Outcomes of ultrasound guided renal mass biopsies

Paediatric renal tumors: An insight into molecular characteristics, histomorphology and syndromic association

Paediatric renal tumors are rare and accounts for about 7% of all paediatric malignant tumors. The spectrum of paediatric renal tumors ranges from benign to malignant. Benign tumors include cystic nephroma, metanephric tumors and ossifying renal tumor of infancy. Tumor with low grade malignancy includes mesoblastic nephroma. Malignant tumors are nephroblastoma, clear cell sarcoma, malignant rhabdoid tumor, anaplastic sarcoma and Ewing sarcoma. Additionally, there are molecularly defined renal tumors, which includes renal cell carcinoma (RCC) with MiT translocations, ALK-rearranged RCC, eosinophilic solid and cystic RCC and SMARCB1- deficient renal medullary carcinoma. These tumors apart from having characteristic clinical presentation and histomorphology, also carry typical molecular mutations and translocations. Certain renal tumors have association with various genetic syndromes such as Beckwith-Weidmann syndrome, Wilm’s tumor, aniridia, genitourinary anomalies and mental retardation syndrome, Denys-Drash syndrome, rhabdoid tumor predisposition syndrome and DICER syndrome. This review article focusses on molecular characteristics, histomorphology and syndromic association of pediatric renal tumors, their immunohistochemical approach to diagnosis with recent updates in molecularly defined renal tumors.

Comparative analysis of different biopsy techniques for pancreatic lesions in diagnostic value, safety, and cost-effectiveness

Background

Pancreatic cancer is highly lethal and often diagnosed at an advanced stage, highlighting the need for early and accurate diagnosis. Although imaging plays a crucial role, definitive pathological confirmation requires biopsy. Percutaneous ultrasound-guided core needle biopsy (US-CNB), computed tomography-guided core needle biopsy (CT-CNB), and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) are the three main biopsy techniques, each differing in diagnostic accuracy, safety, and cost-effectiveness. The aim of this study was to compare the diagnostic value, safety, and cost-effectiveness of these three biopsy techniques for suspiciously malignant pancreatic lesions.

Methods

We retrospectively evaluated patients with suspicious malignant pancreatic lesions who underwent US-CNB, CT-CNB, or EUS-FNA from January 2018 to January 2023. We compared technical success rates, sample adequacy, diagnostic accuracy, sensitivity, specificity, and complication rates of three groups. Additionally, we calculated the cost/effectiveness ratio (C/E) and incremental cost-effectiveness ratio (ICER) for each method.

Results

A total of 399 patients were enrolled (US-CNB, n=86; CT-CNB, n=55; EUS-FNA, n=258), achieving 100% technical success. Sample adequacy satisfaction rates were 97.70% for US-CNB, 90.90% for CT-CNB, and 74.03% for EUS-FNA, with EUS-FNA significantly lower compared to the other two methods (P<0.001). Diagnostic accuracy was significantly higher for US-CNB (97.70%) and CT-CNB (90.90%) compared to EUS-FNA (69.80%) (P<0.001). Complication rates were 15.12% for US-CNB, 16.36% for CT-CNB, and 10.47% for EUS-FNA, with no significant differences (P=0.319). Compared to EUS-FNA, ICER for US-CNB was -14,367.7 yuan and for CT-CNB was -8,279.22 yuan per correct diagnosis, both below the willingness-to-pay threshold.

Conclusions

US-CNB and CT-CNB demonstrate superior diagnostic accuracy and specimen adequacy compared to EUS-FNA for suspected malignant pancreatic lesions. There are no significant differences in postoperative complication rates among three biopsy methods. In terms of cost-effectiveness, US-CNB and CT-CNB have lower costs and higher effectiveness than EUS-FNA, indicating greater economic efficiency.

Spontaneous rupture of renal angiomyolipoma presenting with shock; a case report from Tanzania

INTRODUCTION AND IMPORTANCE

Renal angiomyolipoma (AML) are benign tumors, often incidentally diagnosed with rupture being the commonest complication and cause of mortality. These tumors are rare with a higher prevalence among patients with tuberous sclerosis and female predominance. Management is dependent on tumor size and whether or not the tumor has ruptured.

