Incidence of major hemorrhage after aggressive image-guided liver mass biopsy in the era of individualized medicine

Ultrasound-guided biopsy of challenging abdominopelvic targets

Percutaneous ultrasound-guided biopsies have become the standard of practice for tissue diagnosis in the abdomen and pelvis for many sites including liver, kidney, abdominal wall, and peripheral nodal stations. Additional targets may appear difficult or impossible to safely biopsy by ultrasound due to interposed bowel loops/vasculature, deep positioning, association with the bowel, or concern for poor visibility; however, by optimizing technique, it is often possible to safely and efficiently use real-time ultrasound guidance for sampling targets that normally would be considered only appropriate for CT guided or surgical/endoscopic biopsy.

Safety of percutaneous, image-guided biopsy of hepatocellular carcinoma with and without concurrent ablation

PURPOSE

To determine the prevalence of adverse events after image-guided biopsy of histologically proven hepatocellular carcinomas (HCC) using a standardized, indirect access, coaxial biopsy technique.

METHODS

In this IRB-approved, HIPAA compliant, and retrospective study, we evaluated all consecutive adult patients from 2011 to 2016 who underwent image-guided biopsy of HCC with and without concurrent ablation. Tumor seeding was defined as any new lesion along the needle tract on subsequent imaging. Adverse events were graded using both the Clavien-Dindo Complication Classification system and the most recently proposed Society of Interventional Radiology (SIR) Adverse Event Classification System.

RESULTS

A total of 383 patients underwent 398 biopsies (64 ± 11 years; 112 women, 271 men). Most patients (282; 71%) underwent concurrent ablation. Adverse events occurred after 18 biopsies (4.5%): 13 were Grade I (Clavien-Dindo) or minor (SIR) and included hematoma (7), hepatic vein thrombus (2), portal vein thrombus (2), moderate pleural effusion (1), and small pneumothorax (1). The remaining 5 (1.3%) adverse events were classified as Grade II-IIIa (Clavien-Dindo) or moderate (SIR) and included hematoma requiring blood products (n = 1), arrhythmia (n = 1), and symptomatic pleural effusions requiring treatment (n = 3). Baseline age, sex, cause of liver disease, HCC diameter, and HCC grade were not associated with adverse events. There were no tumor seeding events after a median follow-up of 611 days (interquartile range of 211-1104).

CONCLUSION

Percutaneous image-guided tissue sampling using a standardized, indirect access, coaxial technique can be performed safely with and without concurrent ablation by trained cross-sectional interventional radiologists at a tertiary liver transplant center.

Liver biopsy technique in the era of genomic cancer therapies: a single-center retrospective analysis

BACKGROUND

With the evolution of personalized medicine in the field of oncology, which includes optimal treatment selection using next-generation sequencing-based companion diagnostic systems and tumor-agnostic treatments according to common biomarkers, a liver tumor biopsy technique that can obtain a sufficient specimen volume must be established. The current study aimed to evaluate the safety and availability of a liver tumor biopsy technique with multiple puncture sites made using a coaxial introducer needle and embolization with gelatin sponge particles.

METHODS

Patients with primary or metastatic liver cancer who underwent liver tumor biopsies with puncture tract embolization using gelatin sponge (Spongel^®) from October 2019 to September 2020 were included in the study. The complication and diagnostic rates were evaluated, and whether the specimen volume was sufficient for Foundation^® CDx was investigated.

RESULTS

In total, 96 patients were enrolled in this analysis. The median total number of puncture times per patient was 3 (range 1-8). The pathological diagnostic rate was 79.2%. Using the FoundationOne^® CDx, specimens with a sufficient volume required for genomic medicine were collected in 84.9% of patients. The incidence rate of bleeding was 4.2% (n = 4), and only one patient presented with major bleeding requiring transfusion.

CONCLUSIONS

Liver biopsy with puncture tract embolization using a gelatin sponge may be safe and effective for collecting specimens with a volume sufficient for modern cancer treatments.

