Joao G. Amaral

Image-guided percutaneous biopsy of musculoskeletal lesions in children

BackgroundPercutaneous core needle biopsy (PCNB) of musculoskeletal lesions can provide early and definitive diagnosis and guide decisions on management. The technique is less invasive than open biopsy and has a low complication rate.ObjectivesThe purpose of this study was to assess the diagnostic accuracy and safety of image-guided PCNB of musculoskeletal lesions in children.Materials and methodsRetrospective review of the medical records of patients referred for PCNB of musculoskeletal lesions was performed. Data collected included tumor type and complication rates. Lesion “hit” or “missed”, and core adequacy and ability to reach a definitive pathological diagnosis were reviewed and used to determine whether the biopsy was overall successful or unsuccessful.ResultsA total of 127 biopsies were performed in 111 patients. Of the 127 PCNB procedures, 114 “hit” the lesion and 13 “missed,” and 120 of the cores provided for analysis were deemed adequate for pathological interpretation and 7 were deemed inadequate. A definitive pathological diagnosis was possible in 97 of the 127 PCNB preocedures and not possible in 30. Overall 76% of the PCNB procedures were successful. The diagnostic success of biopsy in primary malignant tumors was significantly higher (92%) than in primary benign tumors (65%; P = 0.008). Six minor complications resulted from PCNB.ConclusionThis study showed that PCNB is accurate and safe for the diagnosis of musculoskeletal lesions in pediatric patients, and its results are comparable to those in adult studies.

Influence of arm movement on central tip location of peripherally inserted central catheters (PICCs)

BackgroundPICCs are increasingly employed in children. Some of their risks relate to the location of the central tip. Despite care when placing lines, they sometimes move.ObjectiveTo evaluate the influence of arm movement on the central tip location of PICCs placed in children.Materials and methodsThe central tip location of PICCs was studied in 85 children, with the arm placed in six positions. The variables of side, vein, site and arm position were examined to measure the direction and range of tip movement.ResultsThe side, site or vein used did not influence the range of movement of the central tip. Change in position of the arm had a significant influence on the central tip location, moving it an average of 2.2 rib spaces, a maximum of 3.5 ribs. Elbow bending and adduction of the arm caused the central tip to move deeper into the chest, compared to when the arm was straight and abducted 90°.ConclusionArm position is the significant variable influencing PICC movement. Side, site and vein do not influence the range of movement significantly. Most PICCs descend deeper into the chest with arm adduction and elbow bending.

Sonographically Guided Percutaneous Liver Biopsy in Infants: A Retrospective Review

OBJECTIVE The purpose of our study was to assess the technical success and complication rate of sonographically guided percutaneous liver biopsies performed in infants under 1 year old at a tertiary pediatric center. MATERIALS AND METHODS Retrospective analysis of 65 biopsies performed in 61 infants between January 1999 and December 2003 was conducted. Data collected included patient demographics; details of the biopsy procedure including indication, needle type and size, number of passes, and samples; pathology results; and procedure-related complications. RESULTS The 61 infants studied included 37 males and 24 females with a mean age of 119 days (age range, 7-348 days; median age, 83 days) and a mean weight of 4.5 kg (1.9-8.3 kg). A total of 65 biopsies were performed in these 61 infants. General anesthesia was used in 66.1% of procedures. An 18-gauge needle was used in 47 (72.3%) procedures. Coaxial technique was used in seven procedures, and five biopsy tracts were embolized. In 63 of 65 procedures, the mean number of passes was 1.8. In two procedures, using a coaxial technique, 11 and 12 passes were made. One biopsy was considered technically unsuccessful, and 64 of 65 (98.5%) of the biopsies provided adequate tissue for pathologic analysis. There were three (4.6%) major complications related to bleeding: one requiring a blood transfusion, one requiring surgery, and one arteriobiliary fistula requiring transarterial embolization. Three (4.6%) minor complications also occurred. There were no deaths. CONCLUSION Sonographically guided percutaneous liver biopsy in infants is a good and effective diagnostic tool. The complication rate, however, even when performed by an experienced physician, is not insignificant in this age group of patients.

