This document provides information on various radiology procedures including aspirations, drainages, and biopsies. It describes how cyst aspirations are performed using ultrasound guidance to insert a needle and drain fluid from cysts in the breast or elsewhere. It also discusses paracentesis for draining ascites and thoracocentesis for draining pleural effusions. The document outlines patient positioning and technical steps for each procedure. Biopsy procedures are also summarized, including how ultrasound is used to precisely guide needle placement and obtain tissue samples from organs like the liver and kidneys.

1. Dr Qurrat-ul-Ain
TMO Radiology

2. 
Aspiration

Drainage

Biopsy

3. 
Aspirations

Cysts aspiration

Paracentesis (Ascites)

Thoracocentesis (Pleural effusion)

4. 
Cysts aspiration:

Cysts are very common.

Usually be diagnosed accurately with
ultrasound.

In most women, they do not usually require
any intervention or follow-up.

5. 
Cyst aspirations are done when :
•
Causing significant tenderness
•
The diagnosis of a cyst remains in question
following the ultrasound

6. 
POSITION

The patient lie on her back or slightly turned to
one side with the arm placed comfortably
under the head.

7. 
The skin is cleaned , numbed with topical
anesthesia. Using ultrasound guidance, a small
needle is advanced into the cyst and suction is
applied to draw the fluid out, causing the lump
to collapse.

9. The lump (arrow) in this
patient’s right breast was
thought to be a cyst, but some
features are not characteristic
and aspiration was necessary.

10. Using ultrasound guidance, a fine
needle (white line) is placed so
that its tip (double arrow) is in the
center of the lump (single arrow).
Aspiration is applied by using a
syringe attached to the needle. If
this is a cyst, fluid is drawn into
the syringe as the lesion collapses.

11. After the aspiration, the
needle (white line) and its
tip (double arrow) are
seen, but the lump is gone.

12. 


If is very helpful to get an ultrasound scan of
the ascites before the procedure.
The radiologist will mark the spot for
paracentesis. Two things are important:
What is the distance from the skin to the
fluid? Usually 1 cm.
What is distance to the midpoint of the
collection? Usually 3 cm.

14. Here we clearly see free fluid in Morrison's pouch that extends
superiorly around the liver

15. See the needle entering the peritoneal cavity obliquely from just
beneath the indicator marker.

16. 
Pleural effusion is an abnormal collection of
fluid in the pleural space. Removal of this fluid
by needle aspiration is called a thoracoentesis.

17. 
Patient should be sitting or in the lateral decubitus
position with pleural effusion side up.

The marker on the probe should be pointed
towards the head. Be sure that the transducer is
perpendicular to the chest .

18. 
The diaphragm and liver or spleen should be
identified first.

The probe can then be moved towards the head
and from side to side to locate the largest pocket of
fluid between the ribs. Once this is located a mark
is made with indelible ink just above the lower rib.

19. 
The distance from the transducer to the pleural
fluid should also be noted.

The probe is then rotated 180 degrees to
visualize the pleural fluid between the ribs to
ensure that there is only fluid visualized ie. no
lung, diaphragm, or liver or spleen.

20. General Anatomy Pleural Effusion

21. Thoracocentesis can be both diagnostic and therapeutic .
Using ultrasound to guide this procedure can decrease the
very high complication rate associated with it.

22. Right Pleural Effusion

23. Left Pleural Effusion

24. 
Procedure allow collections which would
otherwise require open surgery to be drained
via a skin incision only a few mm in size.

25. 
Minimally invasive technique

Little procedure related morbidity and equal
applicability to unfit patients,

26. 
Any abnormal fluid collection which is
accessible, e.g

Complicated Diverticular abscess

Crohn’s disease related abscess

Appendicular abscess

27. 
Localized abscess related to ovary (tubo-ovarian)

Abscess collection after surgery

Hepatic abscess (amebic or post-op)

Renal abscess or retro-peritoneal abscess.

Splenic abscess

28. 
The only common contraindications are:

Abscess is not accessible

Patient has a bleeding tendency

29. 
Abscess is first delineated &a safe route from
skin to the abscess cavity is identified by
ultrasound.

Prior to the catheter introduction, a diagnostic
needle aspiration may also be done.

