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We report a case of tumor dissemination via needle aspiration of a solid hypovascular renal mass. This case emphasizes how needle aspiration of these masses does not always lead to proper management and may be detrimental to the patient.
BACKGROUND: To investigate whether ultrasound-guided core-needle biopsy (US-CNB) has more diagnostic value for breast tumors than ultrasound-guided fine-needle aspiration biopsy (US-FNAB) and to evaluate their combined use in patients with breast tumors. STUDY DESIGN: US-FNAB was carried out in 233 patients with breast tumors (254 lesions); both US-FNAB and US-CNB (combined biopsy) were performed in 81 of these patients (82 lesions). The diagnosis obtained by US-FNAB and US-CNB was compared with the surgical findings and the diagnostic value of US-CNB and combined biopsy were retrospectively evaluated. RESULTS: The sensitivity of US-FNAB was 86.9%, the specificity was 78.6%, and the accuracy was 84%. In contrast, the sensitivity of US-CNB was 86.2%, the specificity was 95.8%, and the accuracy was 89%. The specificity of US-CNB was significantly higher than that of US-FNAB and the inadequate biopsy rate of US-CNB was significantly lower than that of US-FNAB. For combined biopsy, the sensitivity, specificity, and accuracy were all 100%. The sensitivity, specificity, and accuracy of combined biopsy were significantly higher than those of US-FNAB. CONCLUSIONS: These findings suggest that US-CNB is more useful than US-FNAB, and that a combination of US-CNB and US-FNAB can markedly improve the preoperative diagnosis of breast cancer.
BACKGROUND AND OBJECTIVE: This prospective, randomized and blinded study compared the performance of a new needle-through-needle (NTN) kit (Epistar; Medimex, Germany) with the double-space technique for providing combined spinal epidural anaesthesia during Caesarean section. METHODS: Following local Ethics Committee approval and patient consent, 200 females were randomized to receive combined spinal epidural anaesthesia by the double-space (n = 100) or NTN (n = 100) technique. The frequency with which the intrathecal component could achieve a T5 block to touch for Caesarean section without the need for epidural augmentation or an alternative technique was determined. The time from start of procedure to achieving a block height to T5 was recorded. Pain and backache at insertion, and at 24 h follow-up were recorded using a visual analogue scale. To remove any bias due to posture, 50% of each group were further randomized to receive their block in the sitting or in the left lateral position. To evaluate improvement of performance over time the success in the first 100 study patients were compared to the success in the second 100. RESULTS: A successful block to T5 with the double-space and NTN techniques were 80 vs. 54, odds ratio 0.29. Failure to enter the intrathecal space once the epidural space had been located occurred in 29 patients in the NTN group. Time to readiness for surgery was 15 min (95% confidence interval (CI): 12.7-17.4) and 12.9 min (95% CI: 11.5-14.3) for the double-space and NTN techniques, respectively. The median (interquartile range) visual analogue scores for discomfort at insertion were 30 (12.5-51.5) and 32 (12.75-60) and for postoperative backache 0 (0-10) and 0 (0-10.75) in the double-space and NTN groups, respectively. The number of epidural augmentations was similar in both the groups and posture made no difference. There was a tendency to increased success in the second half of the study. CONCLUSION: The double-space technique had a greater success rate than the NTN technique.
