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Ultrasound-Guided Percutaneous Core Needle Biopsy of Abdominal Original Article | Experimental and Others Pictorial Essay | Gastrointestinal Imaging https://doi.org/10.3348/kjr.2017.18.2.309 pISSN 1229-6929 · eISSN 2005-8330 Korean J Radiol 2017;18(2):309-322 Ultrasound-Guided Percutaneous Core Needle Biopsy of Abdominal Viscera: Tips to Ensure Safe and Effective Biopsy Jin Woong Kim, MD1, Sang Soo Shin, MD1, 2 1Department of Radiology, 2Center for Aging and Geriatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61469, Korea Ultrasound-guided percutaneous core needle biopsy (USPCB) is used extensively in daily clinical practice for the pathologic confirmation of both focal and diffuse diseases of the abdominal viscera. As a guidance tool, US has a number of clear advantages over computerized tomography or magnetic resonance imaging: fewer false-negative biopsies, lack of ionizing radiation, portability, relatively short procedure time, real-time intra-procedural visualization of the biopsy needle, ability to guide the procedure in almost any anatomic plane, and relatively lower cost. Notably, USPCB is widely used to retrieve tissue specimens in cases of hepatic lesions. However, general radiologists, particularly beginners, find USPCB difficult to perform in abdominal organs other than the liver; indeed, a full understanding of the entire USPCB process and specific considerations for specific abdominal organs is necessary to safely obtain adequate specimens. In this review, we discuss some points and techniques that need to be borne in mind to increase the chances of successful USPCB. We believe that the tips and considerations presented in this review will help radiologists perform USPCB to successfully retrieve target tissue from different organs with minimal complications. Keywords: Abdomen; Diagnostic technique; Biopsy; Ultrasonography INTRODUCTION accepted technique for the tissue diagnosis of various lesions of the abdominal viscera (1). Among various Although pathologic examinations may not be routinely guidance tools such as US, computed tomography (CT), performed for various diseases of the abdominal viscera, and magnetic resonance (MR) imaging, US has a number they are often necessary because an imaging diagnosis can of advantages for guiding percutaneous biopsy for intra- be declared inconclusive. Ultrasound-guided percutaneous abdominal lesions, including wide availability, portability, core needle biopsy (USPCB) is an accurate, safe, and widely lack of ionizing radiation, relatively short procedure time, real-time visualization of the biopsy needle and target Received May 24, 2016; accepted after revision October 9, 2016. lesion during the procedure, ability to guide the procedure This study was supported by a grant (HCRE13057-7) from in almost any anatomic plane, fewer false-negative biopsies, Dongkook Pharmaceutical Co., Ltd. and relatively lower cost (2-4). These advantages make US Corresponding author: Sang Soo Shin, MD, Department of Radiology, Chonnam National University Hospital, Chonnam more effective than CT and MR imaging in obtaining safe National University Medical School, 42 Jebong-ro, Dong-gu, access to the target lesions without the need to traverse Gwangju 61469, Korea. non-target organs and vessels. USPCB is widely used in • Tel: (8262) 220-5882 • Fax: (8262) 226-4380 • E-mail: [email protected] the diagnosis of various hepatic lesions, but for abdominal This is an Open Access article distributed under the terms of organs other than the liver, it is still considered technically the Creative Commons Attribution Non-Commercial License difficult for general radiologists, especially beginners. (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in The success of USPCB relies on various factors such as the any medium, provided the original work is properly cited. radiologist’s experience and knowledge about the procedure. Copyright © 2017 The Korean Society of Radiology 309 Kim et al. Among these factors, continuous real-time visualization of is irritable or uncooperative or has involuntary movements, the whole length of the biopsy needle, anatomic knowledge USPCB is best avoided. of the abdomen, and specific path of approach for specific abdominal organs are all of great importance (5). The Detailed USPCB Process In this article, we review various aspects of USPCB, including its indications, contraindications, details on the Pre-Biopsy Preparations process including useful tips, specific considerations for Although routine screening tests for coagulation status different abdominal organs, potential complications, and are not universally recommended (13), many centers various clinical scenarios. perform common coagulation tests before USPCB, including