Ultrasound-Guided Visceral Biopsies: Renal and Hepatic

Nirvikar Dahiya, MD, William D. Middleton, MD, Christine O. Menias, MD*

KEYWORDS Ultrasound Biopsy Renal Hepatic Perivascular Pseudoaneurysm

KEY POINTS The basic approach to planning an ultrasound-guided biopsy is similar to performing any other interventional 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 of biopsies. With good technique, these procedures have a very low complication rate.

The authors have provided several related videos at http://www.ultrasound.theclinics.com/.

LIVER BIOPSY imaging tests point to a specific focal or diffuse liver disease. Serial liver biopsies may help to Ultrasound-guided percutaneous biopsy of vis- monitor effects of specific therapy or to identify ceral organs in the abdomen has been in effect recurrence of disease.4 for many years. Paul Ehrlich is credited with performing the first percutaneous liver biopsy in 1883 in Germany.1 Schu¨ pfer2 in 1907 published Preparation for a Liver Biopsy the first liver biopsy series. Huard and Baron The preparation of a liver biopsy constitutes the popularized liver biopsy for general purposes in major portion of the work needed to execute the1930s. Some of the more contemporary arti- a successful biopsy. The actual act of directing cles reporting ultrasound-guided procedures the needle to the target region and collecting the were written in 1972 by Goldberg and Pollack.3 specimen only constitutes a small component of The basic approach to planning an ultrasound- the procedure itself. A thorough history taking is guided biopsy is similar to performing any other in- imperative before the initiation of the biopsy. terventional procedure. However, there are certain With this, the exact clinical question can be under- complexities specific to biopsy of the liver and stood and the correct biopsy technique (fine- kidney that are addressed in this article. needle aspiration [FNA] vs core needle biopsy) determined; accordingly, the proper needle type Indications for a Liver Biopsy and gauge can be selected. For instance, in The indications for doing a liver biopsy are outlined patients with diffuse liver disease and a coexisting in Box 1. A liver biopsy gives invaluable infor- mass, it may be necessary to biopsy the mass mation regarding the staging, prognosis, and (for diagnosis), the liver parenchyma (as part of management even if clinical, laboratory, or preoperative surgical workup), or both depending

Section of Abdomen Imaging, Mallinckrodt Institute of Radiology, Washington University, 510 South Kingshighway, St Louis, MO 63110, USA * Corresponding author. E-mail address: [email protected]

