Radiologically guided percutaneous fine-needle aspiration biopsy of pelvic and retroperitoneal masses: a retrospective study of 68 cases

Transvaginal Ultrasound-Guided Fine-Needle Aspiration Biopsy of Pelvic Lesions

OBJECTIVES

To assess adequacy of transvaginal ultrasound-guided fine-needle aspiration biopsy (TVUS-FNAB) for pathologic diagnosis of pelvic masses performed using onsite cytopathology consultation.

METHODS

In this Institutional Review Board approved, Health Insurance Portability and Accountability Act (HIPAA) compliant study, radiology records were retrospectively queried to identify patients who underwent TVUS-FNAB of a pelvic mass over a 11-year duration. TVUS-FNAB adequacy was determined by correlating cytopathology results with transvaginal ultrasound-guided core-needle biopsy (TVUS-CNB) or surgical pathology results when available, and with clinical diagnostic confidence when additional pathology confirmation was not available. Secondary analysis included patient age, history of hysterectomy, or pelvic malignancy. Target-specific features analyzed included mass size, depth, location, and final pathologic diagnosis.

RESULTS

Sixty patients underwent TVUS-FNAB of pelvic masses, 43 of which underwent FNAB only and 17 underwent both TVUS-FNAB and TVUS-CNB during the same procedure. TVUS-FNAB alone was adequate for diagnosis in 51 (85%) cases and addition of core-needle biopsy (CNB) achieved a diagnosis in additional 4 patients, increasing overall diagnostic accuracy to 92% (55/60). FNAB inadequacy had statistically significant association with increasing mass depth, occurrence of a minor intraprocedural complication, and decision to perform a CNB (P <.05). Number of FNAB passes, mass size, history of hysterectomy, and final diagnosis were not statistically significant predictors of FNAB adequacy.

CONCLUSION

TVUS-FNAB has a high specimen adequacy rate when performed with an onsite cytopathologist and can be considered first-line approach for image-guided sampling of pelvic lesions with option to add CNB if preliminary cytopathologic review does not confirm sample adequacy.

The Role of Ultrasound Guided Sampling Procedures in the Diagnosis of Pelvic Masses: A Narrative Review of the Literature

Ultrasound-guided sampling methods are usually minimally invasive techniques applied to obtain cytological specimens or tissue samples, mainly used for the diagnosis of different types of tumors. The main benefits of ultrasound guidance is its availability. It offers high flexibility in the choice of sampling approach (transabdominal, transvaginal, and transrectal) and short duration of procedure. Ultrasound guided sampling of pelvic masses represents the diagnostic method of choice in selected patients. We carried out a narrative review of literatures regarding the ultrasound-guided methods of cytological and histological evaluation of pelvic masses as well as the positive and negative predictors for the achievement of an adequate sample.

CT-guided biopsy of subdiaphragmatic small renal nodule with the coaxial technique using MPR images

PURPOSE

To demonstrate the advantages of CT-guided biopsy of subdiaphragmatic small renal nodule with the coaxial technique using MPR images.

METHODS

The study included retrospectively 12 patients who underwent CT-guided biopsy with 18 G needle of subdiaphragmatic small renal nodule (<15 mm) suspected. Histology reports have been the reference standard.

RESULTS

The histology was diagnostic in 12 biopsies (100%): out of 10 neoplastic nodule (83.3%), 8 were malignant (80%) and 2 were benign (20%); 2 out of 12 were non-neoplastic (16.6%). No procedural complications were observed (0%).

CONCLUSIONS

By using MPR images there is an effective improvement during coaxial CT-guided biopsy of subdiaphragmatic small renal nodule difficult to reach and to reduce the complication as pneumothorax. (www.actabiomedica.it).