OBJECTIVES: To compare quality of harvested tissue, false-negative rate, and complication rate of large-core needle breast biopsy (LCNBB) and directional, vacuum-assisted breast biopsy (DVABB) in non-palpable breast lesions. PATIENTS AND METHODS: From 1994 to 1999, in 580 non-palpable breast lesions a stereotactically-guided breast biopsy was performed. 14-G LCNBB was used in 168 lesions (29 %). DVABB was used in 412 lesions (71 %; 11-G DVABB: 134 lesions 32.5 %, 14-G DVABB: 278 lesions 67.5 %). Following biopsy, patients underwent either surgical excision (n = 533; 93.8 %) or mammographical follow-up (n = 36; 6.2 %). Histological results of LCNBB, DVABB, surgical breast biopsy and follow-up results were compared and scored for their tissue quality on a three-point scale (1 = disagreement between biopsy and surgery; 2 = partial agreement; 3 = complete agreement). In addition, we determined the false negative and complication rate for both systems. RESULTS: Histological examination after surgery and follow-up proved 262 (45.2 %) to be benign, 15 (2.6 %) to be high-risk lesions and 303 (52.5 %) to be malignant. In the tissue quality there was no significant difference between 14-G LCNBB (score = 2.94), 11-G DVABB (score = 2.92) and 14-G DVABB (score = 2.91) (p > 0.05). Particularly, in calcifications 11-G DVABB scored better (score = 2.92) than 14-G DVABB (score = 2.88) (p > 0.05). 14-G LCNBB had a lower false negative rate (1.8 %) than 11-G DVABB (3 %) and 14-G DVABB (3.2 %) (p > 0.05). There was no difference in the complication rate between the different needle types. CONCLUSIONS: Our results indicate that both LCNBB and DVABB are reliable and safe techniques in the diagnosis of non-palpable breast lesions. However, the use of 14-G LCNBB seems to be advantageous in masses, the use of 11-G DVABB seems to be advantageous in asymmetric densities and calcifications.
BACKGROUND AND STUDY AIMS: It would be desirable to develop minimally invasive methods of tissue diagnosis from lymph nodes as well as solid lesions in the mediastinum. The aim of the present study was to test the combined method of transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal lesions. PATIENTS AND METHODS: EUS-FNA and EBUS-TBNA were compared in 33 patients, for the staging of lung cancer in patients with an established diagnosis of non-small-cell lung cancer (n = 20) or for diagnosis of a suspicious mediastinal lesion in patients with suspected lung cancer (n = 13). EBUS-TBNA and EUS-FNA were unsuccessful in one patient each. The diagnoses were verified in 28 of the remaining 31 patients either at thoracotomy (n = 9) or during the clinical follow-up (n = 19). RESULTS: A total of 119 lesions were sampled by EUS-FNA (n = 59) and EBUS-TBNA (n = 60). EUS-FNA and EBUS-TBNA demonstrated cancer in 26 and 28 lesions, respectively, and benign cytology in 30 and 28 lesions, respectively. Suspicious cells were found in three and four lesions by EUS-FNA and EBUS-TBNA, respectively. When the 60 EBUS-TBNA samples were compared with the 59 EUS-FNA samples, 11 additional cancer diagnoses and three samples with suspicious cells were obtained by EBUS-TBNA that had not been obtained by EUS-FNA. Conversely, EUS-FNA diagnosed 12 additional cancer diagnoses, one suspicious and one specific benign diagnosis (sarcoidosis) in addition to EBUS-TBNA. With a combined approach (EUS-FNA + EBUS-TBNA) in 28 of the 31 patients in whom a final diagnosis was obtained in the evaluation of mediastinal cancer, 20 patients were found to have mediastinal involvement, whereas no mediastinal metastases were found in eight patients. The accuracy of EUS-FNA and EBUS-TBNA, in combination, for the diagnosis of mediastinal cancer was 100 % (95 % CI, 83 - 100 %). CONCLUSIONS: EUS-FNA and EBUS-TBNA appear to be complementary methods. A combined approach with both EUS-FNA and EBUS-TBNA may be able to replace more invasive methods for evaluating lung cancer patients with suspected hilar or mediastinal metastases, as well as for evaluating unclear mediastinal or hilar lesions.
We have used both spinal and extradural anaesthesia with a 26-gauge, long spinal needle through a 16-gauge Tuohy needle for elective Caesarean section. Four different subarachnoid solutions of bupivacaine were compared: 0.5% heavy bupivacaine alone, or with adrenaline, fentanyl or adrenaline and fentanyl. The incidence of complications and time of regression of the sensory block were analysed. The technique is recommended because it allows rapid onset of anaesthesia and the advantages of an extradural catheter. The subarachnoid solution of choice was 0.5% heavy bupivacaine 12.5 mg with fentanyl 10 micrograms.