CASE PRESENTATION

32-year-old female presenting with sudden right flank pain with shock without history of prior trauma or surgeries. Underwent imaging revealing a suspected ruptured AML thus underwent emergent nephrectomy with admission to intensive care.

CLINICAL DISCUSSION

Wunderlich syndrome manifests as the Lenk triad, which includes acute flank pain, flank mass, and hypovolemic shock with signs of internal bleeding such as hematuria. It is a rare manifestation signifying spontaneous renal hemorrhage. Due to the instability of the patient had to undergo emergency laparotomy and nephrectomy.

CONCLUSION

Renal AML occur as a rare benign phenomenon which when ruptured are associated with high mortality rate if not treated promptly in a setting with specialized treatment and intensive unit care. We hope that through our experience patients presenting with Lenk's triad are identified early for adequate intervention.

The success rate of small renal mass core needle biopsy and its impact on lowering benign resection rate

BACKGROUND

Small renal mass (SRM) biopsy remains under-utilized due to stigma. Meanwhile, the alarmingly high benign findings in resected kidney masses highlight the need for improved preoperative diagnosis and patient selection.

METHODS

The purpose of this study is to review the success rate of SRM biopsy and to evaluate its impact on patient management. A total of 168 percutaneous image-guided core needle biopsies (CNBs) of SRMs were retrieved at a tertiary academic center between 2015 and 2019. Subsequent treatment choices, side effects and outcomes were retrospectively reviewed.

RESULTS

The diagnostic rate of CNB was 86.9%. Benign neoplasms accounted for a significant portion (14.3%) of SRM. Renal cell carcinomas (RCCs) were the most common diagnoses (69.6%) as expected. In biopsy-resection correlation, the positive predictive value of CNB was 100%. Tumor typing and subtyping by CNB were highly accurate, 100% and 98.3% respectively. Nuclear grading for clear cell RCC was accurate in 83.8% cases. The CNB results had significant impact on treatment. Most patients with RCCs underwent either resection (54.1%) or ablation (33.9%), in contrast to observation in benign neoplasms (90.5%). Most importantly, the benign resection rate (3.2%) in this series was much lower than the national average.

CONCLUSION

CNB provided accurate diagnoses for the majority of SRMs and revealed benign diagnoses in a subset of clinically suspicious lesions. Employment of CNB in suspicious SRM may help avoid overtreatment for benign lesions.

Sequential liquid-based cytology based on exfoliative cells of 18-gauge core needle groove to improve renal mass core needle biopsy yield: a real-world observational study

Background

Renal mass biopsy (RMB) has regained clinical interest in recent years due to the pursuit of individualized and precision medicine. Renal mass core needle biopsy (RMCNB) for histopathology (HP), with or without liquid-based cytology (LBC), has been used increasingly in our hospital. This study investigated factors influencing the HP diagnostic yield of RMCNB, and compared the diagnostic rate between HP alone and HP plus LBC.

Methods

In this retrospective cross-sectional study, a total of 134 patients who underwent ultrasound-guided percutaneous RMCNB in the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between January 2015 and May 2022 were enrolled. All biopsies were performed using an 18-gauge core needle biopsy gun, and the sampling tissues and exfoliative cells of 18-gauge core needle groove were delivered for HP and LBC diagnosis, respectively. The patient demographics, clinical indications, tumor characteristics, number of biopsies, final pathological diagnosis, and follow-up data were reviewed. Univariate and multivariate logistic regression analyses were performed to evaluate the association between variables and HP diagnostic yield of RMCNB. The diagnostic rate between HP and HP plus LBC was compared using McNemar's test and agreement was evaluated using the Kappa score.

Results

The most common indication of RMCNB was renal masses with a radiological diagnosis of locally advanced disease or distant metastasis (86.6%). The HP diagnostic yield was established in 88.1% (118/134) of cases, and the diagnostic rate of HP plus LBC was 94.0% (126/134). Logistic regression analyses revealed that non-enhanced area exceeding 50% [odds ratio (OR): 0.021, 95% confidence interval (CI): 0.003-0.134, P<0.001] and number of core biopsies (OR: 9.479, 95% CI: 1.528-58.794, P=0.016) were associated with the HP diagnostic yield of RMCNB. The diagnostic rate of HP plus LBC was significantly higher than that of HP alone (94.0% vs. 88.1%, P=0.008), and they showed substantial agreement (Kappa =0.638, P<0.001). Meanwhile, in the non-enhanced area ≥50% subgroup, the diagnostic rate between HP plus LBC and HP alone was significantly different (86.7% vs. 60%, P=0.008), and the agreement was fair (Kappa =0.375, P=0.009).

