Percutaneous image-guided needle biopsy in children--summary of our experience with 57 children

Categorizing Malignant Small Round Cell Tumors in Aspiration Cytology: An Institutional Experience

Aim and Objectives

The study aims to categorize malignant small round cell tumors (MSRCTs) originating in various sites of the body with the objective of utilization of cytomorphological features and ancillary techniques.

Study Design

It is a cross-sectional study conducted over a time span of 3 years (2017-2020). 33 cases of tumors with round cell morphology were evaluated by fine needle aspiration cytology (FNAC).

Materials and Methods

The application of cell block preparation supported by immunohistochemistry aided in the categorization of 23 cases with definite diagnosis and the rest were reported as MSRCTs.

Results

Among the categorized 23/33 cases, the most common diagnosis was Ewing's sarcoma (7/23) followed by 6 cases of lymphoma. There were 2 cases each of rhabdomyosarcoma and Langerhans cell histiocytosis (LCH) and 1 case each of neuroblastoma, desmoplastic small round cell tumor (DSRCT), myeloid sarcoma, neuroendocrine tumor of pancreas, plasmacytoma, and small cell carcinoma. Histopathology confirmation was available in 24/33 cases. Among the categorized tumors (23/33), biopsy correlation was available in 19 cases, of which concordant result was seen in 17 cases (89.47%), which were 6 cases of lymphoma, 5 cases of Ewing's sarcoma (EWS), 2 of rhabdomyosarcoma, and 1 each of neuroblastoma, small cell carcinoma, DSRCT, and LCH. Discordant result was seen in one case of rhabdomyosarcoma and a case of synovial sarcoma reported as extraskeletal EWS in cytology. Out of the uncategorized cases reported as MSRTCs, histopathology was available in 5 cases which were diagnosed as rhabdomyosarcoma (1 cases), lymphoma (1 case), amelanotic melanoma (1 case), and extraskeletal EWS (2 cases).

Conclusion

Categorization of MSRCTs should be done to implement appropriate therapeutic protocol. FNAC provides a rapid diagnosis contributing immensely for the timely management of the patient. Detailed cytomorphological evaluation serves as a guide for further evaluation by ancillary techniques leading to definitive diagnosis.

Efficacy of core needle biopsy in the diagnosis of pediatric extracranial solid malignancies: A 10-year study

Introduction:

Core needle biopsies of solid masses in children are a minimally invasive technique. It guides to a definitive diagnosis and facilitates management.

Aims and Objectives:

To determine the accuracy, sensitivity, and specificity of core needle biopsies in diagnosing pediatric solid masses.

Materials and Methods:

A retrospective analysis of 430 children, who underwent core needle biopsy for solid masses between January 2007 and December 2016 at CMC Vellore, was done.

Results:

Retroperitoneal and intra-abdominal masses constituted 66% of cases. Real-time image guidance was used in 44% of cases. An accurate diagnosis was obtained in 93.6% of cases, while results did not correlate with the final diagnosis in 3.4%. Three percent had inadequate or necrotic tissue. None of the children had postprocedure complications.

Conclusion:

Core needle biopsies serve as good diagnostic modality, with minimal risks, in making a conclusive diagnosis and deciding on the line of management.

The utility of core-needle tumor biopsy for pediatric patients

BACKGROUND

Core-needle biopsy (CNB) is used less frequently for the diagnosis of tumors in pediatric patients. In this report, the utility and safety of CNB for pediatric patients are described.

METHODS

The medical records of patients who underwent CNB at the Department of Pediatric Surgery, Kyushu University Hospital from April 2020 to November 2021 were retrospectively reviewed. A 14 G or 16 G BARDMISSION Disposable Needle Instrument was used. For the diagnosis of neuroblastoma, a 14 G needle was selected; for the diagnosis of other tumors a 16 G needle was selected.

RESULTS

During the above period 17 CNBs were performed in 17 patients, and the median patient age was 8 years (range, 15 days-19 years). The pathological diagnoses of the tumors were as follows: neuroblastoma, n = 6; lymphoma, n = 3; hepatoblastoma, n = 2; and others, n = 6. The quantity and quality of all tumor samples obtained by CNB was sufficient to make a diagnosis. The postoperative course after CNB was uneventful in most cases, with the exception of one case of hepatoblastoma (pseudoaneurysm).

CONCLUSIONS

Core-needle biopsy is useful for pediatric patients. Sufficient tumor specimens were able to be obtained in all cases, irrespective of the type of tumor, and an accurate diagnosis could be made.

Magnetic resonance imaging-guided biopsies in children

Background

Magnetic resonance imaging (MRI) is used far less as an imaging-guided method for percutaneous biopsies than computed tomography (CT) and ultrasound (US), despite its imaging benefits, particularly in children.

Purpose

To evaluate the feasibility, accuracy and safety of MRI-guided biopsies in paediatric patient population.

Material and Methods

The retrospective study included 57 consecutive paediatric patients (<18 years old). A percutaneous core needle biopsy (PCNB) or trephine biopsy was performed in 53 cases, and an additional fine-needle aspiration biopsy (FNAB) in 26 cases. In 4 cases, a stand-alone FNAB was taken. Biopsies were performed with 0.23 T open and 1.5 T closed MRI scanners. Statistical methods used for confidence intervals and p-values were Wilson score method and chi-square test.

Results

The overall diagnostic accuracy of histologic biopsy was 0.94, with sensitivity 0.82, specificity 1.00, positive predictive value (PPV) 1.00 and negative predictive value (NPV) 0.92. In histological bone biopsies, diagnostic accuracy was 0.96, with sensitivity 0.86, specificity 1.00, PPV 1.00 and NPV 0.94. The FNAB sample diagnosis was associated with the histological diagnosis in 79% of cases. There were no major primary complications and only a few late complications. After biopsy, 83% of the children were ambulatory in 6 h. Anti-inflammatory drugs and paracetamol provided satisfactory pain relief in 96% of the patients after biopsy. Most outpatients (71%) were discharged from hospital either on the same day or 1 day later.

