Intratumoral Injection of Immunotherapeutics: State of the Art and Future Directions

Systemic immunotherapies have led to tremendous progress across the cancer landscape. However, several challenges exist, potentially limiting their efficacy in the treatment of solid tumors. Direct intratumoral injection can increase the therapeutic index of immunotherapies while overcoming many of the barriers associated with systemic administration, including limited bioavailability to tumors and potential systemic safety concerns. However, challenges remain, including the lack of standardized approaches for administration, issues relating to effective drug delivery, logistical hurdles, and safety concerns specific to this mode of administration. This article reviews the biologic rationale for the localized injection of immunotherapeutic agents into tumors. It also addresses the existing limitations and practical considerations for safe and effective implementation and provide recommendations for optimizing logistics and treatment workflows. It also highlights the critical role that radiologists, interventional radiologists, and medical physicists play in intratumoral immunotherapy with respect to target selection, image-guided administration, and response assessment.

Hemorrhagic Complications Following Ultrasound-Guided Breast Biopsy: A Prospective Patient-Centered Study

OBJECTIVE

We aimed to evaluate the clinical and imaging factors associated with hemorrhagic complications and patient discomfort following ultrasound (US)-guided breast biopsy.

MATERIALS AND METHODS

We prospectively enrolled 94 patients who were referred to our hospital between June 2022 and December 2022 for US-guided breast biopsy. After obtaining informed consent, two breast radiologists independently performed US-guided breast biopsy and evaluated the imaging findings. A hemorrhagic complication was defined as the presence of bleeding or hematoma on US. The patients rated symptoms of pain, febrile sensation, swelling at the biopsy site, and dyspnea immediately, 20 minutes, and 2 weeks after the procedure on a visual analog scale, with 0 for none and 10 for the most severe symptoms. Additional details recorded included those of nausea, vomiting, bleeding, bruising, and overall satisfaction score. We compared the clinical symptoms, imaging characteristics, and procedural features between patients with and those without hemorrhagic complications.

RESULTS

Of 94 patients, 7 (7%) developed hemorrhagic complications, while 87 (93%) did not. The complication resolved with 20 minutes of manual compression, and no further intervention was required. Vascularity on Doppler examination (P = 0.008), needle type (P = 0.043), and lesion location (P < 0.001) were significantly different between the groups. Patients with hemorrhagic complications reported more frequent nausea or vomiting than those without hemorrhagic complications (29% [2/7] vs. 2% [2/87], respectively; P = 0.027). The overall satisfaction scores did not differ between the two groups (P = 0.396). After 2 weeks, all symptoms subsided, except bruising (50% 2/4 in the complication group and 25% [16/65] in the no-complication group).

CONCLUSION

US-guided breast biopsy is a safe procedure with a low complication rate. Radiologists should be aware of hemorrhagic complications, patient discomfort, and overall satisfaction related to this procedure.

Clinically significant bleeding complications of percutaneous breast biopsy: 10-year analysis and a proposed management algorithm

PURPOSE

Bleeding is a well-known risk of percutaneous breast biopsy, frequently controlled with manual pressure. However, significant bleeding complications may require further evaluation or intervention. Our objectives were to assess the rate, type, and periprocedural management of significant bleeding following percutaneous breast biopsy and to evaluate the success of any interventions.

METHODS

We retrospectively reviewed percutaneous breast biopsies at our institution over a 10-year period with documented post-biopsy bleeding complications in radiology reports. Patients were included if bleeding required intervention (interventional radiology [IR], surgery, or other), imaging follow-up, or clinical evaluation for symptoms. Additional data included patient demographics, anticoagulation, history of bleeding diathesis, biopsy details, bleeding symptoms, histopathology, and intervention details, if applicable.

