Ultrasound-Guided Visceral Biopsies
Ultrasound-Guided VisceralB i o p s i e s : Renal and HepaticNirvikar Dahiya, MD, William D. Middleton, MD,Christine O. Menias, MD*KEYWORDS Ultrasound Biopsy Renal Hepatic Perivascular PseudoaneurysmKEY POINTS The basic approach to planning an ultrasound-guided biopsy is similar to performing any otherinterventional procedure. Visceral organ biopsies are being routinely done these days with excellent diagnostic results. Ultrasound is a safe and reliable imaging modality to provide guidance for the vast majority ofbiopsies. With good technique, these procedures have a very low complication rate.The authors have provided several related videos at uided percutaneous biopsy of visceral organs in the abdomen has been in effectfor many years. Paul Ehrlich is credited with performing the first percutaneous liver biopsy in1883 in Germany.1 Schüpfer2 in 1907 publishedthe first liver biopsy series. Huard and Baronpopularized liver biopsy for general purposes inthe1930s. Some of the more contemporary articles reporting ultrasound-guided procedureswere written in 1972 by Goldberg and Pollack.3The basic approach to planning an ultrasoundguided biopsy is similar to performing any other interventional procedure. However, there are certaincomplexities specific to biopsy of the liver andkidney that are addressed in this article.Indications for a Liver BiopsyThe indications for doing a liver biopsy are outlinedin Box 1. A liver biopsy gives invaluable information regarding the staging, prognosis, andmanagement even if clinical, laboratory, orimaging tests point to a specific focal or diffuseliver disease. Serial liver biopsies may help tomonitor effects of specific therapy or to identifyrecurrence of disease.4Preparation for a Liver BiopsyThe preparation of a liver biopsy constitutes themajor portion of the work needed to executea successful biopsy. The actual act of directingthe needle to the target region and collecting thespecimen only constitutes a small component ofthe procedure itself. A thorough history taking isimperative before the initiation of the biopsy.With this, the exact clinical question can be understood and the correct biopsy technique (fineneedle aspiration [FNA] vs core needle biopsy)determined; accordingly, the proper needle typeand gauge can be selected. For instance, inpatients with diffuse liver disease and a coexistingmass, it may be necessary to biopsy the mass(for diagnosis), the liver parenchyma (as part ofpreoperative surgical workup), or both dependingSection of Abdomen Imaging, Mallinckrodt Institute of Radiology, Washington University, 510 SouthKingshighway, St Louis, MO 63110, USA* Corresponding author.E-mail address: meniasc@mir.wustl.eduUltrasound Clin 7 (2012) 2/ – see front matter Ó 2012 Elsevier Inc. All rights reserved.ultrasound.theclinics.comLIVER BIOPSY
364Dahiya et alBox 1Indications for liver biopsyDiffuse hepatocellular diseaseAlcoholic liver diseaseNonalcoholic hepatic steatosisAutoimmune hepatitisGrading and staging of chronic hepatitis C orchronic hepatitis BHeavy metal storage disorders such as hemochromatosis and Wilson diseaseCholestatic liver diseases such as primary biliarycirrhosis and primary sclerosing cholangitisAbnormal liver function testsEvaluation of efficacy or adverse effects ofdrugs such as methotrexateFever of unknown originHepatosplenomegaly of unknown originLiver transplant rejectionFocal liver diseasePrimary hepatocellular carcinoma,CholangiocarcinomaMetastatic diseaseIndeterminate masson the clinical situation. In patients with multiple livermasses, prior workup may point to specific lesionsthat are worrisome and others that are clearlybenign. If the patient had undergone positron emission tomography/computed tomography (PET-CT)as part of the workup, it is important to makea good anatomic correlation between the hypermetabolic lesion seen on the PET-CT and ultrasound examination. Some of the newer ultrasoundequipments allow for fusion imaging, whereby anoverlaying of the CT, magnetic resonance imaging,or PET can be done with the ultrasound examinationto accurately identify the target.5Once the clinical question has been understood,the prebiopsy workup includes evaluation of thebleeding profile of the patient and a detailed reviewof current medications taken by the patient. At ourinstitution, we routinely obtain international normalized ratio (INR), platelet count, prothrombin time,and partial thromboplastin time (PTT). Our guidelines include performing a biopsy when INR is lessthan 1.5 and the platelet count is greater than70,000/mL. Some institutions take a count of platelets of 50,000/mL as the minimum