TRUS guided biopsy: its simple, harmless and life-saver

Note: This blog is directed mainly to people who actually care about their health.
 
Recently I came across a 55 year old patient, a retired executive, who was having yearly regular check-ups. This time, he came for a MRI of spine, because he was experiencing some back pain. As I looked at the initial images of his MRI, I could see multiple metastases in vertebrae. There was no obvious mass (tumour) in his abdominal scan I did in morning. Prostate was measuring some 30 grams , okay for his age. I looked at his old papers, and only thing that struck me, was his last year PSA was 15 ng/ml (elevated not yet alarming as he was told). Just out of suspicion, I asked the clinician to get repeat PSA...It was whopping 110 now! Next day, I biopsied randomly from all sextants of prostate (TRUS guided), as I could not see any lesion yet. It proved to be prostate cancer.

Dictum is "you should always get TRUS guided biopsy if PSA is above 10 ng/ml, and if digital rectal examination is suspicious, even if PSA is above 4 ng/ml." And above all, whats the harm? whats the contraindication? and whats the radiologist dilemma? Almost all urologists agree with this dictum, but either patients get anxious, or radiologist is not confident enough. This arcane, grand terminology and explanation of procedure - TRUS guided biopsy...whoosh....putting a bulky rod into the rectum, and then a sharp needle over it, and firing many times.....not gonna do it.....is there a way out? Actually, the way out is much worse some times, as seen in the case I mentioned. And the procedure itself is not that traumatic,painful or risky as it seems.

I personally have done many biopsies (no accurate counts but may be close to hundred if not more), and have never ever experience any complications. Never did I witness any serious complications, done by any damn and first-timer radiologist. And almost hundred percent times, it has cleared the air between cancer or no cancer. Even if malignancy (cancer), it did pick at early stages and was well managed afterwards.

In my words, procedure is
 "We do a simple ultrasound of prostate, yes, by putting a probe inside rectum, but it is so well lubricated, it doesn't feel anything. Point is, it will only enter into the rectum, only if patient allows and relaxes, which means, in a painless situation. Else, radiologist would not able to push the probe itself. Its not like older days endoscopies, with a large tube pushed forcefully. Its a two-way thing, and needs some patient co-operation. Almost never did any patient refused to get this done while I was doing the procedure, which means its simple to accept.
Then, we use an accurately single-shot firing biopsy gun. Its not like, we are poking the needle again and again and shearing the hell out of you. Its one shot, like a bee-sting, and that too at a point, where you will never experience pain! Yes, biopsy is always taken when probe is above the dentate line. We can only feel pain if we are shot below this line. Above this line, there can never be any pain by nature of our body. So, its proven painless procedure. Bleeding, yes, when we are actually poking a needle, and that too a few times to get correct number of samples, it would bleed a bit. But, our body is so conditioned, that rectal bleeds of this nature in healthy men (procedure is always done when there is  normal clotting time, PT) would be almost immediately healed. I have never seen a person with continuous bleeding after procedure. In fact, I do it on out-patient basis many-a-times, and patient just walks out and never calls me back that he is having this or that. Though, I always call them back, and just trying to know if the procedure does cause any complications. Even if blood in urine or stool keeps coming, it can be handled with much ease."

There is simply no other way to prove that you definitely have a prostate cancer, or you have not. Biopsy is the only way to go. And last but not the least

PROSTATE CANCER IS THE MOST COMMON CANCER IN MOST COUNTRIES NOW.