Ultrasound Clin 7 (2012) 363–375 doi:10.1016/j.cult.2012.03.004

Box 1 or fresh frozen plasma can be considered dependent Indications for liver biopsy on the clinical evaluation. The decision to proceed can then be based on the location of the mass or Diffuse hepatocellular disease the general condition of the patient. Alcoholic liver disease Once the bleeding profile has been evaluated, it is important to review all the medications the patient is Nonalcoholic hepatic steatosis taking. Some patients may be on long-term antico- Autoimmune hepatitis agulation or antiplatelet therapy, including aspirin, Grading and staging of chronic hepatitis C or warfarin, clopidogrel bisulfate (PLAVIX; Bristol- chronic hepatitis B Myers Squibb [New York, NY, USA]/Sanofi Phar- Heavy metal storage disorders such as hemo- maceuticals [Bridgewater, NJ, USA]), and heparin. chromatosis and Wilson disease The referring physician must then determine if the risk of discontinuing the medicines is worse than Cholestatic liver diseases such as primary biliary cirrhosis and primary sclerosing cholangitis the increased risk of bleeding related to the biopsy. If the medications are to be discontinued, we Abnormal liver function tests follow the guidelines listed in Table 1 to determine Evaluation of efficacy or adverse effects of the period of time they are withheld. Regarding drugs such as methotrexate subcutaneous heparin, the liver biopsy can be per- Fever of unknown origin formed if the PTT is within normal limits. Readers Hepatosplenomegaly of unknown origin are advised to consult with their respective hema- tologic and clinical departments to ascertain Liver transplant rejection guidelines for coagulation parameters and man- Focal liver disease agement of time for holding anticoagulants before Primary hepatocellular carcinoma, doing a biopsy. Many times such decisions are made on a case-by-case basis. Cholangiocarcinoma An informed consent is obtained before pro- Metastatic disease ceeding with the biopsy. An allergy history to latex Indeterminate mass gloves and lidocaine is established at this time. All the steps of the procedure are explained to the patient in detail so that there are no surprises during the procedure itself. on the clinical situation. In patients with multiple liver masses, prior workup may point to specific lesions Procedure of Doing the Liver Biopsy that are worrisome and others that are clearly A critical component of the procedure is choosing benign. If the patient had undergone positron emis- an approach for a liver biopsy. The ideal approach sion tomography/computed tomography (PET-CT) would be to find the shortest course to the target, as part of the workup, it is important to make avoiding lung, diaphragm, and all the vascular a good anatomic correlation between the hyper- structures. However, this is not always possible. metabolic lesion seen on the PET-CT and ultra- For a random liver biopsy, we prefer targeting sound examination. Some of the newer ultrasound the peripheral right hepatic lobe. This region is equipments allow for fusion imaging, whereby an overlaying of the CT, magnetic resonance imaging, or PET can be done with the ultrasound examination Table 1 to accurately identify the target.5 Guidelines for management of anticoagulants Once the clinical question has been understood, before a visceral organ biopsy the prebiopsy workup includes evaluation of the bleeding profile of the patient and a detailed review Suggested Period Suggested Time Frame for of current medications taken by the patient. At our of Discontinuity Restarting Medication institution, we routinely obtain international normal- Coumadin: 5–7 d Resume the day of the ized ratio (INR), platelet count, prothrombin time, procedure and partial thromboplastin time (PTT). Our guide- Plavix: 7 d Resume the next day lines include performing a biopsy when INR is less Ticlid: 10 d Resume the next day than 1.5 and the platelet count is greater than Heparin Drip: 6 h Resume drip 12 h after 70,000/mL. Some institutions take a count of plate- procedure m 6 lets of 50,000/ L as the minimum requirement. Lovenox: 12 h Resume 12 h after If the INR is greater than 1.5 or if the platelets are procedure less than 70,000/mL, a transfusion of platelets and/ Ultrasound-Guided Visceral Biopsies 365 remote from the central hilar vasculature, and cutting-type needles (Vim-Silverman needle and a tamponade effect can be achieved on comple- Tru-cut needle). The cutting-type needles can tion of the biopsy by having the patient to lie in also be spring loaded. Most visceral core biopsies right lateral decubitus position. If a good subcostal are now performed with spring-loaded needles. window is available, it is our first preference. These needles can be further classified as side However, in most cases an intercostal approach notch or end cutting (Figs. 3–6). is performed, in which the needle traverses the They can also be classified as automatic or diaphragm and pleural space. Care should be semiautomatic. The semiautomatic needles allow taken to avoid the aerated lung. For this reason, one to manually advance the side-notch needle we generally position the needle inferior to the into the target. The biopsy is performed if the oper- transducer, so that shadowing from the lung can ator is satisfied with the placement of the notch in be visualized and avoided before the needle is the target. The automatic needle obtains the core advanced into the liver. When using the intercostal without providing the option of manual advance- approach, the needle is directed over the ribs as ment. With this type of needle, it is critical to the vascular bundle courses along the inferior make accurate measurements of the target size edge of the ribs (Fig. 1). to select an appropriate predefined length for A random biopsy of the left hepatic lobe is per- core biopsy. The end-cutting needles used in our formed when the right hepatic lobe is not feasible. department yield full core specimens at lengths In most cases, the lateral section of the left lobe is of 1.3, 2.3, or 3.3 cm, whereas the semiautomatic targeted in a manner such that the left portal vein side-notch needle yields a partial core specimen at and artery can be avoided. Color Doppler is used a length of 1 or 2 cm. This can vary depending on as a mapping tool for all our biopsies. the biopsy device manufacturers. If the biopsy Care is taken to minimize the risk of bleeding by device that is chosen has a loud clicking sound trying to take the maximum length of the core while performing the procedure, it is best to tissue in the first pass. In cases in which the biopsy make patients aware of this so that they do not is of a target lesion within the liver, many have sug- get startled during the procedure when they hear gested choosing a biopsy path that courses the sound. In terms of guidance, the choice is through a part of the normal liver before reaching between using a mechanical guide attached to the target. Although there are no studies to prove the transducer and freehand guidance. The free- it, this approach presumably helps with the tampo- hand technique requires more experience but nade effect if there is any bleeding from the target has the distinct advantage of maneuverability, lesion after the biopsy (Fig. 2). It also may have especially when subtle changes are required in a role in preventing seeding. We believe that there direction or angle. may be some justification to this approach, but we Choice of transducer used to guide the needle is do not hesitate to biopsy lesions on the surface of also important. Provided visualization of the target the liver if they are substantially easier to reach and adjacent vessels is adequate, phased array than the deeper lesions. transducers have many advantages because Needles are categorized as aspiration- or they are small and easy to maneuver, especially suction-type needles (Menghini needle, Klatskin when using an intercostal approach. Linear array needle, Chiba needle, and Jamshidi needle) and transducers provide the advantage of better

