Contrast enhanced spectral mammography (CESM) guided breast biopsy as an alternative to MRI guided biopsy

Objective: Contrast Enhanced Spectral Mammography (CESM) breast biopsy has been recently introduced into clinical practice. This short communication describes the technique and potential as an alternative to MRI guided biopsy. Methods and materials: An additional abnormality was detected on a breast MRI examination in a patient with lobular carcinoma. The lesion was occult on conventional mammography, tomosynthesis and ultrasound and required histological diagnosis. Traditionally this would have necessitated a MRI guided breast biopsy, but was performed under CESM guidance. Results: A diagnostic CESM study was performed to ensure the lesion visibility with CESM and then targeted under CESM guidance. A limited diagnostic study, CESM scout and paired images for stereotactic targeting were obtained within a 10 min window following a single injection of iodinated contrast agent. The time from positioning in the biopsy device to releasing compression after biopsy and marker clip placement was 15 min. The biopsy confirmed the presence of multifocal breast cancer. Conclusion: CESM guided breast biopsy is a new technique that can be successfully used as an alternative to MRI guided breast biopsy. Advances in knowledge: CESM guided biopsy can be used to sample breast lesions which remain occult on standard mammography and ultrasound.

Percutaneous CT-Guided Biopsy of the Craniovertebral Junction: Safety, Diagnostic Yield, and Technical Notes

The craniovertebral junction defined as the occiput, the atlas, and the axis is a complex bony region that contains vital neural and vascular structures. We report the experience of a single academic institution regarding CT-guided biopsy of this skeletal region. We reviewed all of the CT-guided biopsies performed in our department, completed in the craniovertebral junction. We collected data in regard to biopsy procedures, patients’ vital statistics, and histopathological diagnosis. In total, 16 patients (8M and 8F; mean age 52; range 16–86 years old) were included in this series. In eight patients, the lesions were located in the atlas vertebra (8/16—50%), in six patients in the axis (37.5%), and in two patients in the occiput (12.5%). No complications were observed during or after the procedures. All of the procedures were technically successful. The biopsy was diagnostic in 13/16 patients (81.3%): four metastatic lesions (25%—three breast and one prostate cancers), four multiple myeloma bone lesions (25%), three aneurismal bone cysts (18.8%), one aggressive hemangioma (6.3%), and one pseudogout (6.3%). Moreover, in two-thirds (66.6%) of non-diagnostic histological reports, malignancies were excluded. CT-guided percutaneous biopsy is a safe tool and allows obtaining a histological diagnosis, in most cases, even in the most delicate site of the human skeleton—the craniovertebral junction.

Soft-Tip Stylet and Saline Instillation Technique: Making Difficult Percutaneous CT-Guided Biopsies Possible

Finding a safe needle path during percutaneous computed tomography-guided biopsy is sometimes difficult due to concern for injuring a vital structure. Saline instillation technique has been used to displace the structure out of the way. Another useful tool is a soft-tip stylet. A soft-tip also referred as blunt-tip stylet for the introducer cannula is provided with some coaxial biopsy sets in additional to standard sharp-tip stylet. While the sharp-tip stylet is fitted with introducer cannula for piercing skin, muscle, and fascia, a soft-tip stylet may be used for avoiding injury to structures like vessels and bowel loops especially while advancing introducer cannula through fatty tissue. Additionally, it is also useful for avoiding injury to nerves and giving pleural anesthesia. Although its use has been described in medical literature, many radiologists are still not utilizing this tool to its full potential. In this educational exhibit, various applications of soft-tip stylet and saline instillation technique have been depicted using representative cases.

Peroral Cholangioscopy-Guided Targeted Biopsy versus Conventional Endoscopic Transpapillary Forceps Biopsy for Biliary Stricture with Suspected Bile Duct Cancer

Background: The recent improvement of peroral cholangioscopy (POCS) maneuverability has enabled the precise, targeted biopsy of bile duct lesions under direct cholangioscopic vision. However, as only small-cup biopsy forceps can pass through the scope channel, the resulting small sample size may limit the pathological diagnosis of biopsy specimens. This study compared the diagnostic abilities of POCS-guided biopsy and conventional fluoroscopy-guided biopsy for bile duct cancer. Method: This multicenter, retrospective cohort study included patients exhibiting bile duct stricture with suspected cholangiocarcinoma in whom POCS-guided and fluoroscopy-guided biopsies were performed in the same session. The primary endpoint was the diagnostic sensitivity for malignancy. The size and quality of the biopsy specimens were also compared. Result: A total of 59 patients were enrolled. The sensitivity of POCS-guided biopsy was similar to that of fluoroscopy-guided biopsy (54.0% and 64.0%, respectively). However, when the modalities were combined, the sensitivity increased to 80.0%. The mean specimen size from POCS-guided biopsy was significantly smaller than that from fluoroscopy-guided biopsy. The specimen quality using fluoroscopy-guided biopsy was also better than that using POCS-guided biopsy. Conclusions: The diagnostic sensitivity of POCS-guided biopsy is still insufficient, mainly because of the limited specimen quantity and quality. Therefore, conventional fluoroscopy-guided biopsy would be helpful to improve diagnostic sensitivity.

