Ultrasound-Guided Biopsies of the Abdomen Nadia Juliet Khati, MD, Joseph Gorodenker, MD, and Michael C

REVIEW ARTICLE

Ultrasound-Guided Biopsies of the Abdomen Nadia Juliet Khati, MD, Joseph Gorodenker, MD, and Michael C. Hill, MB

tomography (CT) is that it is portable, allows real-time visu- Abstract: Ultrasound is the most useful imaging technique for guid- alization of the biopsy needle and its tip, is less expensive, and ing biopsies and fine-needle aspirations that are performed percu- most importantly does not use ionizing radiation.4 Its greatest taneously. It is a safe and accurate method to guide needles using disadvantage is that that it is more operator dependent. Also, real-time imaging into abdominal and pelvic organs and masses. Its some lesions or organs are difficult to see and may not be advantages over computed tomographyYguided biopsies are that it amenable to biopsy because of the patient’s body habitus or can be done portably, is less expensive, and does not use ionizing intervening structures such as air or bone. In those cases, CT radiation. Even lesions as small as 1 cm can be biopsied assuming the guidance might be preferable. procedure can be performed safely and the mass can be visualized The component parts in performing a biopsy are as sonographically. follows: This review article discusses the different components of per- 1. Review the clinical indications for performing the biopsy forming percutaneous biopsies in adult patients including review of to make sure it is indicated. Look at prior imaging studies the patients imaging studies, coagulation status, and medications. We if available to ascertain if the biopsy can be performed explain when and how we do core biopsies versus fine-needle aspi- safely using ultrasound guidance. rations to obtain a diagnosis depending on the suspected diagnosis 2. Ensure the coagulation status of the patient is within a and organ/mass being biopsied. We also describe how we take care range that allows the biopsy to be performed safely. If not, of the patient after biopsy. consult with the patient’s physician, including a hema- Ultrasound can be used safely and successfully to perform biop- tologist if necessary, to see if the abnormal values can be sies and fine-needle aspirations in solid organs of the abdomen and corrected. pelvis including the retroperitoneum and abdominal wall. This tech- 3. Properly obtain informed consent. nique allows adequate tissue sampling with real-time monitoring du- 4. Perform the biopsy following the appropriate administra- ring placement of the biopsy needle. Postprocedure complications are tion of local anesthesia. extremely rare with the vast majority of our patients requiring only a 5. Perform care of the patient after biopsy. short recovery time of 2 hours following the biopsy. 6. Review quality assurance of pathology reports to deter- Key Words: ultrasound, biopsy, fine-needle aspiration, mine the percentage of failed biopsies. ultrasound-guided biopsies, biopsy abdomen, biopsy pelvis Coagulation Status of the Patient (Ultrasound Quarterly 2011;27:255Y268) In this section of the article, we describe our approach to screening patients by obtaining coagulation status before all of our procedures. We acknowledge that this is a complex ltrasound is the most useful imaging technique for guid- and controversial issue with the literature providing rather U ing percutaneous and endoscopic biopsies. It is safe and confusing guidelines. This is why different medical institu- accurate and allows one to guide a needle in a real-time man- tions may have their own standards for performing screening ner into organs, masses, and lymph nodes.1,2 NolsLe et al,2 in a coagulation tests on their patients based on their experience review of almost 8000 ultrasound-guided percutaneous pro- with complications. cedures, found a complication rate of only 0.187% and a mor- When a procedure is scheduled in our ultrasound de- tality rate of 0.038%. Even small masses down to 1.0 cm can partment, we first review the clinical indications and imaging be successfully biopsied depending on their location and so- studies to ensure that the procedure is both clinically indicated nographic visibility.1,3 Its major advantage over computed and safe to perform. We then have to assess the coagulation status of the patient to minimize the most feared complication related to the procedure, namely, postbiopsy hemorrhage. Be- cause a large number of our biopsies are scheduled on an Received for publication April 8, 2011; accepted August 29, 2011. outpatient basis, we as radiologists have very little clinical in- Department of Radiology, The George Washington University Medical Center, formation on these patients other than the history relevant to Washington, DC. The authors declare no conflict of interest. the procedure itself. For patients who are scheduled for a solid Reprints: Nadia Juliet Khati, MD, Department of Radiology, The George organ biopsy (liver, kidney, spleen, adrenal, and pancreas), we Washington University Medical Center, 900 23rd St, NW Washington, DC routinely screen them by requesting a complete blood count, 20037 (e-mail: [email protected]). a prothrombin time (PT) and international normalized ratio Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions (INR), and activated partial thromboplastin (aPTT). We do not of this article on the journal’s Web site (www.ultrasound-quarterly.com). require repeat coagulation tests if results are available from Copyright * 2011 by Lippincott Williams & Wilkins the past 3 months unless the patient’s clinical status demands