Fig. 1. Liver biopsy technique. (A) Longitudinal view of the liver and lung interface showing the potential danger of puncturing lung when performing biopsy via a superior approach. (B) Corresponding ultrasound image shows a bright reflection and dirty shadow arising from the aerated lung (L). Performing the biopsy from this trajectory risks potential lung puncture and pneumothorax. Arrows indicate the potential trajectories for liver mass biopsy. 366 Dahiya et al

Fig. 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 to traverse 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) partially deployed 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 Biopsies 367 visualization if the target is superficial (ie, within use fentanyl (Sublimaze) and midazolam (Versed). approximately 5 cm of the skin surface). Curved If moderate sedation is used, special credentialing array transducers provide an intermediate choice and privileging to perform sedation may be when lesions are too deep for a linear array, and required.7 visualization is inadequate with a phased array. It helps to give a little extra 1% lidocaine at the The major disadvantage of curved arrays is their capsule (Fig. 8). At times, it helps to inject enough larger size, which makes them more clumsy to so as to cause a slight bump in the contour of the maneuver. Generally, we prefer lining up our parietal peritoneum; this serves as a landmark for biopsy needle along the side of the transducer, the entry point of the biopsy needle. so that we can see the entire shaft of the needle Once the local anesthesia has been satisfacto- as we approach the target (Fig. 7). rily injected, we observe the relation between the The sterile biopsy tray we use for a biopsy biopsy target and the patient’s breathing to deter- procedure includes mine if the biopsy will be done with the patient holding his/her breath in normal or deep inspiration 1. 10 mL of 1% lidocaine buffered with 8.4% or normal expiration. We usually ask the patient to sodium bicarbonate practice a couple of breath-holds at this time to Â 2. 25-gauge 30-mm needle ascertain the best position of the target lesion for Â 3. 4 4 gauze pack the biopsy. When possible, we prefer normal expi- 4. Scalpel #11 blade ration because this is more reproducible than deep 5. 5-mL syringe inspiration and it raises the location of lung paren- Â 6. 25-gauge 5/8-in needle for superficial chyma. However, this expiration may not be anesthesia possible in patients who are short of breath. 7. Applicator prep, gloves, and sterile drapes. For core biopsies, local anesthesia is followed We perform most of our biopsies under local by a small nick in the skin with a surgical blade. anesthesia, using 1% lidocaine mixed with sodium This is important because it can sometimes be bicarbonate. The shorter 25-gauge Â 5/8-in nee- difficult to advance core needles through the dle is used to inject lidocaine for superficial intra- skin. The core needle we like to use is usually the dermal anesthesia after the patient has been spring-loaded 18-gauge needle. For liver biopsies, cleaned and draped in a sterile manner. For deep- we most often use the end-cutting needle that er anesthesia, we use the 25-gauge Â 30-mm yields a full core specimen at lengths of 1.3, 2.3, needles to introduce more lidocaine. Deeper anes- or 3.3 cm. When a focal lesion is near major thesia is injected under ultrasound guidance to vessels, a semiautomatic side-notch needle that determine the proper trajectory for the biopsy yields a partial core specimen at a length of 1 or and to ensure that the anesthesia is injected 2 cm may be preferable. In both cases, the needle deep enough to numb the capsule of the viscera, is introduced to the capsule surface; patients are be it the liver or the kidney. then asked to hold their breath and the needle is Moderate sedation or conscious sedation is usually not necessary for routine liver biopsies; however, there are institutions that may typically

