Biopsies in oncology

Primary Cardiac Intimal Sarcoma: Multi-Layered Strategy and Core Role of MDM2 Amplification/Co-Amplification and MDM2 Immunostaining

Primary cardiac tumours are relatively uncommon (75% are benign). Across the other 25%, representing malignant neoplasia, sarcomas account for 75-95%, and primary cardiac intimal sarcoma (PCIS) is one of the rarest findings. We aimed to present a comprehensive review and practical considerations from a multidisciplinary perspective with regard to the most recent published data in the specific domain of PCIS. We covered the issues of awareness amid daily practice clinical presentation to ultra-qualified management in order to achieve an adequate diagnosis and prompt intervention, also emphasizing the core role of MDM2 immunostaining and MDM2 genetic analysis. An additional base for practical points was provided by a novel on-point clinical vignette with MDM2-positive status. According to our methods (PubMed database search of full-length, English publications from January 2021 to March 2023), we identified three studies and 23 single case reports represented by 22 adults (male-to-female ratio of 1.2; male population with an average age of 53.75 years, range: 35-81; woman mean age of 55.5 years, range: 34-70) and a 4-year-old child. The tumour-related clinical picture was recognized in a matter of one day to ten months on first admission. These non-specific data (with a very low index of suspicion) included heart failure at least NYHA class II, mitral regurgitation and pulmonary hypertension, acute myocardial infarction, ischemic stroke, obstructive shock, and paroxysmal atrial fibrillation. Awareness might come from other complaints such as (most common) dyspnoea, palpitation, chest pressure, cough, asthenia, sudden fatigue, weakness, malaise, anorexia, weight loss, headache, hyperhidrosis, night sweats, and epigastric pain. Two individuals were initially misdiagnosed as having endocarditis. A history of prior treated non-cardiac malignancy was registered in 3/23 subjects. Distant metastasis as the first step of detection (n = 2/23; specifically, brain and intestinal) or during follow-up (n = 6/23; namely, intestinal, brain and bone, in two cases for each, and adrenal) required additional imagery tools (26% of the patients had distant metastasis). Transoesophageal echocardiography, computed tomography (CT), magnetic resonance imagery, and even 18F-FDG positronic emission tomography-CT (which shows hypermetabolic lesions in PCIS) represent the basis of multimodal tools of investigation. Tumour size varied from 3 cm to ≥9 cm (average largest diameter of 5.5 cm). The most frequent sites were the left atrium followed by the right ventricle and the right atrium. Post-operatory histological confirmation was provided in 20/23 cases and, upon tumour biopsy, in 3/23 of them. The post-surgery maximum free-disease interval was 8 years, the fatal outcome was at the earliest two weeks since initial admission. MDM2 analysis was provided in 7/23 subjects in terms of MDM2-positive status (two out of three subjects) at immunohistochemistry and MDM2 amplification (four out of five subjects) at genetic analysis. Additionally, another three studies addressed PCISs, and two of them offered specific MDM2/MDM2 assays (n = 35 patients with PCISs); among the provided data, we mention that one cohort (n = 20) identified a rate of 55% with regard to MDM2 amplification in intimal sarcomas, and this correlated with a myxoid pattern; another cohort (n = 15) showed that MDM2-positive had a better prognostic than MDM2-negative immunostaining. To summarize, MDM2 amplification and co-amplification, for example, with MDM4, CDK4, HMGA3, CCND3, PDGFRA, TERT, KIT, CCND3, and HDAC9, might improve the diagnosis of PCIS in addition to MDM2 immunostaining since 10-20% of these tumours are MDM2-negative. Further studies are necessary to highlight MDM2 applicability as a prognostic factor and as an element to be taken into account amid multi-layered management in an otherwise very aggressive malignancy.

Is it a complication or a consequence - a new perspective on adverse outcomes in Interventional Radiology

The aim of the article is to introduce a new term in post-procedural events related to the procedure itself. All the Societies and Councils report these events as complications and they are divided in mild, moderate and severe or immediate and delayed.On the other hand the term error is known as the application of a wrong plan, or strategy to achieve a goal.For the first time, we are trying to introduce the term "consequence"; assuming that the procedure is the only available and the best fit to clinical indication, a consequence should be seen as an expected and unavoidable occurrence of an "adverse event" despite correct technical execution.

Diagnostic strategy for trigger identification in severe reactive hemophagocytic lymphohistiocytosis: A diagnostic accuracy study

Reactive hemophagocytic lymphohistiocytosis (rHLH) management requires early recognition, trigger identification, and adequate treatment in order to reduce mortality. We assessed the diagnostic yield of tissue biopsies to identify trigger in severe rHLH. We included all consecutive patients presenting an rHLH diagnosis (HLH-2004 criteria) admitted to the intensive care unit (ICU) of a tertiary hospital. This retrospective diagnostic accuracy study was conducted according to the Standards for Reporting Diagnostic Accuracy Statement. Among the 134 included patients (median age 47 years [IQR 47-56]), an underlying immunodeficiency was previously known in 61.2%. rHLH trigger was identified in 127 patients (94.8%) (hematological disorder 75%, infection 16%, systemic disease 4%). Diagnostic yield of tissue biopsies was as follows: lymph node 75% (95% confidence interval [CI], 61-85), skin 50% (95% CI, 27-73), bone marrow 44% (95% CI, 34-55), liver 30% (95% CI, 15-49). Splenectomy (yield 77%; 95% CI, 46-95) was reserved to cases of diagnostic deadlock. Procedural severe adverse events included two cases of reversible hemorrhagic shock. Seventy-eight percent of patients received etoposide regarding to the rHLH severity, and 68% could receive trigger-specific treatment in the ICU. A comprehensive diagnostic workup led to an rHLH trigger identification in 95% of patients, allowing prompt initiation of appropriate therapy. Prospective studies to validate a standardized diagnostic approach are warranted.

