What’s New in Abdominal Biopsy and Drainage? - SD

Introduction

Hello, I'm Dr. John McGann. I'm from the university of California Davis Medical Center, which is located in Sacramento, California.

Update on Interventional Ultrasound

Today, my first talk I'm gonna talk to you about is sort of an update of interventional ultrasound. I'm mainly gonna deal with biopsy or aspiration techniques, not going to drainage techniques.

I would like to get started.

Today, I'm gonna talk to you about what's new in abdominal biopsy. And because of a time I'm not gonna talk about new drainage techniques.

Choosing Imaging Modality for Biopsy

First choice we always have and we're doing a biopsy, is do we do it under ct? Do we do it under ultrasound?

Well, there's certainly lots of ways of doing things and I like this slide here. There's lots of ways of skinning a cat. So if in fact you wanna get the job done, you get it done this way, that would be correct. So whatever eyes is not necessarily correct, if you do something in a different fashion, then that's fine. So whatever it takes to get the job done.

Well, the beauty of ultrasound or now CT fluoroscopy is we need no more blind needle placements.

Well, this is sort of a comic slide. It does have a point in what I do tell my residents or fellows. If in fact you do not see that needle, you have to stop. I've seen many a problems arise where somebody does not see that needle continues on, and then there is some sort of complication, perforation of a loop of bowel or perhaps a bleeding complications.

So the real beauty of ultrasound that we need to take advantage of is the ability to see the needle, basically we from uc, Davis, and that's where I'm from. If we can see something in the abdomen, it usually can be biopsied or drained by ultrasound. Certainly there are a few exceptions there.

Principles for Better Needle Visualization

Well, what are some of the principles that we use for better needle visualization? I call these rock. We look at the angle and we look at color here. Just look at ultrasound physics. The needle shaft is best visualized when it is within the plane of the ultrasound scanner probe. And what we're trying to do is we try to put the needle parallel to the ultrasound plane, not perpendicular.

When I do most of these procedures, what I'd like to try to do is put the needle exactly within the scan plane such as this. But when I watch and I watch different people go ahead and do ultrasound biopsies for the first time, I often note they watch the screen to see where the needle is instead of seeing where the needle is in relationship to the transducer. So initially watch where that needle is in relationship to the transducer or you'll be out a plane if in fact you're out a plane such as in this case here and you do not see the entire length or shaft of the needle, you can rock the transducer back and forth until you visualize the needle.

So what you want to do is rock the transducer in such a way that you can be parallel to the entire shaft of the needle. What this example shows is by rocking the transducer back and forth where we don't see the needle before in this water path. By just rocking the transducer, we can visualize the entire shaft of the needle.

Another thing is look at that angle of the needle with the transducer. The more perpendicular the needle shaft is to the ultrasound beam, the better the needle visualization, such as in this example, this would be ideal. We could potentially see the entire shaft. This on the other hand would not be as ideal, and we may not identify the entire shaft. We may identify the tip only if we set up and we're gonna go ahead and biopsy a lesion and think we should place the needle in this plane. Remember, we may not see that entire shaft in this plane. What we may wanna do is think about a plane in which we could go ahead, switch the transducer into a more ideal plane, rock the transducer in such a way that needle is perpendicular to the ultrasound beam Here.

Here's such an example that I'll show you in the right upper hand column in which we're doing a thyroid biopsy and we can see the entire shaft of the needle because the needle shaft is perpendicular to the ultrasound beam.

A third thing that we can do is move the inners stylet up and down. In this example here you can see the needle placed in a water path. We take that inner stylet up and down and move it. This takes three hands, and since most of us don't have three hands, we have to ask for either a resident, a fellow, or one of our sonographers to help us out, either to hold the transducer or hold the needle as we go up and down, as in this case for better needle visualization.

Probably the most helpful thing that I find is use of color flow. Color flow not only is helpful prebi or pre aspiration to avoid vessels, but it is very helpful post procedure and I'll show you that later in examples for each of these case analysis.

Just think, what am I gonna use CT ultrasound or what would I use CT ultrasound? What would be the approach, the needle path and the needle selection for biopsies? We can do F and a, we can do core, or we may be able to do combined f and a plus core.