Fig. 7. Freehand biopsy technique. Biopsy needle is positioned in the plane of the image, immediately next to the side of the transducer. This allows for visu- Fig. 8. Liver capsule numbing. Needle shaft and tip alization of the needle tip and shaft throughout the (arrows) are positioned such that anesthesia adminis- procedure. tered is at the level of the liver capsule (arrowheads). 368 Dahiya et al

introduced into the liver. In most cases, if the In these cases, coaxial technique can be per- trajectory has been well planned and the needle formed,7 wherein an introducer is initially deployed is well visualized, the needle can be advanced to into the target area and subsequent sampling can the lesion and a sample can be obtained on be done coaxially through it. Although a distinct a single breath-hold. advantage of the coaxial technique is the single The throw of the needle depends on the location puncture through the liver capsule, it is somewhat and size of the lesion and the distribution of offset by the increased risk of capsule shearing or adjacent vessels. It is important, however, to tearing as the needle stays in for a longer period remember that a throw setting of 10 or 13 mm typi- while the patient breathes. cally results in a sample that is several millimeters The choice of performing an FNA biopsy or shorter. So, if safe, it is best to avoid these short a core biopsy depends on the clinical scenario. throws. For random liver biopsies, we mostly use In a patient with a known extrahepatic primary the 3.3-cm throw. cancer in whom the only reason to perform a liver For FNA, we use either a 25-gauge spinal needle biopsy is to prove the presence of metastatic or a 23-gauge Chiba needle. In both cases, we disease, we would do an FNA. If immediate on- prefer introducing the needle with the stylet inside site cytologic analysis is possible, aspirations are to avoid contaminating the lumen with extraneous performed until a diagnostic sample is obtained. cells and to ensure that the needle has some tensile If the initial aspiration result is positive for malig- strength to maneuver. Once the needle tip has nancy and correlates with the primary tumor, no reached the target, the stylet can be removed and additional aspirations are required. If the initial the process of taking the FNA sample can begin specimens are negative for malignancy or suggest (Fig. 9). Typically, we do the first aspiration without an alternative primary, then additional aspirations suction. Subsequent aspirations are performed or core biopsies are obtained. If only semi- with or without suction depending on the yield of immediate off-site cytologic analysis is possible the initial pass. Although we prefer making multiple or if there is no cytologic support, several passes separate passes, sometimes successful and (3–6) should be obtained before terminating the consistent needle placement may be very difficult. procedure.

Fig. 9. FNA. A 55-year-old woman with a history of pancreatic cancer. Small liver mass in the patient with a history of pancreatic cancer and a suspicious lesion seen on CT. (A) Contrast-enhanced CT scan of the liver showing a small low-attenuation lesion in the liver (arrow). (B) Transverse sonogram of the liver shows a 9-mm solid hypoechoic lesion (cursors) corresponding to the lesion seen on CT. (C) Image obtained from a real-time cine clip taken during FNA shows the tip of a 25-gauge spinal needle (arrow) within the lesion. Needle shaft location (arrowheads) was more apparent during real-time imaging. Ultrasound-Guided Visceral Biopsies 369

Despite the presence of a known extrahepatic tumor thrombus.8 At times, referring hepatologists primary tumor, if immunohistochemical studies do not require a tissue diagnosis to confirm are anticipated, we typically do a core biopsy the presence of hepatocellular carcinoma if the rather than an FNA. A core biopsy provides cross-sectional imaging is consistent with hepato- enough tissue for hematoxylin-eosin as well as cellular carcinoma and there is a correlative eleva- immunohistochemical staining. Additional section of a-fetoprotein level. tions can be taken from the paraffin block of the The diagnostic accuracy of percutaneous nee- core biopsy to stain for immunohistochemistry dle biopsy in lesions 1 cm or smaller has increased markers such as estrogen receptor, progesterone from 79% (n 5 24) in 1987 to 87.5% (n 5 24) in receptor, and HER2/neu. 1993 and 99% (n 5 74) in 1999. The use of a free- If the clinical history or prior imaging results hand biopsy technique under ultrasound guidance suggest a primary malignant or benign liver tumor, is a common feature of all the series.9 we generally perform core biopsies with an 18- gauge needle (Fig. 10). Complications If hepatocellular cancer is confirmed, it is permissible to start with FNA and get preliminary Liver biopsies are relatively safe, with a complica- analysis from the respective cytopathologist. If tion rate of 0.2% to 0.3%.10 Hemorrhage is the the diagnosis of hepatocellular cancer is con- most common complication and is more likely to firmed after 1 to 3 passes, no further aspirations occur in patients with underlying cirrhosis or ma- are necessary. But if the initial aspiration results lignancy or bleeding diathesis. Most complications are negative or nondiagnostic, cores become nec- occur soon after completion of the biopsy. A linear essary. In patients with suspected hepatocellular color flow signal may at times be seen along the cancer and tumor thrombus of the portal or needle track immediately after the biopsy.11 Kim hepatic vein, it is possible to confirm the diagnosis and colleagues11 evaluated the predictive role and assist with staging by performing FNA of the this signal played in the detection of postbiopsy

