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AimTo assess the usefulness of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) and the predictive factors for the diagnosis of sarcoidosis in patients with uveitis who have normal thoracic tomography.MethodsWe retrospectively reviewed 67 consecutive patients with uveitis of unknown aetiology or a suspected sarcoidosis. All patients with normal thoracic tomography underwent an 18F-FDG PET/CT, which was blindly reinterpreted. We then assessed the proportion of positive 18F-FDG PET/CT and the impact on the final aetiology, using Abad’s criteria for the diagnosis of intraocular sarcoidosis.Results19 of the 67 patients (28.4%) had mediastinal hypermetabolic foci on their 18F-FDG PET/CT consistent with sarcoidosis. It identified a biopsy site in two cases, which were consistent with sarcoidosis. At the end of the study, six patients (10%) had a proven sarcoidosis, six patients (9%) were considered as having a presumed sarcoidosis and 18 patients (26.9%) as having indeterminate sarcoidosis. 18F-FDG PET/CT enabled the diagnosis of presumed sarcoidosis in these six patients. An older age at diagnosis (p=0.004) and the presence of synechiae (p=0.02) were significantly related to an abnormal 18F-FDG PET/CT, with a trend for an elevated ACE (p=0.0993). We established a nomogram to estimate the probability of having positive findings on the 18F-FDG PET/CT according to different predictive factors.Conclusion18F-FDG PET/CT enabled the diagnosis of intraocular sarcoidosis even in patients with a normal CT scan. Older age at diagnosis, presence of synechiae and elevated ACE are associated with positive findings on 18F-FDG PET/CT consistent with sarcoidosis.

Background:Persistent enlargement of major salivary glands (SGs) is one of the main risk factors for B-cell lymphoma in primary Sjögren’s syndrome (pSS). The Ultrasound-guided Core Needle Biopsy (US-guided CNB) could be a novel technique for the management of SGs enlargement in pSS (1).Objectives:To evaluate the procedure safety and the patient tolerance of US-guided CNB in pSS patients with major SGs enlargement.Methods:Consecutive patients, with either definite or clinically suspected pSS, and with clinical indication for SGs biopsy due to persistent glandular enlargement were screened for US-guided CNB from September 2019 to December 2020. All patients were evaluated clinically between 1 and 2 weeks and 12 weeks following US-guided CNB. All patients were asked to complete a questionnaire to report post-procedural complications (Figure 1, English version) and intra- and post-procedural pain Visual Analogue Scale (VAS). The complications were classified as transient (Results:US-guided CNB was performed in 21 glands (12 parotid and 9 submandibular glands) in 20 pSS patients. 16/20 (80%) patients fulfilled the ACR-EULAR classification criteria for pSS (2). The mean age at the time of biopsy was 62.1 (±11.7) years. US-guided CNB was well tolerated, no long-term complications were reported in the follow-up period (mean 9.5 ±5.7 months). Only transient complications were noticed in 11 patients (55%). In particular, two cases of local swelling at the biopsy site lasting no more than 6 days, one case of local bleeding and subsequently hematoma of the submandibular area, one case of transient facial paresis (lasting less than one hour), seven cases of post-procedural mild local pain, that resolved within 10 days without the need of analgesics (Table 1). The procedure was well tolerated, with a very low reported intra-operative pain (mean VAS 1.74 ±2.49) and a mean post-operative pain VAS of 1.39 (±2.33). The biopsy sampling was diagnostic in 19/20 patients (95%).Conclusion:US-guided CNB represents a novel approach for the management of pSS patients with SGs enlargement. This procedure shows a remarkable patient safety and tolerance, allowing an adequate glandular sampling and definite diagnosis in almost all the studied patients.References:[1]Zabotti A, Zandonella Callegher S, Lorenzon M, Pegolo E, Scott CA, Tel A, et al. Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren’s syndrome? Rheumatology (Oxford) 2020.[2]Shiboski CH, Shiboski SC, Seror R, Criswell LA, Labetoulle M, Lietman TM, Rasmussen A, Scofield H, Vitali C, Bowman SJ, Mariette X; International Sjögren’s Syndrome Criteria Working Group. 2016 American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sjögren’s Syndrome: A Consensus and Data-Driven Methodology Involving Three International Patient Cohorts. Arthritis Rheumatol. 2017 Jan;69(1):35-45. doi: 10.1002/art.39859. Epub 2016 Oct 26. PMID: 27785888; PMCID: PMC5650478.Table 1.Description of complicationsComplications of US-guided CNBPatients presenting complications, n/N (%)11/20 (55%)Description of transient complicationsSwelling at biopsy site, n2Bleeding, n1Hematoma, n1Local Pain, n7Local infection, n0Sialocele or fistula, n0Anaesthesia/paraesthesia, n0Transient facial palsy (< 1 hour), n1No persistent complications reportedAll the above specified complications were transient (< 12 weeks). No persistent complications were reported in the follow up.Figure 1.Post-biopsy complication QuestionnaireDisclosure of Interests:Alen Zabotti Speakers bureau: UCB, Novartis, Janssen, Paid instructor for: Amgen, Consultant of: Janssen, Ivan Giovannini: None declared, Sara Zandonella Callegher: None declared, Valeria Manfrè: None declared, Michele Lorenzon Consultant of: not relevant for this study, Enrico Pegolo: None declared, Cathryn Ann Scott: None declared, Alessandro Tel: None declared, Massimo Robiony Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Chiara Zuiani Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Salvatore De Vita Consultant of: GSK, Roche, Grant/research support from: not relevant for this study