The preoperative fine-needle aspiration (FNA) cytologic diagnoses of microfollicular nodule and suspected cancer include nodules that yield histologic results of typically benign lesions, nodular hyperplasia and follicular adenomas, and differentiated thyroid cancer postoperatively. We reviewed the clinical and pathologic data for patients with palpable thyroid nodules with these two cytologic diagnoses; nodules were also examined by large-needle aspiration biopsy (LNAB) to assess whether the distinction achieved by LNAB in pure microfollicular or mixed microfollicular-macrofollicular nodules could be used preoperatively to better predict the diagnosis of follicular adenoma. One hundred fourteen nodules of this type were excised. Postoperative results were grouped in nodular hyperplasia (90 nodules), follicular adenoma (8), and differentiated carcinoma (16). The prevalence of the follicular adenoma and thyroid carcinoma postoperative findings was 33% among the microfollicular nodules and 5.9% among the microfollicular-macrofollicular nodules at preoperative LNAB, (p = 0.0004). Within the postoperatively benign nodules, the prevalence of follicular adenoma was 14.3% among the microfollicular nodules and 2% among the microfollicular-macrofollicular nodules at LNAB (p = 0.028). These data indicate that histologic examination of the LNAB specimen can be used to identify those thyroid nodules diagnosed by FNA as microfollicular nodules or suspected cancer, which are most likely to be follicular adenomas postoperatively.
Needle core biopsy (NCB) has been the standard procedure for histopathologic diagnosis of hepatic lesions for more than 50 years. In recent years fine needle aspiration cytology (FNAC) has emerged as a minimally invasive, relatively inexpensive and a rapid method of pathologic evaluation of primary or metastatic hepatic masses. The specificity and the positive predictive value of FNAC is very high however, the sensitivity of the procedure widely ranges between 67% to 93%. The two major areas of diagnostic difficulties are differentiation of benign and non-neoplastic hepatic nodules from well differentiated HCC and identification of obviously malignant cells as HCC, cholangiocarcinoma, or metastasis. Preparation of cell blocks, immunohistochemical stains and application of other ancillary techniques are often helpful in difficult cases. In presence of characteristic features a diagnosis of HCC can be established on FNAC however, a negative result does not exclude malignancy. The role of pathologic diagnosis in the assessment of large hepatic masses is well established however, its role in the evaluation of small hepatic nodules (<3 cm) detected during surveillance of high risk patients is still evolving. Considering the overall advantages and cost-analysis, FNAC can be suggested as the initial method of choice for evaluation of hepatic masses in most clinical settings. However, the final choice of the diagnostic procedure should be decided on the basis of working clinical diagnosis and the institutional experience.
Fine needle aspiration (FNA) and non-suction fine needle sampling (FNS) were performed consecutively in 107 lesions from 100 patients. The quality of diagnostic material was assessed using a scoring system based on the cellularity and amount of blood in the smear. The total score in the FNS group was significantly higher (P < 0.05) than that of FNA technique. The FNS procedure is less traumatic and equally cost effective and can be safely undertaken in liver, orbital and thyroid lesions. In lymph nodes, especially in children, FNS gives an excellent cellular yield. However, this procedure can not be advocated in cystic, bony and fibrous lesions.
Two methods of obtaining a pre-operative diagnosis of carcinoma of the breast are compared. Tru-Cut needle biopsy was carried out on 368 consecutive patients with palpable breast lumps, and both Tru-Cut biopsy and fine needle aspiration cytology were performed during part of this study on 163 of the patients. A final histological diagnosis was obtained in each patient, at excision biopsy or mastectomy. There were 278 patients with carcinoma and 90 with benign breast disease. A correct positive diagnosis of carcinoma was made by the Tru-Cut method in 73.5% of cases, but in only 52% of cases by aspiration cytology. More importantly, there were no false positive diagnoses of carcinoma with Tru-Cut biopsy, but five cases of benign breast disease were incorrectly diagnosed as carcinoma by aspiration cytology. It is concluded that Tru-Cut biopsy is sufficiently reliable to be able to proceed direct to mastectomy following a positive diagnosis of carcinoma, in distinction to aspiration cytology with which an unacceptably high number of false positives occurs. The benefits of a pre-operative Tru-Cut biopsy diagnosis are identified.