Fig. 10. A 61-year-old woman with a history of breast cancer. (A) Contrast-enhanced CT scan shows a small superficial low-attenuation lesion in the right lobe of the liver (arrow). (B) Oblique ultrasound image shows an 18- gauge core needle (arrows) in position to obtain a core biopsy. (C) The needle is deployed (arrows) and traverses the entire diameter of the lesion. Note that the throw in this case was selected at 20 mm to ensure sampling of the entire lesion. 370 Dahiya et al

bleeding and referred to it as patent track sign. The imaging, interventional, and cytologic techniques investigators suggested that the postbiopsy have enhanced the role of percutaneous biopsy bleeding events were significantly more likely in the diagnosis of renal masses. The incidental when a patent track sign persisted on scans ob- detection of benign and malignant renal masses tained 5 minutes after the biopsy (Fig. 11). has increased with increase in use of multidetector Ascites should not be considered a contraindica- CT and magnetic resonance imaging.15 tion to liver biopsy; however, in cases of moderate In one study, 25% of masses smaller than 3 cm to large ascites, we prefer to have a paracentesis were benign.16 This factor has led to an increased done before the biopsy. In cases in which patients demand for percutaneous renal biopsies for small- are affected by significant coagulopathy, we er masses. Biopsy of oncocytoma has been recommend a transjugular hepatic biopsy. controversial. The reason lies in the difficulty presented to differentiate benign cells from malignant RENAL BIOPSY cells on pathologic examination. Oncocytic cells can exist in various renal neoplasms, including Percutaneous renal biopsy using an aspiration renal oncocytoma and oncocytic renal cell carci- needle and with the patient in sitting position was nomas, many of which are renal cell carcinomas first described by Iversen and Brun12 in 1951. In of low metastatic potential.17 These include gran- 1954, Kark and Muehrcke13 described the use of ular cell carcinoma, chromophobe renal cell carci- the cutting Vim-Silverman needle in patients in noma, and eosinophilic variant of papillary renal the prone position, with a substantial improvement cell carcinoma.18–21 In some cases, a diagnosis in the rate of success. The 1961 Ciba Foundation of oncocytoma can be strongly suggested on the Symposium on renal biopsy marked the coming basis of histochemical, immunocytochemical, of age of this technique.14 Recent advances in and ultrastructural studies. Oncocytomas could