Conclusion

MRI is a technically feasible, accurate and safe guidance tool for performing percutaneous biopsies in children.

The morbidity of open tumor biopsy for intraabdominal neoplasms in pediatric patients

PURPOSE

Tumor biopsy is often essential for diagnosis and management of intraabdominal neoplasms found in children. Open surgical biopsy is the traditional approach used to obtain an adequate tissue sample to guide further therapy, but image-guided percutaneous core-needle biopsy is being used more often due to concerns about the morbidity of open biopsy. We used a national database to evaluate the morbidity associated with open intraabdominal tumor biopsy.

METHODS

We identified all patients undergoing laparotomy with tumor biopsy in the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database from 2012 to 2018 and measured the frequency of complications in the 30 days postoperatively. We tested associations between patient characteristics and outcomes to identify risk factors for complications.

RESULTS

We identified 454 patients undergoing laparotomy for biopsy of an intraabdominal neoplasm. Median postoperative hospital stay was 7 days (IQR 4-12) and operative time was 117 min (IQR 84-172). The overall complication rate was 12.1%, with post-operative infection (6%) and bleeding (4.2%) being the most common complications. Several patient characteristics were associated with bleeding, but the only significant association on multivariable analysis was underlying hematologic disorder.

CONCLUSION

Open abdominal surgery for pediatric intraabdominal tumor biopsy is accompanied by significant morbidity. Postoperative infection was the most common complication, which can delay initiation of further therapy, especially chemotherapy. These findings support the need to prospectively compare percutaneous image-guided core-needle biopsy to open biopsy as a way to minimize risk and optimize outcomes for this vulnerable population.

Ultrasound-guided core biopsy with on-site cytology-immediate diagnosis in pediatric oncology

BACKGROUND

Accurate and swift tissue diagnosis is extremely important for the timely initiation of treatment in pediatric oncology. In our department, ultrasound-guided core needle biopsy (US-guided CNB) is used for tissue diagnosis. In 2016, we added on-site cytology, allowing for an immediate primary diagnosis. We retrospectively reviewed our performance in terms of safety and accuracy for CNBs and on-site cytology.

METHODS

All pediatric biopsies performed in our hospital between February 2016 and December 2020, were included. Patient clinical, procedural and follow-up data were collected. CNB pathology and cytology results were compared to the final pathologic diagnosis.

RESULTS

We included 71 patients for which 72 biopsies with on-site touch imprint (TI) cytology were performed; the average latency time to biopsy was 1 day. Altogether, we had 61 tumors, (58 malignant, 3 benign) and 11 other lesions. On-site cytology diagnosed 58 malignant tumors, 3 benign tumors and 11 non-tumor tissues. The cytologist correctly differentiated tumor from inflammation in all cases, and diagnosed the precise tumor type in 57 cases, with an accuracy of 94% for final diagnosis. We had no complications related to the procedure or sedation.

CONCLUSION

US-guided CNB with on-site TI cytology for suspected malignancy in the pediatric population is highly available, safe, and accurate, with real-time diagnosis in most cases. This accelerated diagnostic route has a huge impact on patient care.

Diagnosis of solid tumors in infants by fine-needle aspiration cytology: 5 years retrospective study from a tertiary care oncology center in South India

INTRODUCTION

Neuroblastoma (NB), Wilms tumor (WT), hepatoblastoma (HBL), germ cell tumors (GCT), rhabdomyosarcoma (RMS), and so forth are the commonly identified solid tumors in infants. Invasive diagnostic techniques are more challenging in infants than older children. fine needle aspiration cytology (FNAC) is a safe, minimally invasive and outpatient procedure which is time and cost-effective for solid tumor diagnosis. This study aims to evaluate the role of FNAC in the diagnosis of various infantile solid tumors.

METHODS

In this retrospective study, 61 cases of FNA of infant solid tumors were retrieved from the cytology archives over a period of 5 years from January 2013 to December 2017. Cytomorphology was studied and immunohistochemistry on cell block was performed wherever feasible. Histopathological correlation was done in 19 cases.

RESULTS

Of the 61 cases studied, 60 cases were included in the study of which 35 were male and 25 were female. Infantile solid tumors constituted 7.3% of all pediatric solid tumors reported in cytopathology division of our Institute. The most common final diagnosis was NB (15, 25%) followed by HBL (13, 21.6%), WT (10, 16.6%), RMS (nine, 15%) and GCT (nine, 15%). The commonest site was abdominal-pelvic (42, 70%). A definitive independent diagnosis could be made on FNA in 48 cases (80%). Follow-up was done for 1.5 to 4 years (mean 26 months). The highest and lowest mortality was noted in NB (64.3%) and WT (12.5%) respectively.

CONCLUSION

This study concludes that FNAC can be adopted as a diagnostic modality in infant solid tumors.

A Spontaneously Necrotic Wilms' Tumor Mimicking Renal Abscess: A Tricky Diagnosis not to Miss

Wilms' tumor (WT) is the most common renal malignancy in children. Its clinical and radiologic presentation may mimic other pediatric renal diseases, including pyonephrosis or renal abscess. The authors report a case of a 3-year-old girl presenting with pyelonephritis and right renal mass suggestive of a renal abscess, not responding to antibiotics. Further investigations were conducted, including a percutaneous renal needle core biopsy. A stage I fully necrotic WT was finally diagnosed. This amazing case of a fully necrotic WT at diagnosis demonstrates the importance of anatomopathologic analyses in pediatric renal masses, even when the infection is suspected.