RESULTS

Of 5820 unique patients who underwent percutaneous biopsy, 66 patients (66/5820; 1.1%) comprising 71 biopsy cases met inclusion for clinically significant bleeding with 5/71(7.0%) requiring surgery, 9/71(12.7%) requiring IR intervention, and 57/71(80.3%) requiring lower-acuity intervention including prolonged observation (5/57;7.0%), overnight admission (4/57;5.6%), aspiration (4/57;5.6%), lidocaine and suture (2/57;2.8%), primary care visit (7/57;10.0%), blood transfusion (1/57;1.4%), emergency room visit (6/57;8.5%), surgery consult (8/57;11.3%), IR consult (2/57;2.8%), and follow-up imaging (22/57;31.0%). Most patients requiring intervention by surgery or IR had acute signs of bleeding immediately after biopsy while most patients with delayed signs of bleeding required lower-acuity interventions.

CONCLUSION

Clinically significant bleeding is extremely rare after percutaneous breast biopsy and is most often managed non-surgically. Developing an institutional algorithm for management of bleeding complications that consults IR before surgery may help decrease the number of patients managed surgically.

Underreported and underrecognized: a comprehensive imaging review of breast injury

Breast injury is commonly encountered yet it remains significantly underreported. Injury to the breast may arise from either primary mechanisms or secondary or iatrogenic mechanisms. Primary mechanisms of breast injury include blunt force, seat-belt, penetrating, and thermal injury. Secondary or iatrogenic mechanisms of breast injury include breast biopsy or intervention as well as operative intervention and cardiopulmonary resuscitation. The severity of breast injury arising from these mechanisms is broad, ranging from breast contusion to avulsion. Sequelae of breast injury include fat necrosis and Mondor's disease. Radiologists play an integral role in the evaluation and management of breast injury both in the acute and non-acute settings. In the acute setting, radiologists must be able to recognize breast injury arising from primary mechanisms or iatrogenic or secondary mechanisms and to identify rare but potentially life-threatening complications promptly to ensure timely, appropriate management. In the non-acute setting, radiologists must be able to discern the sequalae of breast injury from other processes to prevent potentially unnecessary further evaluation and intervention. Nonetheless, though breast injury is commonly encountered there remain few guidelines and a lack of established recommendations for the evaluation and management of breast injury. We provide a comprehensive multi-modality imaging review of breast injury arising in the acute setting as well as the sequela of breast injury arising in the non-acute setting. Moreover, we provide an overview of the management of breast injury.

Bleeding Events After Image-Guided Breast Biopsies: Comparison of Patients Temporarily Discontinuing Versus Maintaining Antithrombotic Therapy During Biopsy

BACKGROUND. Antithrombic (AT) therapy is commonly temporarily discontinued before breast core needle biopsy (CNB), introducing risks of thrombotic events and diagnostic delay. OBJECTIVE. The purpose of this article was to compare the frequency of postbiopsy bleeding events among patients without AT use, patients temporarily discontinuing AT therapy, and patients maintaining AT therapy during breast CNB. METHODS. This retrospective study included 5302 patients (median age, 52 years) who underwent image-guided breast or axillary CNB between January 1, 2014, and December 31, 2019. From January 1, 2014, to December 31, 2016, patients temporarily discontinued all AT therapy for 5 days before CNB; from January 1, 2017, to December 31, 2019, patients maintained AT therapy during CNB. Immediate postbiopsy mammograms were reviewed for imaging-apparent hematoma. Patients were called 24-48 hours after biopsy and asked regarding palpable hematoma and breast bruise. The EMR was reviewed for clinically significant postbiopsy hematoma (i.e., hematoma requiring drainage, primary care or emergency department visit for persistent symptoms, or hospital admission). Bleeding events were compared among groups, including Firth bias-reduced multivariable logistic regression analysis. RESULTS. During CNB, 4665 patients were not receiving AT therapy, 423 temporarily discontinued AT therapy, and 214 maintained AT therapy. Imaging-apparent hematoma occurred in 3% of patients without AT use, 6% of patients discontinuing AT therapy, and 7% of patients maintaining AT therapy (p = .60 [discontinuing vs maintaining]). Palpable hematoma occurred in 2% of patients without AT use, 4% of patients maintaining AT therapy, and 4% of patients discontinuing AT therapy (p = .92 [discontinuing vs maintaining]). Breast bruise occurred in 2% of patients without AT use, 1% of patients discontinuing AT therapy, and 6% of patients maintaining AT therapy (p < .001 [discontinuing vs maintaining]). In multivariable analysis adjusting for age, biopsy imaging modality, needle gauge, number of biopsy samples, and pathologic result, discontinued AT therapy (using maintained AT therapy as reference) was not a significant independent predictor of imaging-apparent hematoma (p = .23) or palpable hematoma (p = .91) but independently predicted decreased risk of bruise (OR = 0.11, p < .001). No patient developed clinically significant postbiopsy hematoma. CONCLUSION. Frequencies of imaging-apparent and palpable hematoma were not significantly different between patients temporarily discontinuing versus maintaining AT therapy. CLINICAL IMPACT. The findings support the safety of continuing AT therapy during CNB. Patients who maintain AT therapy should be counseled regarding risk of bruise.