Minimally invasive biopsy in retroperitoneal tumors

Minimally invasive biopsy procedures have proven over the years to be essential for obtaining a correct diagnosis of retroperitoneal tumors, that allows proper therapeutical conduct. These procedures offer valuable tissue fragments for histopathological examination, that permits the distinction between benign and malignant tumors, identifying the tumors that can benefit from neo-adjuvant treatments, such as chemotherapy or radiotherapy and those that have a direct surgical indication. We have searched the existing data regarding minimally invasive biopsy in retroperitoneal tumors using the PubMed database, in order to evaluate the role of this procedure in establishing a correct diagnosis, as well as to find out the risks of tumor cell seeding and local recurrence after needle biopsy. The risk of tumor cell seeding is very low (<2%) and in some cases, it is considered negligible (<0.5%). Compared to open biopsy, needle biopsy seems to be associated with a significantly lower risk of tumor cell seeding. According to the existing data, the incidence of needle track tumor cell seeding also depends on the histological type of the tumors. Image-guided retroperitoneal biopsy has proven to be low cost, accessible, and a reliable procedure (in terms of diagnostic accuracy), usually associating with a low rate of complications and a low risk of tumor seeding. Several authors have underlined the importance of the retroperitoneal approach and the association with a co-axial imaging technique in order to avoid potentially deadly complications.

Transvaginal Ultrasound-Guided Core Needle Biopsy of Pelvic Masses

OBJECTIVES

This study assessed the efficacy and safety of transvaginal ultrasound (US)-guided core needle biopsy (CNB) for obtaining adequate pelvic mass samples for histologic analysis and evaluated factors that may affect biopsy success.

METHODS

Two hundred cases underwent transvaginal US-guided CNBs for primary inoperable tumors, suspicion of metastases to the ovaries or peritoneum, recurrence, or other solid lesions in the pelvis. Biopsy samples were obtained from the pelvic cavity (67.0%), vaginal cuff or vaginal wall (17.5%), or peritoneal cake (15.5%). The potential influences of the biopsy site (pelvic cavity, vaginal cuff or vaginal wall, or peritoneal cake), vascularization, ascites, tumor size, and tumor type (inoperable, metastases, recurrence, or solid pelvic tumor) on the success of transvaginal US-guided CNB were evaluated by a univariate analysis.

RESULTS

Adequate samples were obtained in 192 of 200 biopsies (96.0%), of which 190 yielded successful diagnoses (95.0%). The biopsy site had a significant effect on biopsy adequacy, as there was a significantly lower probability of obtaining satisfactory specimens for histologic verification from the peritoneal cake compared to pelvic tumors and the vaginal cuff or vaginal wall (P < .01). Adequacy was also affected by tumor size (P < .05) but not by vascularization, ascites, or tumor type. No complications occurred during the biopsy procedures.

CONCLUSIONS

Transvaginal US-guided CNB is a safe and effective alternative to more invasive methods for evaluating pelvic lesions, such as laparoscopy and laparotomy.

Fine needle aspiration in retroperitoneal lesions

The retroperitoneal space is a potential space extending from lumbar to the pelvic region, behind the peritoneum. It encloses many vital organs like adrenals, kidneys, ureters, pancreas, aorta and its branches, inferior vena cava and its tributaries and many lymph nodes along with loose connective tissue and fat. The literature regarding role of fine needle aspiration cytology (FNAC) for diagnosis of retroperitoneal lesions as a whole, is exceedingly limited. The present study was conducted to elucidate the spectrum of retroperitoneal lesions and to determine the diagnostic accuracy of fine needle aspiration cytology, presenting to a tertiary care referral centre. A total of 389 aspirates from retroperitoneal lesions were reviewed for clinical and radiological details. The smears were studied for the cytological diagnosis. Cytological-histological correlation was assessed and the causes for discordant diagnoses were determined. The patients' age ranged from 1 to 88 years. There were 234 (60.2%) males and 155 (39.8%) females. In 61 (15.7%) aspirations, the yield was inadequate for reporting and 328 were satisfactory. About 113 (29.0%) aspirates were from pancreatic masses alone, 97 (24.9%) from the retroperitoneal lymph nodes, 70 (17.9%) from the kidneys, 45 (11.5%) from the adrenals, 41 (10.5%) from the retroperitoneal soft tissues and 23 (5.9%) from retroperitoneal segments of the gut. There were 249 (64.0%) neoplastic lesions and 79 (20.3%) non-neoplastic lesions, the ratio being 3.1:1. Eight (2.0%) aspirates were reported as suspicious for malignancy, and 5 (1.2%) aspirates were reported as neoplastic but could not be categorized as benign or malignant. Of the neoplastic lesions, malignant neoplasms (n = 216; 87.1%) were much more common than the benign (n = 20; 8.0%), the ratio being 10.8:1. Of all the satisfactory aspirates, subsequent histopathology was available only in 33/327 (10%) cases. A positive correlation between cytological and histological diagnosis was observed in 27/33 (81.8%) cases. We believe FNAC is a useful method for an early, rapid, minimally invasive and reliable pre-operative diagnosis for retroperitoneal lesions and can often obviate the need for open surgical biopsy.

