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Ultrasound Guided Biopsies:�What you Need to Know

Ulrike M. Hamper, MD; MBA;FACRRussell H. Morgan Department of Radiology and

Radiological SciencesJohns Hopkins University School of Medicine

Baltimore, Maryland, USA

Disclosure

Nothing to Disclose No Conflict of Interest !

Image Guided Fine Needle Aspiration �Biopsy - FNAB

•  Replacement of open surgical biopsies in most instances

•  Advances in cross sectional imaging techniques•  Development of different needle types•  Refinement in cytopathology techniques•  Progress in cancer therapy and more aggressive

treatment of metastatic disease and personalized cancer treatment plans (genetic profiling)

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US Guided Interventional Procedures

•  Thoracentesis and paracentesis•  Aspiration of fluid collections•  Organ or mass biopsies•  Abscess Drainage•  Nephrostomy tube placement•  Vascular Access•  Tumor Ablation

US FNAB: Objectives

•  Indications, Contraindications and Complications

•  Patient Preparation•  Imaging Guidance Modalities•  Biopsy Techniques•  Specific Biopsy Applications•  Conclusions

FNAB- Indications

•  Confirm malignancy in suspicious lesion •  Obtain tissue for immunohistochemistry,

genetic and molecular testing•  Diagnosis of an indeterminate lesion•  Confirm a probably benign lesion•  Diagnosis of parenchymal disease or

organ transplant rejection (liver, kidney, pancreas)

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FNAB- Contraindications

• Very Few !!• Uncorrectable bleeding disorder• Uncooperative patient• Lack of safe path to target organ

or mass

FNAB - Complications

•  Serious complications are rare• Minor: vasovagal reaction, pain,

small hematoma- be prepared to treat!

• Complication rate: function of needle size and organ specific

• Needle track seeding rare: 1/20,000

FNAB - Patient Preparation

•  Pre-procedure call (nurse, biopsy coordinator)

• Written informed consent by biopsy physician

•  Premedication as required• A cooperative and relaxed patient

= key to a successful procedure

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FNAB - Anesthesia•  Analgesia: oxycodone, fentanyl,

morphine (i.m. or i.v.), •  Tranquilizers: valium, versed, ativan•  Conscious/deep sedation: rarely needed

for FNAB (tumor ablation, EV drainages, transperineal prostate biopsies)

• Monitoring by biopsy nurse/anesthesia team

FNAB -Hemostatic Evaluation•  Depends on type of procedure•  Depends on patients risk factors,

bleeding & medical history and medications (antibiotics, anticoagulants, nonsteroidal anti-inflammatory drugs, vitamins, fish oil etc.)

•  Routine laboratory tests except for superficial biopsies (breast, thyroid, lymph nodes) and fluid aspirations

FNAB -Hemostatic Evaluation

•  Prothrombin time and Platelet count•  Discontinue aspirin for 5-7 days•  Discontinue heparin for 4-6 hours•  Fresh frozen plasma (FFP) or platelet

transfusion if needed

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FNAB - Biopsy Technique•  Guidance: CT versus US•  Size and location of target•  Visibility by either modality•  Equipment availability•  Physician expertise/preference•  Careful planning of approach imperative

FNAB - CT Advantages/Limitations

•  Guide biopsy in any organ, especially bone or lung

•  Accurate image of needle tip•  Lack of real-time visualization of

needle during insertion & biopsy•  Limited biopsy planes•  Longer procedure time, more

expensive, radiation

FNAB - Advantages of US

•  Ideal guidance modality•  Real time display during biopsy•  Unlimited scan planes- “creative

patient positioning”•  Speed - faster procedure times•  Color Doppler US -vessel visualization

and depiction of viable tissue

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FNAB - Advantages of US

• Direct pressure over lesion with transducer

• Assess echotexture changes- avoid necrotic or cystic areas in lesion

•  Portable for bedside procedures• Lower cost• No radiation

FNAB - US Guidance Limitations

•  Poor visualization of certain lesions -surrounded by bone, air, bowel gas

•  Patient size may limit visibility• Difficult needle tip visualization• Operator dependence and

availability of suitable equipment

FNAB - US Guidance

• Transabdominal guidance• Transthoracic guidance for pleural

based or mediastinal masses/nodes• Endorectal or endovaginal guidance

for accessible pelvic masses, fluid collections or lymph nodes

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FNAB - Free Hand Technique

• More difficult to learn or teach

• More flexibility in approach•  Transducer may be outside

of sterile field• More difficulty to visualize

needle tip in deep lesions

FNAB - Needle Guides

•  Predetermined and controlled path of the needle

•  Faster needle placement and tip check

•  Easier to teach or learn•  2 people procedure

FNAB - Needle Guides

• Expanded role of US guidance: small deep lesions, retroperitoneal lymph nodes, chest masses