Current Practices in Anticoagulation Management for Patients Undergoing Percutaneous Image-guided Breast Procedures

Objective

Given variability in how practices manage patients on antithrombotic medications, we undertook this study to understand the current practice of antithrombotic management for patients undergoing percutaneous breast and axillary procedures.

Methods

A 20-item survey with multiple-choice and write-in options was emailed to 2094 active North American members of the Society of Breast Imaging (SBI) in March 2021. Data were collected anonymously and analyzed quantitatively, with free-text responses categorized by themes.

Results

Three-hundred twenty-six of 2094 members (15.6%) completed the survey. Eighty-seven percent (274/313) reported having a policy for managing antithrombotic medications. Fifty-nine percent (185/312) reported routinely withholding medications before biopsy, more commonly in the Northeast and South (P = 0.08). Withholding of medications did not vary by lesion location (182/308, 59%, breast vs 181/308, 58.7%, axillary; P = 0.81). Respondents were statistically more likely to withhold medications if using a vacuum-assisted device for all classes of antithrombotic medications (P < 0.001). Up to 50.2% (100/199) on warfarin and 33.6% (66/196) on direct oral anticoagulants had medications withheld more stringently than guidelines suggest.

Conclusion

Based on a survey of SBI members, breast imaging practices vary widely in antithrombotic management for image-guided breast and axillary procedures. Of the 60% who withhold antithrombotic medications, a minority comply with recommended withhold guidelines, placing at least some patients at potential risk for thrombotic events. Breast imaging radiologists should weigh the risks and benefits of withholding these medications, and if they elect to withhold should closely follow evidence-based guidelines to minimize the risks of this practice.

Vascular Complications following Vacuum-Assisted Breast Biopsy (VABB): A Case Report and Review of the Literature

INTRODUCTION

Vacuum-assisted breast biopsy (VABB) has been evaluated as a minimally invasive, safe, and accurate procedure with low complication risks; the most frequent one is the mild/moderate hematoma, which occurs with a low-frequency rate, and the majority of patients who experienced it can be treated successfully with only manual compression and dressing. Although cases of uncontrollable catastrophic bleeding are exceedingly rare, local breast vessel involvement is a concrete risk, even in patients with no bleeding propensity.

CASE PRESENTATION

In this article, we aimed to describe a 60 years-old woman who, following VABB, experienced a massive hematoma without external bleeding and was successfully treated with embolization. The woman was called back for a cluster of suspicious microcalcifications identified in the left breast's upper-outer quadrant; however, following histopathological analysis, the few samples collected were negative. She had a silent past medical history, 100% performance status, and no active pharmacotherapy. Approximately 15-30 min after VABB, the patient complained of weakness, pain, and lipothymia. A physical examination revealed a massive hematoma without external bleeding. Clinical data reported PaO 65/40 mmHg and blood chemistry Hb < 10 g/dL. The emergency team was alerted to stabilize the patient, and after that, the breast hemorrhage was controlled by endovascular embolization. Despite this being a rare occurrence, it is important to draw up and follow an appropriate protocol to ensure proper patient management and early treatment.