Retroperitoneal liposarcoma: current insights in diagnosis and treatment

Retroperitoneal liposarcoma (RLS) is a rare, biologically heterogeneous tumor that present considerable challenges due to its size and deep location. As a consequence, the majority of patients with high-grade RLS will develop locally recurrent disease following surgery, and this constitutes the cause of death in most patients. Here, we review current insights and controversies regarding histology, molecular biology, extent of surgery, (neo)adjuvant treatment, and systemic treatment including novel targeted agents in RLS.

Critical clinical appraisal of the role of computed tomography-guided minimally invasive aspiration cytology in evaluation of retroperitoneal masses

Context:

Fine-needle aspiration (FNA) is increasing in popularity as a means of diagnosing mass lesions in retroperitoneal area. With use of radiologic guidance for needle placement, this technique is an effective way to obtain diagnostic material.

Aims:

The aims of the study were (1) to establish the validity and reliability of fine needle aspiration cytology in preoperative diagnosis of retroperitoneal tumor, and (2) to compare the significance of cytological diagnosis with histopathological report.

Settings and Design:

A prospective, cross-sectional hospital-based study.

Materials and Methods:

A prospective, cross-sectional study was designed on 45 cases of clinically and radiologically diagnosed retroperitoneal tumor in a tertiary care hospital. Computerized tomography (CT)-guided percutaneous FNA was performed and cytology smears were stained with May-Grünwald-Giemsa stain and conventional Papanicolaou (Pap) stain. Smears were broadly categorized into unsatisfactory, benign, suspicious of malignancy and malignant lesion. The cytological diagnosis was compared with subsequent histopathology report.

Statistical Analysis:

Positive and negative predictive values, diagnostic accuracy, chi-square test and others.

Results:

The total number of cases studied was 45, which include both epithelial tumors and mesenchymal tumors. Age group varied from 15 to 70 years. The overall sensitivity in our study to diagnose benign and malignant tumors by FNA cytology is 86% and the specificity is 96% with positive and negative predictive value of 86% and 96%, respectively. Diagnostic accuracy was 93.55% with high statistical significance (P < 0.001).

Conclusions:

FNA cytology is a simple, fast, reliable and less expensive method for diagnosis of various retroperitoneal neoplasms.

Image-guided fine-needle aspiration of retroperitoneal masses: The role of the cytopathologist

Background:

Retroperitoneal tumors constitute a difficult diagnostic category as they are not easily accessible. The advent of image-guided fine-needle aspiration (FNA) has resolved this problem significantly.

Aims:

We present a short study based on guided aspiration of retroperitoneal tumors, in which we have tried to assess the role of image-guided fine-needle aspiration cytology as a tool for pre-operative diagnosis.

Materials and Methods:

The study was conducted on patients diagnosed with retroperitoneal masses. FNA was performed under image guidance with the help of ultrasonography and/or computed tomography; smears were prepared and meticulously screened according to a fixed protocol. The results were analyzed to determine sensitivity, specificity, and diagnostic efficacy of cytopathological diagnosis using image-guided FNA techniques.

Results:

We assessed 38 patients with retroperitoneal masses. In all cases, adequate cellular material was obtained. No major complications were encountered. Statistical analysis was carried out in 35 cases; sensitivity, specificity, and diagnostic accuracy were 100% in these cases.

Conclusion:

FNA under image guidance should be considered a first-line diagnostic approach for retroperitoneal and other abdominal tumors, although caution should be exercised in case selection. In areas where advanced tests are not available, the cytotechnologist and cytopathologist have a very important role to play in ensuring accurate diagnoses.

