagnostic accuracy was 93.9% in lesions >50 mm, with 93.65% sensitivity, 100% specificity, 100% PPV, and 42.86% NPV. An adequate sample was obtained in 219 core biopsies (93.2%), while 16 biopsies (6.8%) were nondiagnostic due to necrosis (4.25%) and insufficient biopsy material (2.55%). The most frequent complication was minor pneumothorax, which was seen at a rate of 19.1%; pneumothorax requiring chest tube placement occurred in 3 patients (1.3%).CONCLUSIONDiagnostic accuracy decreased with increasing lesion size. On the other hand, complication rates were higher in smaller lesions, more distanced from the pleura.

Computed tomography (CT)-guided percutaneous needle biopsy is a well-established method in the diagnostic algorithm of various pulmonary lesions, with two types of biopsy techniques employed, fine-needle aspiration biopsy (FNAB) and core biopsy (CB). Both techniques yield high diagnostic accuracy for carcinomas, from 89% in FNAB to 98% in CB (1). Coaxial biopsy technique has a reported overall diagnostic accuracy for both malignant and benign lesions ranging from 82.6% to 95% (2–4).Besides the needle type, other factors such as lesion size, nature of the lesion, experience and skills of interventional radiologist influence the diagnostic accuracy. Lesion size ≥1 cm is reported as a significant risk factor decreasing diagnostic accuracy, but in published data lesions >5 cm and even ≥3.1 cm, are also identified as factors that decrease the diagnostic accuracy mainly due to the higher rates of necrosis (4, 5).The most frequent complication in lung biopsy is pneumothorax, with the reported pooled rate 25.3% for CB and 18.8% for FNAB (6).The aim of this retrospective single-center study was to determine diagnostic accuracy and complication rates of percutaneous CT-guided coaxial lung biopsies of pulmonary lesions stratified by lesion size into <35 mm, 30–50 mm, and >50 mm lesions, as well as to identify the relevant risk factors.     

Navigated MRI-guided liver biopsies in a closed-bore scanner: experience in 52 patients

Objectives

To evaluate clinical effectiveness and diagnostic efficiency of a navigation device for MR-guided biopsies of focal liver lesions in a closed-bore scanner.

Methods

In 52 patients, 55 biopsies were performed. An add-on MR navigation system with optical instrument tracking was used for image guidance and biopsy device insertion outside the bore. Fast control imaging allowed visualization of the true needle position at any time. The biopsy workflow and procedure duration were recorded. Histological analysis and clinical course/outcome were used to calculate sensitivity, specificity and diagnostic accuracy.

Results

Fifty-four of 55 liver biopsies were performed successfully with the system. No major and four minor complications occurred. Mean tumour size was 23?±?14 mm and the skin-to-target length ranged from 22 to 177 mm. In 39 cases, access path was double oblique. Sensitivity, specificity and diagnostic accuracy were 88 %, 100 % and 92 %, respectively. The mean procedure time was 51?±?12 min, whereas the puncture itself lasted 16?±?6 min. On average, four control scans were taken.

Conclusions

Using this navigation device, biopsies of poorly visible and difficult accessible liver lesions could be performed safely and reliably in a closed-bore MRI scanner. The system can be easily implemented in clinical routine workflow.

Key Points

? Targeted liver biopsies could be reliably performed in a closed-bore MRI. ? The navigation system allows for image guidance outside of the scanner bore. ? Assisted MRI-guided biopsies are helpful for focal lesions with a difficult access. ? Successful integration of the method in clinical workflow was shown. ? Subsequent system installation in an existing MRI environment is feasible.

     

Ultrasound-guided percutaneous splenic biopsy using an 18-G core biopsy needle: our experience with 52 cases

Objective:

The spleen is more commonly affected in multiorgan disease, but alternative sites are selected for biopsy owing to perceived haemorrhage risk. If these sites are inaccessible or, less commonly, the spleen is the only disease site, then splenic biopsy is considered, with most studies using a 20- to 22-G needle. The primary aim of biopsy is to exclude underlying malignancy or to obtain histological analysis in known malignancy, usually lymphoma, when reclassification is required for therapy. We present, to our knowledge, the largest series of 18-G ultrasound-guided splenic core needle biopsy assessing diagnostic and complication rates.