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Khati et al Ultrasound Quarterly & Volume 27, Number 4, December 2011 it (history of lupus, chronic use of anticoagulation therapy, Interpretation of the PT, INR, and aPTT results is per- patients with known bleeding disorders). As mentioned at the formed in conjunction with any relevant history pertaining to beginning of this section, we recognize that ordering coagu- chronic liver disease, malabsorption syndromes, and malnu- lation tests is at the discretion of the physician performing the trition. A large number of our scheduled liver biopsy patients procedure. Malloy et al5 recently published extensive detailed have underlying liver disease, most commonly hepatitis and guidelines for coagulation status and management based on cirrhosis, and any of these conditions may abnormally prolong the risk of bleeding of a large group of vascular and nonvas- coagulation parameters, particularly the PT. Knowledge of the cular percutaneous procedures. In general, they classify intra- patients’ prescribed medication specifically the intake of as- abdominal and transabdominal biopsies as ‘‘moderate risk’’ pirin, clopidogrel (Plavix; Bristol-Myers Squibb, New York, for bleeding, whereas renal biopsies are considered to have NY), warfarin, or heparin is crucial to the correct interpreta- a more ‘‘significant risk’’ of bleeding.5 Their consensus panel tion of homeostasis. Aspirin and clopidogrel are both plate- concluded that only INR and aPTT (for patients on heparin) let inhibitors, and we instruct patients to stop taking them 5 to would be necessary for the moderate risk for bleeding group. 7 days before the procedure. This is another topic that is up They recommended adding a platelet count and hematocrit for debate according to the literature and varies from one level for the significant risk group. We also obtain a list of the institution to the next. Whereas Winter et al9 seem to be in patients’ medications, paying specific attentions to ones that agreement with our recommendations, Malloy et al5 have may alter coagulation. This allows correct interpretation of slightly different guidelines. They advise withholding clopi- all test results and a better assessment of comorbidities along dogrel 5 days before procedures that are both in the moderate with avoiding unnecessary rescheduling or cancellation of risk and significant risk for bleeding, whereas aspirin is procedures. stopped only 5 days before a procedure in the last groups of Our accepted cutoff numbers for each of the coagulation patients. On the other hand, Atwell et al7 studied the overall parameters are summarized in Table 1. It should be empha- incidence of significant hemorrhage following 15,181 percu- sized that these are general guidelines that we follow; however, taneous image-guided biopsies from a variety of solid organs they can be altered on a case-by-case basis depending on the in patients taking aspirin within 10 days of the procedure. patient’s clinical condition. Based on a wide review of the lit- They concluded that overall the risk of major hemorrhage was erature and their experience, O’Connor et al6 have suggested not significantly increased in patients on aspirin (0.6%) com- cutoff INR values of up to 3.0 for procedures performed using pared with those not on aspirin (0.4%). a 20-gauge needle and up to 2.0 for most other procedures Withholding clopidogrel is relatively easy for the group including tissue biopsies, transhepatic cholangiograms, and of patients who take these drugs as a preventive measure, that placement of percutaneous catheters. They consider a safe is, to avoid any cardiovascular events. However, patients who platelet count level of 25,000/KL or greater for soft tissue have coronary artery stents or a history of prior heart attack biopsies and other procedures and have no specific cutoff or stroke and those with peripheral artery disease reportedly value when doing FNAs using a 20-gauge needle. It should be have a 3 times higher risk of developing stent thrombosis, tran- remembered that a platelet count is only a number and does sient ischemic attacks, and ischemic strokes if they discontinue not give us information regarding platelet function. Some ad- their aspirin intake.10,11 When it can be stopped safely, clo- vocate the use of the bleeding time to assess platelet function; pidogrel should be restarted as soon as possible after the pro- however, it has limited sensitivity and specificity in predict- cedure using a loading dose.12 All of this should be done after ing the risks of hemorrhage related to invasive procedures. For consulting with the referring physician to ensure that the ben- this reason, we do not routinely use the bleeding time when efits of the procedure outweigh the risks of discontinuing performing our procedures. Others consider safe criteria de- clopidogrel, even temporarily. fined as a platelet count of 50,000/KL and an INR of less than Patients taking either warfarin or heparin are the ones 1.6.7 Caturelli et al8 performed 229 liver punctures under ul- most likely to have bleeding complications following a proce- trasound guidance on 85 patients using fine needles (20- and dure. Warfarin inhibits the formation of vitamin KYdependent 22-gauge) for diagnostic purposes or therapeutic injection coagulation factors, thus prolonging the INR and PT, whereas of ethanol. Their patients had platelet levels of less than heparin inhibits coagulation factors of the intrinsic pathway 50,000/mm3 and/or PT times that were less than 50% of con- prolonging the aPTT. Low-molecular-weight heparin (LMWH) trols, and none had any bleeding complications. In addition, has antiYXa factor activity and, to a lesser degree, inhibition none of their patients received any type of blood products to of all the coagulation factors of the intrinsic pathway; how- correct their coagulation parameters.8 ever, it does not alter the aPTT. We instruct our patients to stop warfarin 3 to 5 days before a procedure and advise bridging anticoagulation therapy with heparin or LMWH for those with TABLE 1. Normal and Cutoff Values for Coagulation Factors the greatest risks of thromboembolic accidents. Alternatively, for Patients Undergoing Organ Biopsies warfarin dosage should be decreased to adjust the INR level Test Reference Ranges Cutoff in Our Practice down to 1.5 to 2. When using heparin or LMWH bridging therapy, they should be stopped 6 and 12 hours, respectively, PT 10Y13 s 10Y13 s Y G before the biopsy. INR 0.9 1.1 1.5 For nonsteroidal anti-inflammatory drugs (NSAIDs) aPTT 25Y35 s 25Y35 s Y K 9 K other than aspirin, patients are instructed to take them as di- Platelets 150,000 450,000/ L 50,000/ L rected by their treating physicians. Although some NSAIDs

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We make sure that the patient has either somebody available TABLE 2. Guidelines Used in Our Department for Managing to drive him/her home. Patients are required to sign a consent Patients on Medications That May Affect Coagulation form, which is witnessed by the sonographer or nurse avail- Medication/ able at the time. In addition to this, a ‘‘time out’’ is called by Anticoagulants Our Guidelines the sonographer with the radiologists in attendance before NSAIDs Do not need to stop the procedure itself, at which time the patient’s identity and Aspirin Stop 5Y7 d before procedure type of biopsy are verified. Clopidogrel Stop 5Y7 d before procedure when safe for the patient We no longer have patients fast and in fact encourage (no stents)*. Restart immediately after with a loading dose them to have a light meal before the procedure. Before starting Warfarin Stop 3Y5 d before procedure or taper dose to get INR any biopsy, we make sure the patient fully understands the pro- at 1.5 on day of procedure and restart original dose cedure. Reassuring the patient and keeping them informed after procedure, or stop 3Y5 d before procedure with throughout the process are very important. This helps relieve heparin or LMWH bridge before and after procedure anxiety and apprehension, and using these techniques, we have for 2 d. Restart warfarin after procedure noted anecdotally a reduction in the number of vasovagal Y Heparin Stop 6 h before procedure and restart 6 12 h after reactions that occur. LMWH Stop 12 h before procedure and restart 12 h after Before starting the biopsy, all the necessary supplies to *Patients with stents cannot stop clopidogrel safely if they are within 2 months of perform the procedure efficiently in the least amount of time bare-metal stent (nonYdrug coated) placement or within 6 to 12 months of drug-eluting stent placement. should be readily available in the room. We use a 5- to 7-mHz curved array probe for deep biopsies to which a biopsy guide can be attached. For more superficial biopsies, we use a 10- to have antiplatelet aggregation function, they are short-acting 12-mHz linear array probe and a freehand technique. The drugs, and the effect is quickly reversible compared with most transducer face of the probe is covered with some ultrasound other anticoagulants. Table 2 shows the guidelines on how we gel and placed into a sterile plastic sheath. A rubber band is manage patients on anticoagulation therapy in our department put around the transducer face to keep the gel in place, and a before scheduling a biopsy. small amount of sterile gel is used to provide good acoustic When the hemostatic status is compromised and the PT, contact between the sheathed transducer and the patient’s skin. aPTT, and INR cannot be corrected by adjusting anticoag- Some authors prefer not to use the plastic sheath as it may ulation therapy, patients should be given the option of having degrade the image.1 They rely on cleaning the transducer with either platelet transfusions or fresh frozen plasma (FFP). We povidone-iodine (Betadine), which works well at preventing usually recommend using 2 to 4 units of platelets or FFP ap- infection.15 proximately 1 hour before the procedure, with preferably the Over the years, we have gone away from using con- last unit being transfused during the biopsy. We do not rou- scious sedation for performing biopsies and rely on the liberal tinely recheck the INR, PT, and aPTT after these transfusions. use of local anesthesia (1% lidocaine). We tell patients that According to the literature, however, there are no set guide- the biopsy procedures that we do are similar to going to the lines to determine the exact dose of FFP needed to correct only dentist. Although the administration of the lidocaine initially mildly elevated INR values, and most of the time, the number 13 14 does hurt, once it is fully administered, patients should feel of units used is insufficient to correct it. Abdel-Wahab et al no pain. The interventional radiologists in our department use evaluated the effect of FFP on 121 patients using pretransfu- conscious sedation as their procedures are more complex and sion and posttransfusion PT and INR values 8 hours after trans- lengthy, whereas our biopsy takes only minutes to perform once fusion. Patients had pretransfusion PTs that varied between the local anesthesia has been administered. Mueller et al16 13.1 and 17 seconds and INR values between 1.1 and 1.85. showed that patients having visceral biopsies experienced They concluded that FFP only partially corrected PT values more pain with local anesthesia alone versus local anesthesia when they were mildly elevated with failure to normalize the and conscious sedation. The satisfaction scores, however, were 14 PT in 99% of cases. In addition, FFP and platelet transfu- similar for each group. The administration of conscious seda- sions carry a risk of severe reactions including transfusion- tion lengthens the procedure and requires constant monitor- related acute lung injury, volume overload, infection, and ing of the patient. Patients also may act differently and may not 6 anaphylactic reactions. When confronted with a situation where obey simple commands such as ‘‘hold your breath,’’ which may the patient would require blood product transfusions to correct be required for some liver and kidney biopsies. their coagulopathic state, we generally discuss the different op- The skin entry site should be cleansed and draped in a tions with the referring physician, making sure that we care- sterile fashion and should not be close to a scar as this can fully weigh the risks of the procedure against the benefits of make it difficult to advance the biopsy needle. Our biopsy obtaining a pathological diagnosis. trays contain either povidone-iodine (Betadine) or chlorhexidine as the topical antiseptic agent. We have no specific pre- ference for using one over the other. The surgical literature PERFORMANCE OF THE BIOPSY PROCEDURE seems to be divided as to their efficacy in preventing infec- Before each procedure, patients are consented by the ra- tion, with some stating that chlorhexidine is comparable to diologist performing the biopsy. We explain every step of the povidone-iodine (Betadine).17 Others conclude that the former process and describe the potential complications associated performs better than the latter as a preoperative antiseptic.18,19 with each individual biopsy and the alternatives to the biopsy. Advantages of chlorhexidine include that it does not cause

