Discordance Rate Among Bilateral Simultaneous and Sequential Temporal Artery Biopsies in Giant Cell Arteritis

Abstract

IMPORTANCEFrozen section temporal artery biopsy (TAB) may prevent a contralateral biopsy from being performed. OBJECTIVE To evaluate the sensitivity and specificity of TAB frozen vs permanent section pathology results for giant cell arteritis (GCA) and determine the discordance rate of bilateral TABs. DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study, medical records were reviewed from 795 patients 40 years or older who underwent TAB from January 1, 2010, to December 1, 2018, treated at a single tertiary care center with the ability to perform both frozen and permanent histologic sections. Data were analyzed from January 2019 to December 2020. MAIN OUTCOMES AND MEASURESSensitivity and specificity of frozen section TAB for detecting GCA, and discordance rates of bilateral permanent section TAB. RESULTSOf the 795 included participants, 329 (41.4%) were male, and the mean (SD) age was 72 (10) years. From the 795 patients with 1162 TABs, 119 patients (15.0%) and 138 TABs had positive findings on permanent section. Of these 119 patients, 103 (86.6%) also had positive results on the frozen section, with 4 false-positives (0.6%) and 20 false-negatives (16.8%). Frozen section had a specificity of 99.4% (95% CI, 98.5-99.8), sensitivity of 83.2% (95% CI, 75.2-89.4), positive predictive value of 96.1% (95% CI, 90.4-98.9), negative predictive value of 96.6% (95% CI, 94.9-97.8), positive likelihood ratio of 140.6 (95% CI, 72.7-374.8), and a negative likelihood ratio of 0.17 (95% CI, 0.11-0.25). Simultaneous bilateral TABs were performed in 60 patients (7.5%) with a 5% discordance rate on permanent section. In comparison, bilateral frozen section-guided sequential TABs were performed in 307 patients (38.6%) with 5.5% discordance based on permanent section. In multivariate models, there was a greater odds of positive findings with age (odds ratio [OR],

Giant cell arteritis: reviewing the advancing diagnostics and management

“…To improve the sensitivity of detecting GCA some clinicians have advocated bilateral simultaneous TABs. However there has been a wide range of discordance rates between 3% to 45% found in people undergoing bilateral simultaneous TABs [ 82 ]. One option, where frozen section is available, is to perform a unilateral biopsy and if this is positive on frozen section it avoids the contralateral biopsy [ 82 ].…”

“…However there has been a wide range of discordance rates between 3% to 45% found in people undergoing bilateral simultaneous TABs [ 82 ]. One option, where frozen section is available, is to perform a unilateral biopsy and if this is positive on frozen section it avoids the contralateral biopsy [ 82 ]. The practice of performing bilateral simultaneous TAB versus unilateral TAB is known to be different worldwide [ 83 ].…”

“…Perivascular inflammation is restricted to the adventitia and periadventitial structures, and encompasses small vessel vasculitis, vasa vasorum vasculitis and inflammation limited to adventitia. It has been estimated to be present in 5-9% of positive TAB biopsies and has fair specificity ranging from 81.4 to 88.1% for GCA [82][83][84][85][86][87]. However, others have reported poor positive predictive values of perivascular inflammation, associating its occurrence with anomalies of ageing, systemic inflammation, malignancy and PMR phenotypes rather than relation to GCA directly [79,[88][89][90][91][92].…”

Is It Always Better to Get Faster Results in Temporal Artery Biopsies?

“…Otherwise, a good amount of the biopsy may be lost, segments that will never be seen, defeating the purpose of the biopsy . In this issue of JAMA Ophthalmology , Cohen et al report on more than 20 years’ experience using frozen sections in TAB to evaluate the need for a synchronous contralateral biopsy.…”

“…For most pathology laboratories outside of the Mayo Clinic, frozen sections on arteries are the exception and are used only in specific scenarios. Cohen et al demonstrate that the frozen section approach to the TAB, in their hands, has 83.2% sensitivity and 99.4% specificity for detecting vascular inflammation consistent with active GCA with an overall positivity of 15% of all the patients studied. They also show, as an important result applying to everyone working with patients suspected for GCA, that the discordance rate of bilateral TABs was 5% to 5.5%.…”