This presentation describes the method of ultrasound guided biopsies and how to optimize needle visualization and avoid false negatives

1. Ultrasound Guided Biopsies
Methods and Challenges
Durr-e-Sabih
MBBS. MSc. FRCP
Director Multan Institute of Nuclear Medicine
and Radiotherapy
Multan- Pakistan
dsabih@yahoo.com

2. More than Biopsies
o
o
o
o
o
Aspirations and drainage
Vessels access
Nerve blocks
Foreign body removals
Injections into cavities, cysts and solid
lesions

3. Guidance
o
o
o
o
Blind
Mark, angle, depth
Free hand real-time
Biopsy adaptor

4. Guidance

5. Blind vs Guided Biopsies
o Large organs, diffuse disease
o Guided biopsies associated with less pain,
less complications, less re-biopsies 1
o Procedure appears to be more accurate and
more safe when performed in conjunction
with US2
o Adding ultrasound altered biopsy procedure
in 15% 3
1Bandar Al
Knawy, Mitchell Shiffman. Percutaneous Liver Biopsy in Clinical Practice Liver International. 2007;27(9):1166-1173.
Gastric Association Guidelines for outpatient LB. Jacobs WH, Goldberg SB. Statement on out-patient percutaneous liver biopsy.
Dig Dis Sci 1989; 34: 322-3.
3Riley TR. III How often does ultrasound marking change the liver biopsy site. Am J Gastroenterol 1999; 94: 3320-2.
2American

6. Ultrasound Guidance Pros and Cons
o
o
o
o
o
Very precise
Patient bedside
No radiation
Real-time
If you can see it you
can get it
o Oblique planes are
easy
o Long learning curve
o Some patients (obese)
and some sites (deep,
deep in lungs, behind
bone, air filled
structures) some
structures (breasts),
some backgrounds
(hyperechoic ) difficult
o Some needles (>20G)

7. Ultrasound vs. CT
o More sites, deeper sites accessible than US
o Limited to axial planes
o More time consuming and costly
o Each needle advancement is followed by a CT
o CT Fluoroscopy is faster
o High patient and operator dose
o Patient dose up to 830 mGy (12kVp, 90 mA
10mm section)
o Physician hand dose up to 18 mGy/month

8. Extremely Accurate Needle
Placement
4 mm
3.5 mm

9. Before the Actual Procedure
Select the Appropriate Needle
o Preliminary ultrasound for most appropriate
site; shortest line of sight without vessels
and preferably without gut
o Length according to depth of target
o Type of needle

10. Depth

11. Depth, Needle Length

12. Needle Description
French and Gauge
o Gauge
o Modification of Birmingham Wire Gauge (1884) and
specifies the thickness of outer diameter. Largest size is
5 or 0.5 inch or (12.7mm). Largest needle size is 7G
(4.572mm), smallest needle size is 34G (0.1842mm).
There is no mathematical formula; the steps get smaller
with increasing gauge numbers (0.046-0.001”)
o French
o D (mm)= Fr/3; you get mm of diameter by dividing the
Fr size by 3

13. Common Needle Gauges and Lengths
Type
Gauge
Length(mm)
LP
90
Other LP
BT set
BD 20 ml
BD 10 ml
16 (donor)-18G (recipient)
21
21
50-190
40
40
38
BD 5 ml
BD 3 ml
Terumo 1 ml
23
23
30
25
25
09

14. Length and Throw

15. Needle Description
Wall Thickness
o
o
o
o
RW
TW
XTW
UTW
walled)
Regular wall (spinal)
Thin Wall
Extra Thin Wall
Ultra Thin Wall (Chiba is Ultrathin

16. Needle Edge and Type
o Aspiration
o LP, Hypodermic, Chiba
o End cutting
o Franseen, Jamshaidi, Klatskin, Menghini,
Westcott, Greene
o Side cutting
o Tru-cut, Vim Silverman, Magnum
o Spring Loaded

17. Tips

18. Bevel
o Turner bevel 45o
o Spinal bevel 30o
o Chiba bevel 24o
Smaller bevel angle is associated with higher tissue yield (Chiba).