Conclusions

RMCNB has a high diagnostic yield with a minimum of two high-quality core biopsies, LBC can improve the diagnostic yield of HP alone, especially in masses with large non-enhanced area.

Atypical Nelson Syndrome Following Right Partial and Left Total Nephrectomy With Incidental Bilateral Total Adrenalectomy of Renal Cell Carcinoma: A Chat Generative Pre-Trained Transformer (ChatGPT)-Assisted Case Report and Literature Review

Nelson syndrome (NS) is a dangerous condition that can sometimes manifest after bilateral adrenalectomy (BA), typically in treating Cushing's disease. It is defined by the collection of systemic signs and symptoms that can arise in a state where there are chronically and massively elevated levels of adrenocorticotropic hormone (ACTH). Traditionally it may manifest from six months to 24 years following the loss of both adrenal glands, with the meantime of development being 15 years following BA. The diagnostic criteria are controversial, with historically many different methods being used, ranging from visual field defects and an enlarged pituitary corticotrophinoma to elevated plasma ACTH levels and skin hyperpigmentation. What remains consistent between criteria is that it is secondary to total BA, traditionally in treating refractory Cushing's disease. We describe here a rare case of a patient diagnosed with bilateral renal cell carcinoma (RCC) treated with right partial and left total nephrectomy, and incidental BA, presenting with the symptoms and signs of NS. Although NS classically presents following total BA for the treatment of Cushing disease, further research is required to look for etiologies of Nelson's-like pathology outside the context of Cushing's disease treatment, thereby necessitating a change to the traditional diagnostic criteria for the syndrome to identify cases that would otherwise go untreated. In addition, this case report's outlining, drafting, and conclusions were written in part by or with the support of Chat Generative Pre-Trained Transformer (ChatGPT), a large language transformer open-source artificial intelligence.

Radiofrequency Ablation, Cryoablation, and Microwave Ablation for the Treatment of Small Renal Masses: Efficacy and Complications

Over the last two decades the detection rate of small renal masses has increased, due to improving diagnostic accuracy, and nephron-sparing treatments have become the first-choice curative option for small renal masses. As a minimally invasive alternative, thermal ablation has increased in popularity, offering a good clinical outcome and low recurrence rate. Radiofrequency ablation, Cryoablation, and Microwave ablation are the main ablative techniques. All of them are mostly overlapping in term of cancer specific free survival and outcomes. These techniques require imaging study to assess lesions features and to plan the procedure: US, CT, and both of them together are the leading guidance alternatives. Imaging findings guide the interventional radiologist in assessing the risk of complication and possible residual disease after procedure. The purpose of this review is to compare different ablative modalities and different imaging guides, underlining the effectiveness, outcomes, and complications related to each of them, in order to assist the interventional radiologist in choosing the best option for the patient.

Ultrasound-Guided Omental Biopsy: Diagnostic Yield and Association With CT Features Based on a Single-Institution 18-Year Series

