Use of navigation bronchoscopy for biopsy and endobronchial fiducial placement

Electromagnetic navigation bronchoscopy (ENB) is a technique that can be used to biopsy pulmonary lesions beyond areas that are traditionally accessible by bronchoscopy. It can also guide biopsies of peribronchial lymph nodes and guide the placement of fiducial markers for stereotactic radiosurgery. With ENB, the patient is placed in a magnetic field and their anatomy is merged with a 3D reconstructed chest cat scan (CCT). A locatable, steerable probe is used to guide a working channel to the target, usually a peripheral tumor. Biopsies can be taken, and markers can be placed. The accuracy of this system depends largely on a small bronchus leading toward to target. The diagnostic yield is similar to CT-guided biopsies, with a false-negative rate of about 30%, although results may be improved with combined ENB and radial endoscopic ultrasound (EUS). The incidence of pneumothorax is 5% to 8% with ENB-directed biopsies compared with approximately 30% with CT-guided transthoracic biopsy.     

Review of different platforms to perform rapid onsite evaluation via telecytology

There is increased utilisation of cytopathology to provide a rapid onsite evaluation (ROSE) of fine needle aspiration and touch preparations of small biopsies. A well‐executed ROSE procedure can significantly impact the diagnostic quality and appropriate specimen triage of procured biopsy materials. To accommodate the demand for ROSE, telecytology has been increasingly implemented to facilitate ROSE occurring remotely. Telecytology can be categorised based on camera systems including eyepiece system, camera port system and robotic microscope/whole slide image scanner system. Image sharing methods include static images, broadcast only live video streaming, teleconferencing and whole slide image management system. In this review, we will discuss the advantages and disadvantages of each of these systems and deployment considerations.     

Clinical evaluation of a novel intraoperative handheld gamma camera for sentinel lymph node biopsy

ObjectivePreoperative lymphoscintigraphy (PLS) combined with intraoperative gamma probe (GP) localization is standard procedure for localizing the sentinel lymph nodes (SLN) in melanoma and breast cancer. In this study, we evaluated the ability of a novel intraoperative handheld gamma camera (IHGC) to image SLNs during surgery.MethodsThe IHGC is a small-field-of-view camera optimized for real-time imaging of lymphatic drainage patterns. Unlike conventional cameras, the IHGC can acquire useful images in a few seconds in a free-running fashion and be moved manually around the patient to find a suitable view of the node. Thirty-nine melanoma and eleven breast cancer patients underwent a modified SLN biopsy protocol in which nodes localized with the GP were imaged with the IHGC. The IHGC was also used to localize additional nodes that could not be found with the GP.ResultsThe removal of 104 radioactive SLNs was confirmed ex vivo by GP counting. In vivo, the relative node detection sensitivity was 88.5 (82.3, 94.6)% for the IHGC (used in conjunction with the GP) and 94.2 (89.7, 98.7)% for the GP alone, a difference not found to be statistically significant (McNemar test, p = 0.24).ConclusionSmall radioactive SLNs can be visualized intraoperatively using the IHGC with exposure time of 20 s or less, with no significant difference in node detection sensitivity compared to a GP. The IHGC is a useful complement to the GP, especially for SLNs that are difficult to locate with the GP alone.     

Development and Evaluation of a Prediction Model for Underestimated Invasive Breast Cancer in Women with Ductal Carcinoma In Situ at Stereotactic Large Core Needle Biopsy

Background

We aimed to develop a multivariable model for prediction of underestimated invasiveness in women with ductal carcinoma in situ at stereotactic large core needle biopsy, that can be used to select patients for sentinel node biopsy at primary surgery.

Methods

From the literature, we selected potential preoperative predictors of underestimated invasive breast cancer. Data of patients with nonpalpable breast lesions who were diagnosed with ductal carcinoma in situ at stereotactic large core needle biopsy, drawn from the prospective COBRA (Core Biopsy after RAdiological localization) and COBRA2000 cohort studies, were used to fit the multivariable model and assess its overall performance, discrimination, and calibration.

