Evaluation of imaging-guided core biopsy of pelvic masses.

OBJECTIVE: The purpose of this study was to evaluate the accuracy and complications of imaging-guided core biopsy in the diagnosis of pelvic masses. CONCLUSION: Imaging-guided core biopsy of pelvic masses is accurate and safe. The accuracy and sensitivity of biopsy under sonographic guidance are higher than those of CT-guided biopsy, although the difference is not statistically significant.

Renal mass core biopsy: accuracy and impact on clinical management.

OBJECTIVE: The objective of our study was to determine the accuracy of imaging-guided percutaneous renal mass biopsy and its impact on clinical management. MATERIALS AND METHODS: With institutional review board approval, we retrospectively reviewed imaging-guided renal biopsies performed by radiologists at our institution between February 1999 and July 2005. Patient records, pathology reports, and imaging studies were reviewed. Concordance of biopsy diagnosis and follow-up data was assessed. Significant impact on clinical management was determined in collaboration with two experienced urologists and was defined as a change from no therapy to therapy, including surgery, tumor ablation, chemotherapy, or radiation. RESULTS: Two hundred seventy-six renal biopsies were performed during the study period. Of these, 123 were random biopsies and fine-needle technique was used for one; these 124 were excluded. One hundred fifty-two renal mass biopsies were performed using coaxial 18-gauge core needle technique in 125 patients (55 women, 70 men; average age, 60 years; range, 28-90 years). There were two (1.3%) postprocedural hematomas (one [0.7%] requiring blood transfusion) and one (0.7%) delayed renal pseudoaneurysm attributed to biopsy. No tumor seeding was identified. In 85 biopsies (56%), malignant neoplasm was found, 61 biopsies (40%) yielded benign findings, and six (4%) were nondiagnostic. The sensitivity for malignancy was 97.7%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 100%. At least 92 (60.5%) biopsy results significantly impacted clinical management. CONCLUSION: Imaging-guided percutaneous core needle biopsy of renal masses is safe and highly accurate. Tissue diagnosis alters clinical decision making in a majority of the cases and may allow a number of unnecessary nephrectomies to be avoided.

Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique.

OBJECTIVE: The objective of our study was to determine the incidence of tumor seeding after biopsy of hepatocellular carcinoma (HCC) using a coaxial cutting needle technique. Seeding along the needle track is a dreaded complication of percutaneous biopsy in patients with HCC, particularly in potential liver transplant recipients. Reported seeding rates range from 0.6% to 5.1% using various biopsy techniques. To our knowledge, the rate of seeding using a coaxial cutting needle technique has not been reported. MATERIALS AND METHODS: Retrospective review identified 128 patients with imaging-guided percutaneous liver biopsies positive for HCC. A coaxial cutting needle technique was uniformly used with a 17-gauge introducer and 18-gauge biopsy needle. Radiology and clinical reports were reviewed, and findings at clinical and imaging follow-up were assessed. RESULTS: During the 6-year study period, 1,012 liver mass biopsies were performed, with 128 positive for HCC (100 men and 28 women; average age, 58.4 years). One hundred one patients had more than 30 days of clinical or imaging follow-up (or both) after biopsy (mean, 410 days; range, 33-1,989 days) and constituted the study population. The remaining 27 were excluded because of inadequate follow-up. No suspected or confirmed tumor seeding on imaging, physical examination, or laparotomy was identified. CONCLUSION: We found no tumor seeding after percutaneous biopsy of HCC using a coaxial cutting needle technique. This rate, 0%, is lower than those reported with other techniques. The use of a needle introducer that remains in position during multiple cutting needle passes protects normal tissue along the track and may reduce seeding. This has particular importance for patients with stage I-II HCC, for whom liver transplantation may be curative.

Evaluation of imaging-guided core biopsy of pancreatic masses.

OBJECTIVE: The purpose of this study was to determine the sensitivity and accuracy of imaging-guided core biopsy in the diagnosis of pancreatic masses. CONCLUSION: Imaging-guided core biopsy is sensitive, safe, and accurate in the diagnosis of malignant lesions of the pancreas. Benign biopsy findings cannot be used to exclude the presence of a neoplasm, and repetition of a biopsy should be considered if there is high clinical suspicion of malignancy.

The short-term clinical outcomes after saline infusion sonohysterography in women with postmenopausal bleeding.

