Publications

OBJECTIVE: To analyze outcomes of non-malignant concordant, discordant, and indeterminate results of CT-guided biopsies determined by standardized radiology-pathology concordance evaluation.

METHODS: In this study, consecutive patients undergoing CT-guided omental and mesenteric biopsy between March 2005 and August 2021 were included. A standardized radiology-pathology concordance workflow was implemented in July 2016, with retrospective concordance assessment applied to earlier cases. Concordance between pathology results and imaging findings was assessed by procedural radiologists.

DEFINITIONS: concordant, for malignant biopsy results or benign pathology where imaging findings agree; discordant, if pathology results are not congruent with imaging; and indeterminate, if imaging could be explained by pathology, but could also represent malignancy.

RESULTS: 222 biopsies were included. Pathology showed non-malignant results in 43/222 (19%), further classified by radiology-pathology concordance evaluation as discordant in 24/43 (56%), indeterminate in 8/43 (19%), and concordant in 11/43 (26%). One patient was lost to follow-up in the indeterminate category. The prevalence of malignancy on follow-up was higher in discordant (13/24, 54%) and indeterminate (2/7, 29%) groups vs. concordant cases (0/11, 0%), p < 0.001. There were 15/42 (36%) patients with final diagnosis of malignancy that would have been missed if radiology-pathology concordance evaluation had not been performed. Median time to diagnosis was shorter with repeat biopsy (18 days, IQR 9-34) and surgery (41 days, IQR 17-60) vs. imaging (185 days, IQR 107-239) and clinical follow-up (330 days, IQR 240-374), p < 0.001.

CONCLUSION: Radiology-pathology concordance evaluation in CT-guided omental and mesenteric biopsies showed high malignancy rates in initially non-malignant discordant (54%) and indeterminate (29%) cases. This practice prevented missed cancer diagnoses in 36% of patients with initial non-malignant results.

BACKGROUND: The lateral upper arm (LUA) pathway is a route of superficial lymphatic drainage that bypasses the axilla by draining to the deltopectoral, clavicular, and cervical lymph nodes. Despite the fact that anatomic variations of the LUA pathway have been implicated in breast cancer-related lymphedema (BCRL) risk after axillary lymph node dissection (ALND), the incidence of the LUA pathway variations in the healthy population has never been reported.

METHODS: Healthy female volunteers underwent bilateral lymphatic mapping of the upper extremities with indocyanine green (ICG) lymphography. ICG was injected in six standard sites in the hand/wrist and upper arm. Major anatomic variations of the LUA pathway were recorded including bundle phenotype (long, short, or absent), proximal visualization sites, and forearm pathway continuation to the long bundle phenotype.

RESULTS: 90 arms of 45 volunteers were included. The LUA pathway was present in 99% of arms and a long-versus-short bundle phenotype was observed in 71% versus 28% of arms. When the long bundle was present, it was formed by continuity with the forearm posterior radial channel alone (47%), posterior ulnar channel alone (34%), or both channels (19%). The LUA pathway was traced proximally to the deltopectoral groove in 89% of arms and to the axilla in 11% of arms.

CONCLUSIONS: We observed similar proportions of arms with long and short bundle phenotypes in comparison to our previous report of the LUA pathway in breast cancer patients with nodal disease. Defining the incidence of the LUA pathway with its variations in the general population is important as variations in this pathway may have implications for an individual's risk of developing BCRL.

Portal vein embolization (PVE) is a minimally invasive intervention that has become the standard of care in preoperative liver augmentation for patients undergoing extended hepatic resections for primary and secondary liver cancers. PVE provides permanent and complete occlusion of the portal venous inflow to diseased hepatic segments, re-directing portal flow to the future liver remnant and inducing hypertrophy sufficient to proceed to major hepatectomy. The aim of this review is to discuss the methods of identifying an insufficient future liver remnant, technical considerations for performing effective PVE, and the alternative/adjunctive measures for PVE.