Ultrasound-Guided Core Biopsy for Tissue Diagnosis in Pediatric Oncology: 16-Year Experience With 597 Biopsies

OBJECTIVE. Percutaneous imaging-guided core needle biopsies (CNBs) for cancer diagnosis in pediatric patients are gaining interest because of their availability, lower rate of complications, and high diagnostic power compared with traditional surgical biopsies. Nevertheless, their precise role in the diagnostic algorithm of pediatric oncology is still unknown. The purpose of this study was to report our accumulated 16-year experience with CNB; discuss the availability, safety, and diagnostic accuracy of the procedure and the adequacy of ancillary testing; and compare our findings with the available literature. MATERIALS AND METHODS. Pediatric ultrasound-guided CNBs performed in our hospital between November 2003 and December 2019 were retrospectively studied. Data collection included demographics, clinical and procedural parameters, complications, and final diagnosis. RESULTS. A total of 597 biopsies were performed in 531 patients (132 performed in known oncologic patients and 465 performed to establish diagnosis). The median time between the biopsy request and the procedure was 1 day. Of 432 biopsies performed in patients with malignancies, 12 (2.8%) had false-negative results. In 165 cases of benign pathologic findings, all had true-negative results. Ancillary testing was adequate in all malignant cases. Overall sensitivity, specificity, and accuracy rates were 97.2%, 100%, and 98.0%, respectively. Five biopsies (0.8%) resulted in complications, including one major bleed and one track seeding. CONCLUSION. Our experience shows that ultrasound-guided CNB for suspected malignancy in pediatric patients has a high safety profile, availability, and accuracy rate compared with surgical biopsy. Our fast-track strategy enables early initiation of designated therapy and has the potential to become the procedure of choice.

Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma

BACKGROUND

Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma.

PROCEDURE

A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification.

RESULTS

A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy.

CONCLUSIONS

PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.

Pediatric neuroblastic tumors: A critical evaluation of cytomorphological features for risk stratification on aspiration cytology

BACKGROUND

Neuroblastic tumor (NT) is the most common extracranial solid tumor of childhood with variable outcome which again depends on risk stratification related to distinct biology of the tumor. The use of fine-needle aspiration (FNA) material for evaluation of cytomorphological parameters and risk stratification in NTs using cytology prognostic score (PS) is limited in routine practice.

METHODS

We reviewed 38 FNA cytology cases diagnosed as pediatric small round cell tumor between time period June 2017 to December 2019 for clinical, cytomorphological and immunohistochemical features.

RESULTS

Ten out of 38 small round cell tumors were NTs. All 10 cases were further subclassified according to International Neuroblastoma Pathology Classification into undifferentiated neuroblastoma (n = 1), poorly differentiated neuroblastoma (n = 5), differentiating neuroblastoma (n = 2), and ganglioneuroblastoma (n = 2). Cytologic PS was done using the morphological criteria as described previously in literature. The patients were divided into favorable and unfavorable cytomorphological prognostic categories with a cut off scoring of 12. A score of more than 12 is associated with high risk morphology and advanced stage. All cases with PS > 12 (n-4) (unfavorable cytomorphology) had a poor outcome compared to six patients with PS < 12 (n-6) (favorable cytomorphology).

CONCLUSION

Aspiration cytology can be used as a first line investigation to evaluate the cytomorphological features for risk stratification and diagnosis in patients with NTs using cytological prognostic scoring system. A larger multi-centric validation study necessitates for cytological risk stratification.

Evolving biopsy techniques for the diagnosis of neuroblastoma in children

BACKGROUND/PURPOSE

To compare the adequacy and safety of percutaneous core needle biopsy and surgical wedge biopsy of neuroblastoma in children.

METHODS

A retrospective review of patients who underwent biopsy for intermediate- or high-risk neuroblastoma at our institution between 2011 and 2015 was performed (recent cohort). Procedure details and outcomes were collected and analyzed using descriptive statistics and Wilcoxon rank tests; P < 0.05 was considered significant. Published data from 2002 to 2010 were compared (historic cohort).

RESULTS

Since 2011, percutaneous, ultrasound-guided, core needle biopsy has been more commonly utilized (47% (16/34) recent vs. 25% (7/28) historic; P = 0.07), and the number of core needle samples increased from median 7 (historic) to 25 (recent). Complications decreased (21% (7/34) recent vs. 64% (18/28) historic; P < 0.01). Biopsy adequacy in the recent cohort was similar (94% percutaneous vs. 89% surgical; P = 1.00), which is improved from the historic cohort (71% percutaneous vs. 100% surgical; P = 0.06). Larger tumors were more likely to have a percutaneous biopsy (82 ± 37 cm percutaneous vs. 47 ± 29 cm surgical; P = 0.04).

CONCLUSIONS

When multiple cores are obtained, percutaneous core needle biopsy is adequate for complete tissue diagnosis of neuroblastoma and can be safely performed. This can be considered as an alternative to open surgical biopsy.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

III.

Ultrasound-guided core needle biopsy in the diagnosis of neuroblastic tumors in children: a retrospective study on 83 cases

AIM

Ultrasound-guided biopsy technique with the large-core needle has widely been applied in the diagnosis of adult abdominopelvic cavity, thyroid, and neck tumors. There are few reports on ultrasound-guided biopsy using large-core needle in pediatric abdominopelvic cavity tumors. This study was to evaluate the ultrasound features and the diagnostic value of ultrasound-guided core needle biopsy for pediatric neuroblastic tumors.

METHODS

The pediatric patients with neuroblastic tumor that underwent ultrasound examination and ultrasound-guided core needle biopsy from January 2009 to November 2015 were reviewed. A minimum of two cores in each case was obtained. The biopsy results were confirmed by subsequent surgical histopathology. The ultrasound features and the diagnostic accuracy of ultrasound-guided core needle biopsy were evaluated.