requirement.6If the INR is greater than 1.5 or if the platelets areless than 70,000/mL, a transfusion of platelets and/or fresh frozen plasma can be considered dependenton the clinical evaluation. The decision to proceedcan then be based on the location of the mass orthe general condition of the patient.Once the bleeding profile has been evaluated, it isimportant to review all the medications the patient istaking. Some patients may be on long-term anticoagulation or antiplatelet therapy, including aspirin,warfarin, clopidogrel bisulfate (PLAVIX; BristolMyers Squibb [New York, NY, USA]/Sanofi Pharmaceuticals [Bridgewater, NJ, USA]), and heparin.The referring physician must then determine if therisk of discontinuing the medicines is worse thanthe increased risk of bleeding related to the biopsy.If the medications are to be discontinued, wefollow the guidelines listed in Table 1 to determinethe period of time they are withheld. Regardingsubcutaneous heparin, the liver biopsy can be performed if the PTT is within normal limits. Readersare advised to consult with their respective hematologic and clinical departments to ascertainguidelines for coagulation parameters and management of time for holding anticoagulants beforedoing a biopsy. Many times such decisions aremade on a case-by-case basis.An informed consent is obtained before proceeding with the biopsy. An allergy history to latexgloves and lidocaine is established at this time. Allthe steps of the procedure are explained to thepatient in detail so that there are no surprisesduring the procedure itself.Procedure of Doing the Liver BiopsyA critical component of the procedure is choosingan approach for a liver biopsy. The ideal approachwould be to find the shortest course to the target,avoiding lung, diaphragm, and all the vascularstructures. However, this is not always possible.For a random liver biopsy, we prefer targetingthe peripheral right hepatic lobe. This region isTable 1Guidelines for management of anticoagulantsbefore a visceral organ biopsySuggested Periodof DiscontinuitySuggested Time Frame forRestarting MedicationCoumadin: 5–7 dResume the day of theprocedureResume the next dayResume the next dayResume drip 12 h afterprocedureResume 12 h afterprocedurePlavix: 7 dTiclid: 10 dHeparin Drip: 6 hLovenox: 12 h
Ultrasound-Guided Visceral Biopsiesremote from the central hilar vasculature, anda tamponade effect can be achieved on completion of the biopsy by having the patient to lie inright lateral decubitus position. If a good subcostalwindow is available, it is our first preference.However, in most cases an intercostal approachis performed, in which the needle traverses thediaphragm and pleural space. Care should betaken to avoid the aerated lung. For this reason,we generally position the needle inferior to thetransducer, so that shadowing from the lung canbe visualized and avoided before the needle isadvanced into the liver. When using the intercostalapproach, the needle is directed over the ribs asthe vascular bundle courses along the inferioredge of the ribs (Fig. 1).A random biopsy of the left hepatic lobe is performed when the right hepatic lobe is not feasible.In most cases, the lateral section of the left lobe istargeted in a manner such that the left portal veinand artery can be avoided. Color Doppler is usedas a mapping tool for all our biopsies.Care is taken to minimize the risk of bleeding bytrying to take the maximum length of the coretissue in the first pass. In cases in which the biopsyis of a target lesion within the liver, many have suggested choosing a biopsy path that coursesthrough a part of the normal liver before reachingthe target. Although there are no studies to proveit, this approach presumably helps with the tamponade effect if there is any bleeding from the targetlesion after the biopsy (Fig. 2). It also may havea role in preventing seeding. We believe that theremay be some justification to this approach, but wedo not hesitate to biopsy lesions on the surface ofthe liver if they are substantially easier to reachthan the deeper lesions.Needles are categorized as aspiration- orsuction-type needles (Menghini needle, Klatskinneedle, Chiba needle, and Jamshidi needle) andcutting-type needles (Vim-Silverman needle andTru-cut needle). The cutting-type needles canalso be spring loaded. Most visceral core biopsiesare now performed with spring-loaded needles.These needles can be further classified as sidenotch or end cutting (Figs. 3–6).They can also be classified as automatic orsemiautomatic. The semiautomatic needles allowone to manually advance the side-notch needleinto the target. The biopsy is performed if the operator is