Advertisement

The challenging image-guided abdominal mass biopsy: established and emerging techniques ‘if you can see it, you can biopsy it’

  • 786 Accesses

  • 29 Citations

Abstract

Image-guided percutaneous biopsy of abdominal masses is among the most commonly performed procedures in interventional radiology. While most abdominal masses are readily amenable to percutaneous biopsy, some may be technically challenging for a number of reasons. Low lesion conspicuity, small size, overlying or intervening structures, motion, such as that due to respiration, are some of the factors that can influence the ability and ultimately the success of an abdominal biopsy. Various techniques or technologies, such as choice of imaging modality, use of intravenous contrast and anatomic landmarks, patient positioning, organ displacement or trans-organ approach, angling CT gantry, triangulation method, real-time guidance with CT fluoroscopy or ultrasound, sedation or breath-hold, pre-procedural image fusion, electromagnetic tracking, and others, when used singularly or in combination, can overcome these challenges to facilitate needle placement in abdominal masses that otherwise would be considered not amenable to percutaneous biopsy. Familiarity and awareness of these techniques allows the interventional radiologist to expand the use of percutaneous biopsy in clinical practice, and help choose the most appropriate technique for a particular patient.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Fig. 31

References

  1. 1.

    Whitmire LF, Galambos JT, Phillips VM, et al. (1985) Imaging guided percutaneous hepatic biopsy: diagnostic accuracy and safety. J Clin Gastroenterol 7:511–515

  2. 2.

    Ferrucci JT Jr, Wittenberg J, Mueller PR, et al. (1980) Diagnosis of abdominal malignancy by radiologic fine-needle aspiration biopsy. AJR Am J Roentgenol 134:323–330

  3. 3.

    Sundaram M, Wolverson MK, Heiberg E, et al. (1982) Utility of CT-guided abdominal aspiration procedures. AJR Am J Roentgenol 139:1111–1115

  4. 4.

    Ho CS, McLoughlin MJ, Tao LC, Blendis L, Evans WK (1981) Guided percutaneous fine-needle aspiration biopsy of the liver. Cancer 47:1781–1785

  5. 5.

    Buonocore E, Skipper GJ (1981) Steerable real-time sonographically guided needle biopsy. AJR Am J Roentgenol 136:387–392

  6. 6.

    Ferrucci JT Jr, Wittenberg J (1978) CT biopsy of abdominal tumors: aids for lesion localization. Radiology 129:739–744

  7. 7.

    Haaga JR (1979) New techniques for CT-guided biopsies. AJR Am J Roentgenol 133:633–641

  8. 8.

    Zornoza J, Wallace S, Ordonez N, Lukeman J (1980) Fine-needle aspiration biopsy of the liver. AJR Am J Roentgenol 134:331–334

  9. 9.

    Middleton WD, Hiskes SK, Teefey SA, Boucher LD (1997) Small (1.5 cm or less) liver metastases: US-guided biopsy. Radiology 205:729–732

  10. 10.

    Chojniak R, Isberner RK, Viana LM, et al. (2006) Computed tomography guided needle biopsy: experience from 1,300 procedures. Sao Paulo Med J 124:10–14

  11. 11.

    Silverman SG, Deuson TE, Kane N, et al. (1998) Percutaneous abdominal biopsy: cost-identification analysis. Radiology 206:429–435

  12. 12.

    Arellano RS, Maher M, Gervais DA, Hahn PF, Mueller PR (2003) The difficult biopsy: let’s make it easier. Curr Probl Diagn Radiol 32:218–226

  13. 13.

    Maher MM, Gervais DA, Kalra MK, et al. (2004) The inaccessible or undrainable abscess: how to drain it. Radiographics 24:717–735

  14. 14.

    Charboneau JW, Reading CC, Welch TJ (1990) CT and sonographically guided needle biopsy: current techniques and new innovations. AJR Am J Roentgenol 154:1–10

  15. 15.

    Schmidt AJ, Kee ST, Sze DY, et al. (1999) Diagnostic yield of MR-guided liver biopsies compared with CT- and US-guided liver biopsies. J Vasc Interv Radiol 10:1323–1329

  16. 16.

    Hata N, Jinzaki M, Kacher D, et al. (2001) MR imaging-guided prostate biopsy with surgical navigation software: device validation and feasibility. Radiology 220:263–268

  17. 17.

    Stattaus J, Kuehl H, Ladd S, et al. (2007) CT-guided biopsy of small liver lesions: visibility, artifacts, and corresponding diagnostic accuracy. Cardiovasc Intervent Radiol 30:928–935

  18. 18.

    Kirchner J, Kickuth R, Walz MV, et al. (1999) CTF-guided puncture of an unenhanced isodense liver lesion during continuous intravenous injection of contrast medium. Cardiovasc Intervent Radiol 22:528–530

  19. 19.