RESULTS

Eighty-three patients were enrolled into the study. Conventional ultrasound examination showed irregular hypoechoic or mixed echo masses and calcification and liquefied necrosis. The diagnostic accuracy of ultrasound-guided core needle biopsy was 96.4% (80/83). Three cases were misdiagnosed because of inadequate tissue sample. No serious complication, infection, or needle track seeding occurred.

CONCLUSIONS

Ultrasound-guided core needle biopsy seems to be an accurate, minimally invasive, and safe diagnostic method of pediatric neuroblastic tumor.

Image-guided percutaneous core needle biopsy of soft-tissue masses in the pediatric population

BACKGROUND

A paucity of literature describes the use of imaged-guided percutaneous core needle biopsy for the diagnosis and characterization of pediatric soft-tissue masses and lesions.

OBJECTIVE

To retrospectively determine whether image-guided percutaneous core needle biopsy is adequate for diagnosing and characterizing benign and malignant pediatric soft-tissue masses and lesions.

MATERIALS AND METHODS

We identified children (≤18 years old) who underwent US- or CT-guided percutaneous core needle biopsy of a soft-tissue mass or other lesion between January 2012 and March 2014. Using medical records, we documented the following data: age and gender, site of the mass or lesion, size and number of biopsy specimens, whether the biopsy procedure was diagnostic, whether sufficient tissue was obtained for necessary ancillary testing (e.g., cytogenetic evaluation), and whether there was a procedural complication within 1 week.

RESULTS

One hundred eight soft-tissue masses or lesions were biopsied under imaging guidance in 84 children; 39 (46%) were girls. Mean age ± standard deviation (SD) was 12.1 ± 5.1 years (range 6 months to 18 years). Of these procedures, 105/108 (97%) were diagnostic; 82/108 (76%) were US-guided; 87/108 (81%) were performed using a 17-gauge introducer needle/18-gauge biopsy instrument. The mean number ± SD of core needle biopsy specimens obtained was 8.9 ± 5.0. For newly diagnosed malignancies, adequate tissue was obtained for ancillary testing in 28/30 (93%) masses. One minor complication was documented.

CONCLUSION

Image-guided percutaneous core needle biopsy of pediatric soft-tissue masses is safe, has a high diagnostic rate, and provides sufficient tissue for ancillary testing.

Factors influencing the diagnostic yield and accuracy of image-guided percutaneous needle biopsy of pediatric tumors: single-center audit of a 26-year experience

BACKGROUND

Image-guided percutaneous core needle biopsy is a common procedure for diagnosis of both solid tumors and hematological malignancies in children. Despite recent improvements, a certain rate of non-diagnostic biopsies persists.

OBJECTIVE

To assess the factors influencing the diagnostic yield and accuracy of percutaneous core needle biopsies of pediatric tumors.

MATERIALS AND METHODS

We conducted a single-center retrospective study of a 26-year experience with image-guided biopsies in children and young adults. Using uni- and multivariate analysis, we evaluated the association of diagnostic yield and accuracy with technical factors (image-guided procedure, pathological technique) and clinical factors (complication rate, histological type and anatomical location).

RESULTS

We retrieved data relating to 396 biopsies were performed in 363 children and young adults (mean age: 7.4 years). Overall, percutaneous core needle biopsy showed a diagnostic yield of 89.4% (95% confidence interval [CI] 85.9-92.2) and an accuracy of 90.9% (CI 87.6-93.6) with a complication rate of 2.5% (CI 1.2-4.6).The diagnostic yield increased with the use of advanced tissue assessment techniques (95.7% with immunohistochemistry versus 82.3% without immunohistochemistry; P < 0.0001) and an increased number of passes (mean: 3.96 for diagnostic biopsies versus 3.62 for non-diagnostic biopsies; P = 0.044).

CONCLUSION

The use of advanced pathological techniques and an increased number of passes are the two main factors influencing the diagnostic success of biopsies in pediatric tumors.

Predictors of diagnostic success in image-guided pediatric soft-tissue biopsies

BACKGROUND

Image-guided percutaneous core needle biopsy (PCNB) of soft-tissue lesions is a minimally invasive technique that can provide a definitive diagnosis for treatment. Anatomical and age considerations in children require judicious use of safe percutaneous biopsy techniques. There are, however, limited data on the determinants of diagnostic yield in soft-tissue lesions in this population.

OBJECTIVES

To assess lesion-related and technical factors that affect diagnostic yield and safety in PCNB of pediatric soft-tissue lesions.

MATERIALS AND METHODS

This was a retrospective cohort study of 205 PCNB performed from January 2000 to July 2014. Diagnostic yield and its associations with technical and lesion-related factors were evaluated using bivariate analysis.

RESULTS

The mean patient age was 11.1 ± 6.9 years (interquartile range [IQR]: 4.3-16 years). Ultrasound guidance alone was used in 91% of cases. The mean number of passes was 7.5 ± 3.2 (IQR: 5-9 passes) per case. The overall diagnostic yield was 75% and the overall accuracy was 88%. Performing fewer than four passes was associated with a nondiagnostic biopsy (P = 0.001). There were no lesion or other technical factors that predicted a diagnostic biopsy. There were two complications (1%) over 14 years.

CONCLUSION

Image-guided PCNB is a safe and effective means for the diagnosis of pediatric soft-tissue abnormalities. Aside from performing at least four passes, our data show no technical or lesion-related factors that increase diagnostic yield in pediatric PCNB of soft-tissue lesions.

Safety and diagnostic accuracy of tumor biopsies in children with cancer

BACKGROUND

Tumor biopsies are central to the diagnosis and management of cancer and are critical to efforts in personalized medicine and targeted therapeutics. In the current study, the authors sought to evaluate the safety and accuracy of biopsies in children with cancer.

METHODS

All biopsies performed in children at the study institution with a suspected or established diagnosis of cancer from 2003 through 2012 were reviewed retrospectively. Patient characteristics and disease-related and procedure-related factors were correlated with procedure-related complications and diagnostic accuracy using logistic regression analysis.

