Outcomes of atypical (B3) core biopsy lesions diagnosed across BreastScreen NSW, Australia.

INTRODUCTION: Atypical or B3 lesions comprise a heterogeneous group of uncertain malignant potential. B3 lesions diagnosed on core biopsy are usually recommended for diagnostic open biopsy. Identifying factors which could allow conservative management of B3 lesions would be helpful in avoiding unnecessary surgery. The aim of this study was to identify the upgrade rate to malignancy for B3 core biopsy lesions and to compare characteristics of lesions which were malignant and benign at excision. METHOD: This retrospective study used data from BreastScreen New South Wales (NSW), Australia, of women who were diagnosed with B3 lesions on needle biopsy from 2011 to 2019. RESULTS: During the study period, 1927 B3 lesions were included. The upgrade rate to malignancy was 26.4%. Of the malignant lesions on excision, 29.6% were invasive and 69.2% were in situ. The rates of upgrade to invasive cancer and DCIS varied substantially with the core biopsy lesion type. Lesions with atypia on core biopsy had significantly higher upgrade rates to malignancy at 34.7% compared to 13.6% for lesions without atypia (p < 0.0001). Lesions with malignant pathology were significantly larger than those with benign pathology (difference = 5.1 mm (95% CI 2.7-7.5 mm), p < 0.001). CONCLUSIONS: The overall upgrade rate of B3 lesions to malignancy was 26.4%. The majority of the lesions were upgraded to DCIS instead of invasive cancer. Upgrade rates varied by lesion type. Lesions with atypia had significantly higher upgrade rates to cancer compared to lesions without atypia. Malignant lesions were significantly larger than benign lesions.

Stromal computational signatures predict upgrade to invasive carcinoma in mass-forming DCIS: A brief report of 44 cases.

Mass-forming ductal carcinoma in situ (DCIS) detected on core needle biopsy (CNB) is often a radiology-pathology discordance and thought to represent missed invasive carcinoma. This brief report applied supervised machine learning (ML) for image segmentation to investigate a series of 44 mass-forming DCIS cases, with the primary focus being stromal computational signatures. The area under the curve (AUC) for receiver operator curves (ROC) in relation to upgrade to invasive carcinoma from DCIS were as follows: high myxoid stromal ratio (MSR): 0.923, P = <0.001; low collagenous stromal percentage (CSP): 0.875, P = <0.001; and low proportionated stromal area (PSA): 0.682, P = 0.039. The use of ML in mass-forming DCIS could predict upgraded to invasive carcinoma with high sensitivity and specificity. The findings from this brief report are clinically useful and should be further validated by future studies.

Diagnosis of giant cell-rich bone tumors on core needle biopsy: A practical approach.

BACKGROUND: The differential diagnosis of giant cell-rich bone tumors comprises a broad spectrum of lesions with prominent reactive osteoclast-like and/or neoplastic giant cells, with substantial differences in biologic behavior and clinical management. Evaluation of giant cell-rich bone tumors on small biopsies can be challenging especially in specimens with limited representative material. An accurate diagnosis requires a high level of skill on the part of both radiologist and pathologist as correlation with clinical and radiologic characteristics is critical. The objective of the study was to assess the utility of touch preparations (TP), immunohistochemistry (IHC) for mutation-specific markers H3G34W and H3K36M, and fluorescence in situ hybridization (FISH) for USP6 rearrangements and MDM2 amplification in the diagnostic workup of core needle biopsy specimens. METHODS: A total of 27 core needle biopsies with TPs from patients with primary giant cell-rich bone tumors (16 giant cell tumors of bone (GCTBs) (including 3 with lung metastasis), 3 chondroblastomas (CBs), 4 primary aneurysmal bone cysts (ABCs), 2 non-ossifying fibromas (NOFs), 1 low grade osteosarcoma (OS), and 1 conventional OS with tumor giant cells were analyzed with IHC for H3G34W and H3K36M and in select cases FISH for USP6 rearrangements and MDM2 amplification. RESULTS: In all cases the core biopsies were sufficient for histologic examination and diagnostic workup. 16 of 16 GCTBs were positive for H3G34W and negative for H3K36M, and 3 of 3 CBs were positive for H3K36M and negative for H3G34W. All other cases were negative for H3G34W and H3K36M. 4 of 4 primary ABCs showed rearrangement of USP6 by FISH and the low grade OS showed amplification of MDM2 by FISH. CONCLUSIONS: On-site adequacy assessment of TPs proved to be an accurate, simple, and fast method for obtaining sufficient material for complete diagnostic workup. The application of IHC for H3G34W and H3K36M and FISH for detection of rearrangements of USP6 and amplification of MDM2 can improve the diagnostic accuracy in core needle biopsy specimens.

