Ultrasound-guided biopsies in the abdomen and pelvis

Review of Diagnostic Modalities for Adrenal Incidentaloma

Adrenal incidentalomas are common findings in clinical practice, with a prevalence of up to 4.2% in radiological studies. Due to the large number of focal lesions in the adrenal glands, it can be challenging to make a definitive diagnosis and determine the appropriate management. The purpose of this review is to present current diagnostic modalities used to preoperatively distinguish between adrenocortical adenoma (ACA) and adrenocortical cancer (ACC). Proper management and diagnosis are crucial in avoiding unnecessary adrenalectomies, which occur in over 40% of cases. A literature analysis was conducted to compare ACA and ACC using imaging studies, hormonal evaluation, pathological workup, and liquid biopsy. Before deciding on surgical treatment, the nature of the tumor can be accurately determined using noncontrast CT imaging combined with tumor size and metabolomics. This approach helps to narrow down the group of patients with adrenal tumors who require surgical treatment due to the suspected malignant nature of the lesion.

Relationship between anxiety and internet searches before percutaneous ultrasound-guided diagnostic procedures: A prospective cohort study

Invasive procedures guided by ultrasound (US) are part of routine medical diagnostic investigation. The lack of knowledge surrounding the technical aspects of such procedures can lead patients to seek complementary information on the Internet, which may in turn trigger anxiety. However, the intersection between the fields of Radiology and Psychology is poorly studied. Here, we identify the profile of an anxious patient before an US-guided intervention. We prospectively studied 133 patients undergoing image-guided procedures. The State-Trait Anxiety Inventory (STAI) was applied for psychometry. Significantly higher anxiety scores were observed in female patients (p = .001), those who believed they had received inadequate information from their referring physician (p = .006), and in patients who considered online information unreliable or difficult to access (p = .007 and p = .001, respectively). Participants who defined themselves as proactive online reported lower anxiety levels (p = .003).

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.

Ultrasound-Guided Thrombin Injection for the Treatment of Bleeding Following Kidney and Liver Biopsies

The purpose of this study was to describe the technique and outcomes of percutaneous thrombin injection into the superficial aspect of actively bleeding liver and kidney biopsy tracks identified with color Doppler ultrasound with the aim of hemorrhage termination. After percutaneous thrombin injection, 15/16 (94%) patients did not require further intervention. Ultrasound-guided thrombin injection into the superficial site of active bleeding is an effective technique for terminating bleeding in the immediate post-procedure period following kidney and liver biopsies and should be considered if active bleeding persists on color Doppler after ≥30 minutes of compression and observation.

Rates of success and failure of biopsies of hollow abdominal organs: descriptive analysis

Abstract Objective: To evaluate the rates of success and failure of ultrasound-guided percutaneous biopsy of lesions in hollow abdominal organs, as well as the influence of contrast enhancement on those rates. Materials and Methods: This was a retrospective, single-center study evaluating patients submitted to ultrasound-guided percutaneous biopsy of abdominal lesions in hollow organs between January 2017 and June 2018. Patient records were reviewed using a standardized data collection form. Results: We included 49 procedures performed in 48 patients, of whom 18 (38%) had a prior diagnosis of cancer. Malignancy was suspected in 44 cases (90%). Among those 44 cases, the suspicion was of a new neoplasm in 28 (64%), of relapse in 11 (25%), and of a metastatic lesion in 5 (11%). The histopathological findings were sufficient to make the diagnosis in all 44 of those cases, 33 (75%) of which were found to be malignant. The diagnosis was consistent with the clinical suspicion in 33 (75%) of the cases in which there was a definitive histological result. There were no complications resulting from the procedure. Conclusion: Ultrasound-guided percutaneous biopsy is a safe procedure that demonstrates high efficacy in providing a sufficient sample for the diagnosis. The main reason to perform such a biopsy is suspicion of a new neoplasm, followed by suspicion of a metastatic lesion. The histopathological results were concordant with the suspicion in the majority of the cases evaluated here.

Tissue sampling in the era of precision medicine: comparison of percutaneous biopsies performed for clinical trials or tumor genomics versus routine clinical care

PURPOSE

The purpose of the study was to determine if patients undergoing percutaneous biopsy for genetic profiling are undergoing more biopsies (procedures, passes per procedure), or experiencing more procedure-related complications.