Background:In IgG4-related diseases (IgG4-RD), usefulness of18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging for detecting the organ involvement of IgG4-RD have been shown and,18FDG PET/CT was more accurate and appeared to be more sensitive as compared to other imaging technics1,2. However, until now, the studies regarding about quantitative analysis of PET/CT imaging in IgG4-RD were few. To avoid unnecessary biopsy and select suitable lesion for biopsy on multi-organ involvement disease such as IgG4-RD, the information which lesion is suspected as disease-involvement lesion in a non-invasive test is important.Objectives:The purpose of this work is to evaluate the usefulness of18FDG-PE/CT imaging in management of IgG4-RD using quantitative analysis of PET/CT imaging.Methods:21 patients with IgG4-RD, in whom PET/CT was undertaken at the time of diagnosis between December 2009 and July 2018, were enrolled. We retrospectively investigated the association between histological findings in which biopsy was performed for diagnosis of IgG4-RD and findings of PET/CT.18FDG uptake was assessed in site of major organ involvement of IgG4-RD which could be differentiated from the normal uptake of background tissue with18FDG-PET/CT. For quantitative analysis, we measured the highest standardized uptake value (SUV) of the pixels within the region of interest (ROI) (SUVmax) and the average SUV within ROI (SUVmean). We also measured SUVmeanof liver as reference tissue. Then, we calculated ratio between SUVmeanof ROI and SUVmean/liver.Results:The age at diagnosis was 64.5 ± 11.9 years, serum IgG4 was 743.8 ± 584.1 mg/dl, and biopsy was performed at 24 sites (Submandibular gland 10, prostate gland 4, pancreas 2, thyroid gland 1, lung 1, retroperitoneum 1, kidney 1). Histological findings were consistent with IgG4RD (positive) at 19 sites.Although SUVmaxat the biopsy site was not correlated with the biopsy results, SUVmeanat the biopsy site were significantly higher in the biopsy-positive group (figure 1). As similar, SUVmean/liver SUVmeanwere also higher in the biopsy-positive group (2.17 vs 1.52, respectively Pmeanto consider biopsy, A receiver operating characteristics (ROC) curve was constructed. ROC curve analysis indicated SUVmean=4.074 as cut-off value which discriminate IgG4-RD related lesion.Conclusion:Our present study suggested that quantitative analysis of18FDG-PET/CT imaging is useful for selecting the biopsy site in IgG4-related disease.Figure 1.XXXXXReferences:[1]Ebbo M, Grados A, Guedj E, et al. Usefulness of 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography for staging and evaluation of treatment response in IgG4-related disease: a retrospective multicenter study. Arthritis Care Res (Hoboken) 2014; 66(1): 86-96.[2]Zhang J, Chen H, Ma Y, et al. Characterizing IgG4-related disease with (1)(8)F-FDG PET/CT: a prospective cohort study. Eur J Nucl Med Mol Imaging 2014; 41(8): 1624-34.Disclosure of Interests:None declared