Is image-guided core needle biopsy of borderline axillary lymph nodes in breast cancer patients clinically helpful?

BACKGROUND: When borderline axillary lymph nodes (bALN) are identified on ultrasound (US) for breast cancer (BC) patients, preoperative management is unclear. We aimed to evaluate if core needle biopsy (CNB) for bALN is clinically helpful or disruptive. METHODS: Retrospective review of BC patients with bALN from 2014 to 2019 was performed. Clinicopathologic data were compared for those who did and did not have CNB. RESULTS: CNB (n = 34) and no CNB (n = 31) were similar with respect to clinicopathologic factors. Surgical LN-positive rate was the same between cohorts (p = 0.26). CNB was disruptive in 58.8 %; all had CNB for pN0 disease. CNB was helpful in 34.2 %: 14.7 % proceeded directly to axillary dissection; 17.6 % had positive LN localized after neoadjuvant chemotherapy. CONCLUSIONS: CNB for bALN is more likely clinically disruptive and did not impact surgical LN positive rate. BC patients with bALN should undergo CNB only if it will change clinical management.

Number of cores needed to diagnose prostate cancer during MRI targeted biopsy decreases after the learning curve.

INTRODUCTION: We hypothesized that the number of cores needed to detect prostate cancer would decrease with increasing MRI-targeted biopsy (TBx) experience. METHODS: All patients undergoing TBx at our institution from May 2017 to August 2019 were enrolled in a prospectively maintained database. Five biopsy cores were obtained from each lesion ≥3 on PI-RADS v2.0 followed by a systematic 12-core biopsy. To assess learning curve, the study population was divided into quartiles by sequential biopsies. Clinically significant prostate cancer (csPC) was defined as Gleason Grade Group 2 or higher. RESULTS: 377 patients underwent prostate biopsy (533 lesions); 233 lesions (44%) were positive for prostate cancer and 173 lesions (32%) were csPC. There was a significant decline in the number of cores required for diagnosing any cancer (P < 0.001) and csPC (P < 0.05) after the first quartile. There was no difference when stratifying by PI-RADS score or lesion volume. Within the first quartile, limiting the biopsy to 3 cores would miss 16.2% of csPC, decreasing to 6.6% after approximately 100 patients. CONCLUSION: MRI TBx is associated with a learning curve of approximately 100 cases. Four or 5 cores should be considered during the initial experience, but thereafter, 3 cores per lesion is sufficient to detect csPC.

Factors Associated with Time to Conversion from Active Surveillance to Treatment for Prostate Cancer in a Multi-Institutional Cohort.

PURPOSE: We examined the demographic and clinicopathological parameters associated with the time to convert from active surveillance to treatment among men with prostate cancer. MATERIALS AND METHODS: A multi-institutional cohort of 7,279 patients managed with active surveillance had data and biospecimens collected for germline genetic analyses. RESULTS: Of 6,775 men included in the analysis, 2,260 (33.4%) converted to treatment at a median followup of 6.7 years. Earlier conversion was associated with higher Gleason grade groups (GG2 vs GG1 adjusted hazard ratio [aHR] 1.57, 95% CI 1.36-1.82; ≥GG3 vs GG1 aHR 1.77, 95% CI 1.29-2.43), serum prostate specific antigen concentrations (aHR per 5 ng/ml increment 1.18, 95% CI 1.11-1.25), tumor stages (cT2 vs cT1 aHR 1.58, 95% CI 1.41-1.77; ≥cT3 vs cT1 aHR 4.36, 95% CI 3.19-5.96) and number of cancerous biopsy cores (3 vs 1-2 cores aHR 1.59, 95% CI 1.37-1.84; ≥4 vs 1-2 cores aHR 3.29, 95% CI 2.94-3.69), and younger age (age continuous per 5-year increase aHR 0.96, 95% CI 0.93-0.99). Patients with high-volume GG1 tumors had a shorter interval to conversion than those with low-volume GG1 tumors and behaved like the higher-risk patients. We found no significant association between the time to conversion and self-reported race or genetic ancestry. CONCLUSIONS: A shorter time to conversion from active surveillance to treatment was associated with higher-risk clinicopathological tumor features. Furthermore, patients with high-volume GG1 tumors behaved similarly to those with intermediate and high-risk tumors. An exploratory analysis of self-reported race and genetic ancestry revealed no association with the time to conversion.

