Introduction Whilst excision biopsy is traditionally preferred, advances in radiological and histological techniques warrant a re‐look at core biopsy as a viable primary diagnostic method. Method Over a 3‐year period, all patients who underwent core biopsy to investigate lymphoma at our centre were included. Results 554 consecutive patients were included (40.1% prior lymphoma and 59.4% new presentations). Three or more cores were taken in 420 (75.8%) cases. Median time from request to biopsy and biopsy to histology report was 2 (0‐40) days and 7 (1‐24) days, respectively. 510/544 (93.8%) biopsies were diagnostic. There was no difference in whether the biopsy was diagnostic based on indication (new vs. relapsed lymphoma) (P = .445), whether biopsy was PET‐directed (P = .507), for T‐cell lymphoma (P = .468) or nodal vs. extra‐nodal (P = .693). Thirty‐eight patients (6.9%) required a second biopsy due to inadequate tissue. In a patient experience survey, only 13.9% reported any complications (1 self‐limiting minor bleeding, 4 bruising) whilst 16.7% reported any discomfort beyond 12 hours. Conclusion Core biopsy performed by experienced radiologists and analysed by expert haemato‐pathologists is a reliable, well‐tolerated method for diagnosing lymphoma and confirming relapse. Multiple cores can be obtained under local anaesthetic yielding sufficient material in the majority of cases.
Introduction Lymph node excision has historically been preferred to core biopsy in diagnosing lymphoma given reported higher diagnostic yield and concerns that core biopsies yielded insufficient material. However, core biopsy is associated with lower morbidity and has been reported to be more cost effective. Consequently, advances in radiological and histological techniques in extracting and processing material warrants a re-look at the efficacy of core biopsy as a viable primary diagnostic method. Method Over a three year period (January 2016 - December 2018), all patients who underwent core biopsy at our centre for investigation of possible lymphoma or relapse, were identified from a local database. Argon medical BioPinceTM needles were used for the majority of procedures. Data collected included: indication and final diagnosis, number of cores taken, waiting times from referral to histological diagnosis, diagnostic rates and any histological request for extra tissue due to sample inadequacy. A patient telephone survey was undertaken to document patient experience and record complications. Results 554 consecutive patients were included. 225 (40.1%) patients had a prior lymphoma diagnosis whilst 329 (59.4%) were new presentations. 78 (14.1%) biopsies were guided by prior PET imaging of which 69/78 (88.5%) were to assess relapsed disease. Biopsies sites were: 326 (58.8%) cervical, 71 (12.8%) axilla, 96 (17.3%) inguinal and 61 (11.0%) extra nodal. Three or more cores were taken in 420 (75.8%) cases. The median time from request to biopsy was 2 days (range 0-40 days) whilst median time from biopsy to histology report was 7 days (range 1-24 days). Final diagnoses were: 195 (35.2%) reactive/non-malignant, 346 (62.5%) lymphoma [88 (15.9%) Diffuse large B cell lymphoma, 76 (13.7%) Follicular lymphoma, 56 (10.1%) Hodgkin lymphoma, 37 (6.7%) T-cell lymphoma, 28 (5.1%) Chronic lymphocytic leukaemia, 61 (11.0%) other B cell lymphoma], 12 (2.2%) other malignancy and 1 (0.18%) inadequate for interpretation. 510/544 (93.8%) biopsies were diagnostic inclusive of 74/78 (94.9%) PET-directed biopsies. 35/37 (94.6%) biopsies confirming T-cell lymphoma were diagnostic whilst in 2 cases repeat biopsy was required. There was no significant difference in whether the biopsy was diagnostic based on whether it was indicated for new or relapsed lymphoma (p=0.445), PET-directed (p=0.507), for a diagnosis of T-cell lymphoma (p=0.468) or nodal vs. extra nodal (p=0.693). The histologist requested additional tissue in 64 (11.6%) cases. Of these, 38/64 (59.4%) patients were adjudged by the clinician to require a second biopsy. 3/195 (1.5%) reactive cases went on to be diagnosed with lymphoma within 6 months. 2/3 had inadequate biopsies and the histology report advised repeat. A third patient was diagnosed with DLBCL based on a repeat biopsy done for clinical suspicion. Of 35 consecutive patients, 31 agreed to participate in the patient experience survey. Only 5/31 (16.1%) reported any complications (1 self-limiting minor bleeding, 4 minor bruising). 6/31 (19.4%) reported any discomfort beyond 12 hours. Median waiting time in department pre-biopsy was 10 minutes (range 5-60 minutes) and all patients left the department within 20 minutes of the procedure. Conclusion Core biopsy performed by experienced interventional radiologists and analysed by expert haemato-pathologists is a reliable and convenient method for diagnosing lymphoma and confirming relapse inclusive of T-cell lymphoma (which is typically harder to diagnose). Multiple cores can be obtained under local anaesthetic and this yields sufficient material without need for further biopsy in the majority of cases (88.4%) including where samples are also required for trials purposes. Using PET to direct biopsy is highly effective in confirming relapse. Core biopsy is well tolerated and can be performed safely and effectively in the outpatient setting with a median time from referral to biopsy of only 2 days in our centre. Disclosures Ardeshna: Celgene: Consultancy, Honoraria; Gilead: Consultancy, Honoraria.