RATIONALE AND OBJECTIVE: To describe the short-term clinical outcomes of women with postmenopausal bleeding (PMB) who underwent saline-infused sonohysterography (SIS) and the impact of SIS results on clinical management. MATERIALS AND METHODS: A retrospective review of the Radiology Information Systems database identified 786 women who underwent SIS between February 1998 and October 2002. Of this group, 144 women (mean age, 60; range, 42-83) presented with PMB. The following clinical data were extracted from the electronic medical record: date of birth, hormone replacement therapy (HRT) status, SIS results, and clinical management before and after the SIS procedure. We categorized post-SIS clinical management into three categories: additional diagnostic or therapeutic procedure performed; HRT change or addition; or no change in clinical management. Between-group comparisons were performed using a chi2 test. RESULTS: Of the 144 women with postmenopausal bleeding who underwent SIS, 119 (82.6%) successfully completed the SIS. Eighty women (67.2%) had a positive SIS exam. Abnormalities detected including polyps (n = 42); submucosal fibroids (n = 6); endometrial thickening (n = 8); a combination of 2 or more of the above (n = 7), or other abnormalities (debris, adenomyosis, or indeterminate findings, n = 17). Of the women with a positive SIS exam, 58% received subsequent diagnostic/therapeutic procedures compared to 5% of women who had a negative SIS (P < 0.001). Conversely, 59% of women with a negative SIS had no change in clinical management compared to 17.5% who had a positive SIS (P < 0.001). CONCLUSION: The trend in short-term clinical management is to pursue more aggressive subsequent diagnostic or treatment procedures if findings are positive on SIS. A negative SIS exam was associated with more conservative management.

Changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies.

OBJECTIVE: Prior series of percutaneous imaging-guided biopsies of adrenal masses before the advent of dedicated CT and MRI of the adrenal glands have shown that 40-57% of adrenal masses biopsied were adenomas-benign lesions requiring no further evaluation or treatment. This study was performed to assess the effect of dedicated adrenal imaging with CT and MRI on the rate of percutaneous imaging-guided biopsies of adrenal masses. MATERIALS AND METHODS: We reviewed 50 consecutive adrenal mass biopsies performed during a 48-month period. The patient demographics, technique of biopsy, pathology results, and results of any prior dedicated adrenal imaging with MRI or CT protocols were noted. RESULTS: Only six (12%) of 50 biopsies were adenomas. Five of these six cases were preceded by dedicated adrenal CT or MRI. Thirty-five cases were metastatic disease, four were adrenal cortical carcinoma, three were pheochromocytoma, and two biopsies were nondiagnostic. Overall, 20 of 50 cases were preceded by a dedicated adrenal CT or MRI examination to exclude an adenoma; in 21 of the remaining 30 cases, the imaging characteristics before biopsy were inconsistent with the potential diagnosis of an adenoma and dedicated adrenal CT or MRI was not recommended. CONCLUSION: The number of adrenal adenomas biopsied has declined markedly with the introduction of dedicated adrenal CT and MRI for adrenal adenomas. Percutaneous imaging-guided biopsy is useful in confirming the presence and nature of suspected metastatic deposits to the adrenal gland and in diagnosing or excluding adrenal adenomas in patients with equivocal imaging characteristics.

T2-weighted MR imaging in the assessment of cirrhotic liver.

PURPOSE: To assess if T2-weighted magnetic resonance (MR) imaging provides added diagnostic value in combination with dynamic gadolinium-enhanced MR imaging in the detection and characterization of nodular lesions in cirrhotic liver. MATERIALS AND METHODS: Two readers retrospectively and independently analyzed 54 MR imaging studies in 52 patients with cirrhosis. In session 1, readers reviewed T1-weighted and dynamic gadolinium-enhanced images. In session 2, readers reviewed T1-weighted, dynamic gadolinium-enhanced, and respiratory-triggered T2-weighted fast spin-echo images. Readers identified and characterized all focal lesions by using a scale of 1-4 (1, definitely benign; 4, definitely malignant). Multireader correlated receiver operating characteristic (ROC) analysis was employed to assess radiologist performance in session 2 compared with session 1. The difference in the areas under the ROC curves for the two sessions was tested. In a third session, readers assessed conspicuity of biopsy-proved lesions on T2-weighted MR images by using a scale of 1-3 (1, not seen; 3, well seen) and identified causes of reduced conspicuity. RESULTS: Two additional benign lesions were detected by each reader in session 2. Fifty-five lesions had pathologic verification, including 32 malignant, three high-grade dysplastic, and 20 benign nodules. There was no significant difference in the area under the ROC curves between the two sessions (P =.48). Thirty-two lesions were inconspicuous on T2-weighted MR images because of parenchymal heterogeneity, breathing artifacts (particularly in patients with ascites), and lesion isointensity with liver parenchyma. T2-weighted MR imaging was useful in the evaluation of cysts and lymph nodes. CONCLUSION: T2-weighted MR imaging does not provide added diagnostic value in the detection and characterization of focal lesions in cirrhotic liver.

Developing a prediction rule to assess hepatic malignancy in patients with cirrhosis.