Role of Systematic Control Biopsies following Partial Gland Ablation with High-Intensity Focused Ultrasound for Clinically Significant Prostate Cancer.

PURPOSE: Partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU) is currently under investigation for clinically significant prostate cancer (Cs-PCa). Our primary objective was to assess the role of systematic control biopsies following HIFU-PGA in a cohort of Cs-PCa patients. MATERIALS AND METHODS: We studied a single-center retrospective cohort of 77 men treated with HIFU-PGA between October 2015 and December 2019. Patients with unilateral Cs-PCa, defined as Gleason grade group (GGG) ≥2, with visible lesion on multiparametric magnetic resonance imaging (mpMRI) and prostate specific antigen (PSA) ≤15 ng/ml were included. All patients underwent mpMRI with systematic and targeted biopsies before and after HIFU-PGA. The primary outcome was the rate of Cs-PCa at control biopsy within 1 year of treatment. Logistic regression was performed to identify predictive factors of our primary outcome. RESULTS: Median age was 67 years (IQR 61-71), median PSA was 7 ng/ml (IQR 5.5-8.9). Pre-treatment biopsies revealed 48 (62.3%) GGG2 lesions, 24 (31.2%) GGG3 and 5 (6.5%) GGG4 lesions. Cs-PCa was found in 24 (31.2%) patients at systematic control biopsy post-HIFU; Cs-PCa was in the treated lobe for 18 (27%) patients. No variables were identified as significant predictors of Cs-PCa at control biopsy, including PSA kinetics and control mpMRI. Median followup time was 17 months (95% CI 15-21). Median time to any retreatment was 32 months (95% CI 23-42). CONCLUSIONS: Systematic control biopsy within a year after PGA for Cs-PCa can identify the presence of residual Cs-PCa in up to a third of patients. From our early experience, control biopsy should be systematically offered patients regardless of PSA kinetics or control mpMRI results.

The Risk of Prostate Cancer Progression in Active Surveillance Patients with Bilateral Disease Detected by Combined Magnetic Resonance Imaging-Fusion and Systematic Biopsy.

PURPOSE: We sought to evaluate whether bilateral prostate cancer detected at active surveillance (AS) enrollment is associated with progression to Grade Group (GG) ≥2 and to compare the efficacy of combined targeted biopsy plus systematic biopsy (Cbx) vs systematic biopsy (Sbx) or targeted biopsy alone to detect bilateral disease. MATERIALS AND METHODS: A prospectively maintained database of patients referred to our institution from 2007-2020 was queried. The study cohort included all AS patients with GG1 on confirmatory Cbx and followup of at least 1 year. Cox proportional hazard analysis identified baseline characteristics associated with progression to ≥GG2 at any point throughout followup. RESULTS: Of 579 patients referred, 103 patients had GG1 on Cbx and were included in the study; 49/103 (47.6%) patients progressed to ≥GG2, with 30/72 (41.7%) patients with unilateral disease progressing and 19/31 (61.3%) patients with bilateral disease progressing. Median time to progression was 68 months vs 52 months for unilateral and bilateral disease, respectively (p=0.006). Both prostate specific antigen density (HR 1.72, p=0.005) and presence of bilateral disease (HR 2.21, p=0.012) on confirmatory biopsy were associated with AS progression. At time of progression, GG and risk group were significantly higher in patients with bilateral versus unilateral disease. Cbx detected 16% more patients with bilateral disease than Sbx alone. CONCLUSIONS: Bilateral disease and prostate specific antigen density at confirmatory Cbx conferred greater risk of earlier AS progression. Cbx was superior to Sbx for identifying bilateral disease. AS risk-stratification protocols may benefit from including presence of bilateral disease and should use Cbx to detect bilateral disease.