Results

348 women with large core needle biopsy-proven ductal carcinoma in situ were available for analysis. In 100 (28.7%) patients invasive carcinoma was found at subsequent surgery. Nine predictors were included in the model. In the multivariable analysis, the predictors with the strongest association were lesion size (OR 1.12 per cm, 95% CI 0.98-1.28), number of cores retrieved at biopsy (OR per core 0.87, 95% CI 0.75-1.01), presence of lobular cancerization (OR 5.29, 95% CI 1.25-26.77), and microinvasion (OR 3.75, 95% CI 1.42-9.87). The overall performance of the multivariable model was poor with an explained variation of 9% (Nagelkerke’s R ²), mediocre discrimination with area under the receiver operating characteristic curve of 0.66 (95% confidence interval 0.58-0.73), and fairly good calibration.

Conclusion

The evaluation of our multivariable prediction model in a large, clinically representative study population proves that routine clinical and pathological variables are not suitable to select patients with large core needle biopsy-proven ductal carcinoma in situ for sentinel node biopsy during primary surgery.     

Remission spectrometry for blood vessel detection during stereotactic biopsy of brain tumors

Stereotactic biopsy is used to enable diagnostic confirmation of brain tumors and treatment planning. Despite being a well‐established technique, it is related to significant morbidity and mortality rates mostly caused by hemorrhages due to blood vessel ruptures. This paper presents a method of vessel detection during stereotactic biopsy that can be easily implemented by integrating two side‐view fibers into a conventional side‐cutting biopsy needle. Tissue within the needle window is illuminated through the first fiber; the second fiber detects the remitted light. By taking the ratio of the intensities at two wavelengths with strongly differing hemoglobin absorption, blood vessels can be recognized immediately before biopsy sampling. Via ray tracing simulations and phantom experiments, the dependency of the remission ratio R = I₅₇₈/I₆₅₀ on various parameters (blood oxygenation, fiber‐to‐vessel and inter‐fiber distance, vessel diameter and orientation) was investigated for a bare‐fiber probe. Up to 800–1200 µm away from the probe, a vessel can be recognized by a considerable reduction of the remission ratio from the background level. The technique was also successfully tested with a real biopsy needle probe on both optical phantoms and ex‐vivo porcine brain tissue, thus showing potential to improve the safety of stereotactic biopsy.

Dual‐wavelength remission measurement for the detection of blood vessels during stereotactic biopsy.     

Needle track seeding of papillary thyroid carcinoma from fine needle aspiration biopsy. A case report

BACKGROUND: Dissemination of tumor cells from needle biopsy has been observed in a wide range of tumor types. Fine needle aspiration (FNA) biopsy has become accepted as the first-line test in the evaluation of thyroid nodules. Local recurrence of thyroid cancer from needle track seeding is an extremely rare complication of thyroid FNA. CASE: A 59-year-old woman developed local recurrence of papillary thyroid carcinoma three years after FNA of the primary cancer. Local metastases developed in the skin and sternocleidomastoid muscle. The location of the recurrent cancer and the linear relationship of the metastases indicated that local recurrence was due to needle track seeding at the time of FNA. CONCLUSION: Needle track seeding has been recognized as a possible, albeit rare, complication of FNA of thyroid cancer. Although proper FNA technique can reduce the potential for needle track seeding, its occurrence is an unavoidable complication of FNA evaluation of thyroid malignancies.     

Impact of Tumor Localization and Method of Preoperative Biopsy on Sentinel Lymph Node Mapping After Periareolar Nuclide Injection

Background

To evaluate whether tumor localization and method of preoperative biopsy affect sentinel lymph node (SLN) detection after periareolar nuclide injection in breast cancer patients.

Methods and Findings

767 breast cancer patients were retrospectively included. For lymphscintigraphy periareolar nuclide injection was performed and the SLN was located by gamma camera. Patient and tumor characteristics were correlated to the success rate of SLN mapping. SLN marking failed in 9/61 (14.7%) patients with prior vacuum-assisted biopsy and 80/706 (11.3%) patients with prior core needle biopsy. Individually evaluated, biopsy method (p = 0.4) and tumor localization (p = 0.9) did not significantly affect the SLN detection rate. Patients with a vacuum-assisted biopsy of a tumor in the upper outer quadrant had a higher odds ratio of failing in SLN mapping (OR 3.8, p = 0.09) compared to core needle biopsy in the same localization (OR 0.9, p = 0.5).

Conclusions

Tumor localization and preoperative biopsy method do not significantly impact SLN mapping with periareolar nuclide injection. However, the failure risk tends to rise if vacuum-assisted biopsy of a tumor in the upper outer quadrant is performed.     