Ectopic pregnancy: The grey zone of radiologist

Suspicion and strong instinctive clinical suspicion is the key to diagnosis of ectopic pregnancy. Its usually a combined effort of obstetrician and radiologist, which usually pinpoints the diagnosis. Serum B-HCG markers, which were introduced in early 1980s, can solve this dilemma much easily in almost all instances. However, for some reasons, confusion and lack of emergent management still persists in clinical practice. Few instances I have personally come across -
Case 1:
26 yr old 2 months pregnant female walks into emergency department in night with P/V bleeding. Emergency call was made to sonologist, who found a tiny gestation sac, and a luteal cyst, with no subchorionic collection or sac separation. Case was closed as early pregnancy, and patient was sent home. Patient returns back same very morning, almost fainting, pale in look, hypotensive on examination. Repeat ultrasound was done, which shows similar findings, with an irregular adnexal cystic lesion (discarded as luteal cyst in night) and dirty free fluid in pelvis. He pens down it as possible ruptured ectopic pregnancy, and reviews the gestation sac as 'pseudo-gestational sac'. Obstetrician sees the contradictory reports and does not believe the radiologist. She orders B-HCG, and here was committed a 'sheer crime'. Patient is deteriorating and B-HCG marker is taking its own time. Finally, the verdict comes, with B-HCG of 2500. Patient undergoes laparoscopy, and an ominous ruptured tube is staring at the surgeon, with blood almost in every pocket of abdomen.

Lessons 

• for radiologist - till you see a fetal pole, consider possibility of pseudogestation sac and always correlate with B-HCG. Also, have a close look at the luteal cyst, sometimes 'tubal ring' with 'ring of fire' can be seen.
• for obstetrician - always be suspicious of ectopic pregnancy, and never wait for too many reports if you think it is clinically ectopic. You can always close the laparoscopy wound, but avoid a rupture. One clue can create a suspicion, second can make you sure, don't wait for third one!

 Case 2:
29 year old female was not getting periods since last one year and was diagnosed with polycystic ovaries 6 months back, for which she is on weight-loss schedule. This time it had been 3 months since she got period. She got her urine pregnancy test done twice in last 2 months, and one two days back, all of them came negative. Gynecologist refers her to evaluate for PCOD. Radiologist saw thick endometrium, tiny follicles in ovaries, and some dirty fluid in pelvis. Just before finishing the examination and labelling it as classical PCOD, he was not sure what to say about this dirty fluid. There was no endometriotic cyst, he was having another cursory look, till he sees some weird soft tissue in left adnexa. He puts on doppler, which shows some vague color flow. Patient was not having any probe tenderness. This is what his report said,
"Heterogenous adnexal soft tissue lesion on left side and fluid with coarse internal echoes in pelvis - Possibilities include ectopic pregnancy, endometriosis or tubal inflammatory etiology. To be correlated with Serum B-HCG and MRI if needed."
Patient got her B-HCG done, and radiologist advised to just delay the MRI till B-HCG report comes. B-HCG came out to be 757 (?). Where do we stand now? Obstetrician felt like she is 'sitting on a bomb' and didn't want to wait for it to explode. She operated it immediately, and saw fiery red fallopian tube, with fimbrial abortion as she could see products of conception floating in pool of blood in pelvis. Rupture could be however avoided or rather contained.

Lessons

• for radiologist- suspicion of ectopic is almost always there! Just have a close look, may be some clue is lying somewhere, while you are rotating your torch (TVS probe) in dark woods.
• for gynecologist - Collect the clues, act at your instinct and at the earliest.

 Case 3
27 year old female visits to get an early pregnancy (1st trimester scan), and she had been having spotting since last 2 days. Its already 6 weeks, and radiologist is searching everywhere for the sac, and he sees mildly thick endometrium and thats it! No sac could be seen anywhere. Patient is wincing while the TVS probe is being rotated, not allowing to explore. Well, some pain is expected sometimes in TVS. Radiologist withdraws the probe, however he has limited explanation. He pens down something like this-
"Possibility of recent abortion, very early intrauterine pregnancy, and occult ectopic pregnancy - to be correlated with B-HCG". While patient is better, and gynecologist sends her home. B-HCG comes a magnanimous 10000 IU (!).
Obstetrician feels something fishy, may be she aborted, as we don't see a sac anywhere, and she goes to sleep. She doesn't know, she is 'sleeping on the bomb'. Bomb explodes the next morning, when a collapsed patient is being strolled down on a wheel-chair. And, she commits another crime, when she waits for another scan by a radiologist. Well, he does it and sees blood in pelvis, abdomen, everywhere...declares it as 'ruptured ectopic pregnancy'. Patient gets operated, a mass was also found somewhere in adnexa probably.

