The management of non-diagnostic soft tissue tumour biopsies using a multi-disciplinary team approach: A 10-year retrospective review at a specialist sarcoma unit

Non-Diagnostic (ND) biopsies are occasionally encountered during the investigation of soft tissue sarcoma. We performed a retrospective review of all ND soft tissue biopsies discussed at our regional Multi-Disciplinary Team (MDT) meeting between 2004 & 2014 with the aim of establishing the incidence of ND biopsies, identifying predictive factors for repeat biopsies and evaluating the effectiveness of MDT decisions. We identified 80 ND out of 3233 biopsies. Diagnostic Yield (DY) was 97.5%, 76.0% and 77.8% for the first, second and third successive biopsy respectively. With an MDT approach utilising radiological and clinical information, the diagnostic success rate achieved was 98.5%, 82.0% and 77.8% for the first, second and third biopsies respectively. Malignant tumours (sarcoma & carcinoma) were 19 times more likely to undergo an increasing number of biopsies compared to benign lesions (p < 0.01), while repeat biopsies were less useful for suspected benign lesion. Although a repeat biopsy was only performed in 63% of cases, there were no patients originally diagnosed with a benign lesion that re-presented with the same lesion subsequently being malignant throughout the study period. Our study shows that a specialist MDT approach leads to high diagnostic rates and is a safe and effective method of preventing unnecessary, repeat biopsies where the initial biopsy is ND.

Histopathologic and clinical outcomes of Milan System categories "non-diagnostic" and "non-neoplastic" of salivary gland fine needle aspirations

INTRODUCTION

The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) specifies six categories with estimated risks of malignancy (ROM) and suggested management. The estimated ROM is 25% for Non-Diagnostic (ND) category, and 10% for Non-Neoplastic (NN). This study aimed to investigate histopathologic and clinical outcomes of MSRSGC categories ND and NN at the authors' institution.

MATERIALS AND METHODS

Cytopathology fine needle aspiration reports from 2008-2020 were searched for the word "salivary", "parotid", and "submandibular". Cases fitting Non-Diagnostic (ND) and Non-Neoplastic (NN) categories were identified. Follow-up cyto-/histopathologic and clinical data were extracted.

RESULTS

There were 43 ND and 46 NN cases. The average age was 58.3 years. Neoplastic lesions were found in 13 of 43 (30%) ND and 3 of 46 (6.5%) NN. The rate of malignancy in ND category was 14.0% (6/43) and 0% (0/46) in NN category. Four cases in ND (9.3%) and 6 (13.0%) in NN had no neoplasm and instead had an underlying reactive condition (e.g., chronic sialadenitis) or inflammatory lesion (e.g., lymphoepithelial cyst) on histologic follow-up. There was no follow-up pathology in 46.5% NDs (20/43) and 82.6% NNs (38/46); however, no lesions were apparent clinically with a mean follow-up of 3 years and 1.5 years, respectively.

CONCLUSIONS

MSRSGC categories ND and NN are helpful for reporting salivary gland FNA results. With proper clinical and radiologic correlation, ROM of NN is low; however, ROM of ND remains significant. Repeat FNA after correlation for ND cases seems prudent as neoplasms and malignancies may have gone undetected.

Managing NON-DIAGNOSTIC biopsies in musculoskeletal tumours in a specialist centre: Deciding on the algorithm

INTRODUCTION

Core needle biopsy is an effective method of obtaining tissue diagnosis. However, a diagnostic dilemma arises when lesional tissue is non-diagnostic which obviates considering radiological guided re-biopsy (RB) or an open surgical biopsy but the question raised is which serves as a better diagnostic tool.

PATIENT AND METHODS

We retrospectively reviewed data from a prospectively collected database of 4516 core needle biopsies performed in our specialist musculoskeletal tumour centre over a 6-year period. Our aim was to evaluate the management of non-diagnostic biopsies (NDB) and establish a safe and accurate diagnostic strategy in the presence of a NDB.

RESULTS

Two hundred fifteen (4.8%) NDB cases with complete follow-up were identified. Of these 157 (73%) were treated definitively on the basis of imaging and 58 (27%) had a RB, 48 (83%) of which led to a positive histological diagnosis. The remaining 10 were again non-diagnostic giving a total of 167 patients being treated definitively without a tissue diagnosis. The sensitivity and specificity for multidisciplinary team (MDT) assessment as a diagnostic tool was 0.75 and 0.88 respectively while that for RB was 0.91 and 0.9.

CONCLUSION

Re-biopsy after first non-diagnostic core needle biopsy offers high sensitivity and specificity, especially in the presence of malignancy. In the absence of tissue diagnosis, however, MDT assessment is also highly accurate and a safe strategy in managing this complex group of patients.

LEVEL OF EVIDENCE

Diagnostic Level III.

Non-Diagnostic CT-Guided Percutaneous Needle Biopsy of the Lung: Predictive Factors and Final Diagnoses

OBJECTIVE

To investigate the predictive factors for a non-diagnostic result and the final diagnosis of pulmonary lesions with an initial non-diagnostic result on CT-guided percutaneous transthoracic needle biopsy.

MATERIALS AND METHODS

All percutaneous transthoracic needle biopsies performed over a 4-year period were retrospectively reviewed. The initial pathological results were classified into three categories-malignant, benign, and non-diagnostic. A non-diagnostic result was defined when no malignant cells were seen and a specific benign diagnosis could not be made. The demographic data of patients, lesions' characteristics, technique, complications, initial pathological results, and final diagnosis were reviewed. Statistical analysis was performed using binary logistic regression.