Needle aspiration is a recognised emergency treatment of spontaneous pneumothorax and in the case of suspected tension is usually performed before chest radiography. Three cases are described of apparent life threatening haemorrhage after anterior aspiration in the second intercostal space, mid-clavicular line (2ICS MCL) requiring resuscitation, and transfer to a cardiothoracic unit. In these patients there was no evidence of haemothorax on initial presentation. Lateral needle aspiration, in the site recommended for chest drain insertion, the 5th intercostal space, anterior axillary line (5ICS ALL) is technically easy and may be a potentially safer option for decompressing pneumothoraces.
A 73 year old woman was admitted to hospital because of an anterior mediastinal mass. For definite diagnosis, needle biopsy was performed under fluoroscopic observation. The histopathological diagnosis was thymoma and combination chemotherapy was given. The tumour almost completely disappeared and the patient was discharged. But the tumour recurred in the left anterior chest wall four months later. It is suggested that the thymoma tissue had been implanted in the needle tract.
AIMS: To investigate the role of needle core biopsy (NCB) in the preoperative assessment of impalpable breast lesions, mainly derived from the NHS Breast Screening Programme (NHSBSP) and to assess our own modifications to a suggested system for the classification of breast NCBs. METHODS: The NCB, fine needle aspiration cytology (FNAC), and radiology scores from 298 women with non-palpable breast lesions presenting between January 1997 and December 1998, together with the open biopsy results (where available) were collated and analysed. RESULTS: The mean follow up period was 15.8 months (range, 5-28). The 298 NCB specimens were categorised as follows: unsatisfactory/non-representative (B1; n = 61; 20.5%), benign but uncertain whether representative (B2r; n = 52; 17.4%), benign (B2; n = 103; 34.6%), lesions possibly associated with malignancy but essentially benign (B3a; n = 9; 3.0%), atypical epithelial proliferations (B3b; n = 10; 3.4%), suspicious of malignancy (B4; n = 7; 2.3%), and malignant (B5; n = 56; 18.7%). Excision biopsy was performed in 43 cases within the B1 (n = 19), B2r (n = 8), B2 (n = 8), and the B3a (n = 8; data unavailable in one case) categories, revealing malignancy in 18 (42.8%) cases and in 65 cases within the B3b, B4, and B5 categories, revealing malignancy in 64 cases (98.5%). The sensitivity of NCB for malignancy was 87.7%, with a specificity and positive predictive value of 99.3% and 98.5%, respectively. FNAC had an inadequacy rate of 58.7%, a complete sensitivity of 34.5% and a specificity of 47.6%. CONCLUSIONS: This study confirms the value of NCB in the preoperative assessment of impalpable breast lesions. Two new categories are suggested for the NCB classification; category B2r for benign breast tissue where representativeness is uncertain, and the subdivision of category B3 into B3a for benign lesions potentially associated with malignancy (for example, radial scars and intraduct papillomas) and B3b for more worrisome atypical epithelial proliferations. These will aid the accurate audit of NCB and identify more clearly the intellectual pathway leading to a particular assessment.
AIMS: To compare the sensitivity and specificity of percutaneous fine needle aspiration (FNA) cytology and needle core biopsy (NCB) in the diagnosis of suspected intra-abdominal tumours. METHODS: One hundred and forty one consecutive patients who underwent radiologically guided combined FNA/NCB of abdominal lesions over a four year period were reviewed. The diagnostic accuracy of both techniques and the value of rapid staining and assessment of cytological preparations were assessed. RESULTS: FNA cytology and NCB identified 111 of 129 (86%) and 104 of 129 (80.6%) malignant lesions, respectively; in combination, the sensitivity increased to 90.7%. The diagnostic specificity was 100% for both methods, although one case of phaeochromocytoma was misinterpreted as undifferentiated carcinoma on biopsy. More accurate tumour subtying was possible in two cases with FNA and four cases on NCB. The series included 12 benign lesions, of which 11 and nine were accurately identified on FNA and NCB, respectively. Two specific benign diagnoses (Budd-Chiari syndrome and hepatic infarct) were made only on biopsy. The use of rapid assessment cytology preparations ensured that appropriate samples were submitted for microbiology in three liver abscesses, and provided an accurate cytological diagnosis at the time of the procedure in 103 of 141 (73%) cases. None of the patients suffered biopsy related complications. CONCLUSIONS: FNA cytology is more sensitive and accurate than NCB in the diagnosis of abdominal lesions, and also offers more rapid diagnosis. However, the combination of these sampling techniques increases diagnostic sensitivity and occasionally provides more accurate classification of tumours and benign lesions. The techniques should be considered complementary in the investigation of abdominal lesions.