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Khati et al Ultrasound Quarterly & Volume 27, Number 4, December 2011 itching and does not leave a brownish stain on the skin like In cases requiring a coaxial technique, we use the co- Betadine.19 axial needle to administer the lidocaine to the level of biopsy In our patients who are all adults, we use up to 25 mL of site using ultrasound guidance. The tip of the needle is usually 1% lidocaine (10 mg/mL) to achieve complete local anesthe- easily seen while the lidocaine is administered as it produces sia. The maximum dosage of lidocaine 1% that can be admi- a swirl of echoes in the soft tissues around the tip. The lido- nistered is 4.5 mg/kg not to exceed 300 mg. Local anesthesia caine left in the needle is removed by fully inserting the blunt- is achieved for up to 30 minutes or more using this dosage. tipped trocar before inserting the biopsy needle. Adverse effects are very rare and involve the central nervous Most of the abdominal and pelvic biopsies are core system (disorientation, convulsions, respiratory depression, biopsies, done using an automated, spring-loaded, 18-gauge coma), cardiovascular system (bradycardia, cardiovascular col- cutting needle that has a variable throw (13, 23, or 33 mm). lapse), and even more rarely allergic reactions. It is important Overall, they provide a diagnosis up to 94% of the time.23Y25 to make sure the skin is properly anesthetized by injecting 2 to Arabas et al26 have shown that a 14- to 18-gauge cutting nee- 3 mL of lidocaine intradermally (not subdermally) by making dle is better in providing a diagnosis than a 20-gauge cutting a wheal. This is done using a 25-gauge, quarter-inch needle. needle. In 841 patients, the larger needle provided a patho- The soft tissues down to the biopsy site are then anesthetized logical diagnosis in 96.8% versus 84.1% for the smaller nee- using ultrasound guidance and a 20- or 22-gauge spinal needle. The needle can be introduced directly to the target site by dle. As the needle is advanced, the plunger of the syringe itself or through a 17-gauge coaxial needle, which we favor. should be drawn back before injecting to make sure the needle The core specimens obtained are placed in 10% formalin so- tip is not in a blood vessel. Patients usually do not experience lution or on a Telfa pad moistened with nonbacteriostatic sa- much pain as the needle goes through fatty tissue. When the line. If a smear is needed for cytopathology, the core can be needle traverses the muscular layer, however, the patients may placed on a glass slide, and a second glass slide can be gently experience some pain. They should be forewarned of this as brushed over the specimen (touch prep). This will deposit one sees the needle-tip approach the muscle layer on the ul- some cellular materials on the glass slide, which can then be trasound monitor (see Video, Supplemental Digital Content smeared and stained for cytopathologic analysis. [SDC] 1, http://links.lww.com/RUQ/A48 which demonstrates In cases where lymphoma is the possible diagnosis, we deep injection of lidocaine to the level of the biopsy site). If do FNAs. At our institution, FNAs are widely used for the the chosen biopsy tract traverses into the peritoneum, we diagnosis of hematologic neoplasms. Our cytopathologists per- make sure to administer 3 to 5 mL of lidocaine directly on form flow cytometry to detect cell markers (immunopheno- the peritoneal surface before advancing the needle through typing) on a small sample of cells. This allows accurate it. The pain elicited by advancing through the peritoneum differential diagnosis between reactive processes and subclas- that is not properly anesthetized can lead to a vasovagal sification of B-cell non-Hodgkin lymphomas and T-cell non- reaction. Once we have achieved good local anesthesia, we Hodgkin lymphomas. We use 22-gauge needles for the FNAs removetheneedleandmakeasmall3-mmnickintheskin in addition to core biopsies, using a coaxial technique. The to allow easy movement of the needle. This nick is made FNA needles should be long enough to extend out beyond the bystretching the skin transversely and introducing a scal- tip of the coaxial needle.27 The 17-gauge coaxial needle is much pel blade at a 45-degree angle into the skin, with the sharp easier to visualize sonographically than the 22-gauge needle and edge facing upward. The skin is then cut in an upward fash- is less likely to bend out of the field of view. The tip of the fine- ion so as to avoid cutting into the deeper soft tissues. The needle that is beyond the tip of the coaxial needle is easily seen biopsy needle is gently pushed through the nick and using within the mass being sampled because of its back-and-forth ultrasound guidance is advanced through the anesthetized motion (Fig. 1, see Video, SDC 3, http://links.lww.com/RUQ/A50, soft tissues down to the organ or mass on which to perform which demonstrates FNAs of the small focal liver lesion seen on a biopsy. the CT scan. Lymphoma was the suspected diagnosis). Before If there is difficulty visualizing the needle tip, we move starting the sampling process, we attach an air-filled syringe the focal zone of the transducer to its expected position. We to the needle, which acts as a handle for the back-and-forth also adjust the acoustic output appropriately, as seeing the nee- motion needed to perform the FNA The air-filled syringe is dle tip, particularly in echogenic soft tissues can be especially then used to expel the cellular contents in the barrel of the difficult.20 Moving the needle tip to and fro (‘‘pump man- needle without having to separately attach/disattach the nee- euver’’) is also helpful as is the use of color flow Doppler.20Y22 dle. Our cytopathologists prefer us not to apply suction to the This technique is especially useful when using fine needles syringe, and so we use a nonaspiration technique that provides and a steep angle.22 If the needle has a stylet, moving this back diagnostically superior specimens.28,29 This technique works and forth in the barrel of the needle improves needle-tip vis- better with larger-bore needles.27 The cellular material is ibility.22 If the target organ moves with respiration, breathing drawn into the barrel of the needle by capillary action.29 The should be suspended for 3 to 5 seconds while performing the use of suction tends to draw blood into the needle, making biopsy. It is often useful to have a few practice runs doing this it difficult to visualize the native cells. We do a minimum of to make sure the patient can correctly follow the command. We 3 FNAs (to ensure adequacy of sampling because our cyto- usually take a video clip documenting the biopsy needle en- pathologists are not always present during the procedure), tering and exiting the tissue being biopsied (see Video, SDC 2, which are smeared onto slides for cytopathology and then http://links.lww.com/RUQ/A49, which demonstrates the biopsy rinsed out of the needle into RPMI medium for flow cyto- needle entering and exiting the liver). metry. After the FNAs, we also perform at least 3 core biopsies