satisfied with the placement of the notch inthe target. The automatic needle obtains the corewithout providing the option of manual advancement. With this type of needle, it is critical tomake accurate measurements of the target sizeto select an appropriate predefined length forcore biopsy. The end-cutting needles used in ourdepartment yield full core specimens at lengthsof 1.3, 2.3, or 3.3 cm, whereas the semiautomaticside-notch needle yields a partial core specimen ata length of 1 or 2 cm. This can vary depending onthe biopsy device manufacturers. If the biopsydevice that is chosen has a loud clicking soundwhile performing the procedure, it is best tomake patients aware of this so that they do notget startled during the procedure when they hearthe sound. In terms of guidance, the choice isbetween using a mechanical guide attached tothe transducer and freehand guidance. The freehand technique requires more experience buthas the distinct advantage of maneuverability,especially when subtle changes are required indirection or angle.Choice of transducer used to guide the needle isalso important. Provided visualization of the targetand adjacent vessels is adequate, phased arraytransducers have many advantages becausethey are small and easy to maneuver, especiallywhen using an intercostal approach. Linear arraytransducers provide the advantage of betterFig. 1. Liver biopsy technique. (A) Longitudinal view of the liver and lung interface showing the potential dangerof puncturing lung when performing biopsy via a superior approach. (B) Corresponding ultrasound image showsa bright reflection and dirty shadow arising from the aerated lung (L). Performing the biopsy from this trajectoryrisks potential lung puncture and pneumothorax. Arrows indicate the potential trajectories for liver mass biopsy.365
366Dahiya et alFig. 2. Liver biopsy technique. (A) Transverse view of the right lobe of the liver showing a large liver metastasis.(B) Magnified high-resolution view of the medial aspect of the lesion showing a preferred needle trajectory totraverse normal liver parenchyma before entering the mass.Fig. 3. Side-notch needle. (A) Side-notch needle in cocked position before biopsy of a focal lesion, (B) partiallydeployed position, and (C) fully deployed position.Fig. 4. Side-notch needles. (A) Side-notch needle in cocked position and (B) deployed position.Fig. 5. Full-core needle. (A) Full-core needle in cocked position, (B) partially deployed position, and (C) fully deployed position.Fig. 6. Full-core needle. (A) Full-core needle in cocked position and (B) fully deployed position.
Ultrasound-Guided Visceral Biopsiesvisualization if the target is superficial (ie, withinapproximately 5 cm of the skin surface). Curvedarray transducers provide an intermediate choicewhen lesions are too deep for a linear array, andvisualization is inadequate with a phased array.The major disadvantage of curved arrays is theirlarger size, which makes them more clumsy tomaneuver. Generally, we prefer lining up ourbiopsy needle along the side of the transducer,so that we can see the entire shaft of the needleas we approach the target (Fig. 7).The sterile biopsy tray we use for a biopsyprocedure includes1. 10 mL of 1% lidocaine buffered with 8.4%sodium bicarbonate2. 25-gauge 30-mm needle3. 4 4 gauze pack4. Scalpel #11 blade5. 5-mL syringe6. 25-gauge 5/8-in needle for superficialanesthesia7. Applicator prep, gloves, and sterile drapes.We perform most of our biopsies under localanesthesia, using 1% lidocaine mixed with sodiumbicarbonate. The shorter 25-gauge 5/8-in needle is used to inject lidocaine for superficial intradermal anesthesia after the patient has beencleaned and draped in a sterile manner. For deeper anesthesia, we use the 25-gauge 30-mmneedles to introduce more lidocaine. Deeper anesthesia is injected under ultrasound guidance todetermine the proper trajectory for the biopsyand to ensure that the anesthesia is injecteddeep enough to numb the capsule of the viscera,be it the liver or the kidney.Moderate sedation or conscious sedation isusually not necessary for routine liver biopsies;however, there are institutions that may typicallyFig. 