FNA Techniques and Examples

Why would we wanna do F and a? Well, what I do, for instance, for thyroid biopsies, I do what is called a five minute thyroid biopsy. You sort of have a rule because patients have a lot of discomfort with this if in fact you take a long time. So what I try to do is go ahead, tell the patients I'm gonna go ahead, do four to five passes. I will be done in five minutes. We'll stop. My old plan of attack was I would do two biopsies. I would stop. I had a cytopathology tech there. I would ask him, is my specimen adequate? I always got the same answer back, yes, it's pretty good, doctor, but we would like more. And after number three, guess what the answer would be? We liked more. So finally I learned after doing many of these, I'd go ahead and do four or five within a four to five minute time and then stop after that time.

Well, let's look at biopsy for either cytology or histology and then consider FNA. Well, we'll consider FNA when we know we have a primary. For instance, we're doing a biopsy in the liver. We know the patient has colon cancer when there's possible infection or even for lymphoma, but we have to do flow cytometry and in combination with core.

Let's take a couple of examples. Six to 8-year-old female with breast cancer question mets. In this case, you can see that there's a very small lesion in the left lobe of the liver. There's a couple of 'em. It ended up, we could see these under ultrasound as we see here, but these are less than one centimeter in each of these cases. Imagine you could do 'em under CT floral, but it may be very difficult to see. And in this case, I went ahead and I'm gonna do this under ultrasound. Again, color flow prebi, that's about my biopsy path. But with color flow, I see the portal vein would be in the way while I'm gonna do a coaxial placement in this case. So I'll place a 17 gauge needle first, and through that I'll go ahead and do a 22. It would gimme the option later to place a core needle. Or in this case, I could go ahead and place a 20 gauge if I knew I was doing only FNAR 19 and do multiple 20 through two needle passes through that.

This case shows me as I go in with the needle here and I'm gonna go ahead and do multiple needle passes again using a coaxial technique. And I've gone ahead and do that. Done that another case, very similar. 63-year-old with lung cancer question mets very small lesions or nodes around the periportal region. These nodes are, again, less than one centimeter. Again, in this case, I see this with ultrasound. I'm gonna do a coaxial technique. I am not afraid to go through the liver, especially when I do color flow and I see no large vessels in my needle path. In this case, I place my needle adjacent to the node with the coaxial technique. And then I go ahead and I do multiple FNAs into this lesion. Again, remembering this is less than one centimeter diagnosis here was metastatic lung cancer to these nodes.

Core Biopsy Techniques and Examples

Finally, when will I do core? Well, there's a whole host of different reasons. For instance, if somebody's failed with FNA or I failed with FNA for lymphomas, that may be very helpful. More so for HCC than RCC. We do a lot of biopsies for potential renal cell carcinomas and we found that FNA is helpful, but core is also good. However, for hepatoma in the liver core is much more helpful than FNA. If we have an unknown primary or we're gonna go ahead and do a random biopsy or we suspect a potential benign lesion, what sort of needle or core biopsy gun would we use?

You can pick what you want to do. At our institution, often cause really trumps everything. So we may decide that we like one type of biopsy device, but because of cost, we go ahead and we select another type of a biopsy device, which will work very well.

Again, core pre-imposed color. In this example of a 39-year-old with hepatitis B, there was a liver lesion. We suspected to be hepatocellular carcinoma. We were asked to do a biopsy. We were asked to do a core. You can see the color flow pre and then color flow post. And I saw this interesting track that came out to the liver surface. I went ahead and placed doppler onto that track and it looked like it may be arterial or some type of venous flow. I compressed for five minutes and eventually that stop. This has been coined the patent track sign, it was published in a GR in 2007 when they looked at this, this occurred about 10% of the time with core biopsies of the liver. And at about 1% of the time, it persisted for greater than five minutes. When they analyze venous versus arterial waveform, if you had an arterial waveform, it was not good. Those were much more frequently associated with bleeding than those with a venous waveform.

Here's an example of a 63-year-old male who had hepatitis C. I've been doing RFA for a number of years and I did a RFA of a hepatoma in 2003 without a problem. I did another RFA of a separate hepatoma in 2005. In 2008, he presented with two hepatoma. You can see these new enhancing masses, one on CT to the left and this is the image of the ultrasound on the right. In this case, this demonstrates the needle being placed for the potential RFA. You can see the slightly hypo coic lesion. Here's the needle as we place it, the fairly echogenic needle and you can see the more hypo coic lesion. And then this is as we do the RFA, you can see the end needle in which it becomes very echogenic at the site in which I place the needle all the way through the lesion to do the RFA.

Now I start my pullback and during my pullback I'll also cauterize the track to prevent any potential bleeding. And as I pull back, you can see as I pull back all the way, I will stop and cauterize that track. But what I find with color flow post, and you have to look very carefully at the capsule, there's a very small area of increased color flow as a mag. That image, you can see the color flow here as a very small bleeder that occurred. And one subcapsular, unfortunately, when I did doppler through this, it was basically a arterial bleeder.

