Helical CT versus intermittent CT fluoroscopic guidance for musculoskeletal needle biopsies: impact on radiation exposure, procedure time, diagnostic yield, and adverse events.

OBJECTIVE: Image-guided percutaneous needle biopsies are essential in the workup of musculoskeletal (MSK) lesions. While helical CT (HCT) is well established, intermittent CT fluoroscopy (iCTF) is an increasingly used alternative. The purpose of this study is to establish whether differences in subject radiation exposure, procedure time, yield, or adverse events exist between HCT and iCTF guidance. MATERIALS AND METHODS: This retrospective cohort study included consecutive MSK needle biopsies performed on a single-CT scanner over a 12-month period at a tertiary academic center. Subject demographics, radiation dose, and outcomes were abstracted from the medical record. Comparisons between the two cohorts were performed using Student's t-test for continuous data and using Fisher's exact test for categorical data and a two-tailed p value less than 0.05 was considered significant. RESULTS: Two hundred sixteen adults (115 (53.2%) females) with a mean age of 58.8 ± 18.4 years, underwent 216 biopsies (109 (50.5%) HCT guided, 107 (49.5%) iCTF guided) between June 2017 and June 2018. Dose-length product (DLP) and volume CT dose index (CTDIvol) were significantly higher for the HCT cohort (HCT 698.9 ± 400.8 mGycm vs iCTF 312.8 ± 170.8 mGycm; p < 0.005 and HCT 19.1 mGy ± 8.8 vs iCTF 6.9 mGy ± 1.5, p < 0.001). No significant difference in diagnostic yield, procedure time, or adverse event rate was identified. CONCLUSION: For CT-guided MSK needle biopsies, iCTF decreases subject radiation dose compared to HCT without negatively affecting outcomes. iCTF should be strongly considered by radiologists performing MSK biopsies given the reduced patient radiation exposure.

Impact of COVID-19 on CT-diagnosed acute appendicitis and diverticulitis: was there collateral damage?

AIM: To evaluate the change in diagnosis rates, disease severity at presentation, and treatment of acute appendicitis and diverticulitis during the COVID-19 shutdown. MATERIALS AND METHODS: Following institutional review board approval, 6,002 CT examinations performed at five hospitals for suspected acute appendicitis and/or diverticulitis over the 12 weeks preceding and following the shutdown were reviewed retrospectively. Semi-automated language analysis (SALA) of the report classified 3,676 CT examinations as negative. Images of the remaining 2,326 CT examinations were reviewed manually and classified as positive or negative. Positive cases were graded as non-perforated; perforated, contained; and perforated, free. RESULTS: CT examinations performed for suspected appendicitis and/or diverticulitis decreased from 3,558 to 2,200 following the shutdown. The rates of positive diagnoses before and after shutdown were 4% (144) and 4% (100) for appendicitis and 8% (284) and 7% (159) for diverticulitis (p>0.2 for both). For positive CT examinations, the rates of perforation, hospitalisation, surgery, and catheter drainage changed by -2%, -3%, -2%, and -3% for appendicitis (n=244, p>0.3 for all) and +6% (p=0.2) +9% (p=0.06), +4% (p=0.01) and +1% (p=0.6) for diverticulitis (n=443). CONCLUSION: CT examinations performed for suspected appendicitis or diverticulitis declined after the shutdown, likely reflecting patients leaving urban centres and altered triage of non-COVID-19 patients. The diagnosis rates, disease severity at presentation, and treatment approach otherwise remained mostly unchanged.

The role of percutaneous CT-guided biopsy of an adrenal lesion in patients with known or suspected lung cancer.

PURPOSE: To determine the sensitivity, specificity, and complication rate of percutaneous adrenal biopsy in patients with known or suspected lung cancer. METHODS: This study was approved by the Institutional Review Board at our institution as a retrospective analysis; therefore, the need for informed consent was waived. All percutaneous adrenal biopsies performed between April 1993 and May 2019 were reviewed. 357 of 582 biopsies were performed on 343 patients with known or suspected lung cancer (M:F 164:179; mean age 66 years). The biopsy results were classified into malignant, benign, or non-diagnostic. The final diagnosis was established by pathology (biopsy and/or surgical resection) or imaging follow-up on CT for at least 12 months following the biopsy. Patients with less than 12 months follow-up were excluded (n = 44). Complications were recorded. RESULTS: The final diagnosis was metastatic lung cancer in 235 cases (77.8%), metastasis from an extrapulmonary primary in 2 cases (0.7%), pheochromocytoma in 2 cases (0.7%), and benign lesions in 63 cases (20.9%). Percutaneous adrenal gland biopsy had a sensitivity of 97% and specificity of 100% for lung cancer metastases. The non-diagnostic rate was 0.6%. Larger lesions were more likely to be malignant (p = 0.0000) and to be correctly classified as a lung metastasis (p = 0.025). The incidence of minor complications was 1.1%. There were no major complications. CONCLUSION: Over 20% of adrenal lesions in patients with known or suspected lung cancer were not related to lung cancer. Percutaneous adrenal gland biopsy is a safe procedure, with high sensitivity and specificity for lung cancer metastases.

Gastrointestinal Erdheim-Chester disease.

We report a rare case of Erdheim-Chester Disease, a non-Langerhans cell histiocytosis. A 60-year old female presented with a seven-month history of vague abdominal symptoms. A large retroperitoneal mass was detected on computed tomography (CT), but multiple CT-guided biopsy samples were inconclusive. Laparoscopy revealed a mass in the distal ileum, which was resected. Histology and immuno-histochemistry supported a diagnosis of Erdheim-Chester Disease.

Radical resection of a late-relapsed testicular germ cell tumour: hepatectomy, cavotomy, and thrombectomy.

Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.