Bleeding management in computed tomography-guided liver biopsies by biopsy tract plugging with gelatin sponge slurry

To evaluate the safety and impact of biopsy tract plugging with gelatin sponge slurry in percutaneous liver biopsy. 300 consecutive patients (158 females, 142 males; median age, 63 years) who underwent computed tomography-guided core biopsy of the liver in coaxial technique (16/18 Gauge) with and without biopsy tract plugging were retrospectively reviewed (January 2013 to May 2018). Complications were rated according to the common criteria for adverse events (NCI-CTCAE). The study cohort was dichotomized into a plugged (71%; n = 214) and an unplugged (29%; n = 86) biopsy tract group. Biopsy tract plugging with gelatin sponge slurry was technically successful in all cases. Major bleeding events were only observed in the unplugged group (0.7%; n = 2), whereas minor bleedings (4.3%) were observed in both groups (plugged, 3.6%, n = 11; unplugged, 0.7%, n = 2). Analysis of biopsies and adverse events showed a significant association between number of needle-passes and overall (P = 0.038; odds ratio: 1.395) as well as minor bleeding events (P = 0.020; odds ratio: 1.501). No complications associated with gelatin sponge slurry were observed. Biopsy tract plugging with gelatin sponge slurry is a technically easy and safe procedure that can prevent major bleeding events following liver biopsy.

Variability in biopsy quality informs translational research applications in hepatocellular carcinoma

In the era of precision medicine, biopsies are playing an increasingly central role in cancer research and treatment paradigms; however, patient outcomes and analyses of biopsy quality, as well as impact on downstream clinical and research applications, remain underreported. Herein, we report biopsy safety and quality outcomes for percutaneous core biopsies of hepatocellular carcinoma (HCC) performed as part of a prospective clinical trial. Patients with a clinical diagnosis of HCC were enrolled in a prospective cohort study for the genetic, proteomic, and metabolomic profiling of HCC at two academic medical centers from April 2016 to July 2020. Under image guidance, 18G core biopsies were obtained using coaxial technique at the time of locoregional therapy. The primary outcome was biopsy quality, defined as tumor fraction in the core biopsy. 56 HCC lesions from 50 patients underwent 60 biopsy events with a median of 8 core biopsies per procedure (interquartile range, IQR, 7–10). Malignancy was identified in 45/56 (80.4%, 4 without pathology) biopsy events, including HCC (40/56, 71.4%) and cholangiocarcinoma (CCA) or combined HCC-CCA (5/56, 8.9%). Biopsy quality was highly variable with a median of 40% tumor in each biopsy core (IQR 10–75). Only 43/56 (76.8%) and 23/56 (41.1%) samples met quality thresholds for genomic or metabolomic/proteomic profiling, respectively, requiring expansion of the clinical trial. Overall and major complication rates were 5/60 (8.3%) and 3/60 (5.0%), respectively. Despite uniform biopsy protocol, biopsy quality varied widely with up to 59% of samples to be inadequate for intended purpose. This finding has important consequences for clinical trial design and highlights the need for quality control prior to applications in which the presence of benign cell types may substantially alter findings.

US Elastography in Hepatic Fibrosis-Radiology In Training

A 72-year-old woman with an elevated body mass index and moderate alcohol intake was seen in the gastroenterology clinic. The patient had a past history of abnormal liver function tests and previous biopsy-proven steatosis with early fibrosis. She was reevaluated, following an initial loss to follow-up, by using US elastography to assess for fibrosis progression. The utility of US elastography in the noninvasive diagnosis and longitudinal monitoring of hepatic fibrosis is discussed. An overview of available technologies, including transient elastography and shear-wave elastography, is provided. ^©RSNA, 2021 Online supplemental material is available for this article.