Methods:

All ultrasound-guided splenic biopsy cases from May 1990 to May 2015 were identified on the radiology information system. Histological diagnosis and complications were identified from laboratory reports, case notes and discharge summaries to assess diagnostic positive and complication rates. Haemorrhages requiring transfusion, embolization or splenectomy, pneumothorax, other significant intra-abdominal injury or death are classified as major complications, whilst conservative haemorrhage management is considered a minor complication.

Results:

A total of 52 splenic biopsies were performed in 47 patients. A positive diagnostic yield for all biopsies was 90.4%. The major and minor complication rates were 0% and 1.9% (1/52), respectively.

Conclusion:

Ultrasound-guided 18-G splenic biopsy is a safe and accurate procedure with no added risk of complications when compared with smaller needles or biopsy of other abdominal organs.

Advances in knowledge:

This is the largest case series of ultrasound-guided splenic biopsy with an 18-G needle, and our experience confirms a high diagnostic yield and a complication rate which compares favourably with the biopsy of other abdominal organs.     

Multiparametric MRI of the prostate with three functional techniques in patients with PSA elevation before initial TRUS-guided biopsy

Objective:

Multiparametric MRI (mp-MRI) of the prostate is increasingly being used for local staging and detection of recurrence of prostate cancer (PCA). In patients with elevated prostate-specific antigen (PSA), mp-MRI could provide information on the position of the cancer, allowing adjustments to be made to the needle depth and direction before repeat transrectal ultrasound (TRUS)-guided biopsy to ensure accurate sampling of lesions. The purpose of the prospective study was to evaluate mp-MRI of the prostate in patients with PSA elevation before initial TRUS-guided biopsy.

Methods:

mp-MRI was performed in 94 patients using a 1.5-T scanner (MAGNETOM Aera^®; Siemens Healthcare, Erlangen, Germany) and 16-channel phased-array body coil (Siemens Healthcare). T₂ weighted images (T2WI), diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MRI and MR spectroscopy were obtained. TRUS-guided random biopsies and additional targeted biopsies of suspicious MRI areas were performed.

Results:

Additional targeted biopsies were obtained in 17 of 43 (40%) patients with PCA. 11 of 17 targeted biopsies contained PCA. 5 of 11 PCAs were diagnosed only by additional targeted biopsies. Sensitivity of mp-MRI in patients was 97.7% and specificity was 11.8%. mp-MRI was false negative in one patient. Sensitivity of mp-MRI in 207 lesions was 80.9% and specificity was 44.7%. In a logistic regression model, the apparent diffusion coefficient value was the only significant parameter to differentiate malignant and benign lesions.

Conclusion:

mp-MRI should be performed in patients with PSA elevation before initial TRUS-guided biopsy to allow additional targeted biopsies from suspicious areas of MRI. We recommend mp-MRI with T2WI, DWI, DCE MRI and MR spectroscopy. DWI as the most reliable technique should be used in every mp-MRI.

Advances in knowledge:

DWI is the most reliable technique in mp-MRI of the prostate.     

The negative predictive value of breast Magnetic Resonance Imaging in noncalcified BIRADS 3 lesions

Purpose

The purpose of this study is to determine whether breast MRI can provide a sufficient NPV to safely rule out malignancy in mammographic BIRADS 3 lesions.

Materials and methods

In a 3-year consecutive mammographic examination study 176 out of 4391 patients had a lesion classified as BIRADS 3. 76 out of 176 patients underwent breast MRI as diagnostic work-up. Lesions which MRI classified as BIRADS 1 or 2 were considered negative for malignancy. Sensitivity, specificity, PPV and NPV were calculated.

Results

In 27 out of 76 (35.5%) patients MRI showed no enhancement and was classified as BIRADS 1. In 25 (32.9%) patients MRI showed focal or mass enhancement classified as BIRADS 2. In these 52 (68.4%) patients no malignancy was found during at least 2 years study follow-up. The other 24 (31.6%) patients had a lesion classified as BIRADS ≥3. Thirteen of these 24 lesions were malignant by pathology. MRI had a sensitivity of 100% (95% CI: 75–100%), specificity of 82.5% (95% CI: 71–91%), PPV of 54.2% (95% CI: 33–74%) and NPV of 100% (95% CI: 93–100%).

Conclusion

Breast MRI should be used in a diagnostic strategy for the work-up of noncalcified BIRADS 3 lesions. Malignancy is ruled out with a very high level of confidence in the majority of patients (68%), herewith avoiding invasive diagnostic procedures.     