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left lateral decubitus position and use a subcostal approach. Less preferably, we would use the intercostal route. We make sure to administer 3 to 5 mL of lidocaine directly onto the liver surface using ultrasound guidance. To limit the number of passes to one, we use an automated, spring-loaded, 18-gauge cutting needle with a throw of 33 mm that provides a nice long specimen (see Video, SDC 5, http://links.lww.com/RUQ/A52, which demonstrates the technique for a core biopsy from the left lobe of the liver using a deep-throw technique).23,27 For biopsy of a liver mass, we usually use a coaxial tech- nique3,26 (see Videos, SDC 6, http://links.lww.com/RUQ/A53, which demonstrates FNAs of a small focal liver lesion, and SDC 7, http://links.lww.com/RUQ/A54, which demonstrates subsequent core biopsy of the same liver lesion). Advantages of this technique over the noncoaxial method for focal lesions FIGURE 1. Contrast-enhanced CT scan of the abdomen are that multiple samples can be obtained once the coaxial showing a small well-defined hypodense solid lesion in the needle is in place and the capsule of the organ is pierced only medial segment of the left lobe (arrow) in a patient with once. There is also evidence in the literature that this method suspected lymphoma. decreases the risk of tumor seeding along the needle track, and this is crucial in potential liver transplant recipients.33 Maturen 33 through the coaxial needle. These additional cores are per- et al found a 0% rate of tumor seeding in 101 patients with formed as a backup for immunohistochemistry or in cases hepatocellular carcinoma using a 17-gauge coaxial system and 34 where diagnoses other than lymphoma are in the differential. an 18-gauge biopsy cutting needle. Hatfield et al compared the complication rate of performing liver and renal biopsies using imaging guidance with a coaxial system (764 biopsies) LIVER BIOPSY and without a coaxial needle (296 biopsies). They found no The usual indications for performing a liver biopsy are differences between the 2 methods, with minor complications for diagnosing hepatocellular disease and the etiology of a occurring in 3.4% and 2.6% of the cases when using the non- hepatic mass30 (Table 3). coaxial and the coaxial techniques, respectively. Major com- A biopsy should be performed on coagulopathic patients plications requiring blood transfusions or surgery occurred in who need a biopsy because of diffuse hepatocellular disease, 1.0% of noncoaxial and 0.9% of coaxial techniques. using the transjugular approach.31,32 When this is not a pro- If the liver is cirrhotic, we examine the expected path of blem, we do our liver biopsies using a subcostal approach the needle using duplex and color flow Doppler to avoid any in the midline epigastrium, taking our core from the left lobe portosystemic venous collaterals that might be in the way. We of the liver (see Video, SDC 4, http://links.lww.com/RUQ/A51, try to perform a biopsy on all masses by advancing the coaxial showing a biopsy of the left lobe of the liver using a short- needle through a cuff of normal liver tissue down to the surface throw technique in a patient with sarcoidosis). If the left lobe of the mass when possible. Taking into account the size of the is small and not easily amenable, we place the patient in the lesion, we take our sample from the outer one third of the mass

TABLE 3. Indications for Liver Biopsy Diffuse hepatocellular disease Alcoholic liver disease Nonalcoholic hepatic steatosis Viral hepatitis Autoimmune hepatitis Heavy metal storage disordersVhemochromatosis, Wilson disease Unexplained liver function test elevation Unexplained cholestasis Use of hepatotoxic drugsVmethotrexate Unexplained Systemic IllnessVFUO, granulomatous disease Unexplained hepatosplenomegaly Suspected liver transplant rejection Liver transplant donor Focal liver disease PrimaryVhepatocellular carcinoma, cholangiocarcinoma SecondaryVmetastatic disease FIGURE 2. Sagittal transabdominal ultrasound showing the biopsy procedure performed through the ascites with the FUO indicates fever of unkwown origin. needle tip into the left lobe of the liver (arrow).

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http://links.lww.com/RUQ/A55, which demonstrates a core biopsy performed on a deep liver lesion in a patient with a cirrhotic liver and ascites). In some cases, paracentesis before the procedure may be helpful. Liver biopsies are very safe to perform when the patient’s blood clotting mechanism is normal. In a series of 715 patients having liver biopsies, there were only 2 major complications because of hemorrhage (Fig. 4) and no deaths.30 The most frequent minor complication was pain. This usually occurs at the time of the biopsy or shortly thereafter. The pain is usually mild but can be severe and is presumably due to blood or bile stretching the liver capsule35 or intraperitoneal bleeding irri- tating not only the peritoneum but also the intestinal tract. Not infrequently, the pain can be referred to the shoulder, often the left. This pain is usually self-limiting and goes away within 2 hours. In some cases, we prescribe acetaminophen by mouth, but only rarely do we have to resort to intramuscular or in- travascular injection of pain medication. A pathological diagnosis can be made in 99.4% of biopsies performed for diffuse hepatocellular disease.30 The accuracy rate for diagnosing even small liver masses has increased from 79% in 1987 to 99% in 1999.1,3