Lessons

• for radiologist - if patient is having pain, you may choose to withdraw the probe, however, convey a strong suspicion of ectopic in view of tenderness.
• for gynecologist - Don't wait till you pile up 'n' number of clues! Stick to the definition, "B-HCG >1000/1500, and no intrauterine gestation sac, thats it, that's what we call ectopic". Never sleep on this report.

All said and done, the mystery and confusion still prevails. Blamegame goes on, but its the patients who suffer.

Radiopaedia: Best and largest radiology collection

I have been browsing as well as contributing for www.radiopaedia.org for quite some time. While there are quite many radiology resources on web, its the only collection which is open-source, yet most keenly monitored. Frank and his team of editors (fortunately I am one of them now), have made it a great website through their hawk-eyes, in spite of their busy daily life. Such a large collection of images, on simple as well as advanced topics, which is growing on daily basis. Its all because of regular contributions from radiologist all over the world. Enthusiastic people like Dr. Sajoscha Sorrentino had built a magnus collection of close to 250 good cases in few months.

I encourage all of this blog readers to visit, contribute and support the cause of this great radiology resource.

Anomaly scan: The Indian dilemma

A patient came to me recently for an obstetric scan at 39 weeks of gestation. She already had anomaly scan (at 19 weeks) from one of the prominent fetal medicine expert in city. Later, he had two scans before coming to me. Fortunately, all the scans were normal. As I first focused my probe at the cranium to measure BPD and HC parameters, I saw enlarged occipital horns bilaterally, measuring 2.5 cm each - colpocephaly. Well, then other things started unfolding, as corpus callosum was not well visualized and paralleling of lateral ventricles was seen. I reviewed the images of previous scans. Although, it seemed evident on later two scans, anomaly scan images were ambiguous. In fact, it was mentioned to review for fetal skull at 24-26 weeks.

Either the fetal medicine specialist had a foresight, or he was playing safe. If anomaly scan was done by expert hands at 24-26 weeks, it would have been conclusive enough. Indian dilemma is - Medical termination of pregnancy can only be done before 20 weeks. Obstetricians are bound to send patient to rule out anomalies before 20 weeks, and sonologist still struggles to see things, which has not yet developed. I personally have missed cleft lip in anomaly scan, which I later picked up incidentally during interval growth scan at 30 weeks. But, our mindset in those scans, is just to calculate the fetal weight, check the placental location and cervix. We ourselves are assured of anomaly scan, if the report was normal.

My suggestions:
To the radiologist: Please double check all the anomalies during 28-30 weeks scan (Always recommend in the reports too).
To the obstetrician: Please classify the anomaly scans as a) Gross anomaly scan (19 weeks) b) Detailed anomaly scan (26 weeks).
To the government authority: Please amend the law accordingly.

Because you said so!

Gone are the days, when clinical acumen held the key to diagnosis. A requisition slip, earmarking a good bunch of diagnostic tests are handed over to the patients. And then, you will receive a call from the clinician, as soon as patient reaches you. While you are still scratching your head to come to a final diagnosis, whatever earliest words you told him, will be put in case sheet. Patient will be dispatched with that diagnosis, and you are still in dilemma. Its just too late before you finally prepare your report.

I remember one of the incidences my colleague shared recently. Patient presented with acute scrotum. He was not even examined by surgeon and sent directly to the radiologist. Radiologist saw a large hypoechoic testes, with some vascularity within. He was still having probe in one hand and phone in another. He told the same on phone, and said...looks like epididymo-orchitis. Surgeon immediately sent him home, with few antibiotics. Radiologist was still reviewing the images, and somehow could not differentiate, finally wrote in the report- ?torsion testes ?epididymo-orchitis. When he called back the surgeon, it was a loud screaming voice from the other end, "I sent him because you said so! What kind of radiologist you are, if you cannot differentiate the two?". The buck didn't stop there and radiologist was fired few days later.

I had many similar experiences, and learnt overtime to speak diplomatically, and reserving my diagnosis till the end. It would be much better in faith of healthcare, if the ball stays in clinician's court for most of the time. Radiologist should be taken as aid in diagnosis, and not as decision-makers. We should not get call from the gynecologists, like "Should we deliver her now?". How would we know?