Freehand versus Grid-Based Transperineal Prostate Biopsy: A Comparison of Anatomical Region Yield and Complications.

PURPOSE: The freehand (FH) technique of transperineal prostate biopsy using commercialized needle access systems facilitates a reduction in anesthesia requirements from general to local or local/sedation. We sought to compare the efficacy and complication rates of the FH method with those of the standard grid-based (GB) method. MATERIALS AND METHODS: The GB method was performed from 2014 to 2018, and the updated FH technique was performed from 2018 to 2020, yielding comparative cohorts of 174 and 304, respectively. RESULTS: The FH and GB techniques demonstrated equivalent yields of ≥Gleason grade group (GGG)-2 prostate cancer (PCa). The FH group had a significantly higher mean number of cores with ≥GGG-2 PCa involvement (p=0.011) but a significantly lower mean number of biopsy samples (p <0.01). The urinary retention rate of the GB group (10%) was significantly higher than that of the FH group (1%; p <0.01). The rates of ≥GGG-2 PCa involvement in the anterior (GB, 31%) and anteromedial (FH, 22%) sectors were higher than those in other sectors (range, 0%-9%). For multiparametric magnetic resonance imaging, the rate of ≥GGG-2 PCa detection in the anteromedial prostate (23%) was nearly half that in other locations (range, 38%-55%). CONCLUSIONS: Compared with GB transperineal biopsy, FH transperineal biopsy demonstrates an equivalent cancer yield with no risk of sepsis, a significantly reduced risk of urinary retention, and reduced anesthesia needs. The higher number of cores with ≥GGG-2 PCa involvement in the FH group suggests that FH transperineal biopsy can sample the prostate better than GB-transperineal biopsy can.

Guy's and St Thomas NHS Foundation active surveillance prostate cancer cohort: a characterisation of a prostate cancer active surveillance database.

BACKGROUND: The routine clinical use of serum prostatic specific antigen (PSA) testing has allowed earlier detection of low-grade prostate cancer (PCa) with more favourable characteristics, leading to increased acceptance of management by active surveillance (AS). AS aims to avoid over treatment in men with low and intermediate-risk PCa and multiple governing bodies have described several AS protocols. This study provides a descriptive profile of the Guy's and St Thomas NHS Foundation Trust (GSTT) AS cohort as a platform for future research in AS pathways in PCa. METHODS: Demographic and baseline characteristics were retrospectively collected in a database for patients at the GSTT AS clinic with prospective collection of follow-up data from 2012. Seven hundred eighty-eight men being monitored at GSTT with histologically confirmed intermediate-risk PCa, at least 1 follow-up appointment and diagnostic characteristics consistent with AS criteria were included in the profile. Descriptive statistics, Kaplan-Meier survival curves and multivariable Cox proportion hazards regression models were used to characterize the cohort. DISCUSSION: A relatively large proportion of the cohort includes men of African/Afro-Caribbean descent (22%). More frequent use of magnetic resonance imaging and trans-perineal biopsies at diagnosis was observed among patients diagnosed after 2012. Those who underwent trans-rectal ultrasound diagnostic biopsy received their first surveillance biopsy 20 months earlier than those who underwent trans-perineal diagnostic biopsy. At 3 years, 76.1% men remained treatment free. Predictors of treatment progression included Gleason score 3 + 4 (Hazard ratio (HR): 2.41, 95% Confidence interval (CI): 1.79-3.26) and more than 2 positive cores taken at biopsy (HR: 2.65, CI: 1.94-3.62). A decreased risk of progressing to treatment was seen among men diagnosed after 2012 (HR: 0.72, CI: 0.53-0.98). CONCLUSION: An organised biopsy surveillance approach, via two different AS pathways according to the patient's diagnostic method, can be seen within the GSTT cohort. Risk of patients progressing to treatment has decreased in the period since 2012 compared with the prior period with more than half of the cohort remaining treatment free at 5 years, highlighting that the fundamental aims of AS at GSTT are being met. Thus, this cohort is a good resource to investigate the AS treatment pathway.

Type of Architecture, Presence of Punctate Necrosis, and Extent of Involvement in Atypical Ductal Hyperplasia Can Predict the Diagnosis of Breast Carcinoma on Excision: A Clinicopathologic Study of 143 Cases.