Benefits of 3D technique in guiding percutaneous retroperitoneal biopsies

PURPOSE

This study aimed to assess the usefulness and advantages of multiplanar reformations (MPR) during multidetector-row computed tomography (MDCT)-guided percutaneous fine-needle aspiration biopsy (FNAB) and core biopsy of retroperitoneal lesions that are difficult to access with the guidance of ultrasound and axial CT alone owing to overlying bony structures, large vessels or abdominal organs.

MATERIALS AND METHODS

MDCT-guided retroperitoneal FNAB and core biopsy was performed on 14 patients with suspected retroperitoneal neoplasm. We used MPR images (sagittal and coronal) obtained with a six-detector-row MDCT scanner and 20-22 gauge Chiba needles.

RESULTS

Using MDCT with 3D MPR allowed biological samples to be obtained in all cases (ten cytological and four histological) and diagnostic samples in 11/14 cases (78.5%). Histological samples were deemed adequate for diagnostic assessment in all cases and cytological samples in 7/10 cases (70%).

CONCLUSIONS

MPR images allowed sampling of retroperitoneal lesions until now considered unreachable with the guidance of axial MDCT alone. Compared with the conventional procedure, the use of MPR images does not increase the procedure time.

Ultrasound-guided tru-cut biopsy of abdominal and pelvic tumors in gynecology

OBJECTIVE

To analyze the safety, adequacy and accuracy of tru-cut biopsy and to evaluate factors potentially affecting adequacy.

METHODS

We analyzed retrospectively a group of patients who had undergone tru-cut biopsy for either primary suboptimally operable tumors, recurrence or suspected non-genital or secondary tumor. Tru-cut biopsy was performed either transvaginally or transabdominally, using an automatic biopsy gun with disposable needle and needle guide attached to the probe. The adequacy, i.e. obtaining a sample sufficient for identification of the origin of the tumor and performance of immunohistochemistry; accuracy, i.e. agreement between biopsy and final postoperative histology; and safety, as determined by complication rate, were assessed. Variables potentially influencing adequacy were analyzed using the orthogonal projections to latent structure method.

RESULTS

A total of 195 biopsies were performed on 190 patients. An adequate sample was obtained in 178 (91.3%) biopsies. The final histology was not in agreement with the result from tru-cut biopsy in two out of 118 patients who underwent subsequent surgery (accuracy 98.3%). There were complications in two cases out of the 195 biopsies performed (1.0%). Ascites, elevated CA 125, primary suboptimal operable tumor, serous epithelial ovarian cancer histology, carcinomatosis and vaginal approach were significant positive predictors for the achievement of an adequate sample, while recurrence as an indication, non-serous and non-ovarian histotypes and transabdominal approach were negative predictors.

CONCLUSION

Ultrasound-guided tru-cut biopsy is an efficient, minimally invasive, accurate and safe diagnostic method in the management of advanced, recurrent or atypical abdominal and pelvic tumors of probable non-genital origin, where unnecessary laparotomy or laparoscopy can be avoided. The adequacy of tru-cut biopsy is mainly influenced by indication group, histology, site of biopsy and approach. Our analysis can help in counseling the patient before the procedure and helps to explain the possible causes of failure of the procedure.

Non-Hodgkin lymphoma as a cause of obstructive jaundice with simultaneous extrahepatic portal vein obstruction: A case report

Non-Hodgkin lymphoma is a rare cause of biliary obstruction. To the best of our knowledge, non-Hodgkin lymphoma in the peripancreatic region causing obstructive jaundice with simultaneous portal vein (PV) invasion has not yet been reported. We present a 50-year-old patient with obstructive jaundice whose extrahepatic portal vein was obstructed by the invasion of a peripancreatic non-Hodgkin lymphoma. The patient denied any other symptoms such as recurrent fever, night sweat and loss of body weight. Computed tomography (CT) revealed a 10 cm mass in the retroperitoneal space behind the head of the pancreas causing obstruction of the distal bile duct and the PV. A pylorus-preserving pancreaticoduodenectomy combined with a PV resection was performed. The PV was reconstructed using an autologous right internal jugular vein graft. The resected specimen showed endoluminal invasion of both the bile duct and the PV. Histological examination showed the mass consisting of diffuse sheets of large malignant lymphoid cells. These cells were positive for CD20 and CD79a, partially positive for CD10, and negative for CD3, CD4, CD5, CD8 and CD30. The pathologic diagnosis was diffuse large B-cell type non-Hodgkin lymphoma and the patient was transferred to the Department of Hematology and Oncology for chemotherapy. He received four cycles of combined chemotherapy including cyclophosphamide, doxorubicin, vincristine and prednisone plus rituximab, and three cycles of intrathecal chemoprophylaxis including methotrexate, cytosine arabinoside and prednisone. The patient is alive with no evidence of the disease for 7 mo after operation and will receive additional courses of chemotherapy.