DISCUSSION

This case illustrates the prompt and accurate management of a rare complication following VABB. Due to the very high number of patients undergoing this particular procedure, we aim to point out the concrete risk of vascular injury; other similar cases are described to support our thesis and provide different clinical manifestations of this rare occurrence.

Antithrombotic Therapy and Hematoma Risk during Image-guided Core-Needle Breast Biopsy

Background For image-guided core-needle breast biopsy (CNBB), it remains unclear whether antithrombotic medication should be withheld because of hematoma risk. Purpose To determine hematoma risk after CNBB in patients receiving antithrombotic medication and to stratify risk by antithrombotic type. Materials and Methods This HIPAA-compliant retrospective study included US-, stereotactic-, or MRI-guided CNBBs performed across six academic and six private practices between April 2019 and April 2021. Patients were instructed to continue antithrombotic medications, forming two groups: antithrombotic and nonantithrombotic. Hematomas were defined as new biopsy-site masses with a diameter of 2 cm or larger on postprocedure mammograms. Hematomas were considered clinically significant if management involved an intervention other than manual compression. Patient age, type of antithrombotic medication, practice type, image guidance modality, needle gauge and type, and outcome of pathologic analysis were recorded. Multivariable logistic regression analysis was used to analyze variables associated with hematomas. Results A total of 3311 biopsies were performed in 2664 patients (median age, 60 years; IQR, 48-70 years; 2658 women). The nonantithrombotic group included 2788 biopsies, and the antithrombotic group included 523 biopsies (328 low-dose aspirin, 73 full-dose antiplatelet drugs, 51 direct oral anticoagulants, 36 warfarin, 32 daily nonsteroidal anti-inflammatory drugs, three heparin or enoxaparin). The antithrombotic group had a higher overall hematoma rate (antithrombotic group: 49 of 523 biopsies [9.4%], nonantithrombotic group: 172 of 2788 biopsies [6.2%]; P = .007), but clinically significant hematoma rates were not different (antithrombotic group: two of 523 biopsies [0.4%], nonantithrombotic group: one of 2788 biopsies [0.04%]; P = .07). At multivariable analysis, age (odds ratio [OR], 1.02; 95% CI: 1.01, 1.03; P < .001), 9-gauge or larger needles (OR, 2.1; 95% CI: 1.28, 3.3; P = .003), and full-dose antiplatelet drugs (OR, 2.5; 95% CI: 1.29, 5.0; P = .007) were associated with higher hematoma rates. US guidance (OR, 0.26; 95% CI: 0.17, 0.40; P < .001) and 10-14-gauge needles (OR, 0.53; 95% CI: 0.36, 0.79; P = .002) were predictive of no hematoma. Conclusion Because clinically significant hematomas were uncommon, withholding antithrombotic medications before core-needle breast biopsy may be unnecessary. Postbiopsy hematomas were associated with full-dose antiplatelet drugs, patient age, and 9-gauge or larger needles. No association was found with other types of antithrombotic medication. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chang and Yoen in this issue.

Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH

Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.

Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Bleeding Complications After Breast Core-needle Biopsy-An Approach to Managing Patients on Antithrombotic Therapy

Image-guided core-needle breast and axillary biopsy (CNB) is the standard-of-care procedure for the diagnosis of breast cancer. Although the risks of CNB are low, the most common complications include bleeding and hematoma formation. Post-procedural bleeding is of particular concern in patients taking antithrombotic therapy, but there is currently no widely established standard protocol in the United States to guide antithrombotic therapy management. In the face of an increasing number of patients taking antithrombotic therapy and with the advent of novel classes of anticoagulants, the American College of Radiology guidelines recommend that radiologists consider cessation of antithrombotic therapy prior to CNB on a case-by-case basis. Lack of consensus results in disparate approaches to patients on antithrombotic therapy undergoing CNB. There is further heterogeneity in recommendations for cessation of antithrombotic therapy based on the modality used for image-guided biopsy, target location, number of simultaneous biopsies, and type of antithrombotic agent. A review of the available data demonstrates the safety of continuing antithrombotic therapy during CNB while highlighting additional procedural and target lesion factors that may increase the risk of bleeding. Risk stratification of patients undergoing breast interventional procedures is proposed to guide both pre-procedural decision-making and post-procedural management. Radiologists should be aware of antithrombotic agent pharmacokinetics and strategies to minimize post-procedural bleeding to safely manage patients.