Fig. 11. A 60-year-old man with chronic hepatitis C referred for an ultrasound-guided random liver biopsy. (A) Oblique view of the liver shows the core needle (arrows) in position obtaining a random liver biopsy. (B) Post- biopsy scan shows a patent tract (arrow) with detectable Doppler signal at the biopsy site. (C) Postbiopsy image obtained 2 hours after the procedure shows an acute hematoma surrounding the liver (arrows). This required Gelfoam embolization by an interventional radiologist. Ultrasound-Guided Visceral Biopsies 371 be confidently distinguished from oncocytic renal Focal mass lesion biopsy cell carcinoma using immunocytochemical anal- For focal biopsies of a mass lesion, FNA and core ysis. In a study done by Liu and Fanning,22 all on- biopsy can both be performed. Some institutions cocytomas were negative for vimentin, whereas may perform both in the same sitting because only granular cell carcinoma and eosinophilic a combination of the two may produce higher variant of papillary renal cell carcinoma were posi- diagnostic yield. Whereas FNA may be performed tive for vimentin. Also, the 2 vimentin-negative using a 22- or 25-gauge needle, 18-gauge needles neoplasms, oncocytoma and chromophobe renal are used for core biopsies. We do 4 to 6 passes for cell carcinoma, could be distinguished by Hale our FNA samples and 2 or more samples for our colloidal iron stain, which was present in all chro- core biopsies. The patient is put in a posterior ob- mophobe renal cancers but only focally or not at lique or lateral decubitus position for most biop- all in oncocytomas. sies. A towel or pillow may be put between the body and the bed to enhance the kyphosis. This Indications for a Renal Biopsy helps in pushing the rib cage up and increasing As with the liver, kidney biopsies may be done the space available for doing the biopsy. We try either to evaluate an indeterminate focal lesion/ to use the posterior axillary line as the point of mass or to evaluate the cortex for a parenchymal entry. This posterolateral approach avoids the disease process. A list of the more important indi- potential inadvertent injury to the colon. Some- cations is presented in Box 2. times the location of the mass may prompt a more posterior approach in prone position Preparation for Renal Biopsy (Fig. 12). Once the mass has been visualized using ultrasound, anesthesia is administered in a manner The issues related to preparation for the biopsy similar to that described for liver biopsies. have already been discussed in the liver biopsy section and are essentially the same. The coagula- Nonfocal renal cortex (cortical) biopsy tion workup and the assessment for medications Nonfocal parenchymal biopsies are performed in that interfere with clotting mechanisms are also whatever position provides optimal visualization similar. The fundamental difference comes in the of the kidney and avoids critical overlying struc- approach to a kidney biopsy and the associated tures. The lower pole of either kidney is the complications. As with hepatic biopsies, renal preferred site. Usually the left kidney is the first biopsies, whether focal or nonfocal, can be per- choice because it is lower in location than the formed as outpatient procedures under ultrasound right. The target is the cortical tissue from the guidance. lower pole of the kidney. Care is taken to avoid the medulla and the collecting system by directing the needle into the superficial cortex in a rela- Box 2 tively tangential manner. An onsite pathology Indications for renal biopsy service determines the adequacy of the sample (Fig. 13). Parenchymal renal disease Nephrotic syndrome Isolated glomerular hematuria Complications Systemic disease with renal dysfunction Renal biopsy is a relatively safe procedure, with Acute nephritic syndrome loss of life extremely rare and major complications, mostly related to bleeding, occurring in only 1% to Unexplained acute renal failure 6% of procedures.23 Renal biopsies have an over- Goodpasture syndrome all low mortality rate of 0.031%.24 Wegener granulomatosis Postbiopsy complications include hemorrhage, Suspected renal transplant rejection pseudoaneurysm, arteriovenous fistula, infection, pneumothorax, adjacent bowel or liver/spleen Solitary renal mass for which partial nephrec- injury, and tumor seeding. Postbiopsy bleeding tomy may be considered can occur in several places: into the collecting Multiple renal masses system, leading to microscopic or gross hematuria Renal mass in a patient with a known primary and possible ureteral obstruction; in a subcapsular malignancy or metastatic disease or lymphoma location, leading to pressure tamponade and Renal mass in a patient with potential focal pain; or into the perinephric space, leading to infection/abscess retroperitoneal hematoma and possibly a drop in the serum hematocrit level (Fig. 14). Most clinically 372 Dahiya et al

Fig. 12. A 24-year-old man with a history of lymphoma. (A) Contrast-enhanced CT scan shows a low-attenuation lesion in the anterior aspect of the left kidney (arrows). Other similar lesions were seen in both kidneys. (B) Trans- verse sonogram showing an 18-gauge core needle (arrowheads) within a hypoechoic solid renal mass (arrows) corresponding to the lesion shown on CT. Pathology from this biopsy was consistent with lymphoma.

significant bleedings are recognized within 12 to retroperitoneal hematoma, the patient will have to 24 hours of the biopsy.25 be closely monitored and may even need other Mild perinephric hemorrhage is self-limiting imaging modalities to assess the extent of and seen in 44% of the cases.26 If there is a large bleed.

Fig. 13. Status after renal transplant in a 45-year-old woman with elevated creatinine levels and concern for rejection. (A) Longitudinal view of the lower pole of the transplant. Identification of cortex without calyces and medullary components is important. (B) Transverse view of the lower pole of the transplant (arrowheads) shows the relationship of the transplant with the external iliac artery (arrow). (C) Transverse view with needle in position showing the eccentric oblique orientation of the needle (arrows) used to obtain cortical tissue with little or no medullary component. Ultrasound-Guided Visceral Biopsies 373

Fig. 14. A 60-year-old woman with parenchymal renal disease referred for a percutaneous biopsy. (A) Transverse view of the lower pole of the kidney obtained during performance of a second core biopsy shows a hypoechoic perinephric hematoma (H). The core needle is shown within the lower pole of the more echogenic kidney (arrows). (B) Longitudinal view following both biopsies again shows the perinephric hematoma (H). (C) Color Doppler view of the lower pole of the left kidney shows extensive perivascular tissue vibration (arrows) consistent with an arteriovenous fistula.