PANCREATIC BIOPSY Nowadays, most pancreatic mass biopsies are performed FIGURE 3. Transabdominal ultrasound of the liver in a using endoscopic ultrasound, which has largely replaced the patient with ascites and a slightly nodular liver. There is a percutaneous approach as both techniques produce similar re- well-defined heterogeneous solid right liver lobe lesion (arrows). sults.36 In cases where the endoscopic approach is not technically feasible or where it fails to yield a diagnosis, the and avoid the center, which may have pathologically non- percutaneous approach can be used. This is usually done to diagnostic necrotic tissue. If the mass is 2.0 cm or less, we take confirm the diagnosis of an unresectable pancreatic cancer. our specimen from its center. The ability to perform biopsies Masses in the head, body, and proximal tail are biopsied using on small masses depends not only on their conspicuity and an anterior approach through the abdominal wall, with the pa- skill of the operator but also on the patient’s ability to hold tient supine (Fig. 5). Filling the stomach with water may al- their breath. low better visualization of the mass, and the biopsy can be The presence of ascites is not a contraindication to performed through-and-through the gastric wall if necessary.37 biopsy, although it can make it more difficult if it is marked A loop of small bowel may also be traversed; however, we in amount (Fig. 2). This is especially true when trying to sam- avoid going through the colon, although others have used this ple a mass deep in a cirrhotic liver (Fig. 3, see Video, SDC 8, approach.38 A mass in the tail may be better approached

FIGURE 4. A, Sagittal abdominal ultrasound of a liver mass showing its subcapsular location (arrow). The biopsy track is shown. B, Contrast-enhanced CT scan of the abdomen in the same patient. Following the biopsy, the patient developed intractable bleeding around the lesion (arrow). C, Contrast-enhanced CT scan of the abdomen in the same patient a few days later. He required arterial embolization with subsequent infarction of the spleen.

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needles). They had better success for masses in the body/tail (93%) compared with the head (84%). The complication rate of percutaneous pancreatic biopsies (1.1%Y2.6%) can be major or minor.38,39,44 Minor complications include vasovagal reactions, pain requiring narcotics, and small bleeds. Major complications include bleeding that requires treatment and acute pancreatitis (2.6%). There does not appear to be any signiﬁcant difference in the rate of complications between FNAs and core biopsies.39 Seeding of the needle tract is a rare but possible complication of percutaneous ﬁne-needle biopsies of primary pancreatic neoplasms or pancreatic liver metastases.47,48 Kosugi et al49 performed biopsies of 73 pancreatic neoplasms using 21-gauge needles. Each lesion required 1 or 2 samples, and the needles were rinsed in 10% alcohol when a second puncture was performed. Tumor implantation along the needle tract was found in only one case 2 months after the procedure in a patient with a moderately differentiated carcinoma. This was subsequently successfully removed with no additional recurrence.49

FIGURE 5. Transabdominal ultrasound of the pancreas showing a large solid hypoechoic mass in the tail (M). SPLENIC BIOPSY This is usually performed to ascertain the pathology of through a left intercostal space, with the patient in the right a splenic mass, usually lymphoma or a metastatic deposit decubitus position. Care must be taken to avoid the adjacent (Table 4). The procedure is carried out using a left intercostal spleen and left colon. approach, with the patient in the right lateral decubitus posi- We use a core needle and a coaxial technique. Before tion (Fig. 6). If the spleen/mass is large, a subcostal approach advancing the needle, color ﬂow Doppler imaging should be may be possible. If lymphoma is the suspected diagnosis, we performed to avoid any intervening vessels.39 This is espe- perform FNAs and core biopsies using a coaxial technique as cially advised in cases where the portal vein or splenic vein described earlier in this article. We do not perform FNAs if is occluded as there may be many small venous collaterals lymphoma is not in the differential diagnosis. Keogan et al50 around the pancreas. recommend traversing as little splenic tissue as possible to get Percutaneous pancreatic biopsies are probably more to the mass, which is the opposite of what is recommended for risky than liver or kidney biopsies as the pancreas has many biopsy of liver masses. normal surrounding blood vessels, which need to be avoided. Splenic biopsies are as safe to perform as liver biopsies, That is why biopsy of a liver metastasis, if one is present, is assuming the patient is not coagulopathic.50,51 In fact, the favored over biopsy of the primary pancreatic mass.40 Biop- diagnostic accuracy and major complication rates are com- sies of liver metastases also allow staging of the pancreatic parable to those reported for renal and liver biopsies when disease. The other problem with making a percutaneous di- using 18-gauge or smaller needles.52 The most common major agnosis is the presence of acute pancreatitis in association complication when it occurs is hemorrhage (Fig. 7), which with the cancer. This may lead to sampling the area of in- may require embolization or even emergency splenectomy.53 ﬂammation rather than the tumoral tissue. Chronic pancreatitis can also be a problem as its symptoms can mimic that of pancreatic cancer. In a study of 81 patients, 54 with pancreatic TABLE 4. Indications for Splenic Biopsy cancer and 27 with chronic pancreatitis, DelMaschio et al41 demonstrated that FNA biopsies were able to differentiate Benign masses between the 2 with an accuracy of 94%. Hemangioma The accuracy rate of ultrasound-guided percutaneous Lymphangioma biopsy reported by Paulsen et al39 was around 92.5%, and the Hamartoma V sensitivity was 93.3%. Other authors have produced similar Abscesses pyogenic, fungal, Pneumocystis carinii, MAI, TB results.25,38,42Y45 Some results using CT guidance show a Inflammatory processes lesser success rate; however, this could be due to the more Sarcoidosis accessible masses that are easier to have a biopsy performed Inflammatory pseudotumor on being triaged to ultrasound.38,46 The size of the mass also Peliosis affects obtaining a diagnosis. Brandt et al38 had a success rate Malignant masses V of 92% for masses larger than 3 cm, whereas the rate fell to Primary neoplasms lymphoma, angiosarcoma V 81% for lesions smaller than 3 cm. In the same study, they Secondary neoplasms metastases from melanoma, breast, lung, ovarian, colon, gastrointestinal demonstrated a better success rate using a larger needle (92% for 16- to 19-gauge cutting needles vs 85% for 20- to 22-gauge MAI indicates mycobacterium avium-intracellulare; TB, tuberculosis.

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FIGURE 6. A, Contrast-enhanced CT scan of the abdomen in a patient with history of melanoma with multiple, solid, partially enhancing splenic lesions (arrows). B, Transbdominal ultrasound of the spleen showing the biopsy tract for one of the splenic lesions. The diagnosis was metastatic melanoma.