Comparison of CT and PET/CT for biopsy guidance in oncological patients

Purpose

To compare FDG PET/CT and CT for the guidance of percutaneous biopsies with histological confirmation of lesions.

Methods

We prospectively evaluated 323 patients of whom 181 underwent FDG PET/CT-guided biopsy (total 188 biopsies) and 142 underwent CT-guided biopsy (total 146 biopsies). Biopsies were performed using the same PET/CT scanner with a fluoroscopic imaging system. Technical feasibility, clinical success and complication rates in the two groups were evaluated.

Results

Of the 188 biopsies with PET/CT guidance, 182 (96.8%) were successful with conclusive tissue samples obtained and of the 146 biopsies with CT guidance, 137 (93.8%) were successful. Therefore, 6 of 188 biopsies (3.1%) with PET/CT guidance and 9 of 146 (6.1%) with CT guidance were inconclusive (p?=?0.19). Due to inconclusive histological results, 4 of the 188 lesions (2.1%) were rebiopsied with PET/CT guidance and 3 of 146 lesions (2.0%) were rebiopsied with CT guidance. Histology demonstrated that 142 of 188 lesions (75.5%) were malignant, and 40 (21.2%) were benign in the PET/CT-guided group, while 89 of 146 lesions (60.9%) were malignant and 48 (32.8%) were benign in the CT-guided group (p?=?0.004 and 0.01, respectively). Patients with a histological diagnosis of benign lesion had no recurrence of disease with a minimum of 6 months follow-up. Of the 188 PET/CT-guided biopsies, 6 (3.1%) were repeat biopsies due to a previous nondiagnostic CT-guided biopsy performed in a different diagnostic centre. The interval between the two biopsies was less than a month in all cases. Histology revealed five malignant lesions and one benign lesion among these. The complication rate in the PET/CT-guided biopsy group was 12.7% (24 of 188), while in the CT-guided group, was 9.5% (14 of 146, p?=?0.26). Therefore, there was no significant difference in complication rates between PET/CT and CT guidance.

Conclusion

PET/CT-guided biopsy is already known to be a feasible and accurate method in the diagnostic work-up of suspected malignant lesions. This prospective analysis of a large number of patients demonstrated the feasibility and advantages of using PET/CT as the imaging method of choice for biopsy guidance, especially where FDG-avid foci do not show corresponding lesions on the CT scan. There were no significant differences in the ability to obtain a diagnostic specimen or in the complication rates between PET/CT and CT guidance.

     

Can unenhanced multiparametric MRI substitute gadolinium-enhanced MRI in the characterization of vertebral marrow infiltrative lesions?

Purpose

To assess the diagnostic effectiveness of unenhanced-multiparametric magnetic resonance imaging (mp MRI) as an alternative to gadolinium (Gad)-enhanced MRI in the characterization of vertebral marrow infiltrative lesions.

Patients and methods

A prospective evaluation of fifty-six patients with suspected or untreated vertebral metastases undergoing MRI of the spine at 1.5 T was carried out. Two groups of sequences were assigned and compared for the characterization of marrow infiltrative lesions: group [A] unenhanced-mp MRI (including T1-weighted, T2-weighted, short time inversion recovery (STIR), diffusion weighted imaging (DWI) and in/opposed phase sequences) and group [B] gadolinium-enhanced MRI (including T1-weighted, T2-weighted, STIR and T1-weighted fat-suppressed gadolinium-enhanced sequence). Qualitative and quantitative image analysis was performed and compared. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for both imaging techniques were calculated.

Results

There was no statistical significant difference between unenhanced-multiparametric MRI and gadolinium-enhanced MRI as regards their diagnostic performance in differentiating benign from malignant vertebral marrow infiltrative lesions (p > 0.05) with calculated sensitivity (94% vs. 97%), specificity (92% vs. 88%), positive predictive value (94% vs. 91%), negative predictive value (92% vs. 95%) and (93% vs. 93%) accuracy.

Conclusion

Unenhanced-multiparametric MRI is compatible with gadolinium-enhanced MRI in reliable characterization of marrow infiltrative lesions. The routine MRI protocol of cancer patients should be altered to accommodate the evolving MRI technology and cost effectively substitute the need for a gadolinium enhanced scan.