The literature shows a wide range in the frequencies of finding breast carcinoma in the excised specimens following a biopsy diagnosis of atypical ductal hyperplasia (ADH), likely due to a poor diagnostic reproducibility among different pathologists as well as an inherent heterogeneity in ADH. We evaluated whether histologic subtyping of ADH would help predict the risk of breast carcinoma. Our study consisted of 143 cases of ADH diagnosed by core needle biopsy and followed by excision. Of these, 54 cases (37.8%) showed carcinoma in the excised specimens (47 cases of ductal carcinoma in situ alone, 3 cases of invasive ductal carcinoma alone, and 4 cases of mixed invasive ductal carcinoma and ductal carcinoma in situ). We arbitrarily divided ADH into two subtypes: type A was considered when one or more ducts were completely replaced by low-grade ductal carcinoma in situ type cells but the lesion was <2 mm and type B was considered when one or more ducts were partially involved by low-grade ductal carcinoma in situ type cells regardless of lesion size. Type A was associated with a significantly higher frequency of breast carcinoma (63.6%) than type B (30.0%). ADH containing punctate necrosis showed a higher association of carcinoma (66.7%) compared to those without necrosis (35.1%). Within type B ADH, involvement of 3 or more foci had a higher frequency of carcinoma (50.0%) than involvement of fewer foci (26.6%). These histologic features of ADH may prove useful in predicting the likelihood of breast carcinoma and provide helpful information for patient's management.

Optimizing Spatial Biopsy Sampling for the Detection of Prostate Cancer.

PURPOSE: The appropriate number of systematic biopsy cores to retrieve during magnetic resonance imaging (MRI)-targeted prostate biopsy is not well defined. We aimed to demonstrate a biopsy sampling approach that reduces required core count while maintaining diagnostic performance. MATERIALS AND METHODS: We collected data from a cohort of 971 men who underwent MRI-ultrasound fusion targeted biopsy for suspected prostate cancer. A regional targeted biopsy (RTB) was evaluated retrospectively; only cores within 2 cm of the margin of a radiologist-defined region of interest were considered part of the RTB. We compared detection rates for clinically significant prostate cancer (csPCa) and cancer upgrading rate on final whole mount pathology after prostatectomy between RTB, combined, MRI-targeted, and systematic biopsy. RESULTS: A total of 16,459 total cores from 971 men were included in the study data sets, of which 1,535 (9%) contained csPCa. The csPCa detection rates for systematic, MRI-targeted, combined, and RTB were 27.0% (262/971), 38.3% (372/971), 44.8% (435/971), and 44.0% (427/971), respectively. Combined biopsy detected significantly more csPCa than systematic and MRI-targeted biopsy (p <0.001 and p=0.004, respectively) but was similar to RTB (p=0.71), which used on average 3.8 (22%) fewer cores per patient. In 102 patients who underwent prostatectomy, there was no significant difference in upgrading rates between RTB and combined biopsy (p=0.84). CONCLUSIONS: A RTB approach can maintain state-of-the-art detection rates while requiring fewer retrieved cores. This result informs decision making about biopsy site selection and total retrieved core count.

In-laboratory breast specimen radiography reduces tissue block utilization and improves turnaround time of pathologic examination.

BACKGROUND: This study was performed to determine whether in-laboratory specimen radiography reduces turnaround time or block utilization in surgical pathology. METHODS: Specimens processed during a 48-day trial of an in-lab cabinet radiography device (Faxitron) were compared to a control group of specimens imaged in the mammography suite during a prior 1-year period, and to a second group of specimens not undergoing imaging of any type. RESULTS: Cases imaged in the mammography suite had longer turnaround time than cases not requiring imaging (by 1.15 days for core biopsies, and 1.73 days for mastectomies; p < 0.0001). In contrast, cases imaged in-lab had turnaround time that was no longer than unimaged cases (p > 0.05 for core biopsies, lumpectomies and mastectomies). Mastectomies imaged in-lab required submission of fewer blocks than controls not undergoing any imaging (mean reduction of 10.6 blocks). CONCLUSIONS: Availability of in-lab radiography resulted in clinically meaningful improvements in turnaround time and economically meaningful reductions in block utilization.