Multimodality imaging of breast hematomas and their mimickers

While breast hematomas are common, their imaging features are often underrecognized or mistaken for other conditions.Diagnosis of acute hematomas is generally easy when associated with a recent history of breast trauma, surgery, or percutaneous biopsy. However, minor trauma might not always be remembered, and breast hematoma might have longlasting imaging manifestations when associated with fat necrosis. Also, because of the increasing use of breast MRI and FDG-PET/CT, breast hematomas are increasingly detected as incidentalomas and may mimic malignancies.Conversely, breast hematomas may also be associated with authentic malignant processes.In this pictorial review, we present the natural history of breast hematomas, their various imaging features, as well as their differential diagnoses, highlighting the situations requiring histopathological correlation.

Postoperative Fluid Collections in Total Joint Arthroplasty: A Narrative Review

A post-operative fluid collection (POFC) represents a common finding in both primary and revision total joint arthroplasty (TJA). Fortunately, most resolve on their own, but in instances where they become symptomatic, prompt identification and management are paramount, especially when they occur adjacent to a joint arthroplasty because of the increased the risk of developing a periprosthetic joint infection. A strong clinical suspicion with appropriate clinical exam is required along with select imaging modalities to arrive at a diagnosis. Meticulous surgical technique is crucial to prevent POFC, but new emerging treatments continue to evolve. This article presents an updated overview of incidence, pathophysiology, diagnosis, and management of POFC in the setting of TJA. We review the role of select imaging modalities as well as summarize current literature regarding new treatments such as sclerotherapy agents, acellular dermal matrices, and negative pressure wound therapy. Future studies are necessary to explore the interplay of inflammatory mediators in POFC formation and to define their role in fluid collection resolution.

Rapid 3D reconstruction guided embolization for catastrophic bleeding following vacuum assisted breast biopsy; A case report and review of the literature

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.

Preprocedural Hypertension Is Not a Risk Factor for Postoperative Bleeding following Image-Guided Core Needle Breast Biopsy

Objective

To evaluate the association between preprocedural hypertension and the risk of prolonged bleeding following image-guided core needle breast biopsy in nonpregnant/nonlactating women.

Methods

A single institution-based, retrospective cohort study of 400 women who underwent image-guided core needle breast biopsy was conducted. Males and pregnant and lactating women were excluded. Preprocedural systolic or diastolic blood pressure greater than 140 or 90 mm of Hg, respectively, was defined as hypertension. Prolonged bleeding was defined >15 minutes of local, manual pressure required to achieve hemostasis following the biopsy. Severe bleeding complications defined as clinical significant hematoma formation, prolonged bleeding requiring an ER visit, hospitalization, or surgical intervention were also recorded.

Results

The difference in the mean time for which manual pressure was held after biopsy for patients with and without preprocedural hypertension was not statistically significant (13 ± 7 vs. 13 ± 8 minutes, respectively, P = 0.856). There was no difference in the number of patients requiring manual postoperative pressure >15 minutes between those with preprocedural hypertension and the normotensive patients (13% vs. 12%, respectively, P = 0.765). Bivariate analysis demonstrated statistically significant association between prolonged bleeding and current antithrombotic or antiplatelet medication use (P = 0.010), the use of stereotactic guidance (P = 0.019), and a tethered vacuum-assisted device (P = 0.045). The use of a tethered vacuum-assisted biopsy device was the only variable associated with prolonged bleeding in the multivariate model (P = 0.044).