    Tatli S, Gerbaudo VH, Mamede M, et al. (2010) Abdominal masses sampled at PET/CT-guided percutaneous biopsy: initial experience with registration of prior PET/CT images. Radiology 256:305–311

  20. 20.

    Ewertsen C, Grossjohann HS, Nielsen KR, Torp-Pedersen S, Nielsen MB (2008) Biopsy guided by real-time sonography fused with MRI: a phantom study. AJR Am J Roentgenol 190:1671–1674

  21. 21.

    Tatli S, Gerbaudo VH, Feeley CM, et al. (2011) PET/CT-guided percutaneous biopsy of abdominal masses: initial experience. J Vasc Interv Radiol 22:507–514

  22. 22.

    Lee F, Gray JM, McLeary RD, et al. (1986) Prostatic evaluation by transrectal sonography: criteria for diagnosis of early carcinoma. Radiology 158:91–95

  23. 23.

    Papanicolaou N, Eisenberg PJ, Silverman SG, McNicholas MM, Althausen AF (1996) Prostatic biopsy after proctocolectomy: a transgluteal, CT-guided approach. AJR Am J Roentgenol 166:1332–1334

  24. 24.

    Zanetta G, Brenna A, Pittelli M, et al. (1994) Transvaginal ultrasound-guided fine needle sampling of deep cancer recurrences in the pelvis: usefulness and limitations. Gynecol Oncol 54:59–63

  25. 25.

    Arellano RS, Boland GW, Mueller PR (2000) Adrenal biopsy in a patient with lung cancer: imaging algorithm and biopsy indications, technique, and complications. AJR Am J Roentgenol 175:1613–1617

  26. 26.

    Tyng CJ, Bitencourt AG, Martins EB, Pinto PN, Chojniak R (2012) Technical note: CT-guided paravertebral adrenal biopsy using hydrodissection—a safe and technically easy approach. Br J Radiol 85(1015):e339–e342

  27. 27.

    Arellano RS, Gervais DA, Mueller PR (2011) CT-guided drainage of abdominal abscesses: hydrodissection to create access routes for percutaneous drainage. AJR Am J Roentgenol 196:189–191

  28. 28.

    Rhim H, Lim HK, Kim YS, Choi D (2008) Percutaneous radiofrequency ablation with artificial ascites for hepatocellular carcinoma in the hepatic dome: initial experience. AJR Am J Roentgenol 190:91–98

  29. 29.

    de Kerviler E, Guermazi A, Gossot D, et al. (1998) Use of an abdominal compression device for CT-guided biopsy of enlarged abdominal or pelvic lymph nodes. J Vasc Interv Radiol 9:353–357

  30. 30.

    Paulsen SD, Nghiem HV, Negussie E, et al. (2006) Evaluation of imaging-guided core biopsy of pancreatic masses. AJR Am J Roentgenol 187:769–772

  31. 31.

    Gazelle GS, Haaga JR (1989) Guided percutaneous biopsy of intraabdominal lesions. AJR Am J Roentgenol 153:929–935

  32. 32.

    Tseng HS, Chen CY, Chan WP, Chiang JH (2009) Percutaneous transgastric computed tomography-guided biopsy of the pancreas using large needles. World J Gastroenterol 15:5972–5975

  33. 33.

    Gervais DA, Gazelle GS, Lu DS, Han PF, Mueller PR (1996) Percutaneous transpulmonary CT-guided liver biopsy: a safe and technically easy approach for lesions located near the diaphragm. AJR Am J Roentgenol 167:482–483

  34. 34.

    Gupta S, Ahrar K, Morello FA Jr, Wallace MJ, Hicks ME (2002) Masses in or around the pancreatic head: CT-guided coaxial fine-needle aspiration biopsy with a posterior transcaval approach. Radiology 222:63–69

  35. 35.

    Sofocleous CT, Schubert J, Brown KT, et al. (2004) CT-guided transvenous or transcaval needle biopsy of pancreatic and peripancreatic lesions. J Vasc Interv Radiol 15:1099–1104

  36. 36.

    Hussain S, Santos-Ocampo RS, Silverman SG, Seltzer SE (1994) Dual-angled CT-guided biopsy. Abdom Imaging 19:217–220

  37. 37.

    vanSonnenberg E, Wittenberg J, Ferrucci JT Jr, Mueller PR, Simeone JF (1981) Triangulation method for percutaneous needle guidance: the angled approach to upper abdominal masses. AJR Am J Roentgenol 137:757–761

  38. 38.

    Sze DY (2001) Use of curved needles to perform biopsies and drainages of inaccessible targets. J Vasc Interv Radiol 12:1441–1444

  39. 39.

    Gupta S, Ahrar K, Morello FA Jr, et al. (2002) Using a coaxial technique with a curved inner needle for CT-guided fine-needle aspiration biopsy. AJR Am J Roentgenol 179:109–112

  40. 40.