A 4K score/MRI-based nomogram for predicting prostate cancer, clinically significant prostate cancer, and unfavorable prostate cancer.

BACKGROUND: The detection of prostate cancer requires histological confirmation in biopsy core. Currently, number of unnecessary prostate biopsies are being performed in the United States. This is due to the absence of appropriate biopsy decision-making protocol. AIM: To develop and validate a 4K score/multiparametric magnetic resonance imaging (mpMRI)-based nomogram to predict prostate cancer (PCa), clinically significant prostate cancer (csPCa), and unfavorable prostate cancer (uPCa). METHODS AND RESULTS: Retrospective, single-center study evaluating a cohort of 574 men with 4K score test >7% or suspicious digital rectal examination (DRE) or Prostate Imaging Reporting and Data System (PI-RADS) scores 3, 4, or 5 on mpMRI that underwent systematic and/or mpMRI/ultrasound fusion-targeted prostate biopsy between 2016 and 2020. External cohort included 622 men. csPCa and uPCa were defined as Gleason score ≥3 + 4 and ≥4 + 3 on biopsy, respectively. Multivariable logistic regression analysis was performed to build nomogram for predicting PCa, csPCa, and uPCa. Validation was performed by plotting the area under the curve (AUC) and comparing nomogram-predicted probabilities with actual rates of PCa, csPCa, and uPCa probabilities in the external cohort. 4K score, a PI-RADS ≥4, prostate volume and prior negative biopsy were significant predictors of PCa, csPCa, and uPCa. AUCs were 0.84, 0.88, and 0.86 for the prediction of PCa, csPCa, and uPCa, respectively. The predicted and actual rates of PCa, csPCa, and uPCa showed agreement across all percentage probability ranges in the validation cohort. Using the prediction model at threshold of 30, 30% of overall biopsies, 41% of benign biopsies, and 19% of diagnosed indolent PCa could be avoided, while missing 9% of csPCa. CONCLUSION: This novel nomogram would reduce unnecessary prostate biopsies and decrease detection of clinically insignificant PCa.

Discordant results in 18F-FDG PET/CT and ultrasound-based assessment for axillary lymph node metastasis detection: A large retrospective analysis in 560 patients with breast cancer.

PURPOSE: Ultrasound is the recommended modality to assess axillary lymph node involvement in breast cancer; nevertheless, 18F-fluorodeoxyglucose (18F-FDG) integrated positron emission tomography/computed tomography (PET/CT) diagnostic efficiency, to identify suspicious lesions, is also considered. We aim to report discrepancies in ultrasound and 18F-FDG PET/CT results. METHODS: This single-centered retrospective analysis selected consecutive patients with invasive ductal biopsy-proven breast cancer, for whom divergent 18F-FDG PET/CT and axillary ultrasound imaging (and/or core needle biopsy if available) had been performed, and described clinical, histological, imaging, and surgery data. RESULTS: This retrospective study included 560 patients and identified discordant results between 18F-FDG PET/CT and ultrasound (suspicious 18F-FDG PET/CT and normal ultrasound imaging and/or core needle biopsy) in 20 (4%) patients. Axillary lymph node involvement was confirmed in 17 (85%) out of these 20 patients. Further, the lymph nodes were smaller than one centimeter in 12 (60%) patients, macrometastasic involvement (involvement >2 mm) was detected in 13 (65%) patients, and more than 3 macrometastases were detected in 6 (30%) patients. All patients had an aggressive breast cancer. The sentinel node biopsy performed in 9 (45%) patients allowed to reveal lymph node involvement, even in cases of macrometastatic involvement. CONCLUSION: Discordant results were issued from normal ultrasound imaging and/or core needle biopsy, and suspicious 18F-FDG PET/CT revealed that 18F-FDG PET/CT may overcome axillary ultrasound limits in the specific case of aggressive breast cancers, especially for axillary lymph nodes smaller than 1 centimeter. Sentinel node biopsy remains a valuable aid, even in patients with macrometastatic involvement.

Efficacy of Ultrasound-Guided Needle Biopsy in the Diagnosis of Kikuchi-Fujimoto Disease.