Conclusion

Preprocedural hypertension is not a risk factor for prolonged bleeding following image-guided core needle breast biopsies in nonpregnant/nonlactating women.

Breast Imaging After Dark

Patients may present to the emergency department with breast complaints due to traumatic or nontraumatic changes in the breast. Benign and malignant breast pathologies may mimic each other both in clinical presentation and imaging appearance. A complex cystic and solid mass seen on ultrasound in a patient with a palpable mass can represent breast cancer, abscess, or hematoma. A unilateral swollen breast may result from inflammatory breast cancer, mastitis, or other benign etiologies; correlation with clinical history, physical exam, and close follow-up are required to ensure complete resolution of symptoms. Uncommon breast entities such as granulomatous mastitis and breast implant-associated anaplastic large-cell lymphoma may cause changes in the appearance of the breast that prompt a patient to seek initial evaluation in the emergency department. Imaging evaluation of the breast in the emergency department is limited, and it is important that patients with a breast complaint be referred to a dedicated breast center for complete evaluation at an appropriate time interval after their discharge from the emergency department.

Transition to digital breast tomosynthesis-guided biopsies: Results and complications compared to stereotactic biopsies

This study evaluates targeting success, pathologic results, and complications of upright digital breast tomosynthesis-guided biopsies (DBTB) compared to prone stereotactic breast biopsies (PSBB) performed during the same time period. In this retrospective study, 252 consecutive mammographically guided vacuum-assisted 9-gauge breast biopsies performed at a single institution from December 2017 to August 2018 were evaluated. This included 153 DBTBs compared to 99 PSBBs. A total of 153 DBTBs (in 139 patients) and 99 PSBBs (in 96 patients) were performed during the study period. Targeting success was similar for DBTB (99%) and PSBB (99%). DBTB was used to target both calcifications (110) as well as non-calcified targets (43), while PSBB only targeted calcifications. Malignant biopsies from DBTB were more likely to be invasive (n = 12, 8%) than PSBB (n = 2, 2%), with P = .03. Moreover, DBTB targets classified as calcifications only were less likely to yield invasive malignancy (2/109, 2% vs 10/43, 23%), with P = .0001. PPV3 was similar for DBTB (24%) and PSBB (27%) as were high-risk pathology results (23% and 18%, respectively). Tissue marker migration > 1cm occurred at a similar frequency (14% vs 13%). Hematomas were slightly more frequent with DBTB (19/152, 13%) than with PSBB (4/98, 4%), with P = .026. Finally, the average number of core biopsies with DBTB was higher than with PSBB (8.32 vs 7.39, respectively), with P = .02. Compared to prone stereotactic breast biopsy, upright digital breast tomosynthesis biopsy has a similar high targeting success frequency, low complication frequency, and additionally allows targeting of calcified and non-calcified targets.

Bleeding risk after percutaneous breast needle biopsy in patients on anticoagulation therapy

Image-guided core needle biopsy (CNB) is the standard of care procedure for tissue diagnosis of suspicious breast lesions. While complications are exceedingly rare, the most common complications include bleeding and hematoma formation. With an increasing number of patients on anticoagulation therapy (AT), it is important to determine whether continuation of these medications during CNB increases bleeding risk. While previous studies have demonstrated the safety in continuation of AT during CNB, American College of Radiology (ACR) guidelines recommend practitioners decide whether cessation is necessary on a case-by-case basis as this may put patients at risk for thromboembolic events. The purpose of this review is to analyze the literature on anticoagulation and bleeding risk during CNB to guide clinical practice.

Do anticoagulation medications increase the risk of haematoma in ultrasound-guided fine needle aspiration of thyroid lesions?

BACKGROUND

A feared complication of thyroid fine needle aspiration (FNA) is bleeding diathesis and haematoma at the biopsy site. Patients are often advised to discontinue antithrombotic/anticoagulant (AT/AC) medications prior to the procedure. The aim of this study was to examine the risk of bleeding in patients on AT/AC medications undergoing cervical ultrasound (US)-guided FNA.