Peripheral T-cell lymphomas (PTCLs) are rare and heterogeneous haematological malignancies that can rarely develop first in the peripheral nervous system, or more commonly, invade nerves from more usual primary locations. Patients with PTCLs usually respond poorly to treatment and have a poor clinical outcome.We report a patient with multiple skin lesions, multifocal mononeuropathies and constitutional symptoms all suggestive of a lymphoproliferative disorder, in whom repeat skin biopsies and clonality studies failed to achieve a diagnosis. Neurophysiological studies confirmed severe post-ganglionic lesions in the lower limbs including the sciatic, femoral, obturator, tibial and sural territories. Based on this neurotropic presentation we undertook a sural nerve biopsy, despite the clinical and neurophysiological presence of a nerve lesion more proximal to the biopsy site, and this allowed us to establish a final diagnosis of PTCL. The patient was treated successfully with chemotherapy and an autologous stem cell transplant.In our case PET imaging and MR neurography provided radiological evidence of widespread lesions in the subcutaneous and nerve tissues, and there is emerging evidence for the importance of PET imaging in the diagnostic work-up of PTCLs. Furthermore, a post-treatment PET scan confirmed the complete metabolic remission, highlighting its usefulness as a surveillance tool.

Idiopathic inflammatory myopathies, such as polymyositis (PM), may present with general symptoms such as fever and fatigue and only minimal muscle weakness, making it difficult to make a definite diagnosis and provide adequate treatment. Here a case is described in which interstitial lung disease was the first and most prominent manifestation of PM. Later, when muscle weakness became apparent and inflammatory muscle disease was suspected the first muscle biopsy was non-diagnostic. However, magnetic resonance imaging (MRI) scans of the clinically weak thigh muscles showed high signal on T2 weighted images, suggesting muscle inflammation more proximal to the first biopsy site. A second biopsy at this site disclosed typical histopathological findings for myositis. After treatment with prednisolone in combination with cyclophosphamide both pulmonary and muscle function improved. CONCLUSION—MRI scans of muscles may be helpful in selection of a site for muscle biopsy in patients with suspected inflammatory myopathy when a first muscle biopsy turns out to be negative. Additionally, patients with interstitial lung disease of unknown cause should be tested for muscular function to exclude an associated inflammatory muscle disorder.

Objective—To audit the 1990 International Society for Heart and Lung Transplantation cardiac rejection criteria and to evaluate the impact on classification and clinical outcomes of a modification in which grade 2 is abolished and grades 1A and 1B are amalgamated into a single "grade 1." Methods—1652 heart biopsies were reviewed over a four year period. The initial 1348 biopsies (group 1), using the original 1990 criteria, were analysed in terms of diagnostic grade and compared with the 304 biopsies analysed with the modified scheme (group 2). Differences in grading with the 1990 scheme were compared between two groups (1.1 and 1.2) reflecting early and late experience with grading. Subsequently all the grade 2 and grade 1B biopsies were rescored in terms of the modified scheme. Clinical results in terms of actuarial patient survival at one year and freedom from 3A rejection were similarly audited. Results—The relative ratios of potentially significant rejection (grade 3A, 3B, 4) remained constant over the entire study in groups 1.1, 1.2, and 2. A 50% reduction in grade 2 biopsy reporting was noted comparing early and late parts of group 1. At subsequent review of the group 1 grade 2 biopsies, 97% could be reassigned to grades 0 or 1 in the modified scheme, with the majority of these diagnoses reflecting Quilty effect/biopsy site reactions. Two cases (3%) of the 77 grade 2 biopsies were regraded as grade 3A rejection, with both occurring within three months of transplantation. None of the grade 1B biopsies had high grade cardiac rejection on review, most of these biopsies similarly showing pronounced Quilty effect and biopsy site reactions. Actuarial survival at one year rose from 86% to 90% during the study, with freedom from 3A rejection remaining unchanged at 80%. Conclusions—The original working formulation produces consistent grading except at grade 2, which is judged to be a misnomer resulting from Quilty effect and other non-rejection phenomena. While acceptable standardisation can be achieved with the 1990 scheme, the modified scheme has advantages in that it appears to encourage clear discrimination between significant and non-significant cardiac rejection. Overall, elimination of grade 2 did not produce an increase in higher grades of cardiac rejection, and thus the value of this diagnostic grade is questioned. Keywords: myocardium; transplant rejection; transplantation