METHODS

60 patients undergoing biopsy procedures for genetic profiling were retrospectively compared with 60 consecutive control patients undergoing routine biopsies. Procedural details and related complications were collected. Results were analyzed using t-tests and logistic regression.

RESULTS

Biopsied organs included mainly lung (n = 31), liver (n = 50), and lymph nodes (n = 18). The average number of core biopsy passes was 3.45 in the study group and 2.18 in the control group (0.73, 1.81; p = 0.0001). The average study patient underwent 1.44 biopsy procedures by radiology from 2016 to 2017, whereas the average control patient underwent 1.08 (0.1657, 0.5010, p = 0.0002). Results were similar when looking at the subset of patients undergoing liver biopsies. In our cohort of 120 patients total, only 6 complications were noted. There were 4 complications in the control patients and 2 complications in the study patients, all of which were pneumothoraces in patients undergoing lung biopsy; only 2 of these required treatment. The odds ratio for a complication occurring from an increase in one core biopsy is 1.07 (0.601, 1.573; p = 0.775), suggesting no significant relationship among the number of biopsies taken and the probability of complication in this cohort.

CONCLUSIONS

Patients being biopsied for genetic profiling or clinical study enrollment are undergoing more biopsy procedures and more biopsy passes per procedure, but are not experiencing a detectable increased rate of complications in this small cohort, single-center study.

Percutaneous needle biopsy of retroperitoneal lesions: technical developments

Percutaneous Needle Biopsy (PNB) is the insertion of a needle into a suspected lesion or an organ with the aim to obtain cells or tissue for diagnosis. It’s a relatively non-invasive procedure and is performed by radiologist under guidance of imaging techniques such as ultrasound (US), computed tomography (CT), fluoroscopy, magnetic resonance imaging (MRI), and positron emission tomography CT (PET-CT). The choice of imaging technique depends on the evaluation of the target lesion and patient compliance. PNB includes two categories: fine-needle aspiration biopsy (FNAB) that is the use of a thin needle (18-25 gauge) to extract cells for cytological evaluation; and core needle biopsy (CNB) that is the use of a larger needle (9-20 gauge) to extract a piece of tissue for histological evaluation. The indications for biopsy are the characterization of nature (benign or malignant) of a lesion, diagnosis and staging of tumor, and biological or immunohistochemical/genetic analisys on tissue. Success of PNB is the procurement of sufficient material to characterize lesions and to guide the patient outcome. Major complications are rare. PNB became a useful technique in diagnosis and study of retroperitoneal lesions, because of a more suitable access to specific intra-abdominal structures, lowering the risk of injury of interposed structures (such as bowel, great vessels). (www.actabiomedica.it)

Interventional radiology of the adrenal glands: current status

As more and more adrenal neoplasms are found incidentally or symptomatically, the need for interventional procedures has being increasing. In recent years these procedures registered continued steady expansion. Interventional radiology of the adrenal glands comprises angiographic and percutaneous procedures. They may be applied both in benign and in malignant pathologies. The present review reports the current status of indications, techniques results and complications of the image-guided procedures.

Transvaginal Ultrasound-Guided Core Needle Biopsy of Pelvic Masses

OBJECTIVES

This study assessed the efficacy and safety of transvaginal ultrasound (US)-guided core needle biopsy (CNB) for obtaining adequate pelvic mass samples for histologic analysis and evaluated factors that may affect biopsy success.

METHODS

Two hundred cases underwent transvaginal US-guided CNBs for primary inoperable tumors, suspicion of metastases to the ovaries or peritoneum, recurrence, or other solid lesions in the pelvis. Biopsy samples were obtained from the pelvic cavity (67.0%), vaginal cuff or vaginal wall (17.5%), or peritoneal cake (15.5%). The potential influences of the biopsy site (pelvic cavity, vaginal cuff or vaginal wall, or peritoneal cake), vascularization, ascites, tumor size, and tumor type (inoperable, metastases, recurrence, or solid pelvic tumor) on the success of transvaginal US-guided CNB were evaluated by a univariate analysis.

RESULTS

Adequate samples were obtained in 192 of 200 biopsies (96.0%), of which 190 yielded successful diagnoses (95.0%). The biopsy site had a significant effect on biopsy adequacy, as there was a significantly lower probability of obtaining satisfactory specimens for histologic verification from the peritoneal cake compared to pelvic tumors and the vaginal cuff or vaginal wall (P < .01). Adequacy was also affected by tumor size (P < .05) but not by vascularization, ascites, or tumor type. No complications occurred during the biopsy procedures.