OBJECTIVES/HYPOTHESIS: Ultrasound-guided fine-needle aspiration cytology (US-FNAC) is a well-established procedure performed to establish the diagnosis of Kikuchi-Fujimoto disease (KFD). Ultrasound-guided core needle biopsy (US-CNB) is an alternative diagnostic tool for KFD. However, the efficacy of US-CNB is not well evaluated. This study aimed to evaluate the efficacy of US-CNB and compare it with that of US-FNAC in the diagnosis of KFD. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed 170 patients who were diagnosed with KFD between January 2009 and May 2019. US-FNAC, US-CNB, and excisional biopsy were performed in 47, 114, and 9 patients, respectively. Diagnostic accuracies of US-FNAC and US-CNB were analyzed and compared. RESULTS: Of the 170 patients, 45 and 125 were men and women, respectively. The mean age was 26.9 ± 9.1 years. The most common symptom was cervical lymphadenopathy, followed by fever, headache, and myalgia. The diagnosis of KFD was established primarily by US-FNAC in 21 (44.7%) of the 47 patients, by US-CNB in 109 (95.6%) of the 114 patients, and by excisional biopsy in all 9 patients. There was no specific major complication related to US-FNAC and US-CNB. CONCLUSION: US-CNB can be considered safe and effective and used as the primary modality for the pathological diagnosis of KFD. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:E1519-E1523, 2021.

A study on clinico-pathological assessment of response to neoadjuvant chemotherapy in breast carcinoma.

CONTEXT: Neoadjuvant chemotherapy (NACT) has become a strategy in the multidisciplinary treatment approach to breast cancer. Since clinical and radiological responses do not correlate well with residual tumor after treatment, pathological evaluation of tumor response to chemotherapy is essential for accurate assessment. AIMS: The aim of this study is to assess clinicopathological response to NACT in patients with invasive breast carcinoma. SETTINGS AND DESIGN: Single institution, retrospective study was conducted for 4 years. SUBJECTS AND METHODS: The study included 95 cases with the clinical diagnosis of locally advanced breast cancer and invasive breast carcinoma on histopathological examination of core needle biopsy/lumpectomy specimen. These cases were assessed for estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) receptors and treated with four cycles of NACT (adriamycin-cyclophosphamide) therapy. Histopathological examination of postchemo modified radical mastectomy specimens was performed following standard protocol. The pathological response of tumor to chemotherapy was assessed on Miller-Payne grading (MPG) and residual disease in breast and lymph node (RDBN) level. STATISTICAL ANALYSIS USED: Data were analyzed in percentages and presented in charts and tables. RESULTS: Histopathological examination of pre-chemo biopsy specimens revealed invasive ductal carcinoma No special type (NST) in maximum, 89 (93.7%) cases. Majority 43 (45.3%) cases were HER2-positive followed by estrogen receptor-positive and/or progesterone receptor positive and HER2-positive type seen in 23 (24.2%) cases and 22 (23.1%) cases were triple negative. Sixteen (16.8%) and 76 (80%) cases showed pathological complete response (pCR) and partial pathological response, respectively, to NACT on MPG; 12 (12.6%) and 83 (87.4%) cases showed pCR and residual disease, respectively, on RDBN level. Majority 37.5% and 50% of cases showing pCR on MPG and RDBN level, respectively, were triple negative. CONCLUSIONS: This study highlights the clinicopathological response to NACT in carcinoma breast patients and identifies the molecular subtypes of these patients likely to respond to NACT.

Evaluation of the Use of Combined Artificial Intelligence and Pathologist Assessment to Review and Grade Prostate Biopsies.

