Image-guided core needle biopsy in the diagnosis of malignant lymphoma

https://doi.org/10.1016/j.ejso.2015.04.015Get rights and content

Abstract

Objective

Current European Society for Medical Oncology (ESMO) guidelines recommend that when feasible, surgical excision biopsy (SEB) is the ideal for diagnosis, sub-typing and grading of malignant lymphoma. We undertook this retrospective study to assess the diagnostic accuracy of image-guided core needle biopsy (CNB) in the diagnosis of malignant lymphoma, to identify the proportion of cases from which oncological treatment was subsequently instigated from the CNB diagnosis, and to evaluate the potential role for minimally invasive CNB techniques in the diagnostic pathway of malignant lymphoma.

Methods

All cases of lymphoma amenable to CNB between 2008 and 2013 were included. Patient records were reviewed to identify the biopsy diagnostic pathway undertaken (fine needle aspiration cytology, CNB, surgical excision biopsy). CNB specimens were graded as fully diagnostic (tumour sub-typing/grading and treatment initiated), partially diagnostic (diagnosis of lymphoma but more tissue required for sub-typing/grading), equivocal or inadequate. The effects of anatomical location, needle gauge, number of core specimens and sub-type of disease on the diagnostic yield of the sample were analysed.

Results

262 patients and 323 biopsy specimens were included in the study. 237 patients underwent CNB as the initial diagnostic intervention. In 230/237 CNB was fully diagnostic (97%), allowing initiation of treatment. In 7 patients, SEB was necessary in addition to CNB to provide additional diagnostic information to allow initiation of treatment. In 72 patients, SEB was the only diagnostic test performed.

Conclusion

Our study showed that in 97% of suitable cases, CNB provided sufficient diagnostic information to allow treatment of malignant lymphoma to be instigated. This minimally-invasive technique is well tolerated and has advantages over surgical techniques, including reduced costs, post-procedural complications and delays on the diagnostic pathway. CNB may obviate the use of surgical techniques in the majority of suitable cases, however its success is dependent on close collaboration and acceptance by clinicians and pathologists.

Introduction

To allow the timely instigation of appropriate oncological therapy in cases of malignant lymphoma, tissue sampling is essential to confirm the diagnosis, and to sub-classify the lymphoproliferative disease.1 Although the importance of core needle biopsy (CNB) for deeper lymph nodes is recognised in the current European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for diagnosis, treatment and follow up of haematological cancers, for peripheral lymph nodes with no surgical risk, the recommended reference standard diagnostic intervention is surgical excision biopsy (SEB) of a whole node.2 However, the diagnostic utility of image-guided CNB in lymphoma diagnosis is being acknowledged in published literature, and as such, it is increasingly considered a valid alternative method of tissue sampling, as it is less expensive, less invasive and has fewer associated complications than SEB.3, 4 CNB has struggled to gain wider acceptance in the haemato-oncological setting because of perceived limitations in the diagnosis and sub-typing of neoplasms associated with small specimen size,4 although recent advances in immunohistological techniques have greatly improved the ability of the general histopathologist to make accurate diagnoses from smaller specimens.5 Frequent reports in the literature of CNB as a diagnostic tool in the oncological setting, particularly in the diagnostic work-up of salivary gland, liver, chest and breast lesions,6 have demonstrated the value of this intervention as an alternative tissue sampling technique – in most cases providing a definitive diagnosis to guide clinical management, without the need for further, more invasive SEB.

We performed this retrospective analysis to evaluate the diagnostic efficacy of CNB specifically in the clinical context of malignant lymphoma, and to determine whether the information obtained by updated immunohistological techniques can provide sufficient tumour typing and characterisation data to instigate further treatment, thus avoiding SEB in suitable cases. We also discuss how CNB can incorporate into the diagnostic pathway for lymphomas, allowing tissue referral for specialist haematopathologist confirmation of diagnosis whilst other investigations/imaging are undertaken, and without excessive delays in treatment initiation.

Section snippets

Patients and methods

All patients diagnosed with malignant lymphoma (including Hodgkin's Disease (HD) and Non-Hodgkin's lymphoma (NHL) sub-types) at Eastbourne District General Hospital over a six-year period between 2008 and 2013 were identified by a Systematized Nomenclature of Medicine (SNOMED) search of the hospital's APEX® pathological information system, and their records subsequently retrieved for review and data collection. Providing the patient records and imaging history were available, all patient data

Terminology

The following definitions were used for key terms used to grade the diagnostic quality of the biopsy specimens;

  • Fully diagnostic – samples were considered to be fully diagnostic if there was adequate material provided in the specimen to allow a diagnosis of lymphoma, such that appropriate treatment was instigated from the biopsy diagnosis.

  • Partially diagnostic – samples were considered to be partially diagnostic if a diagnosis of lymphoma had been reached in the histology report, but further

Results

262 patients (age range 7–99 years) were considered suitable for inclusion in the analysis. In total, there were 225 patients with a single attendance, 32 patients with 1 recurrence, and 5 patients with 2 recurrences. Over the 6-year study period, a total of 323 tissue specimens were obtained from the study group, including 6 FNAC, 207 USCB, 30 CTCB and 80 SEB. The commonest CNB site was the neck/cervical region (131 biopsies). Specimens obtained from the chest/abdomen/pelvis were categorised

Discussion

The diagnostic work-up of malignant lymphomas is complex, and requires cytohistological, immunohistochemical and sometimes molecular genetic analysis of a tissue specimen in order to accurately grade and sub-type disease.8 The extent to which histological evaluation can be undertaken is dependent on the quality of the tissue specimen obtained.1 Traditionally, SEB has been regarded as the reference standard interventional technique,9 however there is a recognised increase in procedural

Conclusion

In patients with suspected malignant lymphoma, a multi-disciplinary approach to diagnosis is required, and input from radiologists, pathologists and oncologists/haematologists is essential. Although existing ESMO guidelines state that when feasible, SEB of a whole node is the ideal for accurate diagnosis, sub-typing and grading of disease, and should be performed in cases of lymphadenopathy where there is no surgical risk, we believe clinical practice is changing. Our study data has shown that

Conflict of interest

None.

Funding received

None.

Ethical approval/patient consent

Not required.

References (29)

  • C. Garcia et al.

    Best practices in contemporary diagnostic immunohistochemistry: panel approach to hematolymphoid proliferations

    Arch Pathol Lab Med

    (2009)
  • D. Strauss et al.

    The role of core needle biopsy in the diagnosis of suspected soft tissue tumours

    J Surg Oncol

    (2010)
  • E. Ravinsky et al.

    Diagnosis of lymphoma by image-guided needle biopsies: fine needle aspiration biopsy, core biopsy or both?

    Acta Cytol

    (2005)
  • J. Pfieffer et al.

    Sonography-assisted cutting needle biopsy in the head and neck for the diagnosis of lymphoma: can it replace lymph node extirpation?

    Laryngoscope

    (2009)
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