Diagnostic yield of image-guided biopsy in patients with suspected infectious spondylodiscitis

Aims The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB. Methods A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis. Results The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay. Conclusion Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120–126.

Multi-parametric MRI prostate PIRAD scoring in a district general hospital: Correlating PIRADS 3 results with histological findings

Objective: Prostate cancer is the most common male cancer in the UK. In many hospitals, patients are now being referred for a multi parametric (mp) MRI scan of their prostate as part of an evaluation for the presence of prostate cancer, prior to an ultrasound guided biopsy. PI-RADS score of 3 are defined as “equivocal” for the presence of prostate cancer. Thus, a PIRADS three lesion does not confidently determine whether there is significant prostate disease or not. Our aim is to determine the correlation of PIRADS three prostatic lesions with histology proven, clinically significant cancer. Methods: We performed a retrospective review on a cohort of 143 consecutive patients. Each patient underwent a mp-MRI scan of their prostate given a PIRADS score. PIRADS three lesions were analysed further based on histology and categorised into malignant and non-malignant lesions. PSA results and prostatic volume of PIRADS three lesions were also analysed. Results: We identified forty five patients with PIRADS 3 lesions out of 143 patients. Thirty-two patients subsequently underwent trans-rectal/trans-perineal ultrasound guided biopsy. 43% of patients were found to have had a malignant prostatic adenocarcinoma on histology. The remaining 56% had non-malignant findings. Of those with malignant disease, there was a higher median PSA and lower mean prostatic volume. Conclusions: The study confirms that a score of PIRADS three does not accurately differentiate between malignant and non-malignant lesions. Further investigations such as ultrasound-guided prostate biopsy and PSA parameters are required to accurately ascertain the nature of a prostate lesion with PIRADS score 3. Advances in knowledge: An ultrasound-guided prostate biopsy in patients with PIRADS 3 remains of paramount importance when distinguishing malignant versus non-malignant lesions. Multicentre data of MRI findings with PIRADS three scores is required to yield a sample size large enough to carry out statistical analysis.

Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways

Introduction: Modern image-guided biopsy pathways at diagnostic centres have greatly refined the investigations of men referred with suspected prostate cancer. However, the referral criteria from primary care are still based on historical prostate-specific antigen (PSA) cut-offs and age-referenced thresholds. Here, we tested whether better contemporary pathways and biopsy methods had improved the predictive utility value of PSA referral thresholds. Methods: PSA referral thresholds, age-referenced ranges and PSA density (PSAd) were assessed for positive predictive value (PPV) in detection of clinically significant prostate cancer (csPCa – histological ⩾ Grade Group 2). Data were analysed from men referred to three diagnostics centres who used multi-parametric magnetic resonance imaging (mpMRI)-guided prostate biopsies for disease characterisation. Findings were validated in a separate multicentre cohort. Results: Data from 2767 men were included in this study. The median age, PSA and PSAd were 66.4 years, 7.3 ng/mL and 0.1 ng/mL2, respectively. Biopsy detected csPCa was found in 38.7%. The overall area under the curve (AUC) for PSA was 0.68 which is similar to historical performance. A PSA threshold of ⩾ 3 ng/mL had a PPV of 40.3%, but this was age dependent (PPV: 24.8%, 32.7% and 56.8% in men 50–59 years, 60–69 years and ⩾ 70 years, respectively). Different PSA cut-offs and age-reference ranges failed to demonstrate better performance. PSAd demonstrated improved AUC (0.78 vs 0.68, p < 0.0001) and improved PPV compared to PSA. A PSAd of ⩾ 0.10 had a PPV of 48.2% and similar negative predictive value (NPV) to PSA ⩾ 3 ng/mL and out-performed PSA age-reference ranges. This improved performance was recapitulated in a separate multi-centre cohort ( n = 541). Conclusion: The introduction of MRI-based image-guided biopsy pathways does not appear to have altered PSA diagnostic test characteristics to positively detect csPCa. We find no added value to PSA age-referenced ranges, while PSAd offers better PPV and the potential for a single clinically useful threshold (⩾0.10) for all age groups. Level of evidence: IV