Peripherally Inserted Central Catheters: Use at a Tertiary Care Pediatric Center

PURPOSE To examine the use of peripherally inserted central catheters (PICCs) in a tertiary care pediatric setting. MATERIALS AND METHODS An observational study of use and referral practices for PICCs in a tertiary care pediatric setting was performed with three distinct approaches: (i) in an institutional overview of trends, data from 2001 to 2012 were initially analyzed to identify high-level trends; (ii) an in-depth analysis of PICC referrals during 1 year was performed to determine details of referral patterns and clinical practices; and (iii) an electronic survey of the perception and understanding of referring clinical staff was conducted. RESULTS During the past decade, there has been a steady increase in the number of PICC insertions and a decrease in median PICC dwell times. Discrepancies were identified between the anticipated versus actual dwell times. A large proportion of patients was found to have multiple PICC insertions, short dwell times, and premature PICC removals, potentially resulting in increasing risks of short- and long-term complications. Large percentages of the staff respondents valued the role of PICCs and had a good understanding of short-term complications, but underestimated the scale of the PICC service (numbers placed, resources involved) and several long-term complications associated with PICCs. CONCLUSIONS The number of PICCs inserted in children is increasing while PICC dwell times are decreasing. Better postprocedure care is important to minimize premature removals and avoid repeat insertions. Associated complications are not fully appreciated by the referring pediatricians. Further education and guidelines are needed.

CT Characteristics of Lung Nodules Present at Diagnosis of Extrapulmonary Malignancy in Children

OBJECTIVE The purpose of this study was to evaluate the CT characteristics of lung nodules present at diagnosis of extrapulmonary malignancies in children. MATERIALS AND METHODS We performed a retrospective analysis of CT images of children seen in our oncology service over a 6-year period. We included all children diagnosed with a non-CNS solid extrapulmonary malignancy or lymphoma who had also undergone chest CT at presentation. Images were reviewed for the presence of lung nodules; if present, the following nodular characteristics were recorded: sidedness, number, distribution, CT attenuation, shape, margins, calcification, and size. When available, pathology results were correlated with the nodules found on CT. RESULTS One hundred eleven infants and children (age range, 14 days-17 years 10 months; median age, 11 years 8 months) had lung nodules on CT. The nodules showed a variety of patterns, but the most common findings were bilateral lung nodules (71 of 111 patients), between two and 10 in number (60 patients), peripheral distribution (98 patients), < or = 5 mm (48 patients), oval shape (45 patients), solid attenuation (74 patients), smoothly marginated (91 patients), and noncalcified (107 patients). Twenty-seven patients underwent biopsy. Seventeen biopsies showed benign lesions and nine, malignant lesions; the results for the remaining biopsy were inconclusive. In the subgroup of lung nodules that underwent biopsy, none of the CT characteristics was able to differentiate benignity from malignancy. CONCLUSION Lung nodules in children with extrapulmonary malignancies showed a variety of patterns on CT. In the subgroup of lung nodules that underwent biopsy, none of the nodule features studied on CT reliably differentiated benignity from malignancy.

Imaging-guided percutaneous needle aspiration or catheter drainage of neonatal liver abscesses: 14-year experience.

