Image-guided adrenal and renal biopsy

Abstract

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.

Figure 1

(a-c): CT guided left adrenal biopsy in a 62 yo female with history of left thigh melanoma resected 9 yrs ago and an incidentally discovered 3 cm adrenal mass. Biopsy requested to help determine diagnosis and stage disease. (a): CT image after patient positioning and placement of the marker grid. (b): CT image during needle advancement from a left paraspinal approach. Note the restricted movement of the left hemidiaphragm in this position. (c): Coaxial technique with the introducer needle tip at the periphery of the lesion. FNA and core specimens were obtained without complication. Pathology revealed metastatic melanoma - Stage IV disease.

Figure 2

(a-c): US guided renal mass biopsy in a 75 yo male with diabetes, CRI, and history of melanoma with new incidentally detected bilateral renal masses. (a,b): Gray scale images demonstrate bilateral, solid, exophytic, heterogeneous renal masses. US guided renal mass biopsy of both masses was performed through a subcostal approach using coaxial technique without complication. (c): Image shows the biopsy needle within the left renal mass. Pathology revealed papillary RCC on the right and RCC with mucinous components on the left. The patient was not a surgical candidate and referred for percutaneous ablation.

Figure 3

(a-c): CT guided renal mass biopsy in a 45 yo female with VHL and history of partial right nephrectomy and RFA of two left and one right renal lesions (RCC). (a,b): CT demonstrated a new 3 cm enhancing mass in the lower pole of the right kidney. (c): Biopsy was performed from a posterior approach with the patient in prone position but a target side down decubitus position could also have been used with an oblique approach. FNA and core specimens were obtained using coaxial technique without complication. Pathology revealed clear cell type RCC, Fuhrman nuclear grade 2. Total right nephrectomy was performed two weeks after biopsy.

Figure 4

(a-d): US guided random biopsy of a patient with renal transplant and ARF. (a): Gray-scale image after obtained after optimizing visualization of target and needle trajectory. (b): Image shows an 18 gauge needle in the target using coaxial technique. (c): Color Doppler image following biopsy shows flow along the tract and into the perinephric space (d): Color Doppler image of the same area following 10 minutes of US guided compression. The flow along the tract has resolved and a small perinephric hematoma is seen. The patient remained completely asymptomatic and was discharged home following overnight observation. Pathology revealed no evidence for acute rejection.

Figure 5

(a-d): Sequential steps during transjugular renal biopsy. (a): Opacification of the IVC and renal veins (carbon dioxide) with subsequent placement of the biopsy sheath and catheter (arrow) in the right renal vein over a guidewire (dashed arrow). (b): Venography demonstrates appropriate position of the sheath and catheter in a peripheral lower pole renal vein just prior to needle deployment (arrows). (c): Image obtained after the biopsy needle was deployed demonstrating the extent of needle excursion into the renal cortex (d): Same image with a schematic outline of the kidney showing that the needle tip did not breech the capsule.