    Warnock NG (1996) Curved needle technique for the avoidance of interposed structures in CT-guided percutaneous fine needle biopsy. J Comput Assist Tomogr 20:826–828

  41. 41.

    Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette PC (2000) Value of CT fluoroscopy for percutaneous biopsy procedures. J Vasc Interv Radiol 11:879–884

  42. 42.

    Silverman SG, Tuncali K, Adams DF, et al. (1999) CT fluoroscopy-guided abdominal interventions: techniques, results, and radiation exposure. Radiology 212:673–681

  43. 43.

    Carlson SK, Bender CE, Classic KL, et al. (2001) Benefits and safety of CT fluoroscopy in interventional radiologic procedures. Radiology 219:515–520

  44. 44.

    Krucker J, Xu S, Glossop N, et al. (2007) Electromagnetic tracking for thermal ablation and biopsy guidance: clinical evaluation of spatial accuracy. J Vasc Interv Radiol 18:1141–1150

  45. 45.

    Tomiyama N, Mihara N, Maeda M, et al. (2000) CT-guided needle biopsy of small pulmonary nodules: value of respiratory gating. Radiology 217:907–910

  46. 46.

    Carlson SK, Felmlee JP, Bender CE, et al. (2005) CT fluoroscopy-guided biopsy of the lung or upper abdomen with a breath-hold monitoring and feedback system: a prospective randomized controlled clinical trial. Radiology 237:701–708

  47. 47.

    Heiberg E, Wolverson MK (1985) Ipsilateral decubitus position for percutaneous CT-guided adrenal biopsy. J Comput Assist Tomogr 9:217–218

  48. 48.

    Carlson SK, Felmlee JP, Bender CE, et al. (2003) Intermittent-mode CT fluoroscopy-guided biopsy of the lung or upper abdomen with breath-hold monitoring and feedback: system development and feasibility. Radiology 229:906–912

Download references

Acknowledgment

We gratefully acknowledge Susanne Loomis, Radiology Education, and Media Services, Massachusetts General Hospital, Boston, for her assistance with the images.

Author information

Correspondence to Nisha I. Sainani.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 3. Cine transabdominal ultrasound images in a 34-year-old female with a 5.0 x 3.5 cm hyperechoic mass in left lobe of liver acquired with normal breathing reveal significant motion of the liver and the mass (MP4 311 kb)

Supplementary material 4. Cine transabdominal ultrasound images acquired at end expiratory breath-hold reveal significant decrease in the motion, resulting in safe targeting of mass for biopsy (MP4 321 kb)

Supplementary material 5. Cine images show the biopsy needle advancing towards the mass under real-time ultrasound and Doppler guidance, under quiet breathing, facilitating rapid targeting of the tumor and avoidance of vessels. A diagnosis of a primary cholangiocarcinoma was achieved (MP4 3099 kb)

Supplementary material 1. 65-year-old male with colon cancer and a partially exophytic 2.4 x 2.0 cm mass at the hepatic dome posteriorly. Transpleural, transhepatic biopsy of the lesion was performed under CT-fluoroscopy guidance after creating an artificial pneumothorax with 30 mL of room air and using an 18-gauge needle sheath. CT-fluoroscopy allowed rapid, intermittent monitoring of 17-gauge introducer placement, avoiding adjacent vital structures (heart). Biopsy samples were acquired coaxially using an 18-gauge, side-cutting, semi-automated needle. The asymptomatic pneumothorax was aspirated following the biopsy and chest tube was not required. A diagnosis of metastatic adenocarcinoma of colon was achieved (MP4 464 kb)

Supplementary material 2. In a 63-year-old female, a 5.2 x 4.4 cm enhancing liver mass was targeted using CT fluoroscopy allowing real-time monitoring of an 18-gauge needle placement and coordination with patient breathing and intravenous contrast enhancement (MPG 5360 kb)

Supplementary material 3. Cine transabdominal ultrasound images in a 34-year-old female with a 5.0 x 3.5 cm hyperechoic mass in left lobe of liver acquired with normal breathing reveal significant motion of the liver and the mass (MP4 311 kb)

Supplementary material 4. Cine transabdominal ultrasound images acquired at end expiratory breath-hold reveal significant decrease in the motion, resulting in safe targeting of mass for biopsy (MP4 321 kb)

Supplementary material 5. Cine images show the biopsy needle advancing towards the mass under real-time ultrasound and Doppler guidance, under quiet breathing, facilitating rapid targeting of the tumor and avoidance of vessels. A diagnosis of a primary cholangiocarcinoma was achieved (MP4 3099 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sainani, N.I., Arellano, R.S., Shyn, P.B. et al. The challenging image-guided abdominal mass biopsy: established and emerging techniques ‘if you can see it, you can biopsy it’. Abdom Imaging 38, 672–696 (2013). https://doi.org/10.1007/s00261-013-9980-0

Download citation

Keywords

  • Image-guided
  • Biopsy
  • Abdominal
  • Percutaneous
  • Challenging