• More difficult if intercostal approach •  Preset path and angle difficult for

very superficial lesions

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FNAB - Needle Tip Visualization

• Needle size or type (echogenic tip)• Angle of needle to US beam• Type of lesion (hypo - vs. is - vs.

hyperechoic target)•  Scanning parameters

FNAB - Hints to Improve Needle �Tip Visualization

• Use echogenic needles• Choose the appropriate transducer• Optimize scanning parameters (focal

zone and depth)• Keep needle in center of the beam

and in view at all times

FNAB - Needle Selection

•  Small caliber (20-25 g) needles: metastasis vs. primary tumor, thyroid lesions

• Good cytologic, less histologic material

• Better yield with cutting tips•  Safe, even to traverse bowel

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FNAB - Needle Selection

•  Large caliber (14 -18g) core biopsy automated devices, min. higher complicatio rate

•  Histologic & some cytologic (“touch-prep”) material

•  Tumor characterization, benign or fibrotic lesions, parenchymal disease

•  Organ rejection (liver, renal, pancreas Tx)

FNAB - Biopsy Technique

•  On-site cytopathologist/cytotechnologist for all biopsies

•  Start with 22g needle (Franseen or Chiba)•  Several passes if necessary for diagnosis

and special stains, immunohistochemistry•  Core biopsy (20, 18 or 16g) as deemed

necessary by pathologist or study protocol

FNAB - Biopsy Technique

• Capillary Technique: less bloody, better needle control, less trauma to cells

• Aspiration Technique: Suction with syringe a/o extension tubing for fibrotic tumors and lung lesions (closed system)

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FNAB - On-Site Cytology

•  Advantages: immediate evaluation and optimization of biopsy :- minimum number of passes, assess adequacy of specimens, appropriate staining/processing of specimens

•  Disadvantages: Increase in cost and procedure time, not universally available

FNAB - Accuracy•  Liver: Sensitivity 94%, Specificity 99%•  Lung: Sensitivity 99%, Specificity 94%•  Pancreas: Sensitivity 87, Specificity 99%•  Lymph nodes: Sensitivity 94%,

Specificity 96%•  Thyroid: Sensitivity 87%,

Specificity 88%

FNAB - Liver

• Most common biopsy site -focal masses or diffuse liver disease

•  Subcostal or intercostal approach• US excellent for high dome lesions• Avoid transpleural biopsy path!• Complications: hemorrhage,

pneumothorax (rare)

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Metastasis - Lung Carcinoma

Subtle right lobe liver lesionCompound imaging

Hepatocellular Carcinoma

FNAB - Pancreas

•  Establish diagnosis of pancreatic ca in unresectable cases (vascular encasement)

•  DDx carcinoma from chronic pancreatitis•  US guidance 95% accuracy•  CT guidance 80 % accuracy, i.v. contrast•  Sensitivity 72-90%, Specificity 99-100%•  Increasing use of endoscopic US guidance

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FNAB - Pancreas

•  Lower accuracy rates in desmoplastic tumors, atypical cells in pancreatitis

• May need cores in addition to FNA•  Transgastric or transcolonic approach•  Complication rates: 1.1 - 6.7 %•  Deaths: pancreatitis or sepsis (6 cases)•  Transplant biopsies with 18 gauge core

Pancreas CarcinomaWith Liver Metastasis

FNAB - Kidney

•  Renal mass in non-surgical candidate•  Renal mass in patient with other primary tumor•  Atypical cystic renal mass•  If multiple renal masses: DDx metastases,

lymphoma or multifocal renal cell ca•  Growing literature about accuracy of biopsies

and importance for management of small renal tumors

•  Core biopsies for renal parenchymal disease or transplant rejection

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Left Renal Cell Carcinoma

Cystic Renal Cell Carcinoma

FNAB – Adrenal Gland

•  To confirm metastatic disease or DDX metastases from adenoma

• Mets: lung, melanoma, renal cell ca•  Right adrenal: transhepatic or posterior

approach•  Left adrenal: anterior, lateral or posterior

approach- avoid transpancreatic or transpleural path

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Right Adrenal Mass- Transhepatic Approach

Adrenal Metastasis from Prostate Cancer

Adrenal Metastasis from Prostate Cancer

anterior approach posterior decubitus approach

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FNAB - Retroperitoneal Masses

•  Sarcomas, lymphoma and metastases•  Pelvic and retroperitoneal adenopathy:

easily biopsied under US with guide•  Transducer pressure compresses bowel

and decreases depth to target•  Visceral penetration usually not a

problem•  CDUS: avoid injury to vessels

Left para-aortic adenopathy

Hodgkin Lymphoma

Left Para-aortic Mass

Left paraoartic mass on CT Large B-cell Lymphoma

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Para-aortic Adenopathy- Metastatic Adenoca