Importance: Expert-level artificial intelligence (AI) algorithms for prostate biopsy grading have recently been developed. However, the potential impact of integrating such algorithms into pathologist workflows remains largely unexplored. Objective: To evaluate an expert-level AI-based assistive tool when used by pathologists for the grading of prostate biopsies. Design, Setting, and Participants: This diagnostic study used a fully crossed multiple-reader, multiple-case design to evaluate an AI-based assistive tool for prostate biopsy grading. Retrospective grading of prostate core needle biopsies from 2 independent medical laboratories in the US was performed between October 2019 and January 2020. A total of 20 general pathologists reviewed 240 prostate core needle biopsies from 240 patients. Each pathologist was randomized to 1 of 2 study cohorts. The 2 cohorts reviewed every case in the opposite modality (with AI assistance vs without AI assistance) to each other, with the modality switching after every 10 cases. After a minimum 4-week washout period for each batch, the pathologists reviewed the cases for a second time using the opposite modality. The pathologist-provided grade group for each biopsy was compared with the majority opinion of urologic pathology subspecialists. Exposure: An AI-based assistive tool for Gleason grading of prostate biopsies. Main Outcomes and Measures: Agreement between pathologists and subspecialists with and without the use of an AI-based assistive tool for the grading of all prostate biopsies and Gleason grade group 1 biopsies. Results: Biopsies from 240 patients (median age, 67 years; range, 39-91 years) with a median prostate-specific antigen level of 6.5 ng/mL (range, 0.6-97.0 ng/mL) were included in the analyses. Artificial intelligence-assisted review by pathologists was associated with a 5.6% increase (95% CI, 3.2%-7.9%; P < .001) in agreement with subspecialists (from 69.7% for unassisted reviews to 75.3% for assisted reviews) across all biopsies and a 6.2% increase (95% CI, 2.7%-9.8%; P = .001) in agreement with subspecialists (from 72.3% for unassisted reviews to 78.5% for assisted reviews) for grade group 1 biopsies. A secondary analysis indicated that AI assistance was also associated with improvements in tumor detection, mean review time, mean self-reported confidence, and interpathologist agreement. Conclusions and Relevance: In this study, the use of an AI-based assistive tool for the review of prostate biopsies was associated with improvements in the quality, efficiency, and consistency of cancer detection and grading.

The Long-Term Risks of Metastases in Men on Active Surveillance for Early Stage Prostate Cancer.

PURPOSE: We assessd the long-term outcomes from a large prospective cohort of men diagnosed with prostate cancer managed with active surveillance and determined the clinical prognostic factors that may predict the risk of metastases. MATERIALS AND METHODS: We retrospectively reviewed data of men enrolled on active surveillance at our institution between 1990 and 2018 with low or intermediate risk disease (stage cT1-2, prostate specific antigen less than 20 ng/ml, and biopsy Grade Group [GG]1-2). Patients were classified into 3 groups by diagnostic GG and prostate specific antigen density. Primary outcome was metastatic prostate cancer detected on imaging or at prostatectomy. In addition, upgrade at surveillance biopsy, active treatment, and overall and prostate cancer specific survival outcomes were assessed. Cox proportional hazards regression models were used. RESULTS: A total of 1,450 men met the inclusion criteria. Median followup was 77 months (IQR 49-114). The 7-year metastasis-free survival rate was 99%. Metastases developed in 15 men at a median of 62 months (IQR 29-104), of which 69% were confined to lymph nodes. Men with GG2 had a lower metastasis-free survival rate compared to those with GG1 disease. GG2, prostate specific antigen velocity and PI-RADS® 4-5 lesions on multiparametric magnetic resonance imaging were associated with a higher risk of metastases. The 7-year prostate cancer specific survival was greater than 99%. CONCLUSIONS: Active surveillance seems to preserve favorable long-term prognosis, as metastases and prostate cancer specific death are rare. However, the higher risk of metastases associated with higher Gleason grade, prostate specific antigen velocity, and characteristics on multiparametric magnetic resonance imaging should be considered when selecting and counseling patients for active surveillance.

Clear Cell Hidradenoma of the Breast Diagnosed on a Core Needle Biopsy: A case report and review of the literature.

Clear cell hidradenoma (CCH) is a tumour originating from the eccrine sweat glands. It usually presents in the limbs, axilla or trunk. CCH of the breast is rare and can present as a cystic lesion in the breast that can be easily misdiagnosed as malignancy. We report a 36-year-old female patient who presented at the Sultan Qaboos University Hospital Breast Clinic, Muscat, Oman, in 2018 with a lump in her left breast. Ultrasound examination reported a complex cystic lesion with a solid, vascular component. An ultrasound-guided core needle biopsy was suggestive of clear cell hidradenoma. Surgical excision was performed and histopathology confirmed the diagnosis of CCH of the breast. This is the first ever case of a diagnosis of CCH made using core needle biopsy. CCH can be challenging to diagnose; therefore, awareness of its histopathological and ultrasonographic features are essential to avoid misdiagnosis and over treatment.