RESULTS

Of 894 biopsies in 861 patients (male:female, 398:463; mean age 67, range 18-92 years), 690 (77.2%) were positive for malignancy, 55 (6.2%) were specific benign, and 149 (16.7%) were non-diagnostic. Of the 149 non-diagnostic biopsies, excluding 27 cases in which the final diagnosis could not be confirmed, 36% revealed malignant lesions and 64% revealed benign lesions. Predictive factors for a non-diagnostic biopsy included the size ≤ 15 mm, needle tract traversing emphysematous lung parenchyma, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Non-diagnostic biopsies with a history of malignancy or atypical cells on pathology were more likely to be malignant (p = 0.043 and p = 0.001).

CONCLUSION

The predictive factors for a non-diagnostic biopsy were lesion size ≤ 15 mm, needle tract traversing emphysema, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Thirty-six percent of the non-diagnostic biopsies yielded a malignant diagnosis. In cases with a history of malignancy or the presence of atypical cells in the biopsy sample, a repeat biopsy or surgical intervention should be considered.

Reappraisal of "cyst fluid only" on thyroid fine-needle aspiration cytology

According to the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), cyst fluid only (CFO) cases are classified in the non-diagnostic category. To date, no large study focusing on CFO has been conducted. To reassess the diagnostic significance of CFO, we compared CFO nodules with non-diagnostic nodules excluding CFO (ND-other). We reviewed the conventional thyroid smears of 715 CFO and 766 ND-other nodules. We compared the timing of and findings at re-aspiration, the histology of resected specimens, and the proportion of malignant nodules between the two groups. Re-aspiration was performed in 9.0% of CFO and 23.8% of ND-other cases. In 12.5% of CFO and 49.4% of ND-other cases, the interval between the first and second aspirations was <3 months. Despite this, there were no cases in which cytological interpretation was complicated by the first aspiration. Overall, 77 CFO nodules (10.8%) were surgically resected; 14 were malignant. In all cases in which re-aspiration cytology revealed malignancy, the initial ultrasound interpretation was a high or intermediate suspicion pattern. The proportion of malignancies subsequently diagnosed in nodules initially classified as CFO and ND-other was 2.0% and 5.6%, respectively (p<0.01). As CFO and ND-other thyroid nodules have different clinical management and malignancy rates, we would like to assert that CFO and ND-other nodules should be separated, and that the former should be considered diagnostic. In terms of clinical management, we recommend that only CFO cases with concerning features on ultrasound undergo re-aspiration.

Comparison of 1869 thyroid ultrasound-guided fine-needle aspiration biopsies between general surgeons and interventional radiologists

BACKGROUND

Thyroid nodules are commonly encountered problems in clinical practice. For patients who have a thyroid nodule, the fine-needle aspiration biopsy (FNAB) is the most important test, as it is the most reliable diagnostic method for distinguishing between benign thyroid nodules and cancerous nodules. FNAB is able to be performed either via an ultrasound (USG) or alone and is the first choice when it comes to diagnosing thyroid nodules, given that it is cheap, safe and provides accurate results.

OBJECTIVE

In this study-a retrospective analysis of FNAB via USG - our aim is to evaluate the multiple variables related to FNAB procedures, including the experience of the person performing the biopsy, the age and gender of the patient, the number of nodules, the size of the nodule(s) and the number of lams recorded from the cytopathology report on non-diagnostic rates, conducted at an invasive radiology clinic and at a general surgery clinic.

MATERIALS AND METHODS

A total of 1062 patients involving 1869 nodules, examined using FNAB via USG, were reviewed retrospectively from records dated between November 2011 and July 2014 and from pathology reports taken from the ANEAH General Surgery clinic and Interventional Radiology clinic. Cytopathology results were classified according to the 2007 Bethesda System for Reporting. Gender, age, number of nodules, diameter of the nodules, biopsied nodules, location of the nodules, number of lams, symptoms and the date of biopsies were the parameters used to examine the factors involved in non-diagnostic cytopathology invasive radiology. These parameters were inspected at both of the clinics (ANEAH General Surgery clinic and Interventional Radiology clinic). In analyzing the results, the statistical significance level was set at 0.05, where in cases that the p value was under 0.05 (p < 0.05), it was determined that no significant relationship existed. In this study, data were analyzed using SPSS 20 software.

RESULTS

Of the nodules reviewed, 1620 were found on females and 249 on males. The age of the patients ranged from 10 to 87 years, with the mean age being 50 years. In the general surgery clinic, 470 nodules of 341 patients were aspirated, and in the interventional radiological clinic, 1399 nodules of 721 patients were aspirated. In the literature review conducted to compare statistical assessments of FNAB via USG, no significant difference was found between the ANEAH General Surgery clinic and the Invasive Radiology clinic (p > 0.05). In the invasive radiology clinic, non-diagnostic rates decreased with the increase in experience of the person who conducted the biopsy (p = 0.001).

CONCLUSION

The results from both of the clinic's rates of non-diagnostic FNAB, performed via USG, were found to be acceptable. Our study also demonstrates that USG-guided FNAB can be performed with a low non-diagnostic rate as experience grows.