prothrombin time, activated partial thromboplastin time, Indications and platelet count (9). Patients are advised to fast without taking solid or semisolid food (water permitted) for at Firstly, USPCB is often required to confirm and stage the least six hours before the procedure when the preoperative malignancy of lesions within the abdominopelvic cavity, imaging shows that the planned biopsy path traverses the except in organs such as the stomach and colon where gastrointestinal (GI) tract or the lesion is located at a site endoscopic approaches are possible (6). In particular, deep in the abdominal cavity such as the pancreas, left USPCB can play an important role in planning treatment adrenal gland, or retroperitoneum (14). It is recommended strategies for patients with cancers of unknown primary that the route for intravenous access be established before origin. Secondly, USPCB enables differentiating between the procedure in patients with high risk of bleeding or benign and malignant lesions, which is difficult to do with anxiety (2). imaging studies alone, and thereby avoiding unnecessary surgery. Thirdly, USPCB is necessary to pathologically Selecting the Biopsy Needle confirm diffuse parenchymal disease in the solid organs Selecting the appropriate biopsy needle is critical to such as the liver and kidney (2, 7). the success of USPCB; the size of the needle is directly correlated with the amount of target tissue required. Contraindications Needles can be classified into two types: small caliber (20-gauge or smaller) and large caliber (19-gauge or larger) Ultrasound-guided percutaneous core needle biopsy should (2). Although needles with small caliber are primarily used be avoided in patients with uncorrectable coagulopathy or to collect cellular samples for cytologic examinations, in the absence of a safe needle path and in uncooperative large-caliber needles can provide sufficient tissue cylinders patients with uncontrolled movement or irritability (6). It for thorough histological evaluations (15-17). Although is contraindicated in patients with a serum platelet count fine needle aspiration (FNA) with a small-caliber needle of less than 50 x 109/L and an international normalized has high diagnostic accuracy with minimal complications, ratio of more than 1.6 (8). Sometimes, before USPCB, its efficacy greatly depends on the on-site availability of transfusion of appropriate blood components may be useful experienced cytopathologists (18); in contrast, core biopsy for correcting coagulopathy when pathologic diagnosis is does not require a cytopathologist. Further, larger tissue necessary for patients with impaired coagulation (9). For samples are usually obtained by core biopsies, which are in-patients who are receiving anticoagulation therapy, such more suitable for the subtype analysis of tumors (2, 6, 19). as aspirin, USPCB can be performed at least five days after In general, USPCB can be successfully performed using an the withdrawal of aspirin (10). USPCB is not recommended 18-gauge needle with an automated spring-loaded biopsy if the operator fails to delineate a safe path for biopsy. gun to obtain sufficient tissue samples (7, 14, 18, 20, 21). However, when direct routes to approach the target lesion Most biopsies are performed more than once by making cannot be identified during the pre-procedural US, it multiple passes into the target lesion. Coaxial biopsy has may be acceptable to advance the biopsy needle through been suggested as a useful method for obtaining multiple major abdominal organs (11, 12). Any motion that is not samples without re-puncturing the capsule of the target anticipated by the operator while performing USPCB may organ (6). Although this technique is expected to decrease cause serious injury to vital organs. Therefore, if the patient the risk of bleeding and time to complete multiple biopsies, 310 Korean J Radiol 18(2), Mar/Apr 2017 kjronline.org Ultrasound-Guided Percutaneous Core Needle Biopsy of Abdominal Viscera it poses a greater risk of lacerating target organs due to the US images. Naturally, the less important the vessels longer dwell times for larger coaxial needles (6). Meanwhile, visualized along the biopsy path, the safer the path will be; non-coaxial techniques feature less dwell time for smaller if major vascular structures lie in the course of the planned biopsy needles in the target organs. Previous studies found biopsy path, the probability of major bleeding due to no significant differences in complication rates between the vascular injuries is high. Color Doppler US can be effectively two techniques (6, 22). used to identify important vessels around major abdominal There are two types of automated cutting needles: fully organs
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