Ante-natal doppler assesment

Quite frequently we need to make a doppler assesment of ante-natal patients, whenever abnormal biometry points towards IUGR. A quick check on umbilical artery, see if there is good diastolic flow, and confirm IUGR if you see a diastolic notch and high pulsatility. S/D ratios may be unreliable many a times. But, taking a ratio of MCA and umbilical artery is very sensitive and specific. I would suggest no panic if you only see low S/D ratio in MCA, while uterine and umbilical arteries are fine.

Checklist
1. Umbilical artery
2. MCA
3. Uterine arteries
4. Umbilical vein
5. Ductus venosus

1. S/D Ratio and PI of MCA/Umbilical artery less than 1 signifies IUGR.

2. Diastolic notch or absence of diastolic flow in umbilical arteries signifies adverse outcome.

3. Diastolic notch with high pulsatility index of Uterine arteries signifies uteroplacental insufficiency.

4. Smooth umbilical venous cord flow with peak velocity of 16 cm/sec signifies IUGR.

5. Decreased pulsatility in MCA signifies redistribution of blood flow.

6. Loss of 'M' Pattern in ductus venosus due to absent or reversed 'a' wave.

Mediastinal cystic masses

Cysts are forte of ultrasonologists but when it comes to mediastinum, confusions prevail. We can very well characterize the cyst but we keep manoevring our transducer through the limited intercostal window to see the relations with mediastinal structures. Chest X-Rays are definitely helpful to guide us but in my view, CT scan can clear all the clouds when it comes to mediastinal cyst.
Differential diagnosis
1. Congenital benign cysts - Bronchogenic cyst, Esophageal duplication cyst, Neurenteric cyst, Pericardial cyst, Thymic cyst.
2. Meningocele
3. Mature cystic teratoma
4. Lymphangioma
5. Tumors with cystic degeneration - Thymomas, Hodgkin's disease, Germ cell tumor, Mediastinal carcinomas, Metastases to lymph nodes, Nerve root tumors.
6. Mediastinal abscess
7. Pancreatic pseudocyst
8. Hydatid cyst
Benign cysts : Fundamentals are same for cysts anywhere else in body. A smoothly marginated cyst with thin enhancing walls and homogenous low attenuation non-enhancing contents, with no infiltration of adjacent mediastinum are usually benign. MR will show T2 hyperintensity within cyst.
1. Bronchogenic cyst: Mostly situated near carina in middle or posterior mediastinum, these cysts are mostly detected incidentally during imaging. If on a CXR, you see a subcarinal homogenous round opacity, often towards right side, think of bronchogenic cyst. Confirmation can be done by CT scan revealing a low attenuation cyst. But, again it depends on whether the cyst is infected or got hemorrhage, attenuation may vary and even be more than 100 HU. Sometimes, air-fluid or fluid-fluid levels may also be seen.
2. Duplication cyst: CT/MR imaging appearance are identical to bronchogenic cyst except that they have more intimate contact with esophagus and walls are little bit thicker.
3. Pericardial cyst: You see a cyst at cardiophrenic angle, mostly on right side and if you can demonstrate a communication with pericardial sac, you will hit the bull's eye! But, you get misguided right from the CXR. Some may ignore it as mediastinal fat pad. While the sceptic ones may evaluate for morgagnian hernia. CT does the trick most of the time. (I even got confused with loculated pleural effusion today!)
4. Meningocele: CXR looks similar to a neurogenic tumor radiograph, where you see paraspinal mass in posterior mediastinum, with enlarged intervertebral foramina. CT shows a cyst and you are done with diagnosis.
5. Thymic cyst: Very very rare cyst. Anterior mediastinal cystic mass lesion (just like any other thymic mass lesion) with CT characteristics of cyst should be a thymic cyst.
6. Mature cystic teratoma: Mostly in anterior mediastinum, with soft tissue, fat and calcification. within. Hardly any doubt remain in most of the cases.
7. Lymphangioma: A lobulated cystic lesion insinuating here and there in the mediastinum, even extending to neck sometimes. Seldom they cause any compressive symptom.
Recommended article: http://radiographics.rsna.org/content/22/suppl_1/S79.abstract