RESULTS

A total of 1073 biopsies were performed in 808 patients. Of 1025 biopsies with adequate follow-up, 79 (7.7%) were associated with an adverse event, 35 (3.4%) of which were minor (grade 1-2) and 32 (3.1%) of which were major (grade 3-4) (grading was performed according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]). The most common major adverse events were blood transfusion (>10 mL/kg; 24 cases) and infection requiring intravenous antibiotics (6 cases). Eleven deaths (1.4%) occurred within 30 days after the procedure, but the procedure may have contributed to the outcome in only 2 cases. A total of 926 biopsies (90.3%) provided definitive histologic diagnoses. Using multivariable analysis, biopsy site, preprocedure hematocrit level, and body mass index were found to be associated with the risk of postprocedural complications (P<.0001, P<.0001, and P =.0029, respectively). Excisional biopsy and biopsy site were found to be independently associated with obtaining a diagnostic result (P =.0002 and P =.0008, respectively).

CONCLUSIONS

Tumor biopsies in children with cancer are associated with a low incidence of complications and a high rate of diagnostic accuracy. The predictive factors identified for adverse outcomes may aid in risk assessment and preprocedural counseling.

Ultrasound-guided core needle biopsy in diagnosis of abdominal and pelvic neoplasm in pediatric patients

BACKGROUND

Ultrasound-guided core needle biopsy of abdominal and pelvic masses in adults has gained tremendous popularity. However, the application of the same treatment in children is not as popular because of apprehensions regarding inadequate tissues for the biopsy and accidental puncture of vital organs.

METHODS

Data of the application of ultrasound-guided core needle biopsy in 105 pediatric patients with clinically or ultrasound-diagnosed abdominopelvic masses were reviewed. Diagnostic procedures were conducted in our institution from May 2011 to May 2013.

RESULTS

The biopsies were conducted on 86 malignant lesions and 19 benign lesions. 86 malignant tumors comprised neuroblastomas (30 cases), hepatoblastomas (15 cases), nephroblastomas (11 cases), and primitive neuroectodermal tumors/malignant small round cells (6 cases). Among malignant tumor cases, only a pelvic primitive neuroectodermal tumor did not receive a pathological diagnosis. Therefore, the biopsy accuracy was 98.8 % in malignant tumor. However, the biopsies for one neuroblastomas and one malignant small round cell tumor were inadequate for cytogenetic analysis. Therefore, 96.5 % of the malignant tumor patients received complete diagnosis via biopsy. 19 benign tumors comprised mature teratoma (10 cases), hemangioendothelioma (3 cases), paraganglioma (2 cases), and infection (2 cases). The diagnostic accuracy for benign neoplasm was 100 %. Five patients experienced postoperative complications, including pain (2 patients), bleeding from the biopsy site (2 patients), and wound infection (1 patient).

CONCLUSION

Ultrasound-guided core needle biopsy is an efficient, minimally invasive, accurate, and safe diagnostic method that can be applied in the management of abdominal or pelvic mass of pediatric patients.

Needle core vs open biopsy for diagnosis of intermediate- and high-risk neuroblastoma in children

BACKGROUND

Open biopsy has been the mainstay for definitive diagnosis of neuroblastoma in pediatric patients. However, needle core biopsy may represent a faster, less invasive, and safer alternative to open biopsy in children. The purpose of this study was to compare safety and efficacy between needle core and open biopsy in the diagnosis of patients with intermediate- and high-risk neuroblastoma at our institution.

METHODS

We retrospectively reviewed the medical records of children with intermediate- and high-risk neuroblastoma who underwent open or needle core biopsies from 2002 to 2010. Data collected included patient demographics, tumor size, sample adequacy for diagnosis and risk stratification (histology and cytogenetics), length of hospital stay, time to initiate chemotherapy after biopsy, need for repeat biopsy, and both intraoperative and postoperative complications. Mann-Whitney U and Fisher's exact tests were used for statistical analysis.

RESULTS

During the study period, 7 patients underwent needle core primary biopsies (5 intermediate-risk primary tumors and 2 high-risk primary tumors), and 4 patients underwent needle core biopsy for metastatic tumors, whereas 21 patients had open biopsies (10, intermediate risk; 11, high risk). Median age at biopsy and median tumor size were similar in both groups. There was no significant difference in adequacy of biopsy, need for repeat biopsy, time to initiate chemotherapy, length of stay, or minor complications. The rate of major complications differed significantly between the 2 groups with 0% after needle core biopsy vs 48% after open biopsy (P = .027).

CONCLUSIONS

In children, needle core biopsy is comparable in efficacy with open biopsy in the diagnosis of intermediate- and high-risk neuroblastoma with significantly lower rates of major postoperative complications. These findings warrant a larger scale evaluation of diagnostic needle core biopsies in pediatric patients with solid tumor.

Clinical features and surgical outcome of a suprarenal mass detected before birth

PURPOSE

With the widespread use of the obstetrical ultrasound, identification of a fetal suprarenal mass has become more common. Most of these masses prove to be congenital neuroblastomas (CNB), but the diagnosis is often confused with other benign lesions and the postnatal management remains to be controversial.

METHODS

The medical records of 18 patients that underwent primary surgical excision for an antenatally detected suprarenal mass, between January 1995 and April 2009, were reviewed. The clinical, radiological, surgical, and pathological data were collected. Staging evaluation was performed after histological confirmation of the CNB.

RESULTS

There were 13 cases of CNB, 1 adrenal cyst, 2 adrenal hemorrhages, and 2 pulmonary sequestrations. The differential diagnosis was impossible before surgery. Most of the CNBs were stage I (N = 11), with 1 stage IV and 1 stage IV-S. Four patients (3 stage I and 1 stage IV-S) had more than one copy of N-myc gene. The stage I patients were cured by surgery alone, and stage IV patients underwent nine cycles of adjuvant chemotherapy and currently have no evidence of disease. The five benign lesions were cured with excision alone. There were no postoperative complications.

