Low Diagnostic Yield With Second Biopsies in Suspected Giant Cell Arteritis

Danesh‐Meyer, Helen V.; Savino, Peter J.; Eagle, Ralph C.; Kubis, Kenneth C; Sergott, Robert C.

doi:10.1097/00041327-200020030-00011

Cited by 85 publications

(41 citation statements)

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“…The most symptomatic artery is usually selected for biopsy and is most likely to show evidence of pathological findings. In some centres, it has previously been a routine procedure to sample both temporal arteries in suspected cases, but the value of bilateral testing is relatively low, 44 with only one of 91 bilateral biopsies showing discordance. In a recent study of 132 cases undergoing bilateral biopsies, the diagnostic yield increased by 12.7% 45 as a result of the second simultaneous biopsy (38 patients had bilateral findings of GCA, compared with an additional 13 patients whose biopsies showed abnormalities confined to one side only).…”

Section: Diagnosis Of Giant Cell Arteritis Relying On a Gold Standardmentioning

confidence: 99%

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

386

404

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Background Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases. Objective To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. Design Prospective multicentre cohort study. Setting Secondary care. Participants A total of 381 patients referred with newly suspected GCA. Main outcome measures Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. Results We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). Limitations There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. Conclusion We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. Future work Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. Funding The National Institute for Health Research Health Technology Assessment programme.

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Section: Diagnosis Of Giant Cell Arteritis Relying On a Gold Standardmentioning

confidence: 99%

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

386

404

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“…Danesh-Meyer et al report a concordance rate of 98.9% (38/39 positive biopsy results) within the positive biopsy results. When combined with 7 previous studies on bilateral TA biopsies, the pooled concordance rate of 96% indicates that there is a 4% chance that a unilateral biopsy alone will fail to yield the correct diagnosis (Danesh-Meyer et al, 2000). While there are no criteria that specifically address this decision-making point, certain features such as jaw claudication, new-onset headache, pallid optic disc swelling, or high ESR would make the diagnosis of GCA more likely (Danesh-Meyer et al, 2000).…”

Section: Temporal Artery Biopsymentioning

confidence: 96%

Giant Cell Arteritis

Tehrani

Ostrowski

Hariman

et al. 2008

Seminars in Ophthalmology

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This review summarizes the diagnosis, clinical manifestations and management of giant cell arteritis. Giant cell arteritis is an immune-mediated vasculitis of medium to large sized arteries that affects individuals older than the age of 50. Patients typically present with signs of vascular insufficiency of the extracranial arteries of the head and systemic inflammation. Temporal artery biopsy remains the hallmark of diagnosis. Specific treatment regimens must be tailored to each individual, but steroids remain the backbone of therapy.

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“…It is common practice to recommend a second biopsy only in cases in which the clinical presentation is still consistent with TA and is unexplained by another diagnosis. Danish-Meyer et al [56] and Pless et al [57] agree that there is a high concordance rate between the right and left temporal arteries and biopsy of the contralateral artery increases the chance of a positive result only minimally.…”

Section: Diagnostic Evaluationmentioning

confidence: 97%

Recent advances in temporal arteritis

Redillas

Solomon

2003

Current Science Inc

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Temporal arteritis was first described in the late nineteenth century. Despite considerable progress in understanding the disease, its rarity in the young and in those who are not of Scandinavian ethnicity remains unexplained. Microbiologic agents and immunologic mechanisms have been implicated as causative factors. Although steroids remain the drug of choice, the use of other immunologic therapies has been proposed. This paper reviews the disease's history, probable etiologies, clinical manifestations, and its diagnostic and treatment challenges.

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Low Diagnostic Yield With Second Biopsies in Suspected Giant Cell Arteritis

Cited by 85 publications

References 0 publications

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Giant Cell Arteritis

Recent advances in temporal arteritis

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