METHODS

A retrospective chart review of 803 patients who underwent US-guided FNA of thyroid nodules over 8 years by a single endocrine surgeon was undertaken. Clinical variables, patient demographics and use of AT/AC medications were collected and analysed. The principle outcome measures included the incidence of procedure-related haematoma formation. Multivariable logistic regression was used to investigate the possible independent association between post-FNA haematoma and anticoagulation, adjusting for age, African American race, body mass index, vascularity and lesion size.

RESULTS

A total of 1568 lesions were included in 803 patients. The mean age for the patients on AT/AC was 63.0 ± 10.4 years and those not on AT/AC was 50.1 ± 14.2 years (P < 0.001). Of those, 148 patients had 336 lesions (21%) biopsied while taking one or more daily AT/AC agent (81 patients: aspirin; 11 patients: Plavix; 17 patients: aspirin and warfarin; 30 patients: aspirin and Plavix; seven patients: rivaroxaban and aspirin; and two patients: ticagrelor and aspirin). Three patients (0.89%) in the AT/AC group compared to six patients (0.49%) not receiving AT/AC medications developed a haematoma (P = 0.41). All complications were treated conservatively and none required intervention.

CONCLUSIONS

US-guided FNA of thyroid lesions can be safely performed on patients taking AT/AC including newer agents, without an increase in adverse outcomes or decreased diagnostic rate. Further larger prospective multi-institutional studies are warranted to further investigate this important finding.

MR Imaging-Guided Breast Interventions: Indications, Key Principles, and Imaging-Pathology Correlation

MR imaging is now routinely performed for breast cancer screening and staging. For suspicious MR imaging-detected lesions that are mammographically and sonographically occult, MR imaging-guided breast interventions, including biopsy, clip placement, and preoperative needle localization, have been developed to permit accurate tissue diagnosis and aid in surgical planning. These procedures are safe, accurate, and effective when performed according to key principles, including proper patient selection, use of appropriate technique, adequate preprocedure preparation and postprocedure patient care, and postprocedure imaging-pathology correlation. Imaging-pathology correlation after MR imaging-guided biopsy is essential to confirm accurate sampling and guide development of a comprehensive management plan.

Costly coagulation profile tests prior to performing breast biopsies. Do we really need it?

Objectives:

To reassess the need for routine coagulation profile testing in patients undergoing image-guided breast biopsies.

Methods:

This is a retrospective cross-sectional study. Data was collected from the logbook of patients that underwent image-guided biopsies in the breast unit at the Department of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients’ electronic records between November 2013 and October 2014 were included in the study. Exclusion criteria were those on anticoagulants, or platelet aggregation inhibitors, and patients with known primary, or secondary bleeding diathesis. The study was analyzed using the IBM Statistical Packages for Social Sciences Version 22 (IBMCorp, Armonk, NY, USA).

Results:

A total of 136 patients were included in our study. Neither partial thromboplastin time (PTT), or thrombocytopenia was related to bleeding with p-values of 0.536 PTT and 0.997 thrombocytopenia. Needle gauge was found to be significantly related to bleeding episodes with a p=0.020.

Conclusion:

We advise against the routine use of coagulation profiles to predict bleeding risk. A thorough bleeding assessment is more advantageous. Laboratory tests should be tailored according to the patient’s history and examination findings.

Peri-procedural use of anticoagulants in radiology: an evidence-based review

Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.

Is breast cancer surgery safely performed in patients receiving antithrombotic therapy?

Aim

The aim of the study was to assess the safety of surgery for breast cancer in patients with antithrombotic therapy (ATT), including antiplatelet therapy (APT) and anticoagulation therapy (ACT) for thromboembolic risks.

