Ultrasound-Guided Percutaneous Core Needle Biopsy of Abdominal Viscera: Tips to Ensure Safe and Effective Biopsy

Abstract

Ultrasound-guided percutaneous core needle biopsy (USPCB) is used extensively in daily clinical practice for the pathologic confirmation of both focal and diffuse diseases of the abdominal viscera. As a guidance tool, US has a number of clear advantages over computerized tomography or magnetic resonance imaging: fewer false-negative biopsies, lack of ionizing radiation, portability, relatively short procedure time, real-time intra-procedural visualization of the biopsy needle, ability to guide the procedure in almost any anatomic plane, and relatively lower cost. Notably, USPCB is widely used to retrieve tissue specimens in cases of hepatic lesions. However, general radiologists, particularly beginners, find USPCB difficult to perform in abdominal organs other than the liver; indeed, a full understanding of the entire USPCB process and specific considerations for specific abdominal organs is necessary to safely obtain adequate specimens. In this review, we discuss some points and techniques that need to be borne in mind to increase the chances of successful USPCB. We believe that the tips and considerations presented in this review will help radiologists perform USPCB to successfully retrieve target tissue from different organs with minimal complications.

Keywords: Abdomen; Biopsy; Diagnostic technique; Ultrasonography.

Fig. 1. Influence of echogenicity of intervening traversed structures on visibility of biopsy needle.

A. Echogenic shaft of biopsy needle (arrowheads) is relatively well visualized within subcutaneous fat layer, spleen, and mass (asterisk) in 50-year-old man. B. Biopsy needle (arrowheads) is poorly seen, especially within hyperechoic abdominal fat and bowel gas in 55-year-old man.

Fig. 2. 57-year-old woman with dysplastic nodule in left hepatic lobe.

A. Gadoxetic acid-enhanced T1-weighted hepatocyte-phase MR image displays heterogeneously hypointense mass (arrows) measuring 2 cm with surrounding focal fat deposition (arrowheads) in left hepatic lobe. Trapezoid outline indicates US scan area (B). B. Oblique transverse subcostal US image shows hyperechoic mass (arrows) in left hepatic lobe. USPCB with 18-gauge needle (arrowhead; needle length: 11.5 cm, size of cutting notch: 1.6 cm) using subcostal approach was performed while patient was in supine position with one breath-hold; operator used two-stage biopsy action during procedure. After advancing needle tip to position 0.5 cm proximal to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 22 mm). US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 3. 63-year-old man with well-differentiated ductal adenocarcinoma in pancreatic uncinate process.

A. Coronal enhanced T1-weighted MR image shows hypointense 2.8 cm mass (arrows) in uncinate process of pancreas. Dotted line indicates plane of sagittal US image (B, C). Biopsy gun model indicates planned transabdominal caudocranial approach to mass in uncinate process. B. Corresponding sagittal color Doppler US image planned in (A) shows vascular structures around mass (arrows) that should be avoided. Biopsy gun model indicates planned trans-omental caudocranial approach. Note that there is no major vessel along planned safe path. C. Sagittal US image shows echogenic line (arrowheads), which indicates 18-gauge needle (needle length: 11.5 cm, size of cutting notch: 1.6 cm), and hypoechoic mass (arrows) in uncinate process along planned safe path. Operator used two-stage biopsy action during procedure. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by advancing outer cutting cannula to extract tissue specimen (stroke length: 22 mm). US = ultrasound

Fig. 4. 20-year-old woman with multiple microabscesses in spleen.

A. Contrast-enhanced CT image displays multiple, small lesions (arrows) in spleen with low attenuation. B. Longitudinal US image during biopsy with 18-gauge needle (arrowhead) shows multiple, small hypoechoic lesions within spleen. Note that peripherally located 0.8 cm lesion (arrow) was chosen for biopsy to traverse as little normal splenic parenchyma as possible. Operator used 18-gauge biopsy needle (needle length: 11.5 cm, size of cutting notch: 0.6 cm). After advancing needle tip to position 0.5 cm proximal to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 11 mm). US = ultrasound

Fig. 5. 67-year-old man with GB cancer.

A. Contrast-enhanced CT image shows enhancing thickened wall (arrows) measuring 2.8 cm in GB. Trapezoid outline indicates US scan area (C). B. Illustration of transverse US image (C) shows target (GB) surrounded by liver and colon. Biopsy gun model indicates planned transhepatic approach to target lesion. C. US image during procedure with 18-gauge needle (arrowheads; needle length: 11.5 cm, size of cutting notch: 1.6 cm) via transhepatic approach shows appropriate path for adequate acquisition of specimen. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 22 mm). There were no symptoms from bile peritonitis after biopsy. GB = gallbladder, US = ultrasound

Fig. 6. 77-year-old man with GB cancer.