OBJECTIVE: The objectives of our study were to identify independent clinical, demographic, and MR imaging correlates of malignancy in patients with cirrhosis and to develop a predictive model based on identified correlates of malignancy. MATERIALS AND METHODS: Sixty examinations of 58 patients with biopsy proof of lesions suggestive of hepatocellular carcinoma on MR imaging were retrospectively reviewed. The signal intensity of the lesion on T2-weighted imaging and dynamic gadolinium-enhanced imaging, the size of the lesion, and the number of suspicious lesions were recorded; in addition, patient age and sex, alpha-fetoprotein level, and hepatitis C viral genotype were noted. The association between malignancy and each predictor variable was evaluated using the chi-square test or the two-group t test. The final logistic regression model included the variables that were shown to have a significant association with malignancy and the clinically relevant predictors. We used the adjusted odds ratios to measure the strength of each association. The discriminant ability of the model for detecting hepatic malignancy was assessed using receiver operating characteristic curve analysis. RESULTS: The prevalence of hepatic malignancy in our study population was 64%. The area under the receiver operating characteristic curve for the logistic regression model was 0.82. Venous washout (odds ratio = 9.2), alpha-fetoprotein level (odds ratio = 3.2), and number of lesions (odds ratio = 1.5) were significant predictors for malignancy (p < 0.05). When arterial enhancement and venous washout were either both present or both absent, alpha-fetoprotein level contributed little to the prediction of malignancy. CONCLUSION: The MR characteristics of hepatic lesions during the dynamic venous phase in conjunction with the serum alpha-fetoprotein level and number of lesions are predictors of hepatic malignancy. The use of these predictors can facilitate explicit estimation of malignancy in individuals with underlying cirrhosis, potentially improving clinical decision-making.

Is it necessary to study accessory arteries when screening the renal arteries for renovascular hypertension?

PURPOSE: To determine the prevalence of isolated hemodynamically significant stenoses of accessory renal arteries when the main renal arteries are patent. MATERIALS AND METHODS: In 68 adults (24 men, mean age, 67 years +/- 10; 44 women, mean age, 67 years +/- 12), angiograms that fulfilled the following criteria were studied: (a) technically adequate renal angiograms obtained to evaluate suspected renovascular hypertension and (b) angiographically documented hemodynamically significant stenosis of any renal artery. The percentage of kidneys and the percentage of patients with hemodynamically significant isolated stenoses of accessory renal arteries were calculated. RESULTS: Eighty-seven kidneys in 68 patients had hemodynamically significant renal artery stenoses. Fifteen kidneys had 16 accessory renal arteries. Four accessory arteries in three patients had hemodynamically significant stenoses. Only one of 68 patients (1.5%) had an accessory artery stenosis unaccompanied by a main renal artery stenosis in either kidney; this patient had bilateral hemodynamically significant accessory artery stenoses. Two patients had coexistent hemodynamically significant stenoses of accessory and main renal arteries. CONCLUSION: The prevalence of a hemodynamically significant stenosis isolated to an accessory renal artery was 1.5% in our study. Thus, failure to detect accessory renal arteries should not unduly affect the utility of a noninvasive test for detecting renovascular hypertension.

Hepatic arterial phase MR imaging with automated bolus-detection three-dimensional fast gradient-recalled-echo sequence: comparison with test-bolus method.

Sixty-two patients underwent magnetic resonance (MR) imaging of the liver with the automated contrast material bolus-detection technique. Arterial phase MR images were assessed quantitatively and qualitatively. In 23 patients, a test bolus of contrast material was injected intravenously before dynamic MR imaging. There was good correlation and agreement between delay times estimated with both timing methods. Eighty-three percent of arterial phase images obtained with automated contrast material bolus detection were optimal. There was good correlation and agreement between delay times estimated with both timing methods. Optimal hepatic arterial phase MR images can be obtained routinely with automated detection of a contrast material bolus.

Effectiveness of MR imaging in characterizing small hepatic lesions: routine versus expert interpretation.

OBJECTIVE: The aim of our study was to compare the effectiveness of MR imaging characterization of small (

Evaluation of sonographically guided percutaneous core biopsy of renal masses.

OBJECTIVE: Our objective was to determine the utility of sonographically guided percutaneous core biopsy to evaluate renal masses. MATERIALS AND METHODS: We conducted a retrospective analysis of our imaging-guided procedures from January 1999 to June 2001. We performed 26 sonographically guided percutaneous core biopsies of renal masses in 26 patients. From two to five specimens were obtained from a single mass in each patient using an 18-gauge automated biopsy system. We examined the patients' medical records, pathology results, and imaging studies. Core biopsy results were compared with surgical pathology (n = 6) or clinical follow-up (n = 20). RESULTS: All biopsies provided sufficient material for analysis. Biopsy findings were positive for malignancy in 19 (73%) of 26 masses. Histologic diagnoses included renal cell carcinoma were (n = 11), metastasis (n = 3), lymphoma (n = 2), and transitional cell carcinoma (n = 2). Specific cell type characterization could not be made on one biopsy, but the specimens were highly suspicious for malignancy. Biopsy revealed seven (27%) of 26 benign diagnoses: oncocytoma (n = 3), angiomyolipoma (n = 2), and fibrosis (n = 2). The average follow-up period for patients with benign diagnoses was 10 months. One case of surgically proven necrotic pyelonephritis was mischaracterized as fibrosis at core biopsy. Sonographically guided percutaneous core biopsy of renal masses showed a sensitivity of 100% and a specificity of 100% for the diagnosis of malignancy. The core specimens yielded a specific diagnosis in 92% (24/26) of masses. No immediate complications occurred after the procedure. One patient developed a pseudoaneurysm that presented 3 months after the biopsy. CONCLUSION. Sonographically guided percutaneous core biopsy is a reliable and accurate method for evaluating renal masses.