Pseudoaneurysm and arteriovenous fistula for- Doppler and CT angiography are both sensitive for mation are also well-recognized complications of making the diagnosis. In some cases arterial embo- percutaneous renal biopsy (Fig. 15). They can be lization may be required.27,28 Tumor seeding is clinically silent, or the patient may present with always a theoretical possibility; however, only 7 hematuria or retroperitoneal bleeding. Color duplex cases have been reported in the literature.27–34

Fig. 15. A 66-year-old man, 8 months after renal transplant with pain one day after renal biopsy. (A) Longitudinal view of the lower pole of the transplant shows a hypoechoic perinephric lesion (arrows). (B) Color Doppler image confirms internal vascular flow. An arterial signal was documented on waveform analysis consistent with a perinephric pseudoaneurysm (arrow). 374 Dahiya et al

POSTBIOPSY CARE 7. Winter TC, Lee FT Jr, Hinshaw JL. Ultrasound- guided biopsies in the abdomen and pelvis. Ultra- We observe patients after a liver or renal biopsy for sound Q 2008;24(1):45–68. at least 4 hours. After a baseline assessment of 8. Tarantino L, Francica G, Sordelli I, et al. Diagnosis of vital signs in the department, the patients are benign and malignant portal vein thrombosis in observed in the postanesthesia care unit. Pulse cirrhotic patients with hepatocellular carcinoma: rate, blood pressure, and oxygen saturation are color Doppler US, contrast-enhanced US, and fine- monitored. Some patients will have local tender- needle biopsy. Abdom Imaging 2006;31:537–44. ness once the effect of lidocaine wears off, which 9. Yu SC, Liew CT, Lau WY, et al. US-guided percuta- can be symptomatically treated with a variety neous biopsy of small (1-cm) hepatic lesions. of analgesics. Some patients complain of right Radiology 2001;218:195–9. shoulder pain after a liver biopsy. This is likely a vis- 10. Piccinino F, Sagnelli E, Pasquale G, et al. Complica- 35 cerosomatic referred pain and is self-limiting. tions following percutaneous liver biopsy. A multi- Right shoulder pain does not seem to be an indi- centre retrospective study on 68,276 biopsies. cation of a severe complication such as intra- J Hepatol 1986;2(2):165. 36 abdominal bleeding. 11. Kim KW, Kim MJ, Kim HC, et al. Value of “patent If the patients complain of severe pain at the site track” sign on Doppler sonography after percuta- of the biopsy or if the blood pressure falls, they are neous liver biopsy in detection of postbiopsy brought back to the department to assess the bleeding: a prospective study in 352 patients. Am biopsy site by ultrasonography. Rarely a patient J Roentgenol 2007;189(1):109–16. may need a CT scan if concerns for a more severe 12. Iversen P, Brun C. Aspiration biopsy of the kidney. hepatic or renal injury are high. Patients without Am J Med 1951;11:324–30. complaints are discharged with instructions to 13. Kark RM, Muehrcke RC. Biopsy of kidney in prone avoid strenuous activity for the remaining day. position. Lancet 1954;266:1047–9. 14. Wolstenholme GE, Cameron MP, Ciba Foundation. SUMMARY Ciba Foundation Symposium on Renal Biopsy: clin- Visceral organ biopsies are being routinely done ical and pathological significance. London: J these days with excellent diagnostic results. Ultra- Churchill; 1961. sonography is a safe and reliable imaging modality 15. Silverman SG, Gan YU, Koenraad J, et al. Imaging- to provide guidance for the vast majority of biopsy. guided percutaneous renal biopsy: rationale and With good technique, these procedures have approach. AJR Am J Roentgenol 2010;194(6): a very low complication rate. 1443–9. 16. Frank I, Blute ML, Cheville JC, et al. Solid renal tumors: an analysis of pathological features related SUPPLEMENTARY DATA to tumor size. J Urol 2003;170:2217–20. Supplementary data related to this article can be 17. Krejci KG, Blute ML, Cheville JC, et al. Nephron- found online at doi:10.1016/j.cult.2012.03.004. sparing surgery for renal cell carcinoma: clinico- pathologic features predictive of patient outcome. REFERENCES Urology 2003;62:641–6. 18. Wiatrowska BA, Zakowski MF. Fine-needle aspira- 1. van Leeuwen DJ, Wilson L, Crowe DR. Liver biopsy tion biopsy of chromophobe renal cell carcinoma in the mid-1990s: questions and answers. Semin and oncocytoma: comparison of cytomorphologic Liver Dis 1995;15:340–59. features. Cancer 1999;87:161–7. 2. Schu¨pfer F. De la possibilite de faire “intra vitam” un 19. Akhtar M, Ali MA. Aspiration cytology of chromo- diagnostic histo-pathologique pre´cis des maladies phobe cell carcinoma of the kidney. Diagn Cytopa- due foie et de la rate. Sem Med 1907;27:229 [in thol 1995;13:287–94. French]. 20. Alanen KA, Tyrkko JE, Nurmi MJ. Aspiration biopsy 3. Goldberg BB, Pollack HM. Ultrasonic aspiration cytology of renal oncocytoma. Acta Cytol 1985;29: transducer. Radiology 1972;102:187–9. 859–62. 4. Bravo AA, Sheth SG, Chopra S. Current concepts: 21. Granter SR, Renshaw AA. Fine-needle aspiration of liver biopsy. N Engl J Med 2001;7:495–500. chromophobe renal cell carcinoma: analysis of six 5. Kru¨cker J, Xu S, Venkatesan A, et al. Clinical utility of cases. Cancer 1997;81:122–8. real-time fusion guidance for biopsy and ablation. 22. Liu J, Fanning CV. Can renal oncocytomas be distin- J Vasc Interv Radiol 2011;22(4):515–24. guished from renal cell carcinoma on fine-needle 6. Khati NJ, Gorodenker J, Hill MC. Ultrasound-guided aspiration specimens? A study of conventional biopsies of the abdomen. Ultrasound Q 2011;27(4): smears in conjunction with ancillary studies. Cancer 255–68. 2001;93:390–7. Ultrasound-Guided Visceral Biopsies 375