BACKGROUND. The greater omentum can serve as a useful target for percutaneous biopsy; in clinical practice, CT is commonly used for biopsy guidance. OBJECTIVE. The purpose of this study was to evaluate the diagnostic yield of percutaneous ultrasound (US)-guided omental biopsy and to explore the association of the diagnostic yield with prebiopsy diagnostic CT findings. METHODS. This retrospective study included 163 patients (120 women and 43 men; mean age, 65 ± 12 [SD] years; mean body mass index [BMI], 28.9 ± 7.9) who underwent US-guided omental biopsy between 2002 and 2020 at a single institution at which US served as the first-line modality for omental biopsy guidance. Biopsies were performed by abdominal radiologists without dedicated interventional radiology fellowship training. Postbiopsy clinical follow-up and imaging follow-up were reviewed to establish the ultimate diagnosis for each patient. Omental biopsies were characterized as diagnostic or nondiagnostic relative to the ultimate diagnosis. Associations were explored between diagnostic yield and findings on prebiopsy CT and biopsy US. RESULTS. US-guided omental biopsy was performed using an 18-gauge core needle biopsy technique in 156 patients and fine-needle aspiration in seven patients. The mean number of biopsy passes was 2.5 ± 1.0, and mean omental thickness near the biopsy site on CT was 2.6 ± 1.2 cm. On prebiopsy diagnostic CT, omental disease appeared infiltrative in 127 (78%) patients versus mass-forming in 36 (22%) and appeared hypoechoic in 105 (64%) patients versus iso- to hyperechoic in 58 (36%). The ultimate diagnosis was malignant tumor in 154 (95%) patients (most commonly, gynecologic tumors in 82 patients [high-grade serous adenocarcinoma in 56] and gastrointestinal tumors in 45 patients) and a benign finding in nine (6%) patients. The omental biopsy was diagnostic relative to the ultimate diagnosis in 155 (95%) patients. A diagnostic versus nondiagnostic biopsy was not associated (p > .05) with age, BMI, number of biopsy passes, or omental target thickness or attenuation. A total of 94% (120/127) of US-guided omental biopsies of infiltrative cases and 97% (35/36) of biopsies of mass-forming cases were diagnostic (p = .50). A total of 96% (102/106) of US-guided omental biopsies of hypoechoic cases and 93% (53/57) of biopsies of iso- to hyperechoic cases were diagnostic (p = .36). No complications occurred. CONCLUSION. US-guided biopsy of omental disease suspected on CT is safe and effective for tissue diagnosis. Although omental disease commonly appears on US as diffuse infiltrative thickening without a discrete target, sampling based on prebiopsy CT landmarks is diagnostic in most cases. CLINICAL IMPACT. US should be considered the first-line modality for omental biopsy guidance when feasible.

Contemporary Results and Clinical Utility of Renal Mass Biopsies in the Setting of Ablative Therapy: A single center experience

PURPOSE

Clinical guidelines have recently included renal mass biopsy (RMB) in management algorithms, especially in the setting of small renal masses ≤ 4 cm (SRM) and ablative therapy. We sought to evaluate the diagnostic rates of RMB, factors associated with a non-diagnostic biopsy, its clinical utility, and its safety profile in the setting of ablative therapy.

MATERIALS AND METHODS

A total of 174 RMB from 167 patients, performed in a tertiary academic center from 01/2015 to 01/2019, were included. Patient demographics, radiographic mass size, RMB diagnoses, subsequent clinical management, and complications were retrospectively reviewed. RMBs were classified as diagnostic or non-diagnostic based on set criteria.

RESULTS

The mean mass size was 3.0 cm (range: 0.5-15.3 cm) and 140 biopsies (80%) were SRM. Among all RMB, 159 (91%) were diagnostic and 15 (9%) were non-diagnostic. Non-diagnostic biopsies were associated with small mass size, the presence of a cystic component (p < 0.00001) and fewer number of cores submitted (p = 0.0046). All non-diagnostic biopsies occurred in SRMs, where the mean mass size was significantly smaller than diagnostic biopsies (1.3 versus 3.2 cm, p = 0.001). RMB with concurrent ablation yielded non-diagnostic results more frequently than isolated RMBs (15% vs 2%, respectively).

CONCLUSIONS

RMB is useful for definitive diagnosis and clinical management in the setting of ablative therapy. Small mass size, cystic lesions, and fewer number of passes obtained are associated with non-diagnostic biopsies. When a renal mass diagnosis is particularly critical, a separate biopsy procedure prior to ablative therapy is recommended.

Safety and efficacy of ultrasound-guided percutaneous coaxial core biopsy of pancreatic lesions: a retrospective study

BACKGROUND AND OBJECTIVE

Pancreatic cancer tumors are difficult to access for biopsy. The use of coaxial needles during ultrasound (US)-guided coarse needle biopsy (CNB) may help to improve specimen collection yields and avoid tissue damage. In this retrospective study, the safety, efficacy, and clinical benefits of US-guided percutaneous coaxial CNB of pancreatic masses were evaluated and compared to those of non-coaxial CNB.

