Core Biopsies Performed By Experienced Radiologists and Analysed By Expert Haemato-Pathologists Reliably Permit the Rapid and Safe Diagnosis of Lymphoproliferative Diseases and Negate the Need for Excisional Biopsy in Almost All Patients. Experience from 554 Sequential Core Biopsies from a Single Centre

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 BioPince^TM 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.