23. Korbet SM. Percutaneous renal biopsy. Semin 31. Kiser GC, Totonchy M, Barry JM. Needle tract seed- Nephrol 2002;22:254–67. ing after percutaneous renal adenocarcinoma aspi- 24. Smith EH. Complications of percutaneous ab- ration. J Urol 1986;136:1292–3. dominal fine-needle biopsy. Radiology 1991;178: 32. Wehle MJ, Grabstald H. Contraindications to needle 253–8. aspiration of a solid renal mass: tumor dissemina- 25. Whittier WL, Korbet SM. Timing of complications in tion by renal needle aspiration. J Urol 1986;136: percutaneous renal biopsy. J Am Soc Nephrol 446–8. 2004;15(1):142. 33. Shenoy PD, Lakhkar BN, Ghosh MK, et al. Cuta- 26. Lechevallier E, Andre´ M, Barriol D, et al. Fine needle neous seeding of renal carcinoma by Chiba needle percutaneous biopsy with computerized tomog- aspiration biopsy: case report. Acta Radiol 1991; raphy guidance. Radiology 2000;216:506–10. 32:50–2. 27. Abe M, Saitoh M. Selective renal tumor biopsy under 34. Slywotzky C, Maya M. Needle tract seeding of transi- ultrasonic guidance. Br J Urol 1992;70:7–11. tional cell carcinoma following fine-needle aspiration 28. Silberzweig JE, Tey S, Winston JA, et al. Percuta- of a renal mass. Abdom Imaging 1994;19:174–6. neous renal biopsy complicated by renal capsular 35. Hartmann H, Beckh K. Nerve supply and ner- artery pseudoaneurysm. Am J Kidney Dis 1998;31: vous control of liver function. sections 1–13. In: 533–5. Mclntyre N, Benhamou JP, Bircher J, editors. Oxford 29. Gibbons RP, Bush WH Jr, Burnett LL. Needle tract textbook of clinical hepatology, vol. 1. Oxford (UK): seeding following aspiration of renal cell carcinoma. Oxford University Press; 1993. p. 93. J Urol 1977;118:865–7. 36. Eisenberg E, Konopniki M, Veitsman E, et al. Preva- 30. Auvert J, Abbou CC, Lavarenne V. Needle tract lence and characteristics of pain induced by percu- seeding following puncture of renal oncocytoma. taneous liver biopsy. Anesth Analg 2003;96(5): Prog Clin Biol Res 1982;100:597–8. 1392–6.