CONCLUSION

For early diagnosis and treatment, surgical excision should be considered as the primary therapy for an antenatally detected suprarenal mass. The surgery can be safely performed during the neonatal period and provides a cure in most cases.

Ultrasound-guided core needle biopsy for the diagnosis of rhabdomyosarcoma in childhood

BACKGROUND

Most commonly a tissue diagnosis of rhabdomyosarcoma (RMS) in children is made by biopsy as opposed to primary resection. Open surgical procedures are often recommended to obtain sufficient material for accurate and complete diagnostic work up. Our institution has routinely used image-guided needle biopsies for soft tissue tumour diagnosis. We therefore sought to assess diagnostic accuracy and completeness, and procedure safety of consecutive patients diagnosed by needle biopsies in a single institution.

METHODS

A retrospective review of consecutive biopsies of patients who were diagnosed with RMS or undifferentiated sarcoma in a single institution over a 9-year period.

RESULTS

There were 24 children diagnosed with RMS or undifferentiated sarcoma who underwent 37 procedures (30 primary site and 7 draining lymph nodes). In the primary site diagnostic procedures, definitive diagnosis was made in all cases. In the majority of cases there was sufficient material for molecular analysis, cytogenetics and freezing. There were no complications of biopsy.

CONCLUSIONS

In the hands of experienced operators, image-guided needle biopsies of RMSs allow for accurate diagnosis, allow sufficient material to be obtained for supplementary studies and research, and are associated with minimal morbidity.

[Nephrogenic tumors]

Nephroblastomas are the most common malignant renal tumors in childhood. According to the guidelines of the SIOP (Société Internationale d'Oncologie Pédiatrique) and GPOH (Gesellschaft für Pädiatrische Onkologie und Hämatologie) pre-operative chemotherapy can be started without histological confirmation and thus initial imaging studies, in particular ultrasound, play an outstanding role for diagnostic purposes.

Punção aspirativa por agulha fina no diagnóstico de linfadenopatias e tumores sólidos em crianças e adolescentes

OBJETIVO: Avaliar a importância diagnóstica da punção aspirativa por agulha fina (PAAF) em crianças e adolescentes portadores de linfadenopatias e tumores sólidos. MÉTODOS: Análise retrospectiva dos pacientes com idade igual ou inferior a 18 anos, atendidos no Centro de Pediatria Cirúrgica do Hospital Universitário de Brasília, Universidade de Brasília, no período de julho de 2000 a julho de 2005. Foram calculados: sensibilidade, especificidade, precisão (acurácia) diagnóstica, valor preditivo positivo e valor preditivo negativo. RESULTADOS: Em 50 pacientes estudados, os resultados da PAAF mostraram sensibilidade de 90,9%; especificidade de 100%, precisão diagnóstica de 95% e valores preditivos positivo e negativo de 100% e 90%, respectivamente. CONCLUSÃO: Em nossa experiência, a PAAF é um método preciso, simples e seguro, útil no diagnóstico de linfadenopatias e tumores sólidos em crianças e adolescentes.

Interventional radiology and the care of the pediatric oncology patient

Interventional radiology has become increasingly involved in the diagnosis and management of the pediatric oncology patient. Percutaneous biopsy and needle aspiration can be performed for solid and liquid lesions with image guidance, both for the primary diagnosis and for management of sequelae of cancer therapy. Therapeutic options also can be performed with image guidance, including radiofrequency ablation and transarterial chemoembolization. When surgical resection is required, image guided tumor localization can be used to aid in identifying small lesions.

Analysis of needle versus open biopsy for the diagnosis of advanced stage pediatric neuroblastoma

BACKGROUND

Adequate tissue biopsy is necessary for the appropriate diagnosis and risk stratification of pediatric neuroblastoma (NB). We compared the quality and adequacy of biopsy tissue and complication rates in children with NB who underwent open (OBX) and image-guided needle biopsy (NBX) at our center.

METHODS

We retrospectively reviewed all patients diagnosed with stage III and IV NB from September 2001 to August 2004. The 24 patients were divided into two groups: those in whom the diagnosis was initiated using NBX, and those diagnosed using OBX. In addition to demographic data, we collected data pertaining to sufficiency of biopsy tissue for biology studies including: Shimada Classification, MYC-N amplification, and DNA index analysis and complications associated with the procedure. Chi-Square and Student's t-test were used to analyze the categorical and continuous variables, respectively.

RESULTS

Of 24 patients, 11 underwent NBX, and 13 patients underwent OBX. Eighteen patients had stage IV disease, 5 patients had stage III disease, and 1 stage IVS. Ten major complications occurred in four NBX patients and six OBX patients. There was no difference in days of narcotic use, time to DAT, or hospital stay between the two groups. Ten patients (seven NBX and three OBX, P = 0.045) had tissue that was insufficient for biology studies. Three of the seven NBX patients underwent a second biopsy for clarification of risk group.

CONCLUSIONS

This study demonstrated that more than half of patients undergoing NBX for NB had insufficient tissue for complete histological and molecular classification and that the incidence of procedural complications between NBX and OBX are similar.

Surgical robotics and image guided therapy in pediatric surgery: emerging and converging minimal access technologies

Minimal access surgery (MAS) is now commonplace in the armamentarium of the pediatric surgeon, and is being applied to a growing list of pediatric surgical diseases. Robot-assisted surgery and image guided therapy (IGT) have evolved as innovative minimal access approaches, and hold the promise of advancing MAS far beyond what is currently possible. The aims of this article are to describe the currently available robotic, and image guided therapy systems, review their present and potential applications, and discuss the future directions of these converging technologies.