The accuracy of splenic biopsy in making a pathological di- If the kidney is still not adequately visualized, an intercostal agnosis is around 84% to 91%.50,53,54 approach in the prone position can be attempted. This approach is technically more difﬁcult than the other two. Visu- alization of the kidney is limited, making it more likely the RENAL BIOPSY core needle will enter the renal sinus and damage the renal Renal biopsies are performed to determine the etiology collecting system or vasculature. of renal parenchymal disease and the pathology of renal We do renal biopsies using an automated, spring-loaded, masses (Table 5).55,56 The procedure is performed with the 18-gauge cutting needle and a coaxial technique.23,27 The patient in a prone position. A pillow is placed under the ab- tip of the coaxial needle is guided down to the outer cap- domen in thin patients. The biopsy is taken from the lower sule of the lower pole of the kidney (see Video, SDC 9, pole of either kidney to obtain cortical tissue that contains glo- http://links.lww.com/RUQ/A56, which demonstrates core bi- meruli. An initial scan is done to evaluate the kidneys’size and opsy of the lower pole of the kidney in a patient with im- echogenicity and to determine which lower pole is most ame- munoglobulin A nephropathy). The biopsy is performed in nable to biopsy. In some obese patients, the prone position will suspended respiration, and 3 to 4 specimens are obtained mea- not work as the kidney may be poorly visualized or be too deep suring 1.3 cm in length. These are placed on individual Telfa to have a biopsy performed on. In that case, the decubitus pads moistened with nonbacteriostatic normal saline and given position has to be used. In this position, the kidney moves both directly to the pathologist for processing. The need for 3 to 4 inferiorly and anteriorly, placing it closer to the skin surface. cores is dictated by the required number of glomeruli per specimen to make an accurate diagnosis. The nephrologists at our institution prefer to have at least 15 to 20 glomeruli per core. Of the 4 cores obtained, 2 are used for histology:

TABLE 5. Indications for Renal Biopsy Parenchymal renal disease Unexplained renal failure Nephrotic syndrome Unexplained hematuria Systemic disease with renal dysfunction : systemic lupus erythematosis Goodpasture syndrome Wegener granulomatosis Renal transplant rejection Renal mass Small renal mass amenable to local resection or ablation Renal mass in renal insufficiency FIGURE 7. Contrast-enhanced CT scan of the abdomen Renal mass in a solitary kidney following splenic mass biopsy (same patient as Fig. 6). The Multiple renal masses patient developed a small postprocedure hemorrhage Renal mass in a patient with a known primary malignancy (thin arrow). The curved arrow denotes a large left adrenal Renal mass in a patient with metastatic disease gland metastatic lesion.

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resonance imaging protocol or when indicated a CTYpositron emission tomography scan, some of the masses remain indeterminate.62Y65 Biopsy of an adrenal gland mass is usually performed to determine if it is a metastatic lesion in a patient with a known primary. It is also indicated where there is metastatic disease, and the primary could be adrenocortical carcinoma. If a pheochromocytoma is suspected based on the clinical symptoms or imaging findings, biochemical testing (ie, mea- surement of fractionated metanephrines and catecholamines in a 24-hour urine specimen) should be done before performing a biopsy because of the higher risk of bleeding and hy- pertensive crises.66Y68 Most of these biopsies are performed using CT guidance as many of these lesions cannot be visualized using ultrasound.69 Occasionally, if the mass is large enough to be visualized with ultrasound, a biopsy can be performed.69 This is done using a coaxial technique and an intercostal or subcostal approach, with the biopsy side up and the patient in the decubitus position. FIGURE 8. Abdominal CT scan of the abdomen without In a study of biopsies of 50 indeterminate adrenal contrast in a patient who developed a hematoma after renal masses performed using ultrasound or CT guidance by biopsy in the right retroperitoneum (arrows). Paulsen et al,69 a correct diagnosis was made in 96%. These included metastatic disease (70%), adrenocortical cancer (8%), adenoma (12%), and pheochromocytoma (6%). Some authors 1 for electron microscopy and 1 for immunofluorescence do not recommend biopsy of a possible pheochromocytoma microscopy. because of the risk of severe hypertension.70 If this is the sus- The appropriate approach to biopsy depends on the lo- pected diagnosis, this can usually be determined by clinical cation of the mass within the kidney and can be determined and laboratory methods. only by scanning the patient. We use the same coaxial technique that we use for parenchymal renal disease and usually obtain 3 tissue specimens that are placed in formalin (see Video, SDC PERITONEAL AND MESENTERIC BIOPSY 10, http://links.lww.com/RUQ/A60, which demonstrates a core This is performed on mesenteric masses (intra-abdominal biopsy performed on a large left lower pole renal mass in a carcinomatosis, carcinoid) and lymph nodes (Table 6). We patient with lymphoma). use a coaxial needle technique and check for blood vessel Renal biopsies are a safe procedure; however, compli- location using color flow Doppler before advancing the nee- cations do occur and include hematoma at the biopsy site, dle. Because most of these biopsies are performed based on hemorrhage that may require embolization, and pseudoan- CT findings, we make sure to note the position of loops of 57,58 59 eurysm formation (Fig. 8). Maya and Allon performed bowel in relation to the mass (Fig. 9 and see Video, SDC 11, ultrasound-guided renal biopsies in 100 outpatients to evaluate http://links.lww.com/RUQ/A61, which demonstrates a core bi- the safety of the procedure. They used 16-gauge needles and opsy of an omental mass obtained through a small amount of observed their patients for 8 hours following the biopsies with ascites in a patient with intraperitoneal carcinomatosis). One 1 or 2 needles passes done in 91 patients and 3 to 4 passes in may traverse small bowel as its contents are sterile. We do not the remaining 9 patients. Only 13 developed a small postpro- like to go through the colon; however, other authors have done cedure perinephric hematoma, and 4 were hospitalized over- so without complications. When loops of bowel are in the way, night because of a drop of greater than 4% in their hematocrit. they can be displaced by putting pressure on the abdominal However, none developed major complications that would wall with the transducer.71 Once the coaxial needle tip is at the require a blood transfusion or other intervention.59 They produce a pathological diagnosis in up to 100% of patients with parenchymal renal disease and in 82% to 100% of renal masses.56Y58,60 TABLE 6. Indication for Mesenteric/Omental/Lymph Node Biopsy ADRENAL BIOPSY Peritoneal carcinomatosisVovarian carcinoma, gastrointestinal malignancies (pancreatic, gastric, or colon cancer) Small adrenal masses are frequently found during CT V and magnetic resonance imaging studies of the abdomen per- Lymphoma peritoneal lymphomatosis in non-Hodgkin disease Carcinoid formed for other reasons. These are usually nonfunctioning ad- V enomas unless there is a history of malignancy.61 Even with Desmoid Gardner syndrome the history of malignancy, the likelihood of metastatic disease Lymphadenopathy is only 50% unless the patient has small cell carcinoma of Primary peritoneal mesothelioma the lung. Despite a workup using an adrenal CT or magnetic Amyloidosis