Genomics applied to the treatment of breast cancer

Breast cancer remains a major health issue in the world with 1.7 million new cases in 2012 worldwide. It is the second cause of death from cancer in western countries. Genomics have started to modify the treatment of breast cancer, and the developments should become more and more significant, especially in the present era of treatment personalization and with the implementation of new technologies. With molecular signatures, genomics enabled a de-escalation of chemotherapy and personalized treatments of localized forms of estrogen-dependent breast cancers. Genomics can also make a real contribution to constitutional genetics, so as to identify mutations in a panel of candidate genes. In this review, we will discuss the contributions of genomics applied to the treatment of breast cancer, whether already validated contributions or possible future applications linked to research data.

US-guided core needle biopsy under assistance of hydrodissection to diagnose small lymph node metastases adjacent to cervical large vessels

PURPOSE

We aimed to evaluate the safety and effectiveness of ultrasonography (US) guided core needle biopsy (CNB) with hydrodissection to diagnose small lymph node metastases adjacent to cervical large vessels.

METHODS

From January 2013 to October 2017, 31 patients with 31 cervical lymph node metastases adjacent to large vessels presented for US-guided CNB. The mean maximal diameter of lymph nodes was 0.93±0.16 cm (range, 0.6-1.2 cm). All patients underwent US-guided CNB with 18-gauge true-cut biopsy needle after hydrodissection with saline. The separation success rate (SSR) of the hydrodissection, technical success rate (TSR) of CNB, histopathologic success rate (HST), and complications were assessed.

RESULTS

The SSR of hydrodissection was 100% (31/31). After effective separation between the lymph node metastases and the adjacent large vessels with saline injection, the procedures of CNB were performed with a TSR of 100% (31/31). The HST of the lymph node metastases was 100% (31/31). Two patients complained of mild cervical swelling sensation during saline injection. No major complications such as injury of the large vessels or massive hemorrhage occurred.

CONCLUSION

Hydrodissection can facilitate safely and effectively US-guided CNB of subcentimeter cervical lymph nodes adjacent to large vessels, potentially impacting further therapeutic decisions.

[Hospital tumor registry in the Hospital La Paz (Spain)]

INTRODUCTION

We present the case for the establishment of hospital tumour registries in order to facilitate the use of epidemiological data and the development of preventive policies.

MATERIAL AND METHODS

Retrospective descriptive analysis of the data of the tumour registry of the Hospital "La Paz" including tumoral location (ICD-O), diagnostic method, tumour grade and treatment.

RESULTS

1987 cases were included. Median age at diagnosis was 66.2 years; 53.3% of cases were male and 46.7 female. The most frequent tumoral sites recorded were the digestive tract, skin, breast and urinary tract. The most common diagnostic method used was biopsy (83.1%), followed by cytology (5.7%). 84.5% of cases were originally recorded as localized disease, whilst 15.4% were disseminated. Surgery was the most common treatment (78.8%), followed by systemic therapy (16.2%).

CONCLUSION

The establishment of hospital tumour registries should be prioritized, in order to collect epidemiological data which will enhance our understanding of cancer.

Accuracy of core needle biopsy for the diagnosis of osteosarcoma: A retrospective analysis of 73 patients

PURPOSE

The goals of this retrospective study were to evaluate the accuracy of core needle biopsy (CNB) for the diagnosis of osteosarcoma and to identify criteria that may predict failed CNB.

MATERIALS AND METHODS

From 2002 to 2012, 73patients with a total of 73osteosarcomas underwent CNB. Patients demographics and procedure details were recorded, including tumor size, tumor characteristics (hemorrhagic or not, lytic, sclerotic [>50% bone condensation], or mixed), the type of anesthesia, the number of tissue samples, the size of the biopsy needle and pathology report. Procedures were analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

A diagnosis was not made in 5/73patients (6.8%) with an overall sensitivity of 93.1%, a specificity of 100%, a PPV of 100% and a NPV of 99.9%. No complications due to CNB were observed. No criteria were identified as predictors of CNB failure.

CONCLUSION

Even in the presence of sclerotic tumors, CNB should be the first line diagnostic test for suspected osteosarcomas, pending performance by a well-trained radiologist and reading by a specialized pathologist.

LEVEL OF EVIDENCE

IV.

Extra-intestinal malignancies in inflammatory bowel diseases: An update with emphasis on MDCT and MR imaging features

Inflammatory bowel diseases (IBD) are associated with an increased risk of gastrointestinal cancers and more specifically in sites affected by chronic inflammation. However, patients with IBD have also an increased risk for developing a variety of extra-intestinal cancers. In this regard, hepatobiliary cancers, such as cholangiocarcinoma, are more frequently observed in IBD patients because of a high prevalence of primary sclerosing cholangitis, which is considered as a favoring condition. Extra-intestinal lymphomas, mostly non-Hodgkin lymphomas, and skin cancers are also observed with an increased incidence in IBD patients by comparison with that in patients without IBD. This review provides an update on demographics, risk factors and clinical features of extra-intestinal malignancies, including cholangiocarcinoma, hepatocellular carcinoma and lymphoma, that occur in patients with IBD along with a special emphasis on the multidetector row computed tomography and magnetic resonance imaging features of these uncommon conditions.