Methods

One hundred ninety-three consecutive patients receiving breast surgery for breast cancer at our institution between 2010 and 2015 were retrospectively reviewed. Among them, ATT was regularly used in 50 patients (25.9%). Our perioperative management included maintenance of preoperative aspirin monotherapy for APT and bridging heparin for ACT in patients at high thromboembolic risks and early postoperative reinstitution in all ATT cases. The outcome variables of patients with ATT (ATT group) were compared to those of patients without ATT (non-ATT group), and the significant risk factors for postoperative complications were determined by multivariate analysis.

Results

This series included 127 mastectomy and 66 breast-conserving surgery. ATT group showed significantly high frequency of history of cerebral infarction and percutaneous coronary intervention (PCI). In the ATT group, 32 patients (16.6%) were categorized as high risk for thromboembolism, but there was neither thromboembolic event nor perioperative death in the whole cohort. Surgical blood loss and rates of intraoperative transfusion were identical between the groups. Whereas overall postoperative bleeding complication was more frequently observed in the ATT group compared to the non-ATT group (12.0% vs. 3.5%, p=0.360) in univariate analyses, multivariate analysis showed that neither ATT nor preoperative aspirin continuation affected postoperative bleeding complications.

Conclusion

Even in patients undergoing ATT, surgery for breast cancer is safely performed without any increase in blood loss or postoperative bleeding, and no thromboembolism was experienced in the series. Our perioperative management of ATT patients is valid during breast surgery, although this patient population is still challenging and should be rigorously managed.

Growing concern following compression mammography

A patient without clinical symptoms had a mammogram in October 2008. The procedure caused intense persistent pain, swelling and development of a haematoma following mediolateral left breast compression. Three months later, a 9×11 cm mass developed within the same region. Core biopsies showed a necrotizing high-grade ductal carcinoma, with a high mitotic index. Owing to its extensive size, the patient began chemotherapy followed by trastuzumab and later radiotherapy to obtain clear margins for a subsequent mastectomy. The mastectomy in October 2009 revealed an inflammatory carcinoma, with 2 of 3 nodes infiltrated by the tumour. The stage IIIC tumour, oestrogen and progesterone receptor negative, was highly HER2 positive. A recurrence led to further chemotherapy in February 2011. In July 2011, another recurrence was removed from the mastectomy scar. She died of progressive disease in 2012. In this article, we discuss the potential influence of compression on the natural history of the tumour.

Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature

This review compiles the current literature on the bleeding risks in common musculoskeletal interventional procedures and attempts to provide guidance for practicing radiologists in making decisions regarding the periprocedural management of patients on antithrombotic therapy. The practitioner must weigh the risk of bleeding if therapy is continued against the possibility a thromboembolic occurring if anticoagulation therapy is withheld or reversed. Unfortunately, there is little empirical data to guide evidence-based decisions for many musculoskeletal interventions. However, a review of the literature shows that for low-risk procedures, such as arthrograms/arthrocenteses or muscle/tendon sheath injections, bleeding risks are sufficiently small that anticoagulants and antiplatelet therapies need not be withheld. Additionally, relatively higher-risk procedures, such as needle biopsies of bone and soft tissue, may be safely performed without holding antithrombotic therapy, provided pre-procedural INR is within therapeutic range. Thus, while a patient's particular clinical circumstances should dictate optimal individualized management, anticoagulation alone is not a general contraindication to most interventional musculoskeletal radiology procedures.

Breast ultrasound for the interventionalist

Ultrasound (US)-guided interventional procedures are routinely performed for lesions visualized on US and are the standard of care in the diagnosis and management of breast disease. When performed correctly, these procedures are safe, minimally invasive, and have a high diagnostic accuracy comparable to surgical biopsy. The most commonly performed US-guided procedures include fine-needle aspiration, core needle biopsy, and preoperative wire localization. The success of these procedures depends on a thorough understanding of the indications, strong technical skills, and appropriate postbiopsy management. This article reviews the indications and techniques for US-guided interventional procedures. Concordance of imaging and pathology results, potential challenges, and associated complications are also discussed.