7. Freehand biopsy technique. Biopsy needle ispositioned in the plane of the image, immediatelynext to the side of the transducer. This allows for visualization of the needle tip and shaft throughout theprocedure.use fentanyl (Sublimaze) and midazolam (Versed).If moderate sedation is used, special credentialingand privileging to perform sedation may berequired.7It helps to give a little extra 1% lidocaine at thecapsule (Fig. 8). At times, it helps to inject enoughso as to cause a slight bump in the contour of theparietal peritoneum; this serves as a landmark forthe entry point of the biopsy needle.Once the local anesthesia has been satisfactorily injected, we observe the relation between thebiopsy target and the patient’s breathing to determine if the biopsy will be done with the patientholding his/her breath in normal or deep inspirationor normal expiration. We usually ask the patient topractice a couple of breath-holds at this time toascertain the best position of the target lesion forthe biopsy. When possible, we prefer normal expiration because this is more reproducible than deepinspiration and it raises the location of lung parenchyma. However, this expiration may not bepossible in patients who are short of breath.For core biopsies, local anesthesia is followedby a small nick in the skin with a surgical blade.This is important because it can sometimes bedifficult to advance core needles through theskin. The core needle we like to use is usually thespring-loaded 18-gauge needle. For liver biopsies,we most often use the end-cutting needle thatyields a full core specimen at lengths of 1.3, 2.3,or 3.3 cm. When a focal lesion is near majorvessels, a semiautomatic side-notch needle thatyields a partial core specimen at a length of 1 or2 cm may be preferable. In both cases, the needleis introduced to the capsule surface; patients arethen asked to hold their breath and the needle isFig. 8. Liver capsule numbing. Needle shaft and tip(arrows) are positioned such that anesthesia administered is at the level of the liver capsule (arrowheads).367
368Dahiya et alintroduced into the liver. In most cases, if thetrajectory has been well planned and the needleis well visualized, the needle can be advanced tothe lesion and a sample can be obtained ona single breath-hold.The throw of the needle depends on the locationand size of the lesion and the distribution ofadjacent vessels. It is important, however, toremember that a throw setting of 10 or 13 mm typically results in a sample that is several millimetersshorter. So, if safe, it is best to avoid these shortthrows. For random liver biopsies, we mostly usethe 3.3-cm throw.For FNA, we use either a 25-gauge spinal needleor a 23-gauge Chiba needle. In both cases, weprefer introducing the needle with the stylet insideto avoid contaminating the lumen with extraneouscells and to ensure that the needle has some tensilestrength to maneuver. Once the needle tip hasreached the target, the stylet can be removed andthe process of taking the FNA sample can begin(Fig. 9). Typically, we do the first aspiration withoutsuction. Subsequent aspirations are performedwith or without suction depending on the yield ofthe initial pass. Although we prefer making multipleseparate passes, sometimes successful andconsistent needle placement may be very difficult.In these cases, coaxial technique can be performed,7 wherein an introducer is initially deployedinto the target area and subsequent sampling canbe done coaxially through it. Although a distinctadvantage of the coaxial technique is the singlepuncture through the liver capsule, it is somewhatoffset by the increased risk of capsule shearing ortearing as the needle stays in for a longer periodwhile the patient breathes.The choice of performing an FNA biopsy ora core biopsy depends on the clinical scenario.In a patient with a known extrahepatic primarycancer in whom the only reason to perform a liverbiopsy is to prove the presence of metastaticdisease, we would do an FNA. If immediate onsite cytologic analysis is possible, aspirations areperformed until a diagnostic sample is obtained.If the initial aspiration result is positive for malignancy and correlates with the primary tumor, noadditional aspirations are required. If the initialspecimens are negative for malignancy or suggestan alternative primary, then additional aspirationsor core biopsies are obtained. If only semiimmediate off-site cytologic analysis is possibleor if there is no cytologic support, several passes(3–6) should be obtained before terminating theprocedure.Fig. 9. FNA. A 55-year-old woman with a history of pancreatic cancer. Small liver mass in the patient with a historyof pancreatic cancer and a suspicious lesion seen on CT. (A) Contrast-enhanced CT scan of the liver showing a smalllow-attenuation lesion in the liver (arrow). (B) Transverse sonogram of the liver shows a 9-mm solid hypoechoiclesion (cursors) corresponding to the lesion seen on CT. (C) Image obtained from a real-time cine clip taken duringFNA shows the tip of a 25-gauge spinal needle (arrow) within the lesion. Needle shaft location (arrowheads) wasmore apparent during real-time imaging.