A. Contrast-enhanced CT image displays irregularly thickened enhancing wall (arrows) measuring 2.6 cm in GB neck and metastatic lymphadenopathy (arrowhead). B. ¹⁸F-FDG PET/CT image shows focal hot uptakes in GB wall (arrows) and lymphadenopathy (arrowhead) that are seen on (A). C. Longitudinal US image depicts irregularly thickened hypoechoic wall (arrows) in GB neck. US image during procedure with 18-gauge needle (arrowhead; needle length: 11.5 cm, size of cutting notch: 1.1 cm) via transabdominal approach shows needle path for adequate acquisition of specimen. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 16 mm). There were no signs or symptoms of bile peritonitis after biopsy. FDG = fludeoxyglucose, GB = gallbladder, PET = positron emission tomography, US = ultrasound

Fig. 7. 70-year-old man with angiomyolipoma in right kidney.

A. Coronal T2-weighted MR image displays exophytic hypointense 2.3 cm mass (arrows) in lateral aspect of right kidney. Trapezoid outline indicates US scan area (B). B. Longitudinal US image shows exophytic isoechoic mass (arrows) in right kidney. USPCB with 18-gauge needle (arrowhead; needle length: 11.5 cm, size of cutting notch: 1.6 cm) via posterolateral approach was performed while patient was in prone position. After placing needle tip at anterior border of target, operator sequentially advanced inner trocar and outer cutting cannula to extract tissue specimen (stroke length: 22 mm). Procedure was performed as quickly as possible with patient holding his breath in order not to cause tumoral rupture. US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 8. 42-year-old man with clear cell renal cell carcinoma in right kidney.

A. Axial contrast-enhanced T1-weighted MR image shows exophytic poorly enhancing 1.8 cm mass (arrows) in anterior aspect of right kidney. Trapezoid outline indicates US scan area (B). B. Transverse US image shows exophytic isoechoic mass (arrows) in right kidney. USPCB with 18-gauge needle (arrowhead; needle length: 15 cm, size of cutting notch: 1.1 cm) via transhepatic approach was performed while patient was in supine position. After placing needle tip at anterior border of target, operator sequentially advanced inner trocar and outer cutting cannula to extract tissue specimen (stroke length: 16 mm). Procedure was performed as quickly as possible with patient holding his breath in order not to cause tumoral rupture. US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 9. 69-year-old woman with metastasis in left adrenal gland.

A. Contrast-enhanced CT image shows well-defined enhancing mass (arrows) measuring 2.5 cm in left adrenal gland. Trapezoid outline indicates US scan area (B). B. Transverse US image shows hypoechoic mass (arrows) in left adrenal gland. C. USPCB of left adrenal mass (arrows) with 18-gauge needle (arrowheads; needle length: 11.5 cm, size of cutting notch: 1.1 cm) via transabdominal approach was performed while patient was in supine position. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 16 mm). US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 10. 65-year-old woman with small bowel GIST.

A. Contrast-enhanced CT image shows well-defined heterogeneously enhancing mass (arrows) measuring 6.8 cm in left sided mesentery. Trapezoid outline indicates US scan area (B). B. Transverse US image shows hypoechoic mass (arrows). USPCB with 18-gauge needle (arrowheads; needle length: 11.5 cm, size of cutting notch: 1.6 cm) using transabdominal approach and graded compression of abdominal wall was performed while patient was in supine position with shallow breathing. After advancing needle tip to position 1 cm distal to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 22 mm). Note that there is no bowel between tumor and abdominal wall. GIST = gastrointestinal stromal tumor, US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 11. 70-year-old man with metastatic retroperitoneal lymphadenopathies.

A. Contrast-enhanced CT image demonstrates multiple enlarged lymphadenopathies (arrows) around abdominal aorta. Trapezoid outline indicates US scan area (B, C). B. Transverse color Doppler US image using graded compression shows aorta and both renal vessels around lymphadenopathies (arrows), which should be avoided during biopsy. C. USPCB with 18-gauge needle (arrowheads; needle length: 11.5 cm, size of cutting notch: 1.6 cm) via transabdominal approach and graded compression of abdominal wall in supine position was performed. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 22 mm). Note that there is no bowel between retroperitoneal nodes and abdominal wall. US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy

Fig. 12. 56-year-old woman with metastatic adenocarcinoma in greater omentum.

A. Contrast-enhanced CT image shows reticular infiltrations (arrows) in greater omentum. B. Transverse US image shows thickened omentum with increased echogenecity (arrows) near anterior abdominal wall. C. USPCB of greater omentum (arrows) with 18-gauge needle (arrowheads; needle length: 11.5 cm, size of cutting notch: 1.6 cm) via transabdominal approach was performed while patient was in supine position. After advancing needle tip to anterior border of target, operator pressed firing trigger to thrust inner trocar forward and confirmed that needle tip was within target, accompanied by second firing of outer cutting cannula to extract tissue specimen (stroke length: 22 mm). US = ultrasound, USPCB = ultrasound-guided percutaneous core needle biopsy