19. Echogenic Needles
o
o
o
o
Scoring
Cornerstone reflectors
Echocoating
Bevel angle and length

20. Choices
FNA or Core
Core
Choose needle
Length, gauge and throw
FNA
Choose needle
Length and gauge
Suction
Capillary
Larger lesions larger throw
Smaller lesions
smaller gauge
Freehand or guided

21. Aspiration or Core?
o How good is your cytologist?
o Aspirations are less traumatic, cheaper,
faster…
o Failure rates… you don’t know if you got
the cells

22. FNA Needle Movement
o
o
o
o
o
Insert into the target
To and fro
Rotate
Suction/capillary
Narrow gauge is better

23. FNA Needle movement

24. Needle Movement for FNA

25. Core Biopsy
o Know your throw
o Assess where the tip will be after firing,
calculate your angle
o Go to the periphery of lesion
o Use an introducer sheath

26. The Biopsy Movement

27. The Biopsy Movement

30. Work UP
o FNA 20G or smaller … no workup
o Core
o Platelet count >50,000
o INR <1.5
o Prothrombin time …normal – normal + 4 sec.
o Vascularity is perhaps as, or even more
important

31. Complications
More Passes, More Complications
o Pain, referred pain (right shoulder with liver biopsy)
o Hypotension (Vasovagal, hemorrhage)
o Hematoma, hemoperitoneum, biliary peritonitis,
pneumothorax, pancreatitis, air embolism
o Hematuria, urinary retention, peri-site abscess
o “Overshooting” into other organs
o Seeding
o AVM
o Transient bacteremia
o Death
o False negative/inadequate sample

32. Terminology for Hemorrhagic Complication
o Grade 1. Minimal symptoms; invasive intervention
not indicated
o Grade 2. Minimally invasive evacuation or aspiration
indicated
o Grade 3. Transfusion, interventional radiology
procedure, or operative intervention indicated
o Grade 4. Life-threatening consequences; major urgent
intervention indicated
o Grade 5. Death
McGill DB, Rakela J, Zinsmeister AR, Ott BJ. A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology 1990;
99:1396–1400

33. Incidence of Bleeding after 15181 Percutaneous
Biopsies and the Role of Aspirin1
o Grade 3…..70 patients (0.5%) including 3 deaths
(0.02%, 1: 5000).
o All deaths with liver mass biopsies (one
hemothorax [DNR], one perihepatic hematoma,
progressive hypotension [DNR])
o No difference with aspirin use
o Size of needles not important
o Death 1: 12,0002
1Thomas
D. Atwell, Ryan L. Smith, Gina K. Hesley, Matthew R. Callstrom, Cathy D. Schleck, W. Scott Harmsen, J. William Charboneau, Timothy
J. Welch. Am J Roentgenol. 2010;194(3):784-789.
2Garcia-Tsao
G, Boyer JL. Outpatient liver biopsy: how safe is it?. Ann Intern Med. Jan 15 1993;118(2):150-3

34. Post Biopsy Hematoma

35. Perirenal Haematomas
http://emedicine.medscape.com/article/2093338

36. When You Shouldn’t
o Bleeding diathesis
o Uncontrolled blood pressure
o Obesity and uncooperative
patient
o Skin infection at biopsy site
o Very vascular lesion
o Back up invasive radiology/surgery not
available

37. Suggested Guidelines for Outpatient
Liver Biopsy
o
o
o
o
o
The patient must be able to easily return to the hospital where the procedure
was performed within 30 minutes of developing any adverse symptoms.
A reliable individual must be available to stay with the patient during the
first night after the liver biopsy and provide care and transportation to the
hospital, if necessary.
The patient should not have any preexisting serious medical problems that
might increase the risk of complications from the biopsy. Such problems
may include encephalopathy, ascites, liver failure with severe jaundice,
significant extrahepatic obstruction, significant coagulopathies, or serious
comorbidities such as severe congestive heart failure. Also, patients should
not be very old, very young, or so anxious that they require sedation.
The facility where the biopsy is to be performed should have an approved
laboratory, blood banking unit, easy access to an inpatient bed, and
personnel to monitor the patient for 6 hours after the biopsy.
The patient should be hospitalized after biopsy if any evidence exists of
bleeding, bile leak, pneumothorax, or other organ puncture. Hospitalization
is suggested if the patient’s pain requires more than 1 dose of an analgesic
in the first 4 hours after the biopsy.
Position Statement American Gastroenterological Association 1989