Ultrasound-guided tru-cut biopsy in the management of advanced abdomino-pelvic tumors

The goal of this study was to evaluate the accuracy and safety of ultrasound-guided tru-cut biopsy in patients with either primarily inoperable pelvic tumor, advanced tumor and compromised performance status, or recurrent pelvic tumor. Altogether, 90 patients were enrolled and only 4 were not suitable for tru-cut biopsy. The biopsy was taken either from pelvic tumor (54.6%), peritoneal visceral or parietal metastases (31.4%), or omental cake (14%). Samples were obtained transvaginally (53.5%) or transabdominally (46.5%). A diagnosis consistent with primary ovarian malignancy was made in 62.8%, metastatic ovarian involvement was found in 10.5%, and extraovarian tumor in 26.7%. The obtained tissue was adequate for histologic diagnosis in 80 out of 86 cases. In four cases, repeated biopsy was required to obtain a sufficient tissue sample. False-negative samples without tumor tissue were obtained in two cases, and those patients were referred for either laparoscopy or minilaparotomy. The diagnostic accuracy of ultrasound-guided tru-cut biopsy reached 97.7% (95% CI 91.85-99.72%). There was only one complication, a bleeding from tumor in a patient with mild thrombocytopenia, requiring laparotomy. In conclusion, ultrasound-guided tru-cut biopsy is safe, reliable, and cost-effective diagnostic method. It can be performed in an outpatient setting without the need for general anesthesia and provides an adequate specimen for histologic analysis, including immunohistochemical methods. It should, therefore, be considered as a method of choice for histologic verification of both advanced primary and recurrent abdomino-pelvic tumors.

Clinical value of image-guided fine needle aspiration of retroperitoneal masses and lymph nodes in gynecologic oncology

OBJECTIVE

Evaluation of the sensitivity and specificity of fine needle aspiration of retroperitoneal masses and lymph nodes in gynecologic oncology.

METHODS

Retrospective study of 101 punctures administered to 84 patients aged 23-86 years. The method's sensitivity and specificity were evaluated by clinical follow-up.

RESULTS

A satisfactory sampling was obtained in 89.1% of punctures, and a cytological diagnosis was made in 88.1%. The size of the lymph nodes punctured was less than 14 mm in 46.5%. This test has a sensitivity of 87.5%, specificity of 88.9%, positive predictive value of 98%, negative predictive value of 53.3%, and accuracy of 87.7%. Four patients presented complications: pain (2), hematoma (1), and right ureteral perforation (1).

CONCLUSIONS

The fine needle aspiration technique has excellent positive predictive value and low morbidity. As a method of visualization, CT-scan, in combination with lymphography, allows the location of small lesions and the definition of their internal structures. The weak negative predictive value of fine needle aspiration might be correctible by laparoscopy-directed biopsy, and its potential is clearly ensured by the development of techniques for locating sentinel lymph nodes.

Chirurgie des sarcomes rétropéritonéaux

Retroperitoneal sarcomas comprise approximately 15% of all soft tissue sarcomas and 50% of all retroperitoneal tumours. Helical CT of the abdomen and pelvis, with selective use of MRI will establish the extent of the tumour, its retroperitoneal location, the degree of necrosis, and the evidence of metastasis. A CT guided core needle biopsy is the optimal pre operative tissue sampling. A complete surgical resection is the mainstay of the treatment with a rim of normal tissue that often requires removal of adjacent organs. The 5-year probability of local control is approximately 50%. The role of adjuvant therapy is evolving and at present should not be used outside the investigational setting.