Pathological diagnosis of paediatric tumours from image-guided needle core biopsies: a systematic review

BACKGROUND

Image-guided core needle biopsy is widely used in paediatric oncology, but many protocols continue to discourage this practice. No published randomized studies compare image-guided needle biopsy with surgical techniques.

OBJECTIVE

To perform a systematic review of the literature on image-guided core needle biopsy in paediatric oncology.

MATERIALS AND METHODS

Several computerized databases were searched using the terms [(needle OR core) AND (biops*[ti]) AND (paediatric OR pediatric OR child OR children OR childhood OR boy OR girl)[ti]] to identify series of more than five cases of needle core biopsy for tumour diagnosis in children. Data from included studies were combined to calculate pooled estimates of adequacy, accuracy and complication rates.

RESULTS

Thirteen studies fulfilled the inclusion criteria. Overall biopsy adequacy rate (defined as sufficient to make a diagnosis) was 94% (95% CI 92-96%). The diagnostic accuracy rate in cases with adequate material (defined as achieving the correct specific diagnosis) was 94% (95% CI 92-96%). Complications requiring treatment occurred in 1%.

CONCLUSIONS

Available pooled data suggest that about 95% of image-guided needle core biopsies provide an adequate sample for diagnosis of malignant disease in childhood. In such cases, the pathological diagnosis is correct in about 95%. Complications are rare.

Pulmonary sarcoidosis in a 14-year-old boy diagnosed by low-dose CT-guided transthoracic lung biopsy

Pulmonary sarcoidosis is a rare disease in the pediatric age group, characterized by the presence of epitheloid-cell granulomas. In stage 3 sarcoidosis, pulmonary infiltrates without hilar lymphadenopathy occur. Definitive diagnosis requires a histopathological specimen, which might be difficult to obtain by transbronchial biopsy. Multidetector computed tomography (MDCT)-guided transthoracic lung biopsy (TLB) is a well-established procedure in adults, but has only rarely been applied in children.A 14-year-old boy was admitted to hospital for evaluation of a chronic systemic disease with severe pulmonary manifestation. All investigations, including bronchosopy and bronchoalveolar lavage with microbiological and virological testing, had been negative. MDCT-guided TLB was performed on a 16-section scanner with a low-dose protocol (single slices, 120 kV, 20 mAs), using a 16-gauge biopsy device. The total effective dose was 0.4 mSv for the biopsy procedure. Histopathological examination revealed multiple epitheloid-cell granulomas with giant cells in the absence of microbiological or virological abnormalities. A diagnosis of stage 3 pulmonary sarcoidosis was made and systemic anti-inflammatory therapy was administered, which led to complete remission within weeks. MDCT-guided TLB can be a valuable instrument in assessing pulmonary manifestations of pediatric sarcoidosis, enabling precise histopathological diagnosis and adequate therapy. The use of low-dose protocols can substantially reduce radiation exposure without relevant loss of image information. MDCT-guided lung biopsy should be considered prior to open-lung surgery in selected patients with unclear pulmonary disease.

MR Imaging-guided percutaneous procedures in children

Magnetic resonance imaging (MRI)-guided therapeutic interventions in children are very rare. In comparison to other imaging techniques, it is very unusual for MRI to be used for diagnostic percutaneous interventions despite its imaging benefits. We provide a brief description of available MRI systems and instruments and use clinical examples to present and discuss typical indications for percutaneous procedures while showing possibilities for percutaneous therapeutic interventions.

MR-guided biopsies of lesions in the retroperitoneal space: technique and results

The purpose of this study was to evaluate the safety and precision of MRI-guided biopsies of retroperitoneal space-occupying tumors in an open low-field system. In 30 patients with indistinct retroperitoneal tumors [paraaortic lesion (n=20), kidney (n=2), suprarenal gland (n=3) and pancreas (n=5)] MR-guided biopsies were performed using a low-field system (0.2 T, Magnetom Concerto, Siemens, Germany). For the monitoring of the biopsies T1-weighted FLASH sequences (TR/TE=160/5 ms; 90 degrees ) were used in all patients and modified FLASH sequences (TR/TE=160/13 ms; 90 degrees ) in ten patients. After positioning of the needle in the tumors 114 biopsy specimens were acquired in coaxial technique with 16-gauge cutting needles (Somatex, Germany). The biopsies were successfully performed in all patients without vascular or organ injuries. The visualization of the aortic blood flow with MRI facilitated the biopsy procedures of paraaortic lesions. The size of the lesions ranged from 1.6 to 7.5 cm. The median distance of the biopsy access path was 10.4 cm. Adequate specimens were obtained in 28 cases (93.3%) resulting in a correct histological classification of 27 lesions (90%). In conclusion, MR-guided biopsies of retroperitoneal lesions using an open low-field system can be performed safely and accurately and is an alternative to CT-guided biopsies.

Fine-needle aspiration biopsy in pediatric oncology patients: a review of experience with 829 patients (899 biopsies)

The authors review their 20-year (1985-2004) experience with fine-needle aspiration biopsy (FNAB) in 829 children (all but 1 younger than 18 years), from whom 899 samples were obtained. All patients presented with clinical data suggesting malignancy. The procedure followed standard methods (22- to 24-gauge needle; mean of six alcohol-fixed and/or air-dried, H&E- or Giemsa-like-stained smears/procedure; leftover clots processed as a biopsy). Interpretation of cytologic smears was performed taking into consideration the clinical, laboratory, and imaging data. Smears diagnosed as positive for malignant cells were reported in 510 samples (56.7%) (463 patients); 1.89% of the smears were found inadequate for diagnosis. Positive for malignancy cases included 467 primary tumors, 52% of which were localized to the abdomen. NMYC status was determined on neuroblastoma samples by fluorescent in situ hybridization. Overall sensitivity of the procedure was 98% (500/510 FNAB); specificity was 92.6% (463/500 FNAB); positive predictive value was 1 and negative predictive value was 0.99. All FNABs diagnosed as benign tumors or inflammatory lesions correlated with histology and/or clinical outcome. FNAB proved to be highly cost-effective, avoiding a surgical biopsy. The procedure was found to be extremely helpful when deciding on preoperative chemotherapy.