Ultrasound-Guided Visceral BiopsiesDespite the presence of a known extrahepaticprimary tumor, if immunohistochemical studiesare anticipated, we typically do a core biopsyrather than an FNA. A core biopsy providesenough tissue for hematoxylin-eosin as well asimmunohistochemical staining. Additional sections can be taken from the paraffin block of thecore biopsy to stain for immunohistochemistrymarkers such as estrogen receptor, progesteronereceptor, and HER2/neu.If the clinical history or prior imaging resultssuggest a primary malignant or benign liver tumor,we generally perform core biopsies with an 18gauge needle (Fig. 10).If hepatocellular cancer is confirmed, it ispermissible to start with FNA and get preliminaryanalysis from the respective cytopathologist. Ifthe diagnosis of hepatocellular cancer is confirmed after 1 to 3 passes, no further aspirationsare necessary. But if the initial aspiration resultsare negative or nondiagnostic, cores become necessary. In patients with suspected hepatocellularcancer and tumor thrombus of the portal orhepatic vein, it is possible to confirm the diagnosisand assist with staging by performing FNA
Ultrasound is a safe and reliable imaging modality to provide guidance for the vast majority of biopsies. . Some of the newer ultrasound equipments allow for fusion imaging, whereby an overlayingoftheCT, magnetic resonance imaging, . Primary hepatocellular carcinoma, Cholangiocarcinoma Metastatic disease Indeterminate mass
Three-dimensional ultrasound, may be acquired and displayed over time. This is variously known as 4D ultrasound, real-time 3D ultrasound, and live 3D ultrasound. When used in conjunction with 2D ultrasound, 3D ultrasound has added diagnostic and clinical value for select indications and circumstances in obstetric and gynecologic ultrasound.
Australasian Society for Ultrasound in Medicine Arterial spectral Doppler waveforms Tumour angiogenesis New technologies in ultrasound Fetal ultrasound video compression algorithm Quality of compressed ultrasound video ISSN 1441-6891 ULTRASOUND BULLETIN ASUM Multidisciplinary Ultrasound Workshop 2006 Gold Coast 24-25 March 2006
Blind versus guided glenohumeral joint injection. A guided injection is more accurate. Patients prefer ultrasound to fluoroscopy and there is the added benefit of no radiation, no claustrophobia, lower cost and decreased procedure time. Ultrasound guided injections confer added benefit especially in the first 2 weeks.
THE ROLE OF OBSTETRIC ULTRASOUND IN PRIMARY HEALTH CARE AT A SECONDARY HOSPITAL IN SOUTH AFRICA. . Antenatal Ultrasound. 9 3. Routine Ultrasound. 9 Section II. _High Risk Pregnancies , 12 . Clinical Indications for Ultrasound Scans .49 Chart 9: Centres From Where the Patients came to Ultrasound 50 .
United States2 (lCDA-8), with some modifications. In this report, the term “sprgery” includes biopsies and . Biopsies of breast and female genital organs ac-counted for 48 percent of all biopsies on women. . the number of female patients hospitalized for surgery in 1978 was approximately 29.7 percent
Key words: ultrasound phantoms, ultrasound-guided procedural skills. Introductıon Ultrasound (US) guided nerve blocks, cricothyroid punctures and vascular cannulations require, for safety reasons, initial training in animal models or phantoms. In-vitro models can facilitate learning of scanning techniques and hand-eye coordination skills.
ultrasound injection, whereas 1 was uncertain. The injection was successful in 202 of the first 206 patients (98%) to undergo ultrasound injection, whereas 4 patients required a second pass for a successful injection. Discussion Our data clearly show that ultrasound-guided office-based intra-articular injection of the hip is an effective
Joanne Freeman – The American Revolution Page 3 of 265 The American Revolution: Lecture 1 Transcript January 12, 2010 back Professor Joanne Freeman: Now, I'm looking out at all of these faces and I'm assuming that many of you have