38. Type of Guidance
Real-time Visualization or
Mark/Guide
o For large lesions only guidance
o Mark, angle, depth
o Smaller or non palpable lesions
o Real-time

39. Needle Tip Echogenicity
o
o
o
o
o
o
As near parallel to the probe
Gauge, bigger is better
Closer is better
Echogenic needle shafts
Needle bevel towards the probe
Long axis easier than short axis

40. Losing the Needle Echo
Commonest problem, plagues experts as well
as novices
o Get needle in line ..know your probe’s “sweet
spot”
o Look where the needle is going most of the time,
not the monitor
o Move the stylet in and out
o Jiggle the needle
o Subsequent passes are more difficult

41. Out of Plane

42. Stylet

43. Before Beginning the Procedure
Decide on the Insertion Site and Angle

44. The Biopsy Procedure

47. Mark, Angle, Depth (MAD)

48. Insertion Points
Long-axis
< 20o
Short- axis insertion needs more practice

49. Insertion Points Short Axis
Identify the needle tip and follow this
as you advance it.
Sometimes shaft echo is mistaken
for needle tip.
Much more practice needed for
short-axis visualization

50. False Negatives
o Needle length
o Beam thickness and
side lobes
o Focus, frequency
o Air echoes on
subsequent passes
(biopsy tracks)
o Very dense tissue
o Very soft tissue

51. Avoiding false negatives
o
o
o
o
o
Larger gauge, 14G needles
Post-fire images
Practice
Practice
Practice
Needle track

52. Pearls
o
o
o
o
o
Breast
Thyroid
Liver
Kidney
Retroperitoneum

53. Breast Biopsy
o Stabilize the mass
o Parallel to the chest
wall
o If not possible, lift
the mass using the
needle

54. Ultrasound Histology Correlation
Concordant Malignancy Malignant on image,
malignant on HP
Oncology/Surgery
Discordant Malignancy
Benign on Image,
Malignant on HP
Treat as concordant
malignancy
Oncology/Surgery
Discordant Benignity
Malignant on Image,
Benign on HP
Possible false negative,
redo, very close followup, inform
surgeon/oncologist
Borderline or high-risk
finding
Atypia, lobular neoplasm,
radial sclerosing lesion,
papilloma, phylloides
Discuss with surgeons,
possible close follow-up
or excision
Youk, J. H., E. K. Kim, et al. (2007). Missed breast cancers at US-guided core needle biopsy: how to reduce them.
Radiographics 27(1): 79-94.

55. Thyroid
o 5% likelihood of a thyroid nodule being
malignant1
o Likelihood increases with suspicious findings
(hypoechogenicity, taller than wide, irregular
contour, central vascularity, microcalcification), in
recurring cysts, complex lesions, history of
radiation. Under 30 or over 60 yrs.
o Usually FNA, core rarely and very carefully
1Tollin
SR, Mery GM, Jelveh N, et al. The use of fine-needle aspiration biopsy under
ultrasound guidance to assess the risk of malignancy in patients with a multinodular goiter.
Thyroid. 2000;10:235–241.

56. Thyroid
o FNA with 22-26G hypodermic or chiba
needle
o 95% accuracy
o 209 core biopsies of thyroid with 16-18 G
minor complications in 2%, no major
complications
o Sensitivity of 96%

57. Renal Biopsy

58. Renal Biopsy
Contraindications
Kidneys
o Multiple cysts
o Solitary kidney (?)
o Acute pyelonephritis/
perinephric abscess
o Small kidneys
o Highly vascular tumours

59. Splenic Biopsy
o Complication rate similar to liver biopsy but
prudent to biopsy a non-splenic lesion if
present

60. Mesenteric Nodes
o Compress the gut away
o Safe with 20 G

61. Thank You