It is well recognised that breast biopsy procedure can ‘implant’ tumour nests into the stroma such that displaced neoplastic epithelium may be interpreted as invasive carcinoma at subsequent wide local excision or biopsy. Usually the presence of reactive changes abrogates the probability of overdiagnosis of invasive disease. The diagnosis of invasive carcinoma of breast requires great certainty, as there are significant treatment differences between in situ and invasive disease, and the presence of invasion has profound implications for the patient and their families. We write to outline the case of a diagnosed invasive breast carcinoma occurring within a biopsy site that subsequently was shown to be displaced in situ carcinoma that was exceptional in the extent of implanted tumour material spanning 25 mm of excision tissue. An elderly female presented for investigation of palpable breast lump and bloody nipple discharge. Breast core biopsy was performed and a diagnosis of pure ductal carcinoma in situ (DCIS) was rendered. The patient subsequently underwent a wide local excision. The original pathology reported a 25 mm Grade 1 invasive ductal carcinoma of no special type, arising in a background of extensive intermediate-grade DCIS. The …

Introduction Gastric intestinal metaplasia (IM) is part of a carcinogenesis sequence leading to gastric cancer. Recent evidence-based European Society of Gastrointestinal Endoscopy (ESGE) guidelines highlight additional risk factors, such as extensive intragastric distribution of IM and the presence of Helicobacter pylori . The former is identified with ≥2 antral and ≥2 corpus biopsies, involving the greater and lesser curvature, and warrants three-yearly surveillance endoscopies. The latter should be eradicated to slow carcinogenesis progression. Methods Using keywords “intestinal metaplasia”, the histology database for the Queen Elizabeth Hospital, South London, was reviewed over 2000–11 to identify patients with IM on gastric biopsy. Gastro-oesophageal junctional IM was excluded. The number and site of biopsies taken and the presence of H. pylori was identified. The terminology used, with regards to “extensive” and “focal” IM, was compared with the suggestions from the ESGE guidelines. To investigate the development of cancer in patients with IM, histology and upper gastrointestinal cancer databases were compared. Results 175 patients with gastric IM were identified. Of these, only one patient developed gastric cancer. Helicobacter pylori was associated with 20/175 (11.4%) of gastric IM biopsies. After review of pathology reports, in 37/175 (21.1%) of cases with gastric IM, the pathologist did not receive sufficient clinical information specifying the site of the biopsies. Of those where the biopsy site was specified, only 10/138 (7.2%) had sufficient biopsies. The term “extensive” was used in 27/175 (15.4%) pathology reports, despite either insufficient number or non-specified location of biopsies. Conclusion This study identified 175 patients with gastric intestinal metaplasia over 2000–2011. One patient developed gastric adenocarcinoma after 8 years. Since surveillance endoscopy is not routine practice in the Trust, all biopsies were incidental findings. This study suggests that, where biopsy site details were provided, only 7.2% of patients were adequately biopsied. Remaining cases should have repeat biopsies to decide on surveillance. “Extensive metaplasia” refers to a wide intragastric distribution of IM to include the antrum and corpus. We identified discrepant use of nomenclature in pathology reporting in 15.4%. Helicobacter pylori was associated in 11.4%, where ESGE advocates its eradication. This study reveals further work is needed to risk stratify and survey this important pre-cancerous condition. Reference Dinis-Ribeiro M, Areia M, de Vries A, Marcos-Pinto R, Monteiro-Soares M, O’Connor A, et al . Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2011 Dec 23;44(01):74–94 Disclosure of Interest None Declared.

Background IgG4-related disease (IgG4-RD) is a relatively common and clinically important disease. It is very difficult to confirm the diagnosis due to the ubiquity of its lesions, which can involve the pancreas, salivary glands, retroperitoneum, and kidney. An elevated serum IgG4 level is not diagnostic of the disease. In 2011, comprehensive diagnostic criteria for IgG4-RD were established. These criteria require histopathology to confirm the diagnosis, as well as to exclude malignancy or other similar diseases. However, the diagnostic rate is low due to difficulty in determining the site to be biopsied. Objectives FDG-PET/CT is a non-invasive imaging technique commonly used in clinical oncology. 18 F-FDG accumulation is recognized as useful for diagnosing and monitoring the response to therapy in patients with some inflammatory disorders. We investigated the utility of FDG-PET/CT to determine the diagnosis in patients suspected of having IgG4-RD. Methods We studied 36 patients with suspected IgG4-RD in our facility between Jan. 2008 and Dec. 2013. We retrospectively studied the relation of serum IgG4 levels, pattern of FDG uptake, maximum standardized uptake value (SUVmax), pathological findings, and clinical course. Results We diagnosed 27 patients with IgG4-RD or other diseases. There were nine cases in which FDG-PET/CT was the only modality indicating a disease site for biopsy. Other diagnoses included lymphoma, Castleman9s disease, and tuberculosis. There was no correlation between serum IgG4 and SUVmax, but there was a correlation between SUVmax and histopathological findings. Conclusions FDG-PET/CT is useful in selecting a biopsy site for the pathological examination of tissue that is necessary to diagnose or exclude IgG4-RD. Its regular use has the potential to improve the diagnostic rate of this entity. References Umehara H, Okazaki K, Masaki Y, et al. Comprehensive diagnostic criteria for IgG4-related disease (IgG4-RD), 2011. Mod Rheumatol. 2012 Feb;22(1):21-30. Ebbo M. Usefulness of 2-[18 F]-fluoro-2-deoxy-D-glucose Positron Emission Tomography/Computed Tomography for Staging and Evaluation of Treatment Response in IgG4-Related Disease: A Retrospective Multicenter Study. Arthritis Care Res. 2014 Jan;66(1):86-96. Nakatani K. Utility of FDG PET/CT in IgG4-related systemic disease Clin Radiol. 2012 Apr;67(4):297-305. Nguyen VX. Usefulness of PET/CT Imaging in Systemic IgG4-related Sclerosing Disease. A Report of Three Cases JOP: Journal of the Pancreas. 2011 May 6;12(3):297-305. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3036