Now, he asked the question, what do you do? And as I told you, the history of the patient was a Jehovah's Witness. And in fact I asked his wife, 'cause he was under anesthesia, can I give him blood products? And the answer is absolutely not. He did have slight elevation of his INR, so there was nothing I could do. So we went ahead and embolized this patient very successfully.

So the real question, what would've happened to this patient if we did not monitor with color flow or perform the procedure under CT guidance? And we have not known there was an active bleeder in this case. So ultrasound in this case with color flow post procedure was very helpful.

Finally, again, consider color flow with random biopsy. Um, in such a case here in renal biopsy, the same sort of thing can occur. These are sort of the pat track sign, but this occurred after a random biopsy of native kidneys. They again demonstrated vascular abnormalities in a higher percentage of the patients. About 20% of the patients.

Here's a 33-year-old male status postrenal transplant. Possible rejection for a biopsy. This is, we go ahead and do the biopsy through the cortex post biopsy and you'll note the time's on here. This is AM We go ahead and eventually do some compression through there. And as the time goes on, this site of increased color doppler or increased bleeding, decreased with time to the point of AM and it completely stopped.

Combined FNA and Core Techniques

When we do combined, if an in core, we do it in a number of different cases and we sort of have to say we wanna get an adequate diagnosis or do we wanna minimize complications? So we're sort of teetering between this all the time. So open biopsy, we'll get an adequate diagnosis. But FNA core, you sort of wanna minimize complications. I use a coaxial technique here because it does provide a margin of safety. And that margin of safety is if I note a lot of bleeding, I can go ahead and do a gel foam slurry and inject gel foam into my needle or do a blood patch injection 80-year-old with breast cancer. This is question liver mets question abscess put in my initial needle. This is what it image looked like. My coaxial needle that I was gonna put in a 17 gauge. And then I'm gonna do potential core. And this shows as the initial needle is placed into the lesion aspirating all the central fluid.

After that, I go ahead and I place another needle or I reposition that needle. And now I'm gonna go ahead and do FNA through that. After I've done FNA into the solid portion of the lesion, I'm gonna go ahead and do core. And with both FNA core, we found that this was not infected at all. This was a necrotic metastatic and no carcinoma.

Here's another patient, transitional cell of the bladder with liver lesion called likely unmet. You can see it on ultrasound. On ct. We went ahead it in a a 22 FNA and a core and we did a coaxial technique, but we got bleeding afterwards. What I did in this is in fact I went ahead and use the blood patch technique or you can use the gel foam slurry. We thought questionably after this, this was a ous heman. But even if you had biopsy cameras, heman, you could still use this gel foam slurry or the blood patch technique if you have a needle in there, such as a biopsy guide needle where we go ahead and do a core and FNA.

Special Techniques

I'm gonna show you two special techniques, not specifically utilized with ultrasound, but with CT use of a blunted needle and use of hydro dissection. Here's a case here with 30 5-year-old female with cancer and there was two hot areas identified on PET in the peri aortic region on the left hand side, CT on the left. And then we put her in this, in the prone position and left is over to your right and these areas where we're gonna biopsy are very close to the hydro nephrotic ureter. We only have a window there of less than one centimeter. In this case, we went ahead and I did a biopsy using a coaxial technique with a blunt and needle. So I use the sharp inners eyelet to go through the muscle. But when I get into a critical area, I'll go ahead, put in the blended tip and go ahead, push gently down through that area and push the ureter out the out of the way. Take out that inters eyelet and then do multiple FNAs. And this unfortunately turned out to be cervical cancer.

Another patient here who had a renal cell carcinoma. And on the left hand side there was an adrenal enlargement. This is thought to be a question. Adrenal metastasis went ahead, set 'em up for biopsy. I was gonna use the left hand side, but there was no window between the spleen and the colon. So what I did here is I took a 21 gauge injection needle injected some water through there. You can inject D five W in these cases injected to displace the bowel and the spleen in such a way that I eventually had a window went ahead with my needle here you can see as my needle is going in, eventually got in and to that. And this turned out to be with FNA metastatic renal cell to the left adrenal.

Summary

Well, in summary here, I would say probably one of the most important things for you to do is to do color flow pre and post. So you can do it pre to a to note the route you're gonna do and you can do post for potential complications. Again, I would emphasize with ultrasound, think about that coaxial technique for needle placement in case you do get into complications. That will be helpful. Thank you very much.