Percutaneous fine-needle biopsy of deep thoracic and abdominal masses in dogs and cats

Percutaneous fine-needle biopsy was used to investigate thoracic and abdominal masses in the dog and cat. One hundred and thirty-two cases were included in the study; 20 cases were excluded from the comparative study due to poor cellularity or blood contamination (retrieval rate 86.8 per cent). One hundred samples (56 dogs and 44 cats) were classified by cytology as neoplastic. All the cytological diagnoses of neoplasia were confirmed by histological samples obtained either by non-surgical methods, at surgery or during postmortem examination. No false positive diagnoses of neoplasia were made. Thirty-two samples were cytologically classified as 'negative for neoplasia'. Subsequent histological examination revealed 18 true negative and 14 false negative results. The procedure had an overall 89.4 per cent (118 cases out of 132) agreement between the diagnosis of inflammatory disease versus neoplasia, with a sensitivity of 87.8 per cent, a specificity of 100 per cent, a predictive value of a positive test of 100 per cent and a predictive value of a negative test of 56.3 per cent.

Percutaneous image-guided fine-needle aspiration of peritoneal lesions

Fine-needle aspiration (FNA) is a widely accepted technique for the initial tissue diagnosis of a variety of lesions arising within retroperitoneal and intraabdominal viscera. Fear of complications secondary to perforation of the bowel wall has limited the use of FNA in the diagnosis of gastrointestinal and peritoneal masses. A variety of primary and secondary neoplasms involving the peritoneum may present as multiple nodules, as masses, or as diffuse involvement of the peritoneum. When these lesions are associated with mass lesions or areas of significant peritoneal thickening, they become amenable to percutaneous image-guided FNA. We report on our experience with a series of 23 peritoneal lesions investigated by FNA for which subsequent histologic confirmation was available in 19, along with an additional 4 cases without histologic confirmation. One to four passes were made into each lesion, and immediate assessment for adequacy was performed by a cytopathologist in all cases. All 17 cases with a specific cytologic diagnosis and histologic confirmation represented either primary or metastatic neoplasms (5 gastrointestinal stromal tumors, 4 metastatic melanomas, 2 mesotheliomas, 1 lymphoma, 1 example of Kaposi's sarcoma, 1 serous papillary carcinoma of ovarian origin, 1 mucinous adenocarcinoma of ovarian origin, 1 intraabdominal desmoplastic small-cell tumor, and 1 solitary fibrous tumor of the peritoneum). In an additional 4 cases, the aspirates were judged as insufficient for diagnosis, with the smears containing only blood and benign mesothelial cells and/or inflammatory cell elements. These four smears were associated with both neoplastic and nonneoplastic lesions. Surgical confirmation was obtained in only 2 of these cases (1 metastatic melanoma and 1 example of omental and peritoneal involvement by an ovarian adenocarcinoma). Two cases without histologic confirmation were associated with clinically confirmed metastases. In our series, no acute or chronic postprocedural complications were identified, indicating that FNA in this setting is a safe technique. Accurate cytologic diagnosis was achieved in 74% of cases. The overall insufficiency rate was 26%.

Fine-needle aspiration biopsy of the retroperitoneum: a series of 111 cases not including specific organs

We report on our experience in fine-needle aspiration (FNA) biopsy of the retroperitoneum: 111 FNA biopsies performed on 99 patients. Cytologic diagnoses were divided into four groups: nondiagnostic (unsatisfactory samples because of a low cellularity and/or improperly prepared smears) aspirates (20%), benign (16%), suspicious for malignancy (13%), and malignant (50%). There were no known false-positive samples. We had two false-negative diagnoses due to sampling errors. Among diagnostic smears, the procedure showed a sensitivity of 97% and a specificity of 100%. The predictive value of a positive result was 100% and the predictive value of a negative result was 90%. The overall accuracy was 98%. Metastatic carcinomas accounted for the largest number of lesions in the group of malignant tumors. A primary tumor site was known for the majority of the cases before the aspiration was performed. In the remaining cases we were unable to suggest an origin. It is therefore important to emphasize the role of ancillary studies in patients that are at the first assessment of the disease or when a second intercurrent malignancy is suspected. In our limited experience, a suggestion of the correct subtype of retroperitoneal sarcoma was not possible. As in the rest of cytopathology, a multidisciplinary approach is mandatory in this setting to improve patient management.