Introduction Elevated serum ferritin (hyperferritinemia, HF) can result from increased iron load, increased inflammation or from liver damage. In the most common forms of hereditary hemochromatosis (HH), elevated ferritin is usually seen with elevated transferrin saturations, [1,2]. In patients with HF but without raised liver iron concentration (LIC, mg/g dry wt [dw]), increased liver fat (hepatic steatosis, HS), either in isolation or as part of a metabolic syndrome, needs to be considered. HS is important to identify as it may progress to chronic liver damage and is potentially reversible with lifestyle interventions. Hepatic fat can now be quantified with magnetic resonance imaging (Hepafat-Scan®)[3]. Here, we evaluate the usefulness of this method in the diagnosis and subsequent management of patients referred with HF. Methods A total of 132 patients (median age 48 years, range 21-86 ; female: male ratio 1:2.5) referred for investigation of HF and who underwent estimation of liver iron concentration (LIC) by R2-MRI (FerriScan®) over a four-year period (January 2015 - December 2018) are included in this analysis. Data on patient demographics, presenting serum ferritin (SF) and transferrin saturation were obtained. Genetic testing for C282Y and H63D was also performed. Genetic testing for rarer forms of haemochromatosis was confined to patients with unexplained raised LIC. Patients with iron overload secondary to chronic iron ingestion or blood transfusion were excluded from this analysis. Results Patients were subdivided by genetic diagnosis: C282Y homozygote (26, 19.7%), C282Y/H63D (18, 13.6%), H63D homozygote (10, 7.6%), C282Y heterozygote (8, 6.1%), H63D heterozygote (18, 13.6%), autosomal dominant ferroportin disease (4, 3%) and negative HFE gene testing (48, 36.4%). There was no statistical difference between mean presenting SF (p= 0.307) between the different groups. C282Y homozygotes, and those with autosomal ferroportin disease had a significantly higher LIC than others (p<0.001). C282Y homozygotes and compound heterozygotes had a significantly higher transferrin saturation than other groups (p<0.001). SF positively correlated with LIC (p<0.001). After genetic testing and LIC quantification, 32 patients underwent a HepaFat-Scan®. Median age was 63 years, range 23 - 74 years; female: male ratio 1:3.5. 54.5% had a volumetric liver fat fraction (VLFF) > 5%. 7.4% of patients, who did not undergo Hepafat-Scan®, had HS based on sonographic findings. Patients with definitive evidence of HS as defined by VLFF >5% had mean LIC of 1.36mg/g dw, and a higher mean presenting SF of 926 µg/L than those with HS <5% (NS, p= 0.47). Those with VLFF <5% had a mean presenting SF of 783 mg/ml and mean LIC of 2.2 mg/g dw. In patients with LIC ≤3mg/g dw (n= 91, mean 1.6), mean presenting SF was 728 mg/ml. 28 of these patients went onto have a Hepafat-Scan®, 16 of which (57.1%) had confirmed steatosis with VLFF >5%. In patients with LIC >3mg/g dw (n= 41, mean LIC 6.9), mean presenting SF was significantly higher at 1056 mg/ml (p=0.021). 4 patients with LIC >3mg/g dw also had a Hepafat-Scan®, with 1 patient having VLFF >5%. Patients with confirmed steatosis were referred for specialist hepatology consultation. Conclusion In patients referred for investigation of HF, demonstrable steatosis (VLFF >5%) by Hepafat-Scan® is remarkably high (13.3% of all referred patients and 54% of patients who received Hepafat-Scan®). The Hepafat-Scan® data show that HS is generally confined to patients with low LIC (≤3mg/g dw) (Figure 1) reflecting the selective decision pathway adopted of excluding hepatic siderosis before proceeding to Hepafat-Scan®. SF is significantly higher in non-iron overloaded patients with HS (VLFF >5%) than those without HS (Figure 1). Estimation of HS should be considered in the diagnostic pathway of patients referred for investigation of HF, particularly when LIC values are not found to be meaningfully increased. References 1. Cullis JO et al. Investigation and management of a raised serum ferritin. British Journal of Haematology 2018; 181:331-340 2. St Pierre TG et al. Noninvasive measurement and imaging of liver iron concentration using proton magnetic resonance. Blood. 2005; 105(2):855-61 3. St Pierre TG et al. Stereological Analysis of Liver Biopsy Histology Sections as a Reference Standard for Validating Non-Invasive Liver Fat Fraction Measurement by MRI. PLoS ONE August 2016; 11(8):e0160789 Disclosures Eleftheriou: Novartis: Honoraria. Garbowski:Imara: Consultancy; Vifor Pharma: Consultancy. St. Pierre:Resonance Health Ltd: Consultancy, Other: Share ownership. Porter:Agios: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Protagonism: Honoraria; La Jolla: Honoraria; Vifor: Honoraria; Silence therapeutics: Honoraria; Bluebird bio: Consultancy, Honoraria. Drasar:Novartis: Honoraria.
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