Para-aortic Adenopathy- Metastatic Adenoca

FNAB - Lymphoma

•  Accuracy lymphoma < metastases•  FNAB plus core biopsies (subtype,

histologic grade (esp. Hodgkin disease)•  DNA flow cytometry, molecular and

immunohistochemical studies•  Overall diagnostic accuracy: 70-75%

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Peripancreatic Lymphoma

Parotid Lymphoma

Thigh Lymphoma

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Thigh Lymphoma

FNAB – Thoracic Masses

•  Parenchymal lung lesions: fluoroscopy or CT guidance

•  Pleural masses or lung masses abutting chest wall: US guidance

•  Mediastinal masses lateral and superior to sternum: US guidance

•  CDUS: avoid thoracic vessels, especially internal mammary artery and vein

•  Cx: hemoptysis, pneumothorax, hemothorax

Metastatic Esophageal Carcinoma

Small left subpleural mass

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Metastatic Squamous Cell Carcinoma from Head andNeck Primary

Small left subpleural mass

Small Pneumothorax Re-expansion and Repeat Bx

Lung Adenocarcinoma

Small parenchymal mass

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Metastatic BreastCancer

Pleural based mass

Thymus Teratoma

Left anterior mediastinal mass

Hodgkin Lymphoma

Right anterior mediastinal mass Avascular on CDUS

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Castleman Disease

Right posterior mediastinal mass

FNAB - Spleen

• Rarely necessary, disease process often involves other organs e.g. liver

• Highly vascular organ - higher hemorrhage complication rate if biopsied

• Main indication: DDx recurrent lymphoma from metastases or fungal infection in patient with new splenic lesions

Lymphoma Spleen

Hypoechoic splenic mass

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FNAB – Other Applications

•  Neck masses, lymphadenopathy, parotid lesions

•  Musculoskeletal masses•  Bony lesions with broken cortex a/o

associated soft tissue mass•  CT or MRI images helpful to localize

target with US prior to biopsy•  US allows “creative positioning”

Metastatic EsophagealCarcinoma

Left supraclavicular adenopathy

Lymph node Metastasis fromThyroid Carcinoma

Suprasternal approach with endovaginal US probe

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Anterior Abdominal Wall Mass

Anterior Abdominal Wall Mass

Metastatic Colon Cancer

Lobulated Right Forearm Mass

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Lobulated Right Forearm Mass

Schwannoma

Intramuscular Gluteal Myxoma

Right gluteal muscle mass

Left pelvic/adnexal mass

Metastatic Colon Cancer

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Left pelvic/adnexal mass

Metastatic Colon Cancer

Metastatic Renal Cell Carcinoma

Destructive left iliac wing mass

Enhancing Spinous Process Mass

Metastatic Thyroid Carcinoma

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Left Paraspinal Mass - Hot on PET

Left Paraspinal Mass

Recurrent Rhabdomyosarcoma

FNAB – Endocavitary Approach

• Transrectal: prostate biopsies, other pelvic masses

• Transvaginal: pelvic masses, fluid collections, abscess drainages

• CT review prior to procedure helpful• Appropriate antibiotic coverage.

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Left Presacral Mass

Anterior approach

Left Presacral Mass

Schwannoma

endorectal approach

Left Pelvic Node Biopsy�

anterior approach

B

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Left Pelvic Node Biopsy�

Metastatic Prostate Ca

posterior approach

FNAB - Pitfalls

• Non diagnostic specimen: scant cellularity, necrotic lesion

• False negative result: sampling error: lesion not sampled or sample not representative of the entire lesion

• False positive result: rare, however may occur

FNAB - Negative Pathology

• Only acceptable if the diagnosis of non-malignancy can be explained by lesion or imaging characteristics: e.g. scar tissue, infarction or inflammation

• Repeat biopsy if non-diagnostic: e.g. insufficient material or material not representative of lesion and imaging abnormality

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FNAB – Keys to Success

• Careful review of patient’s history other and imaging studies

• Good technique and equipment to obtain sufficient sample

•  Interpret pathology in context of clinical and imaging findings

• Close radiologic-pathologic collaboration

FNAB – Keys To Success

Team Approach:•  Referring physician & patient•  Biopsy coordinator•  Dedicated biopsy nurse(s)•  Experienced Radiologist•  Experienced sonographer/CT

technologist•  Experienced Cytopathology team

FNAB - Conclusions• US = premier guidance modality for

many diagnostic and therapeutic interventional procedures

•  Superiority to CT: real-time visualization, vessel depiction, flexibility in biopsy approaches, portability, speed, lack of ionizing radiation and decreased cost

• Use US whenever possible for FNAB!!

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FNAB – Future Applications• More precise tissue typing: carcinogenic

embryonic antigen (CEA), receptors...• Molecular imaging•  Percutaneous delivery of chemotherapy

agents and gene therapy•  Organ or tumor specific delivery of

substances in conjunction with contrast agents and local bubble destruction

THANK YOU !

umhamper@jhu.edu