Multiple Inflammatory Pseudotumors of the Liver Demonstrating Spontaneous Regression: A Case Report

Inflammatory pseudotumor (IPT) of the liver is a rare benign disease. IPTs generally develop as solitary nodules, and cases with multiple lesions are uncommon. We herein report a case of multiple IPTs of the liver that spontaneously regressed. A 70-year-old woman with a 10-year history of primary biliary cholangitis and rheumatoid arthritis visited our hospital to receive a periodic medical examination. Abdominal ultrasonography revealed multiple hypoechoic lesions, with a maximum size of 33 mm, in the liver. Contrast-enhanced computed tomography revealed low-attenuation areas in the liver with mild peripheral enhancement at the arterial and portal phases. We first suspected metastatic liver tumors, but fluorodeoxyglucose positron emission tomography, magnetic resonance imaging and contrast-enhanced ultrasonography suggested the tumors to be inconsistent with malignant nodules. A percutaneous biopsy showed shedding of liver cells and abundant fibrosis with infiltration of inflammatory cells. Given these findings, we diagnosed the multiple tumors as IPTs. After careful observation for two months, the tumors almost vanished spontaneously. Physicians should avoid a hasty diagnosis of multiple tumors based solely on a few clinical findings, and a careful assessment with various imaging modalities should be conducted.

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.

Chest Imaging in the Diagnosis and Management of Pulmonary Tuberculosis: The Complementary Role of Thoraci Ultrasound

Tuberculosis (TB) is a severe infectious disease that still represents a major cause of mortality and morbidity worldwide. For these reasons, clinicians and radiologists should use all the available diagnostic tools in the assessment of the disease in order to provide precise indications about starting an anti-tubercular treatment and reduce risk of TB transmission and complications especially in developing countries where the disease is still endemic. As TB mycobacteria are mainly transmitted through respiratory droplets, the pulmonary parenchyma is usually the first site of infection. As a result, chest imaging plays a central role in the diagnostic process. Thoracic ultrasound (TUS) is a portable, non-invasive, radiation-free, and cost-contained technology which could be easily available in resource-limited settings. This perspective article focuses on the potential role of TUS in the diagnosis and management of patients with pulmonary TB. Unfortunately, there are still insufficient evidence and too contrasting data to judge TUS as an appropriate diagnostic method for the screening of the disease. Despite this, TUS may have a useful role in identifying pleural and anterior pericardial effusions or in the identification of abscesses of the anterior chest wall and paraspinal collections in low- and middle-income settings. In addition, TUS seems to have a milestone role in guiding minimally invasive interventional procedures, such as placement of chest tubes, drainage of loculated collections, thoracentesis and pericardiocentesis, and percutaneous biopsy of subpleural pulmonary consolidations or pleural plaques.

Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy

<b><i>Background:</i></b> The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST. <b><i>Summary:</i></b> In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST – both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar – “no tumor on ink” for invasive cancer. Oncoplastic breast surgery after NST is feasible – both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach. <b><i>Key Messages:</i></b> Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.

Endoscopic ultrasound-guided trans-duodenal fine-needle biopsy of a small renal mass: case report and review of the literature

Background The incidental detection of small renal masses (SRMs) is increasing and biopsy to obtain pathological diagnosis is increasingly proposed as a diagnostic tool to guide further management. Renal mass biopsies are traditionally performed via a percutaneous approach. However, this is not always feasible due to anatomical limitations. A rarely reported alternative biopsy approach for SRMs is endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB). Herein, we describe a case of EUS-guided trans-duodenal FNB for a SRM that was not amenable to standard percutaneous biopsy. Case presentation A 48-year-old man was incidentally found to have a right-sided SRM measuring 2.9 × 2.2 × 2.4 cm during evaluation for a hernia. It was anterior, interpolar, completely endophytic and near the renal hilum. The tumor was not amenable to traditional percutaneous biopsy due to its anterior location. However, the renal mass was in close proximity to the descending duodenum and so it was felt that an EUS-guided trans-duodenal FNB would be feasible. The procedure was successful without any complications. The specimen adequacy was satisfactory for evaluation and consistent with renal papillary carcinoma with WHO/ISUP grade 3 nuclear changes. Conclusion Our case report demonstrated that EUS-guided trans-duodenal FNB was a safe and feasible approach to obtaining biopsy tissue diagnosis of a SRM that was not amenable to percutaneous biopsy.

Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) from peritoneal lesions: a prospective cohort pilot study

Background Diagnostic laparoscopy is often a necessary, albeit invasive, procedure to help resolve undiagnosed peritoneal diseases. Previous retrospective studies reported that EUS-FNA is feasible on peritoneal and omental lesions, however, EUS-FNA provided a limited amount of tissue for immunohistochemistry stain (IHC). Aim This pilot study aims to prospectively determine the effectiveness of EUS-FNB regarding adequacy of tissue for IHC staining, diagnostic rate and the avoidance rate of diagnostic laparoscopy or percutaneous biopsy in patients with these lesions. Methods From March 2017 to June 2018, patients with peritoneal or omental lesions identified by CT or MRI at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand were prospectively enrolled in the study. All Patients underwent EUS-FNB. For those with negative pathological results of EUS-FNB, percutaneous biopsy or diagnostic laparoscopy was planned. Analysis uses percentages only due to small sample sizes. Results A total of 30 EUS-FNB passes were completed, with a median of 3 passes (range 2–3 passes) per case. For EUS-FNB, the sensitivity, specificity, PPV, NPV and accuracy of EUS-FNB from peritoneal lesions were 63.6%, 100%, 100%, 20% and 66.7% respectively. Adequate tissue for IHC stain was found in 25/30 passes (80%). The tissues from EUS results were found malignant in 7/12 patients (58.3%). IHC could be done in 10/12 patients (83.3%). Among the five patients with negative EUS results, two underwent either liver biopsy of mass or abdominal paracentesis, showing gallbladder cancer and adenocarcinoma. Two patients refused laparoscopy due to advanced pancreatic cancer and worsening ovarian cancer. The fifth patient had post-surgical inflammation only with spontaneous resolution. The avoidance rate of laparoscopic diagnosis was 58.3%. No major adverse event was observed. Conclusions EUS-FNB from peritoneal lesions provided sufficient core tissue for diagnosis and IHC. Diagnostic laparoscopy can often be avoided in patients with peritoneal lesions.

SP8.1.8 Factors influencing the post-operative upgrade of ductal carcinoma in situ (DCIS) to invasive cancer

Aims Ductal carcinoma in situ (DCIS) can be upgraded on pathological histology to invasive cancer and require a subsequent sentinel node biopsy (SNB). This second procedure increases the morbidity and costs of treating DCIS. Our study aims to establish the proportion of preoperatively diagnosed DCIS that is upgraded and identify factors associated with this upgrading. Method A retrospective review was conducted of 122 consecutive patients undergoing surgery following diagnosis of DCIS on percutaneous biopsy at our institution, from 1st January 2017 to 30th November 2019. Histological upgrade was evaluated against clinical, radiological and pathological parameters. Results Of the 122 patients, 31 (25.4%) were upgraded, with 11 (9.1%) having microinvasive disease (T1mi) only. A third of the upgrade group (n = 11) did not have a SNB during the initial surgery. Upgraded patients were younger (median 54yrs v 62yrs P = 0.005), had a higher BMI (median 28.9 v 26 P = 0.02) and more likely to have a palpable lesion (41.9% v 14.9% P &lt; 0.001). Multivariate logistic regression analysis showed that mass detected on ultrasound (OR 3.6 P = 0.04), a palpable lump (OR 5.2 P = 0.03) and finding high grade DCIS on percutaneous biopsy (OR 11.9 P &lt; 0.001) were independently associated with final tumour upgrade. In contrast, patients undergoing vacuum assisted biopsy were less likely to be upgraded after surgery (OR 0.23 P &lt; 0.001). Conclusion Patients that have a higher BMI, palpable lump, mass on ultrasound and percutaneous biopsy showing high grade DCIS are at increased risk of harbouring invasive cancer and should be considered for SNB at initial surgery.