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TABLE 7. Indication for Retroperitoneal/Pelvic Biopsy Lymphoma LymphadenopathyVmetastatic Retroperitoneal fibrosis Primary malignancies Liposarcoma Malignant fibrous histiocytoma Leiomyosarcoma Benign tumors Paraganglioma Neurofibroma

patient had a small hematoma at the biopsy site. Another complication can be cellulitis in the abdominal wall at the needle FIGURE 9. Contrast-enhanced CT scan of the abdomen entry site and rarely peritonitis.73 In a study by Ho et al,73 they showing ascites (asterisk) with enhancement and thickening made a correct diagnosis in 23 (92%) of 25 omental masses, of the peritoneum as well as irregular thickening of the whereas Spencer et al74 had a lesser rate of diagnosis of 77%. omentum (arrows) in a patient with peritoneal carcinomatosis. RETROPERITONEAL/PELVIC BIOPSY biopsy site, the throw of the cutting needle should be adjusted Lymphadenopathy and masses in the retroperitoneum/ so that the well of the needle will end up within the mass. If it pelvis are often too small to have a biopsy performed on us- extends too far beyond the mass, it may lacerate an adjacent ing ultrasound unless the patient is thin enough to allow vi- mesenteric vessel leading to bleeding. If lymphoma is the sualization (Table 7). When they are sonographically visible suspected diagnosis, we perform FNAs (Fig. 10, see Video, through the anterior abdominal with the patient supine, this SDC 12, http://links.lww.com/RUQ/A62, which demonstrates 75 approach can be used. Pressure with the transducer on the FNAs of an omental implant in a patient with a history of lym- 71 anterior abdominal wall will shorten the needle path. Al- phoma) with or without a coaxial needle (see Video, SDC 13, though bowel may be traversed, careful attention should be http://links.lww.com/RUQ/A63, which demonstrates FNAs paid to avoid mesenteric vessels. For this reason, we prefer the of iliac lymph nodes in a patient with a remote history of decubitus or prone approach through the back if this allows breast cancer). visualization of the lymph node/mass (Fig. 11). In the pelvis, In a study using both CT (82%) and ultrasound guidance the transgluteal route can be used, making sure to avoid the (18%), Souza and his colleagues72 had a success rate of 89% area of the sciatic nerve. on 111 patients with peritoneal/omental masses. The majority We use a coaxial technique, and when lymphoma is sus- of these masses were malignant, and in patients with a known pected, we perform both FNAs and core biopsies as previously primary, the biopsy revealed a second malignant tumor in described. Using FNAs on retroperitoneal lymph nodes (mean 10%. They used FNAs (58.6%), a combination of FNAs and diameter, 2.1 cm), Fisher et al71 had a success rate of 86%. core needles (38.7%), and core needles only (3%). They had They had 1 major complication due to injury to the inferior 3 minor complications: pain requiring medication in 1 patient, epigastric artery that required embolization (Fig. 12). Yarram hypotension requiring ﬂuid resuscitation in another, and 1 76 et al evaluated the effectiveness of ultrasound (60%) and CT-guided (40%) core biopsies in diagnosing pelvic masses. The majority of the masses were malignant (70%), and ultrasound guidance had an accuracy of 95.4% compared with 84.6% for CT. In a study by Memel et al,75 they had a success rate of 91% when the lymph nodes could be visualized for biopsy.

ABDOMINAL WALL BIOPSY Masses of the abdominal wall include primary mes- enchymal mass such as a desmoid tumor and metastatic lesions (Table 8). These biopsies are performed using a high- frequency transducer and a freehand coaxial technique. The throw of the needle needs to be adjusted to reﬂect the size of the mass. The coaxial needle is brought in from the side so that the biopsy will be along the longest axis of the mass. This technique is both safe and effective. If lymphoma is the suspected FIGURE 10. Contrast-enhanced CT scan of the abdomen diagnosis, we perform FNAs using the technique described showing a well-deﬁned solid omental mass (arrow). previously (see Video, SDC 14, http://links.lww.com/RUQ/A65,

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FIGURE 11. A, Contrast-enhanced CT scan of the abdomen showing a large well-deﬁned hypodense solid mass in the retroperitoneum (asterisk) displacing the pancreas anteriorly. B, Ultrasound-guided biopsy of the retroperitoneal mass showing the biopsy needle tip within the mass (arrow). which demonstrates FNAs in an anterior abdominal wall major postbiopsy complications. Others advocate that dis- metastatic lesion of a patient with squamous cell carcinoma of charging asymptomatic patients 1 hour after liver biopsies per- the tongue). formed with an 18-gauge needle is safe and cost-effective.78,79 Their pulse rate, blood pressure, and O2 saturation are moni- tored. We do not remeasure the hemoglobin and hematocrit. POSTBIOPSY OBSERVATION Some patients experience pain following the biopsy, which we Following the biopsy, we assess patients for pain, and we treat with acetaminophen 650 mg given orally. Uncommonly, obtain a baseline postprocedure set of vital signs in the ul- we have to use oxycodone orally or injectable narcotic drugs trasound department. Those who had a core biopsy of a solid such as morphine sulfate intramuscularly to control the pain. organ are then transferred to the postanesthesia care unit for This may prolong their stay in the postanesthesia care unit. at least 2 hours of observation in the supine position at com- Patients who have core biopsies of lymph nodes or FNAs of a plete bed rest. For patients undergoing renal biopsies, different solid organ, mass, or lymph node are discharged immediately authors recommend varied observation periods ranging from following the procedure, provided they are asymptomatic. postprocedure hospitalization with 24 hours of rest after per- Before being discharged, patients are instructed on cutaneous renal biopsy as 33% of complications occur after wound care and on resumption of their medications that may 8 hours55 to releasing patients after only 6 or 8 hours of ob- have been stopped before the procedure. They are also advised servation.59,77 At our institution, when renal biopsies are per- to avoid vigorous activity including heavy lifting or pushing formed with the nephrologists, patients are kept in the hospital for at least 1 week. Patients are given a 24-hour number to call overnight for an observation period, which totals approxi- one of our on-call physicians in case they experience weak- mately 18 hours, and this is usually because of associated ness, dizziness, or any new pain after going home. comorbidities. So far, our nephrologists have not reported any The pathology report is usually available within a week. Patients are instructed to call their doctor’s ofﬁce at that time to make an appointment to discuss the results. We review all of our pathology reports and tabulate the results to determine our success rate in making a pathological diagnosis. Any complications are also discussed at our regular quality assurance meetings.

TABLE 8. Indication for Anterior Abdominal Wall Biopsy Benign tumors Neurogenic tumorsVschwannomas, neurofibromas Desmoid tumors Malignant tumors Malignant fibrous histiocytoma Lymphoma Liposarcomas FIGURE 12. Contrast-enhanced CT scan of the abdomen in Rhabdomyosarcoma the same patient as in Figure 11, who developed pancreatitis Melanoma after biopsy of the large retroperitoneal mass. There is a MetastaticVSister Mary Joseph nodule pseudocyst anterior to the pancreas (arrow).