30. 
The catheter is introduced into the abscess
cavity, either directly using a trocar catheter (as
used for chest intubation (or by modified
Seldinger’s technique using a guide-wire.

31. 
Maneuvering of the trocar or guide-wire within
the abdominal cavity should be done strictly
under ultrasound surveillance

32. 
Once in position, the catheter is secured and
attached to a drainage bag.

Drainage is recorded daily ,response to the
treatment is assessed by clinical parameters &
u/s.

35. Indications
Icterus/liver enzyme elevation/elevated bile
acids
Focal nodules or masses anywhere
Renal disease sometimes (i.e. renal dysplasia,
renal masses, lymphosarcoma suspects)
Prostatomegaly
Free abdominal fluid
Cysts
Lymphadenopathy

36. 
U/S guided FNA/biopsies generally not done
on:

Adrenal glands

Transitional cell carcinoma suspect masses

Chronic renal failure, glomerulonephritis

37. Probe orientation
Reference
marker corresponds
to left side of screen
(see
Screen Orientation
Probe
Skin
Superficial “lesion”
to biopsy
Deep “lesion”
to biopsy

38. Rock and/or slide the probe
to line up the lesion
to a “reachable” position
Deep lesion needs
to be lined up
toward the edge of
the beam
Superficial lesion
can be toward the edge
or in the center
of the beam

39. Angle to use for a superficial lesion:
Aim needle more perpendicular to beam

40. Superficial lesion FNA

41. Superficial lesion FNA

42. Superficial lesion core biopsy

43. Superficial lesion core biopsy
Take biopsy

44. Superficial lesion core biopsy

45. 
Percutaneous needle biopsy of the breast
provides reliable diagnosis of both benign and
malignant disease and is a proven alternative
to open surgical biopsy

46. 
Ultrasound guidance is an accurate and reliable
biopsy guidance technique and is the method
of choice and suitable for all breast lesions
visible on ultrasound

47. 
CNB & FNAB are effective methods for the
diagnosis of most breast lesions

Although CNB has higher sensitivity & positive
predictive value for abnormalities like micro-
calcifications & distortions of architecture.

48. 
Focal mass or other lesion of unknown nature –
palpable or non-palpable

Architectural distortion

Micro-calcifications

Cyst aspiration

49. 
PROCEDURE:

The long axis of the needle, should be visible along
the long axis of the transducer.

Occasionally, during an FNA biopsy or cyst
aspiration, the transducer can be rotated 90
degrees to visualize the echogenic dot of the
needle within the lesion.

52. 
Liver biopsies are performed for both focal and
nonfocal lesions.

The primary indication for parenchymal liver
biopsy is for the diagnosis of hepatic disease.

54. 

When imaging guidance is employed, it can
take one of two forms:
US-guided "marking" in which a mark is made
upon the skin during US examination for a
biopsy to be performed later without imaging
guidance or real-time US guidance.

55. 
The patient is positioned supine, with the
hands comfortably resting behind the head

A preliminary US scan is performed to identify
the target and mark the skin.

56. 
The preliminary scan also ensures that no major
vessels, dilated biliary channels or gall bladder are
in the path of the biopsy needle.

57. 
Before the procedure is started, breathing
instructions are practiced with the patient.

performed with the breath held in expiration.

This minimize risk of injury to the pleura or lung.

58. 
The skin site is prepped and draped to ensure
asepsis The local area is anesthetized with a
local anesthetic.

The cutting needle is then fired with US
documentation of the site.

63. 
Indications:

Biopsy of a focal solid lesion /suspicious cystic
lesion for diagnosis.

Nonfocal biopsy to evaluate for nephropathy
or renal transplant rejection

64. 
US has the advantages of real-time needle
placement

No radiation & is therefore well suited for most
nonfocal renal biopsies in thin pts and in biopsies
of some focal solid masses or cystic masses .

65. 
The patient is placed in the prone position and
the biopsy is typically taken from the lower
pole of the kidney if there are no specific
locations of interest.

66. 
The biopsy needle is guided using ultrasound
to ensure visualization of the needle as it
pierces the kidney parenchyma.

67. 
Care is taken not to enter the collecting system
(as it would result in haematuria) or to go near
the renal hilum (to prevent injury to the
vessels).

71. THANK YOU