OBJECTIVE The purpose of our study was to review the clinical aspects and long-term outcomes of imaging-guided percutaneous aspiration or drainage of liver abscesses in neonates. MATERIALS AND METHODS We retrospectively reviewed the clinical and imaging records of eight neonates with liver abscesses referred for imaging-guided percutaneous aspiration or drainage, including one autopsy-proven case in whom the percutaneous aspiration or drainage was not performed. Clinical and imaging features, complications, and long-term follow-up results were assessed. RESULTS Eight neonates with liver abscesses were referred for imaging-guided percutaneous aspiration or drainage (five males, three females; age range, 7-100 days; weight, 610-3,400 g). Six were born prematurely (24-29 weeks of gestation). Six had a history of umbilical catheterization. All were clinically septic. All neonates received long-term i.v. antibiotics. Five neonates had solitary multiloculated abscesses (right lobe [n = 3], straddling both lobes [n = 2]), and three had solitary uniloculated abscesses (right lobe [n = 1] and left lobe [n = 2]). Imaging-guided drainage catheter insertion (n = 4), aspiration (n = 2), and aspiration followed by drainage catheter insertion (n = 1) were performed in seven neonates within 1 day after referral. Coagulase-negative Staphylococcus (4/8) was the most common organism isolated from blood and pus. There were no procedure-related complications. Catheter repositioning was required in one. Serial sonography (mean, 12.5 months) and clinical follow-up (mean, 20.7 months) showed complete clinical remission in seven cases. Three healed with calcification in the previous abscess site. Long-standing left portal vein thrombosis was seen in two cases. CONCLUSION Neonatal liver abscess is associated with good long-term outcome and minimal complications when imaging-guided percutaneous aspiration or drainage is performed in conjunction with long-term antibiotic coverage.

Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg.

PURPOSE To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children. MATERIALS AND METHODS Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis. RESULTS PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001). CONCLUSIONS Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.

Fluoroscopy-guided Topical Application of Mitomycin-C in a Case of Refractory Esophageal Stricture

Esophageal strictures refractory to conservative treatment (balloon dilation, bouginage) are difficult to manage. Recently, some investigators reported great success using endoscopy-guided topical application of mitomycin-C to prevent scar formation and restenosis in children with benign esophageal strictures unresponsive to balloon dilation. Herein, the authors report a fluoroscopic approach for topical application of mitomycin-C in a case of refractory esophageal stricture after surgical repair in a child with congenital esophageal atresia. This technique is a feasible alternative to endoscopic techniques.

Complex Combined Vascular Malformations and Vascular Malformation Syndromes Affecting the Extremities in Children

Complex combined vascular malformations affecting extremities are an interesting group of vascular malformations because, in addition to the vascular channel anomalies present, they can be associated with other tissue changes and sometimes altered limb growth. At present, magnetic resonance imaging is the gold standard imaging tool to evaluate such complex conditions in children because of its inherent tissue specificity and vascular capabilities that enables characterization of tissues and the vascular channel anomalies both for diagnosis and management of the patient. A brief review of some of these conditions is presented, including Klippel-Trénaunay syndrome, Parkes Weber syndrome, extensive diffuse low-flow venous malformations, Bannayan-Riley-Ruvalcaba syndrome, cutis marmorata telangiectatica congenita, Maffuccis syndrome, and Gorham-Stout disease.

Peripherally inserted central catheters for long-term parenteral nutrition in infants with intestinal failure.

Background and Aim: Infants with intestinal failure often require long-term central access for delivery of parenteral nutrition (PN). Traditionally, surgically placed central venous catheters (CVCs) have been used; however, the complications associated with these catheters can lead to significant morbidity. Peripherally inserted central catheters (PICCs) are potentially superior to CVCs because they tend to be smaller, and can be placed without general anesthesia. The purpose of the study is to report the use of PICCs for long-term administration of PN in infants with intestinal failure and compare with previously published catheter infection and venous thrombosis rates. Methods: A 4-year review of infants younger than 12 months with intestinal failure and a PICC for PN delivery was performed to determine the incidence of catheter-related bloodstream infections (CRBSIs) and PICC-associated venous thrombosis. The complication rates were compared with those reported for CVCs and PICCs in the pediatric literature. Results: A total of 45 infants with intestinal failure, receiving PN through a PICC were included in the study. Data from 95 PICCs accounting for 10,189 catheter days were collected. The overall incidence of CRBSI was 5.3/1000 catheter days and the incidence of venous thrombosis was 2.0/1000 catheter days. Conclusions: PICCs offer an advantage over CVCs in that they can often be inserted without a general anesthesia and do not require manipulation of the vein. Given the low rate of CRBSI and venous thrombosis, we recommend PICCs for infants with intestinal failure requiring PN.