METHODS

A total sample of 220 biopsies performed from August 2015 to August 2019 were analyzed, including 114 performed with a coaxial needle (17-gauge coaxial coarse needle combined with an 18-gauge coarse biopsy needle) and 106 performed with a non-coaxial needle (18-gauge coarse biopsy needle without a coaxial sheath). The coaxial CNB group was stratified by lesion location to further evaluate the applicability of coaxial core needles. The satisfactory specimen rate, diagnostic efficiency, operating time, and complication rate were compared statistically between groups and subgroups.

RESULTS

Compared to the non-coaxial CNB group, the coaxial CNB group had a greater satisfactory specimen rate (98.3% vs. 92.3%; p = 0.048), a lesser mean operating time (8.9 ± 3.27 min vs. 16.8 ± 5.77 min; p < 0.001), and a lower complication rate (2.6% vs. 9.6%, p =0 .04). A better diagnostic efficiency was obtained for coaxial CNBs in the head of pancreas (98.7%) than in the body or tail of the pancreas (90%, p = 0.047).

CONCLUSION

For pancreatic masses, coaxial CNB can yield a higher satisfactory sample rate, lower complication rate, and shorter operating time than non-coaxial biopsy. US-guided percutaneous coaxial CNB is a safe and efficient puncture technique for pancreatic lesion diagnosis.

Clinical utility of contrast-enhanced ultrasonography in the diagnosis of benign and malignant small renal masses among Asian population

We assessed the clinical utility of contrast-enhanced ultrasonography (CEUS) in the diagnosis of benign and malignant small renal masses using a meta-analysis of diagnostic test. We performed a comprehensive online search in the following database including PubMed, Embase, Web of Science, Wanfang, and Chinese National Knowledge Infrastructure from the inception to August 25, 2019. the following index were calculated for assessing the diagnostic ability, including sensitivity, specificity, diagnostic odds ratio (DOR), negative likelihood ratio (NLR), positive likelihood ratio (PLR), area under the curve (AUC) with 95% confidence intervals (CIs). Seventeen studies were included in the qualitative and quantitative analyses. The overall sensitivity was 0.93 with 95% CI of 0.88-0.95. The specificity was 0.71 and the 95% CI was 0.60-0.80. The pooled AUC was 0.91 (95% CI: 0.88-0.93). The diagnostic odds ratio was 31 (95% CI: 21-45). The NLR and PLR were 0.10 (95% CI: 0.07-0.15) and 3.2(95% CI: 2.3-4.4), respectively. There is a slight heterogeneity within studies. The subgroup analysis was also performed. For retrospective and perspective, the sensitivity and specificity were 0.93, 0.92 and 0.71, 0.73; For different diameter lesions, the sensitivity and specificity were 0.93, 0.94 and 0.64, 0.74; For sample size (≤median vs. >median), the sensitivity and specificity were 0.94, 0.93 and 0.67, 0.77. The Deek's funnel plot asymmetry test in indicated no publication bias. The CEUS have a high diagnostic ability in differentiating benign and malignant small renal masses among Asian population.

Contrast-Enhanced Ultrasound in Renal Imaging and Intervention

PURPOSE OF REVIEW

In recent years, there has been renewed interest in the use of contrast-enhanced ultrasound (CEUS) in abdominal imaging and intervention. The goal of this article is to review the practical applications of CEUS in the kidney, including renal mass characterization, treatment monitoring during and after percutaneous ablation, and biopsy guidance.

RECENT FINDINGS

Current evidence suggests that CEUS allows accurate differentiation of solid and cystic renal masses and is an acceptable alternative to either computed tomography (CT) or magnetic resonance imaging (MRI) for characterization of indeterminate renal masses. CEUS is sensitive and specific for diagnosing residual or recurrent renal cell carcinoma (RCC) following percutaneous ablation. Furthermore, given its excellent spatial and temporal resolution, CEUS is well suited to demonstrate tumoral microvascularity associated with malignant renal masses and is an effective complement to conventional grayscale ultrasound (US) for percutaneous biopsy guidance. Currently underutilized, CEUS is an important problem-solving tool in renal imaging and intervention whose role will continue to expand in coming years.