Computer-assisted stereotactic biopsy of intracranial lesions

The use of a computer program that allows the integration of stereotactically gathered CT, MRI and digital angiographic data in the planning of a biopsy trajectory is described. This system has been used to perform 447 stereotactic biopsies in 439 patients. Intracranial hemorrhages occurred in three patients; combined morbidity and mortality was less than 1%. Incorporation of angiographic data and visualization of the surgical trajectory enhances the safety and accuracy of stereotactic biopsy of intracranial lesions.     

A multipurpose CT-guided stereotactic instrument of simple design

The instrument is based upon a radiolucent ring fixed to the skull by four pins. This locks into a frame for CT scanning from which the x, y and z stereotactic coordinates are derived. The head ring may be locked into a compatible support on the operating table for biopsy. A similar support and localization system is used for rotational radiotherapy. With the current 14 MeV apparatus, fields as small as 2 cm in diameter are available with 90% dosage fall-off in the surrounding 1-cm shell.     

A new apparatus for CT-guided stereotactic surgery

Combining whole-body CT scan with a stereotactic system, the authors have developed and applied clinically an apparatus which readily provides intraoperative CT images, making it possible to confirm the location of the target point and ascertain the intraoperative environment. It takes about 9 s to obtain a CT image. Our purpose is to make stereotactic surgery, a kind of blind surgery, as safe and reliable as a visualized procedure by intraoperative CT scanning. By the method, in which there is very little invasion under local anesthesia, evacuation of deep-seated intracerebral hematomas as well as brain abscesses and also biopsy or brachytherapy of brain tumors in the brain can be done with safety and reliability.     

Animal research stereotactic instrument modified for computed tomographic guidance

While target localization for human stereotactic surgery has been refined by computed tomographic (CT) and magnetic resonance imaging (MRI), stereotaxis in experimental animals has remained dependent upon external cranial landmarks and standardized atlas coordinates. To overcome the limitations and inaccuracies of animal devices using the original Horsley-Clarke method, we modified a standard animal stereotactic instrument in order to make target localization and coordinate determination possible with CT imaging. Although the device can be adapted to any medium-sized animal species, we demonstrate its use with dogs here.     

Digital stereophotogrammetry based on circular markers and zooming cameras: evaluation of a method for 3D analysis of small motions in orthopaedic research

Background  

Orthopaedic research projects focusing on small displacements in a small measurement volume require a radiation free, three dimensional motion analysis system. A stereophotogrammetrical motion analysis system can track wireless, small, light-weight markers attached to the objects. Thereby the disturbance of the measured objects through the marker tracking can be kept at minimum. The purpose of this study was to develop and evaluate a non-position fixed compact motion analysis system configured for a small measurement volume and able to zoom while tracking small round flat markers in respect to a fiducial marker which was used for the camera pose estimation.     

Image processing algorithms to facilitate and enhance sentinel node detection using a hand-held gamma ray camera in surgical breast cancer staging

We have developed a miniature scintillation camera to be used in surgical cancer staging. The availability of such a compact hand-held gamma camera may in certain cases improve localization of the sentinel lymph node and reduce the duration of a surgical breast cancer staging procedure. We have investigated image processing algorithms applied to planar images that may improve node detection capabilities for breast cancer staging. We have also studied contrast enhancement methods that may be able to identify nodes that would otherwise be missed. Exposure duration for a given camera position can be adaptively shortened or increased by using an optical flow algorithm to estimate camera motion with respect to the current frame. By determining if the camera is in motion or not, the exposure time may be increased to allow more image counts to accumulate at a given camera position. Adaptive exposure time may improve the ease of use of the hand-held camera, and allow regions of interest to be imaged more effectively. We feel that these image processing techniques can improve the utility of a hand-held gamma ray imager for sentinel lymph node detection during breast cancer staging.     

A novel stereotactic frame for real PET-guided biopsies: A preclinical proof-of-concept

Purpose: To design, build and test a stereotactic device that allows PET image-guided biopsies to be performed. Methods: An initial prototype consisting of four main pieces, one of which contains radioactive markers to make it visible in the PET images, was built using a 3D printer. Once the device is mounted, a spherical coordinate system is built with the entrance needle point in the skin as the origin of coordinates. Two in-house software programs, namely getCoord.ijm, which obtains the spherical coordinates of the tumour tissue to be biopsied, and getNeedle.ijm, which virtualizes the inner needle tip once the puncture has taken place, were written. This prototype was tested on an FDG-doped phantom to characterize both the accuracy of the system and the procedure time. Results: Up to 11 complete biopsy procedures were conducted. The mean total procedure time was less than 20 min, which is less than the procedure time of conventional standard CT-guided biopsies. The overall accuracy of the system was found to be 5.0 ± 1.3 mm, which outperforms the criterion used in routine clinical practice when targeting tumours with a diameter of 10 mm. Conclusions: A stereotactic frame to conduct real PET image-guided biopsies has been designed and built. A proof-of-concept was performed to characterize the system. The procedure time and accuracy of the system were found to meet the current needs of physicians performing biopsies.     