Recent development of mammographic stereotactic localization devices has created considerable interest in the possibility of fine-needle aspiration biopsy (FNAB) of non-palpable breast lesions. The results of FNAB performed during the course of 50 breast lesion localizations were evaluated. The authors compared two methods of lesion localization, one using a standard mammographic unit and localization technique and the other a stereotactic unit and localization technique. The results of FNAB were similar regardless of technique. With all inadequate specimens considered benign, sensitivity, specificity, and diagnostic accuracy for the standard technique were 71%, 100%, and 93%, respectively, and for the stereotactic technique, 80%, 100%, and 95%. Although these results are preliminary and the number of cases is small, the findings suggest that needle placement for FNAB with the standard localization technique may be as accurate as that with the stereotactic technique.
OBJECTIVE: To determine the value of fine needle aspiration biopsy (FNAB) in comparison to cut needle biopsy (CNB) for the diagnosis of malignancy of focal liver lesions. STUDY DESIGN: A retrospective analysis was conducted on 68 FNAB and 49 CNB procedures performed on 62 patients with focal liver lesions. RESULTS: Cytology permitted a diagnosis of the lesion in 78% of cases. When punctures with insufficient material were excluded (11), the diagnostic accuracy of FNAB was 93%. For the 49 patients who underwent both procedures, FNAB and CNB had the same diagnostic accuracy, 78%, when considered separately and of 88% when considered in combination. Sensitivity, specificity and positive predictive value were similar for the 2 techniques. The negative predictive value was 64% for FNAB and CNB used separately and reached 78% when the 2 techniques were combined. There were no complications during the execution of FNAB and CNB. CONCLUSION: FNAB is an effective and safe method for the diagnosis of focal hepatic lesions, with diagnostic accuracy similar to that of CNB. When the 2 techniques are combined, the accuracy of the diagnosis of malignancy of focal liver lesions increases.
OBJECTIVE: To investigate whether fine needle capillary (FNC) sampling gives quantitatively and qualitatively superior cytologic material as compared to the conventional technique of fine needle aspiration (FNA) when performed by a single aspirator. STUDY DESIGN: Cross-sectional diagnostic test evaluation study. FNA and FNC were performed by a single operator on 200 diffuse and nodular thyroid lesions. RESULTS: A statistically significant difference in favor of FNC was observed for the parameter amount of cellular material. For the rest of the parameters--background blood or clot, degree of cellular degeneration, degree of cellular trauma and retention of architecture--the average score favored FNC but was not statistically significant--i.e., smears prepared from FNC displayed cellular material that was more concentrated, less damaged and less likely to be obscured by blood. CONCLUSION: Although FNC sampling was diagnostic in a greater number of cases than FNA sampling, this study did not prove a clear superiority of FNC over FNA. Until greater experience shows clear sampling superiority of FNC alone, rather than performing only FNA in diffuse or nodular thyroid lesions, incorporating FNC into the second puncture will definitely improve the quality and quantity of material at the patient's first visit.
OBJECTIVE: To determine the diagnostic value of percutaneous core needle biopsy (PCNB) in comparison with fine needle aspiration (FNA) in patients with benign pulmonary lesions. STUDY DESIGN: A retrospective review was undertaken of computed tomography-guided PCNBs and FNAs performed between 1988 and 1997. Both FNA and PCNB biopsies were carried out sequentially at the same visit in every patient. RESULTS: A specific benign diagnosis was made in 10/60 cases (16.7%) by FNA and in 49/60 (81.7%) by PCNB. PCNB findings resulted in significant modification of the diagnosis established by FNA. The only significant complication encountered was pneumothorax, at a rate of 11.7%, which is compatible with that reported in the literature for complications induced by FNA alone. CONCLUSION: Radiologically guided PCNB is a safe procedure, can provide sufficient histologic material for a specific diagnosis of peripheral lung disease and can avoid more-invasive surgical procedures in many cases. Our experience demonstrated that the histologic analysis provided by PCNB can greatly increase the diagnostic accuracy in benign pulmonary diseases as compared with the yield of FNA.