BACKGROUND AND OBJECTIVES: Generating computed tomography (CT) angiography (CTA) 3-dimensional (3D) volume-rendered (3DVR) images can be time consuming without specialized technical staff or artificial intelligence solutions. However, their role in aneurysm detection in patients with subarachnoid hemorrhage is not known. Our aim was to assess the diagnostic utility of 64-detector row CTA with 3DVR (CTA+3DVR) vs without 3DVR (CTA-3DVR) in intracranial aneurysm detection.

METHODS: A retrospective analysis of patients presenting with spontaneous subarachnoid hemorrhage (regardless of location) who underwent 64-detector row CTA and subsequent digital subtraction angiography (DSA) between 2013 and 2020 was performed. DSA was the reference standard. Almost all DSAs were performed with 3D rotational angiography. Two neuroradiologists blinded to the DSA results separately reviewed CTA source and maximum intensity projection images without 3DVR images (CTA-3DVR) and then immediately followed by the 3DVR images (CTA + 3DVR). Disagreements were resolved by consensus review. Aneurysm size was measured on DSA.

RESULTS: In total, 200 patients were included in the study. 140 aneurysms in 114 patients were detected on DSA. CTA-3DVR detected 135 of 140 aneurysms (96.4%), and CTA+3DVR detected 136 of 140 aneurysms (97.1%). All missed aneurysms measured 2-4 mm. Three of four missed aneurysms were associated with multiple aneurysms, and 1 was a singly occurring, 2-mm M3 segment aneurysm. The 1 additional aneurysm detected by CTA + 3DVR was a 3-mm left A3 segment aneurysm. No false positives occurred with or without 3DVR.

CONCLUSION: CTA+3DVR detected 1 additional distal A3 aneurysm vs CTA-VR. 3DVR does not seem to substantially improve the detection of aneurysms but may be useful in the emergent setting for aneurysm morphology characterization.

OBJECTIVE: Assess the incidence and clinical outcomes of inadvertent bowel sampling with a 17-G coaxial system with an 18-G semi-automatic biopsy needle, omental and mesenteric CT and US-guided biopsy.

METHODS: In this retrospective study, consecutive patients undergoing omental and mesenteric CT and US-guided biopsy with a 17-G introducer, an 18-G semi-automatic biopsy device performed at a single tertiary academic institution between March 1, 2005, and March 1, 2024, were included to assess the incidence and clinical outcomes of inadvertent bowel sampling. Descriptive statistics were used.

RESULTS: Among 265 biopsies, there were six cases (6/265, 2.3%) with inadvertent bowel sampling identified on pathology. The median age was 83.5 years (IQR: 65.6-85.3) in patients with inadvertent bowel sampling, and 66 years (IQR: 58-74) in patients without inadvertent bowel sampling, p = 0.02. In patients with inadvertent bowel sampling, 4/6 (66.7%) of biopsies were from mesentery, in contrast to the patients without inadvertent bowel sampling, with 210/259 (81.1%) omental biopsies, p: 0.04. The bowel mucosa on pathology was arising from the colon in 3/6 (50%), the duodenum in 2/6 (34%), and the distal ileum in 1/6 (17%). All patients underwent a standard post-procedure observation time of 1 hour, during which no signs or symptoms of clinically significant bowel perforations were identified. No patients were admitted after the procedure, and no patients required admission within 30 days after the procedure for bowel-related indications.

CONCLUSION: Inadvertent bowel sampling during percutaneous omental and mesenteric biopsy with a 17 G introducer, and an 18 G semi-automatic needle is a rare, but likely benign event, even in patients without bowel preparation or antibiotic coverage.

KEY POINTS: Question The incidence and clinical consequences of unintended intestinal sampling in percutaneous omental and mesenteric core needle biopsies are unknown. Findings Inadvertent bowel sampling occurred in 2.3% of omental and mesenteric biopsies. No clinically significant complication was observed, despite the lack of bowel preparation or antibiotic prophylaxis. Clinical relevance Inadvertent bowel sampling is rare, more common in elderly patients and mesenteric biopsies, and likely benign, even without preparatory measures. However, given the potential for serious complications reported in the literature, meticulous technique remains crucial to minimizing the risk.