Pediatric MR-guided interventions

MRI guided interventions are a relatively new but steadily growing field within surgery in pediatric age. Besides the advantages of MRI, such as multiplanar capability and excellent soft tissue contrast and spatial resolution, particularly relevant for the pediatric population is the lack of ionizing radiation. There is meanwhile a group of well defined diagnostic or therapeutic indications for applying MR imaging during pediatric interventions. Aim of this review is to give an overview about indications of MR-guided procedures in children as well as the advantages and disadvantages of MR-guided interventions. We also briefly discuss interventional MR-systems and MR-compatible devices. It is our opinion that MR-guidance for pediatric interventions is a promising technique at the beginning of its development.

Evaluation of chronic infectious interstitial pulmonary disease in children by low-dose CT-guided transthoracic lung biopsy

BACKGROUND

Children with chronic infectious interstitial lung disease often have to undergo open lung biopsy to establish a final diagnosis. Open lung biopsy is an invasive procedure with major potential complications. Transthoracic lung biopsy (TLB) guided by computed tomography (CT) is a less-invasive well-established procedure in adults.

OBJECTIVE

Detailing the role of low-dose CT-guided TLB in the enhanced diagnosis of chronic lung diseases related to infection in children.

MATERIALS AND METHODS

A group of 11 children (age 8 months to 16 years) underwent CT-guided TLB with a 20-gauge biopsy device. All investigations were done under general anaesthesia on a multidetector CT scanner (SOMATOM Volume Zoom, Siemens, Erlangen, Germany) using a low-dose protocol (single slices, 120 kV, 20 mAs). Specimens were processed by histopathological, bacteriological, and virological techniques.

RESULTS

All biopsies were performed without major complications; one child developed a small pneumothorax that resolved spontaneously. A diagnosis could be obtained in 10 of the 11 patients. Biopsy specimens revealed chronic interstitial alveolitis in ten patients. In five patients Chlamydia pneumoniae PCR was positive, in three Mycoplasma pneumoniae PCR was positive, and in two Cytomegalovirus PCR was positive. The average effective dose was 0.83 mSv.

CONCLUSION

Low-dose CT-guided TLB can be a helpful tool in investigating chronic infectious inflammatory processes in children with minimal radiation exposure. It should be considered prior to any open surgical procedure performed for biopsy alone. In our patient group no significant complication occurred. A disadvantage of the method is that it does not allow smaller airways and vessels to be assessed.

Percutaneous biopsy of pediatric solid tumors

BACKGROUND

The objective of the current study was to determine the diagnostic accuracy of percutaneous biopsy of pediatric solid tumors, a procedure that is less invasive than open biopsy.

METHODS

The authors conducted a retrospective analysis of clinical data related to 202 percutaneous core-needle biopsies of solid tumors at St. Jude Children's Research Hospital over 5.5 years (from 1997 to 2003). In 103 patients, the procedure was performed to establish an initial diagnosis of a suspected malignancy; and, in 99 patients, disease recurrence was suspected. Biopsies were guided by ultrasound, computed tomography, or fluoroscopic imaging. From each tumor, 1-17 core biopsy samples (median, 6 samples) were obtained; the median needle size was 15 gauge (range, 13-20 gauge). The specimens were submitted for histopathologic analysis and other ancillary procedures (molecular pathology and/or cytogenetic analyses). The accuracy of the diagnoses from the biopsies was determined by subsequent surgery with or without pathologic assessment or by outcome.

RESULTS

When the biopsy samples were assessed for the presence of malignancy, there were 121 true-positive results (90% sensitivity), 67 true-negative results (100% specificity), and 14 false-negative results (93% accuracy). In 103 tumors, when the procedure was performed for initial diagnosis, percutaneous needle biopsy showed a sensitivity of 97%, a specificity of 100%, and an accuracy of 98%. The 99 procedures for suspected recurrence were less reliable (sensitivity, 83%; specificity, 100%; accuracy, 88%).

CONCLUSIONS

Image-guided percutaneous biopsy was highly accurate and safe in the diagnosis of pediatric malignant solid tumors. This technique may be able to supplant diagnostic open biopsy.

Aberrant immunohistochemical expression in nonrhabdomyosarcoma soft tissue sarcomas of infancy: retrospective review of clinical material

Malignant soft tissue tumors other than rhabdomyosarcoma (RMS) are uncommon in infancy, representing approximately 5% of pediatric sarcomas. The pathological categorization of non-RMS soft tissue malignancies from these young patients is complicated by variation in both morphologic and immunohistochemical features. A search covering an 11-year period identified 19 patients presenting at birth or in infancy with a clinical or referral diagnosis of soft tissue sarcoma. After histologic and immunohistochemical review, nine of these tumors were classified as primitive neuroectodermal tumor (PNET), three as infantile hemangiopericytoma (HPC), two as infantile fibrosarcoma (FS), and five as undifferentiated sarcoma. Those identified as undifferentiated sarcomas showed an atypical spindle and ovoid cell morphology, with cellular pleomorphism and high mitotic rate, but lacking the fascicular growth pattern of classic infantile fibrosarcoma. Immunohistochemical staining in this group showed variable weak positivity for a range of markers (desmin, smooth muscle actin, Myo-D1, PGP, NSE, S100, CO56, cytokeratin, and CD99), and did not fit readily into any distinct diagnostic category. In this series, tumors classified as soft tissue PNETs had a poor prognosis despite aggressive treatment. However, once RMS, PNET, and other rare specific lesions are excluded, the remaining undifferentiated sarcomas, despite their unusual morphology and immunohistochemistry, appear to behave in a similar favorable manner to infantile fibrosarcoma.