Introduction and Objectives Lung biopsy is frequently used in the management of children with chronic pulmonary disease to obtain a histological diagnosis. Previous studies have reported a high diagnostic yield and a low complication rate following lung biopsy in children. We set out to further evaluate the role of lung biopsy in this group of clinically challenging patients by reviewing our experience of this procedure. Methods A retrospective case-note review was carried out of all patients under 18 yrs who underwent a lung biopsy from 1998 to 2011. Data collected included age, mode of biopsy, histological findings, pre and post biopsy diagnosis, pre and post biopsy treatment, and complications of the procedure. Results Thirty three children (12 boys) underwent lung biopsy in the period studied. Their ages ranged from three months to 16 years (median 5 years 5 months). Five biopsies were obtained using a thoracoscopic approach, the remainder via thoracotomy. Following the procedure, 17 patients required ventilation on the intensive care unit for a median of two days. Eight children (24%) experienced a direct complication of the procedure. Seven required an intercostal drain for a pneumothorax, one a tension pneumothorax presenting six days post-operatively. The operative mortality was 12% (4/33). Three children (9%) died within 28 days of surgery, two due to progressive respiratory failure and one following pneumonia. One patient died three months post-operatively due to a persistent air leak from the biopsy site. Twenty-six (79%) biopsies provided a sample adequate for definitive histological diagnosis. In 16 (48%) children the working diagnosis and treatment was changed following lung biopsy. Conclusion Lung biopsy retains a place in the management of children with chronic pulmonary disease when there is diagnostic doubt. However it carries a significant morbidity and mortality which must be borne in mind when considering the need for histological diagnosis.

EDITOR—Among the possible drawbacks of sentinel node biopsy, discussed by Kell and Kerin,1 is the risk of false positive findings because of reactive lymph node swelling in the biopsy site. Periodic follow up of the sampled lymph node area has become a common practice after sentinel node …

Bone specimens were obtained from four different sites in the ilium of necropsy cases using a Jamshidi 8G trephine needle. Undecalcified histological sections were prepared and two structural histomorphometric parameters were estimated. Estimates of the percentage of trabecular bone volume (%TBV) deviated systematically, with variation of the biopsy site around the usual location, increasing in magnitude from the anterior to the posterior ilium. Such differences highlight the importance of understanding the degree of variation which exists in histomorphometric data. The histomorphometry of a vertical biopsy specimen of the iliac crest did not differ significantly from that of a transilial biopsy specimen of similar diameter taken from an adjacent site. When taken at the standard site, and when providing a long core of cancellous bone, with minimal discomfort to the patient, the vertical biopsy specimen compares well with the transiliac biopsy specimen for use for investigating metabolic bone disorders.

Transilial bone samples were obtained at necropsy using trephine instruments with internal diameters of 2 mm and 7 mm. Undecalcified histological sections were prepared and two structural histomorphometric variables (percentage of trabecular bone volume and surface density of bone) were estimated by a Quantimet 720 image analyser. The differences between the variables measured from the two adjacent cores were due to differences in biopsy site rather than the size of the sample. The smaller diameter needle is therefore recommended for use as the biopsy procedure is simpler and tissue sections can be prepared sooner than is the case with the larger needle.