CONCLUSIONS

Transvaginal US-guided CNB is a safe and effective alternative to more invasive methods for evaluating pelvic lesions, such as laparoscopy and laparotomy.

Percutaneous Pancreatic Biopsies-Still an Effective Method for Histologic Confirmation of Malignancy

PURPOSE

To determine the accuracy and safety of the percutaneous biopsy of pancreatic mass lesions.

MATERIALS AND METHODS

Over a 12-year period clinical parameters, imaging, pathologic results, and complications were assessed in patients undergoing percutaneous biopsies pancreatic lesions.

RESULTS

One hundred fifty-three patients underwent pancreatic biopsy. The preferred modality for performing the biopsy was ultrasound (93%, n=143) followed by computerized tomography (7%, n=10). Histologic diagnosis was achieved in 147 patients, of which 3 (2%) were benign and 144 (94%) were malignant. Complications included a single death from overwhelming hemorrhage and 2 patients with morbidity (hematoma and cerebrovascular accident). The sensitivity and specificity of percutaneous biopsies was 90% and 95%, respectively.

CONCLUSIONS

Ultrasound-guided and computerized tomographic-guided percutaneous biopsy of pancreatic lesions is an effective and safe method to confirm or refute malignancy in suspicious pancreatic lesions. Endoscopic ultrasound-guided Tru-Cut may have the added advantage of avoiding the risk of peritoneal soiling.

Percutaneous biopsy in the abdomen and pelvis: a step-by-step approach

Percutaneous abdominal biopsies provide referring physicians with valuable diagnostic and prognostic information that guides patient care. All biopsy procedures follow a similar process that begins with the preprocedure evaluation of the patient and ends with the postprocedure management of the patient. In this review, a step-by-step approach to both routine and challenging abdominal biopsies is covered with an emphasis on the differences in biopsy devices and imaging guidance modalities. Adjunctive techniques that may facilitate accessing a lesion in a difficult location or reduce procedure risk are described. An understanding of these concepts will help maintain the favorable safety profile and high diagnostic yield associated with percutaneous biopsies.

Sonographically guided puncture of the pancreas: incidence of complications, and risk factors

PURPOSE

Data yielded by transabdominal ultrasound-guided puncture techniques are valuable for determining the malignancy of inoperable mass lesions of the pancreas. In this study we analyzed the incidence of complications and the risk factors.

METHODS

A total of 430 punctures of the pancreas were performed for 281 patients. Risk factors were prospectively assessed and complications were recorded. All punctures were sonographically guided.

RESULTS

The 281 patients underwent a total of 351 puncture procedures including 430 punctures and 901 passes. The maximum diameter of the pancreatic mass lesion was documented; the mean diameter was 48.3 ± 29.1 mm. 75.8 % of punctures were performed with a needle diameter of 0.7-0.95 mm, and 23.0 % of punctures were performed as cutting biopsies producing a tissue sample 1.2 or 1.6 mm in diameter. In 77.8 % of punctures, one puncture was performed, and in 21.9 %, two punctures were performed. Three punctures were performed for one patient (0.3 %) only. The incidence of major complications was 0.3 %. None of the assessed risk factors was associated with an elevated incidence of complications.

CONCLUSION

Our findings demonstrate the safety of transabdominal percutaneous puncture of the pancreas but do not enable conclusions to be drawn with regard to individual risk factors.

Percutaneous ultrasonographically guided liver punctures: an analysis of 1961 patients over a period of ten years

Background

Ultrasonographically guided punctures of the liver represent a decisive tool in the diagnosis of many diseases of the liver. Objective of the study was to determine the extent to which the complication rate for ultrasonographically guided punctures of the liver is affected by less comprehensively studied risk factors.

Methods

A total of 2,229 liver biopsies were performed in 1,961 patients (55.5% males; 44.5% females). We recorded actual complications and assessed the following risk factors: needle gauge, puncture technique, examiner experience, coagulation status, puncture target (focal lesion versus parenchyma), lesion size, patient sex and age.