Image-guided biopsy in the age of personalised medicine: strategies for success and safety

Oncology has progressed into an era of personalised medicine, whereby the therapeutic regimen is tailored to the molecular profile of the patient's cancer. Determining personalised therapeutic options is achieved by using tumour genomics and proteomics to identify the specific molecular targets against which candidate drugs can interact. Several dozen targeted drugs, many for multiple cancer types are already widely in clinical use. Molecular profiling of tumours is contingent on high-quality biopsy specimens and the most common method of tissue sampling is image-guided biopsy. Thus, for radiologists performing these biopsies, the paradigm has now shifted away from obtaining specimens simply for histopathological diagnosis to acquiring larger amounts of viable tumour cells for DNA, RNA, or protein analysis. These developments have highlighted the central role now played by radiologists in the delivery of personalised cancer care. This review describes the principles of molecular profiling assays and biopsy techniques for optimising yield, and describes a scoring system to assist in patient selection for percutaneous biopsy.

Biopsy of Deep Pelvic and Abdominal Targets With Ultrasound Guidance: Efficacy of Compression

OBJECTIVE. The purpose of this study was to evaluate the utility of compression of tissues with the ultrasound transducer in decreasing distance to the biopsy target and establishing a safe percutaneous biopsy route to deep abdominopelvic targets. MATERIALS AND METHODS. Ultrasound-guided biopsies of nonsolid organ abdominopelvic targets performed from 2006 to 2017 were reviewed. Skin-to-target distance was measured on preprocedure CT scans for reference standard and on procedure ultrasound images for actual real-time distance after compression. The skin-to-target CT distance groupings were 0-3 cm, 3-6 cm, 6-10, cm, and > 10 cm. Deep targets were defined as > 6 cm. Differences in skin-to-target distance between static CT and compression ultrasound were calculated. Body mass index, procedure details, diagnostic yield, and complication rate were recorded. RESULTS. The biopsies of 389 patients (167 men, 222 women; mean age, 62.4 years; mean body mass index, 28.2) were assessed. Skin-to-target distance was 0-3 cm in 108 patients, 3-6 cm in 163 patients, 6-10 cm in 99 patients, and > 10 cm in 19 patients. A total of 118 deep targets were identified. The mean skin-to-target distance in the entire cohort was 5.0 cm on CT scans and 3.6 cm on ultrasound images with a 10% mean decrease in distance with ultrasound compression. For skin-to-target distances of 6-10 cm, distance decreased 39% at ultrasound, and for skin-to-target distances > 10 cm, distance decreased 48%. Thirty-three patients (8.5%) had no safe identifiable path for CT biopsy, most commonly because of intervening bowel, displacement of which at ultrasound allowed a safe biopsy trajectory. Ultrasound-guided biopsy had a diagnostic yield of 91.5% and a favorable safety profile. The complication rate was 1.3%. CONCLUSION. Application of compression with the ultrasound transducer decreased skin-to-target distance 40% or more for deep targets in addition to displacing bowel and establishing a safe path for biopsy in approximately 8.5% of cases.

Outcome and safety of targeted liver biopsies for indeterminate lesions in patients with chronic liver disease: A single centre experience

INTRODUCTION

To evaluate the histopathological and safety outcomes of indeterminate lesions in patients at high risk for developing hepatocellular carcinoma (HCC) who underwent ultrasound-guided biopsies.

METHODS

Ultrasound-guided targeted liver biopsies for indeterminate lesions performed in a 10-year period at our institution were reviewed retrospectively for lesion characteristics, biopsy techniques, histopathological results and post procedural complications.

RESULTS

A total of 172 biopsies were performed in 152 patients. Most common background liver disease included hepatitis C, hepatitis B, alcoholic and non-alcoholic steatohepatitis. 65.1% had known cirrhosis at time of biopsy. HCC was the most common histopathological finding accounting for 55.8% of all biopsies, followed by cholangiocarcinoma, dysplastic nodule and metastasis. Rarer lesions including lymphoma, neuroendocrine tumour and angiomyolipoma were also encountered. No mortality, clinically significant bleeding or tumour seeding was detected.

CONCLUSIONS

Ultrasound-guided liver biopsies of indeterminate lesions in patients at high risk of HCC yield important histopathological findings, important for management options including the provision of curative treatments and assisting future novel therapies such as immunotherapy and targeted therapies. The low complication rates confirm its safety and the procedure should not be avoided for fear of complications.