Histochemical and immunohistochemical protocols for routine biopsies embedded in Lowicryl resin.

Tissue processing and analysis require good preservation of both the shape and content of cells. Lowicryl resin is one of the few embedding media that allow good preservation of both tissue architecture and cellular contents. Therefore, different histochemical and immunohistochemical reactions can be applied to semithin sister sections from one biopsy. Further examination of a zone of interest can be carried out under the electron microscope. The hydrophilic property of Lowicryl resins makes possible different histochemical reactions; however, the technique used for paraffin sections must be adapted for each reaction. Antigenic preservation of cells by low temperature embedding allows immunolabeling on either semithin sections or in the zone of interest on ultrathin sections. We have shown the application and adaptation of different histochemical and immunohistochemical reactions on semithin and ultrathin sections from hepatic biopsies that were large, but thin. The variety of techniques that can be used on sister Lowicryl sections of a single biopsy makes this medium useful for extensive pathological studies of precious needle biopsies.     

Technique of stereotactic biopsy of two cranial target employing spherical coordinates to define a single trajectory

A 'spherical coordinate system' has been developed to allow either stereotactic biopsy of two intracranial lesions using a single predetermined trajectory or biopsy of a single lesion through an existing burr hole. By means of the Gildenberg technique, the CT coordinates of the targets (or target and burr hole) are obtained. These are employed in three simple trigonometric equations to give three coordinates-two angles for the probe carrier (theta and alpha) and the radius (T) of a sphere, defined by one target as the center and the other target on the surface. These can be utilized in the Todd-Wells stereotactic frame. This system was evaluated using hollow skulls and crossed 30-gauge wire for phantom targets. The system was tried on ten different target combinations, and eight successful trajectories were obtained to within 3 mm. Two target combinations were inaccessible because of technical limitations of the Todd-Wells frame. This 'spherical coordinate system' can decrease the time to localize multiple targets as well as minimize the number of passes.     

Factors determining survival of patients with malignant gliomas diagnosed by stereotactic biopsy

We analyzed the prognostic significance of tumor histology, location, treatment, and selected clinical features at presentation in 91 consecutive patients with malignant gliomas diagnosed by stereotactic biopsy. In 64 patients with glioblastoma multiforme (GBM) the following factors were associated with longer survival: lobar tumor location, adequate radiation therapy (RT) tumor dose 5,000-6,000 cGy, Karnofsky performance rating (KPR) at presentation greater than or equal to 70, and a normal level of consciousness before biopsy. In 27 patients with anaplastic astrocytoma, factors associated with longer survival were lobar tumor location, adequate RT, age less than 40 years at presentation, and a history of seizures. Delayed cytoreductive surgery in lobar GBM extended median survival but did not improve long-term survival. For patients with deep or midline malignant gliomas and for selected patients with lobar tumors, stereotactic biopsy followed by RT may be the most reasonable initial treatment strategy.     

Transcranial Doppler ultrasonography: stereotactically guided examinations using magnetic resonance angiography]

The accurate localization of specific intracranial blood vessels is a major difficulty with transcranial Doppler sonography (TCD). It was the purpose of this study to develop a system enabling stereotactic navigation during a TCD examination on the basis of high-resolution three-dimensional magnetic resonance angiographic (MRA) data. During TCD, the examiner is provided--on a computer screen--with a projected view of the respective intracranial vessel anatomy. With the aid of an optoelectronic localization system, the spatial orientation and localization of the US probe is determined in real time, and correlated with the patient's MRA data using a dedicated stereotactic mask. Subsequently, the US beam and the points of insonation are displayed on the screen overlaid on the vessel anatomy. In this way the examiner gains real time control of the localization of the respective intracranial vessel insonated. Points of insonation can be stored and recalled for follow-up examinations. In addition to the successful verification of the system, it was shown that, in comparison with conventional TCD, stereotactic navigation distinctly improves the reproducibility of repeat TCD examinations.