Results

he rate of complications stood at 1.2% (n = 27), of which 0.5% (n = 12) were major and 0.7% (n = 15) minor complications. A significant increase in complications involving bleeding was observed with larger-gauge needles compared with smaller-gauge needles and for cutting biopsy punctures compared with aspiration biopsies (Menghini technique). In the bivariate analysis complications were 2.7 times more frequent in procedures performed by experienced examiners compared with those with comparatively less experience. Lower values for Quick’s test and higher partial thromboplastin times were associated with a higher rate of bleeding. Neither the puncture target, lesion size or patient sex exerted any measurable influence on the puncture risk. Advanced patient age was associated with a higher rate of complications involving bleeding.

Conclusions

Our study helps to establish the importance of potential and less comprehensively studied risk factors and may contribute to further reduction in complications rates in routine clinical practice.

Image-guided adrenal and renal biopsy

Image-guided biopsy is a safe and well-established technique that is familiar to most interventional radiologists. Improvements in image guidance, biopsy tools, and biopsy techniques now routinely allow for safe biopsy of renal and adrenal lesions that traditionally were considered difficult to reach or technically challenging. Image-guided biopsy is used to establish the definitive tissue diagnosis in adrenal mass lesions that cannot be fully characterized with imaging or laboratory tests alone. It is also used to establish definitive diagnosis in some cases of renal parenchymal disease and has an expanding role in diagnosis and characterization of renal masses before treatment. Although basic principles and techniques for image-guided needle biopsy are similar regardless of organ, this paper highlights some technical considerations, indications, and complications that are unique to the adrenal gland and kidney because of their anatomic location and physiological features.

Role of sonography for implantation and sequential evaluation of a VX2 rabbit liver tumor model

OBJECTIVE

We investigated the role of sonography in the implantation process of a VX2 rabbit liver tumor model and sequential evaluation.

METHODS

Fifty rabbits were divided into 2 groups. Animals in group I underwent surgical implantation, whereas those in group II received percutaneous sonographically guided implantation. At 7, 14, 21, and 28 days after implantation, respectively, 5 rabbits in each group were examined with conventional, color Doppler (CD), contrast-enhanced (CE) pulse inversion harmonic (PIH), and CE CD sonography. Pathologic examination was performed with hematoxylin-eosin, nicotinamide adenine dinucleotide phosphate-diaphorase, and succinic dehydrogenase stains.

RESULTS

Twenty-one rabbits with tumors survived in group I, and 22 with tumors survived in group II. The mean duration of implantation +/- SD in group II was 16.9 +/- 3.4 minutes, whereas that in group I was 21.5 +/- 4.1 minutes (P < .05). The tumor volume measured by conventional sonography increased from 0.28 +/- 0.14 cm(3) at 7 days to 16.49 +/- 5.50 cm(3) at 28 days in group I and from 0.31 +/- 0.19 to 19.79 +/- 4.70 cm(3) in group II, whereas no significant difference existed between the groups. On CD, CE PIH, and CE CD sonography, most tumors were hypervascular before 14 days and after 14 days had peripheral vessels and central hypovascular areas, which were shown as necrotic areas by pathologic examination.

CONCLUSIONS

Sonographically guided implantation achieved a good success rate with convenient inoculation performance. Conventional gray scale, CD, CE PIH, and CE CD sonography were useful in sequential evaluation of tumor growth and characteristic vascularity.

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Bladder-flap haematoma (BFH) is a puerperal complication after caesarean section; it consists of a blood collection between the bladder and the lower uterine segment, in the vesico-uterine space, and it results from bleeding at the uterine suture. Ten symptomatic women were hospitalized and underwent a laparoscopy performed by tumescence incision, bladder wall detachment from the vesico-uterine space, drainage of the fluid material inside the collection, washing of the haematoma site and peritoneal suturing. After seven days, the time it takes to develop a BFH after caesarean section, laparoscopically collected dates were, on average: Total laparoscopy time 31 min, intrasurgical blood loss 36.5 ml, two patients with a draining catheter in the pelvis, two women who developed post-operative urinary symptoms; the duration of hospital stay was 1.3 days. None of the women had complications during the post-dismissal follow-up, and no further therapeutic intervention was required. No clear, defined and standardized protocols exist for the clinical and surgical management of post-caesarean section BFH; the conservative laparoscopic approach proposed would offer women a potentially safe and feasible minimally invasive treatment, reserving hysterectomy for severe uterine necrosis, myometritis or abscess formations. These findings should be confirmed by large extensive trials.