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CONCLUSIONS procedures: patient anxiety, perception of pain, understanding of procedure, and satisfaction with medicationVa prospective study. Ultrasound is a safe, effective, and convenient method Radiology. 2000;215:684Y688. for performing image-guided biopsies, often preferred as it is 17. Sistla SC, Prabhu G, Sistla S, et al. Minimizing wound contamination relatively inexpensive and portable and does not depend on in a ‘‘clean’’surgery: comparison of chlorhexidine-ethanol and ionizing radiation. It is, however, operator dependent, and its povidone-iodine. Chemotherapy. 2010;56:261Y267. 18. Noorani A, Rabey N, Walsh SR, et al. Systematic review and use is limited to sonographically visible lesions. We review the meta-analysis of preoperative antisepsis with chlorhexidine versus approach to common targets of ultrasound-guided biopsy, with povidone-iodine in clean-contaminated surgery. Br J Surg. specific emphasis on procedure safety and efficiency. As post- 2010;97:1614Y1620. biopsy hemorrhage is the most worrisome complication, we 19. Darouiche RO, Wall MJ, Itani KM, et al. Chlorhexidine-alcohol versus discuss our approach to the patient’s coagulation profile, in- povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362:18Y26. cluding routine screening with recent complete blood count, 20. Feld R, Needleman L, Goldberg BB. Use of needle-vibrating device and PT, INR/aPTT, and review of coagulation-affecting medica- color Doppler imaging for sonographically guided invasive procedures. tions before the procedure. It is emphasized that this is per- AJR Am J Roentgenol. 1997;168:255Y256. formed on an individual basis, with consideration to the 21. Bisceglia M, Matalon TA, Silver B. The pump maneuver: an atraumatic adjunct to enhance US needle tip localization. Radiology. patient’s underlying pathology and appropriate and timely 1990;176:867Y868. coordination with the ordering physicians. We address details 22. Hamper UM, Svader BL, Sheth S. Improved needle-tip visualization of patient preparation, needle and approach selection, sample by color Doppler sonography. AJR Am J Roentgenol. preparation with a view toward suspected pathology, and rec- 1990;156:401Y402. ommendations for postbiopsy observation and discharge in- 23. Hopper KD, Abendroth CS, Sturtz KW, et al. Blinded comparison of biopsy needles and automated devices in vitro: 1. Biopsy of diffuse structions. Finally, we stress the importance of regular review hepatic disease. AJR Am J Roentgenol. 1993;161:1293Y1297. of pathology reports and tabulation of results to improve future 24. Hopper KD, Abendroth CS, Sturtz KW, et al. Blinded comparison of practice. biopsy needles and automated devices in vitro: 2. Biopsy of diffuse hepatic disease. AJR Am J Roentgenol. 1993;161:1299Y1301. 25. Jennings PE, Donald JJ, Coral A, et al. Ultrasound-guided core biopsy. REFERENCES Lancet. 1989;1:1369Y1371. 1. 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Short-stay, out-of-hospital, radiologically 2002;179:1591 1596. guided liver biopsy. MJA. 2002;176:67Y69. 54. Kang M, Kalra N, Gulati M, et al. Image guided percutaneous splenic interventions. Eur J Radiol. 2007;64:140Y146. 55. Whittier WL, Korbet SM. Renal biopsy: update. Curr Opin Nephrol Hypertens. 2004;13:661Y665. APPENDIX 56. Lebret T, Poulain JE, Molinie V, et al. Percutaneous core biopsy for renal masses: indications, accuracy and results. JUrol. Video Clip 1 Y 2007;178:1184 1188. Video that demonstrates deep injection of Lidocaine 57. Caoili EM, Bude RO, Higgins EJ, et al. Evaluation of sonographically guided percutaneous core biopsy of renal masses. AJR Am J Roentgenol. to the level of the biopsy site (video; Supplementary Digital 2002;179:373Y378. Content 1, http://links.lww.com/RUQ/A48). 58. Constantin A, brisson ML, Kwan J, et al. Percutaneous US-guided renal biopsy: a retrospective study comparing the 16-gauge end-cut Video Clip 2 and 14-gauge side-notch needles. J Vasc Interv Radiol. Video that demonstrates the biopsy needle entering and 2010;21:357Y361. 59. Maya ID, Allon M. Percutaneous renal biopsy: outpatient observation exiting the liver (video; Supplementary Digital Content 2, without hospitalization is safe. Semin Dial. 2009;22:458Y461. http://links.lww.com/RUQ/A49). 60. Johnson PT, Nazarian LN, Feld RI, et al. Sonographically-guided renal mass biopsy: indications and efficacy. Ultrasound Med. Video Clip 3 2001;749Y753. Video that demonstrates FNAs of a small focal liver 61. Song JH, Chaudry FS, Mayo-Smith WW. The incidental adrenal mass lesion seen in a patient with a suspected diagnosis of on CT: prevalence of adrenal disease in 1049 consecutive adrenal masses in patients with known malignancy. AJR Am J Roentgenol. 2008;190: lymphoma (video; Supplementary Digital Content 3, 1163Y1168. http://links.lww.com/RUQ/A50). 62. Boland GW. Adrenal imaging: why, when, what, and how? Part 1. Why and when to image. AJR Am J Roentgenol. 2010;195:W377YW381. Video Clip 4 63. Boland GW. Adrenal imaging: why, when, what, and how? Part 2. What Video that demonstrates a biopsy of the left lobe of technique? AJR Am J Roentgenol. 2011;191:W1YW5. 64. Boland GW. Adrenal imaging: why, when, what, and how? Part 3. The the liver in a patient with sarcoidosis using a short algorithmic approach to definitive characterization of the adrenal throw technique (video; Supplementary Digital Content 4, incidentaloma. AJR Am J Roentgenol. 2011;195:W109YW111. http://links.lww.com/RUQ/A51).

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Video Clip 5 Video Clip 10 Video that demonstrates the technique used for a Video that demonstrates a core biopsy performed core biopsy from the left lobe of the liver, using a deep of a large left lower pole renal mass in a patient with throw technique (video; Supplementary Digital Content 5, lymphoma (video; Supplementary Digital Content 10, http://links.lww.com/RUQ/A52). http://links.lww.com/RUQ/A60). Video Clip 6 Video Clip 11 Video that demonstrates FNAs of a small focal Video that demonstrates a core biopsy of an omental liver lesion (video; Supplementary Digital Content 6, mass obtained through a small amount of ascites in a patient http://links.lww.com/RUQ/A53). with intraperitoneal carcinomatosis (video; Supplementary Digital Content 11, http://links.lww.com/RUQ/A61). Video Clip 7 Video Clip 12 Video that demonstrates subsequent core biopsy of the Video that demonstrates FNAs of an omental implant in same liver lesion as in supplement digital content 6 (video; Sup- a patient with a history of lymphoma (video; Supplementary plementary Digital Content 7, http://links.lww.com/RUQ/A54). Digital Content 12, http://links.lww.com/RUQ/A62). Video Clip 8 Video Clip 13 Video that demonstrates a core biopsy performed Video that demonstrates FNAs of iliac lymph nodes in a on a deep liver lesion in a patient with a cirrhotic liver patient with a remote history of breast cancer (video; Supple- and ascites (video; Supplementary Digital Content 8, mentary Digital Content 13, http://links.lww.com/RUQ/A63). http://links.lww.com/RUQ/A55). Video Clip 14 Video Clip 9 Video that demonstrates FNAs of an anterior abdomi- Video that demonstrates core biopsy of the lower pole nal wall metastatic lesion in a patient with squamous cell of the kidney in a patient with IGA nephropathy (video; Sup- carcinoma of the tongue (video; Supplementary Digital Con- plementary Digital Content 9, http://links.lww.com/RUQ/A56). tent 14, http://links.lww.com/RUQ/A65).

268 www.ultrasound-quarterly.com * 2011 Lippincott Williams & Wilkins