Interventional breast sonography

This review article covers the basic applications of and latest developments in interventional breast sonography (US). For breast masses, US has become the standard for guiding needle biopsy, whether a fine needle or a core biopsy needle is used. US has also become the preferred method for guiding insertion of various localization devices for nonpalpable masses, and US's intraoperative use for this purpose is expanding. Recently, US has been used to monitor the placement of percutaneous ablation devices, such as radiofrequency ablation needle-electrodes, into breast masses, including carcinomas. US is not indicated for the routine evaluation of microcalcifications. However, on occasion, clusters of microcalcifications without a mass can be visualized on sonograms with sufficient clarity to undertake a US-guided core biopsy if stereotactically guided biopsy cannot be performed for technical reasons.     

Ultrasound guided tumour biopsy in the anterior mediastinum. An alternative to thoracotomy and mediastinoscopy.

To evaluate percutaneous ultrasound (US) guided tumour biopsy of the anterior mediastinum all patients scheduled for open mediastinal biopsy were considered for percutaneous biopsy during a 2-year period. US guided biopsy was chosen when CT had shown the tumour to be in contact with the thoracic wall. US guided biopsy was performed in 23 patients on 28 occasions. The procedure was technically successful in all cases and no complications occurred. In 27 of 28 cases the biopsy diagnosis was identical to the final diagnosis. In one patient with a malignant lymphoma a false diagnosis of connective tissue remnant was reached. US guided tumour biopsy of the anterior mediastinum is a safe, cost-effective and reliable method and a good alternative to the traditional biopsy techniques via mediastinoscopy or thoracotomy.     

Incidentalomas

A liver incidentaloma corresponds to a liver lesion detected during work-up of for unrelated pathology. The frequency of incidentalomas is directly related to the incidence of liver tumors in the general population. After detection of an incidental liver lesion, the goal is to assess if diagnosis can be made based on imaging features alone or if biopsy is required. As such, radiologists must be familiar with the imaging features of different types of liver lesions, irrespective of the imaging modality. US is useful to determine the number of lesions (single versus multiple) and the cystic or solid nature of each lesion. Cystic lesions are usually benign. Incidental solid liver lesions are typically benign, but detection of a malignant lesion, hepatocellular carcinoma and metastases, is possible. The most frequent benign incidental solid liver lesions are hemangioma, focal nodular hyperplasia and liver cell adenoma. Accurate imaging diagnosis may not always be achievable, and biopsy, percutaneous or surgical, may be required.     

Single-Pass Percutaneous Liver Biopsy for Diffuse Liver Disease Using an Automated Device: Experience in 154 Procedures

Purpose: To describe our experience with ultrasound (US)-guided percutaneous liver biopsies using the INRAD 18G Express core needle biopsy system. Methods: One hundred and fifty-four consecutive percutaneous core liver biopsy procedures were performed in 153 men in a single institution over 37 months. The medical charts, pathology reports, and radiology files were retrospectively reviewed. The number of needle passes, type of guidance, change in hematocrit level, and adequacy of specimens for histologic analysis were evaluated. Results: All biopsies were performed for histologic staging of chronic liver diseases. The majority of patients had hepatitis C (134/153, 90.2%). All patients were discharged to home after 4 hr of postprocedural observation. In 145 of 154 (94%) biopsies, a single needle pass was sufficient for diagnosis. US guidance was utilized in all but one of the procedures (153/154, 99.4%). The mean hematocrit decrease was 1.2% (44.1–42.9%). Pain requiring narcotic analgesia, the most frequent complication, occurred in 28 of 154 procedures (18.2%). No major complications occurred. The specimens were diagnostic in 152 of 154 procedures (98.7%). Conclusions: Single-pass percutaneous US-guided liver biopsy with the INRAD 18G Express core needle biopsy system is safe and provides definitive pathologic diagnosis of chronic liver disease. It can be performed on an outpatient basis. Routine post-biopsy monitoring of hematocrit level in stable, asymptomatic patients is probably not warranted.     

Percutaneous biopsy (PB) of solid thoraco-abdominal formations with instrumental guidance. The authors' experience

The results are reported of 283 percutaneous biopsies performed on solid thoracic and abdominal masses. Indications to biopsy are examined at first, which are relatively limited in number if compared to other authors' opinion on the subject--i.e., when the tumor cannot be characterized with any other methodology, or in case of neoplasms whose histological type is to be known in order to plan therapy. The techniques employed are then evaluated, with a special emphasis on the needle caliber and the guidance method (US, radioscopy and CT). Correct samplings have been obtained in more than 90% of cases. Minor complications were observed in less than 10% of cases, while major complications were totally absent. In conclusion, percutaneous biopsy proves useful in those cases where exam indication is respected and an accurate selection is previously performed.     

US-guided percutaneous biopsy of small (< or = 1-cm) hepatic lesions

PURPOSE: To determine the accuracy of ultrasonography (US)-guided percutaneous biopsy in diagnosing malignant neoplasms for hepatic lesions 1 cm or smaller. MATERIALS AND METHODS: In this prospective study, 64 consecutive patients with 74 discrete focal hepatic lesions depicted at US were referred for liver biopsy to confirm the exact nature of the lesions. Mean lesion size was 0.84 cm +/- 0.13 (range, 0.5-1.0 cm). Biopsy was performed with an 18-gauge automated biopsy gun in 46 lesions (once [n = 37], twice [n = 7], three times [n = 2]) or a 22-gauge needle in 28 lesions (once [n = 23], twice [n = 4], three times [n = 1]). Measures were taken to ensure accurate and effective lesion sampling. The histologic diagnosis of malignant tumor and findings on follow-up US images of "benign" nodules for 15-39 months were the criterion standard. RESULTS: No complications occurred. All specimens obtained were sufficient for diagnosis. Histologic examination revealed various types of primary and secondary malignant tumors (n = 44), hemangioma (n = 5), cirrhosis (n = 13), focal fatty change (n = 8), focal fatty sparing (n = 2), and abscess (n = 2). The diagnostic discrimination of US-guided biopsy in diagnosing malignant tumors in these small lesions was sensitivity, 98%; specificity, 100%; positive predictive value, 100%; negative predictive value, 97%; and accuracy, 99%. CONCLUSION: Percutaneous biopsy under US control is highly accurate in providing a definitive histologic diagnosis of malignant neoplasms for small hepatic lesions if measures for ensuring precise and effective lesion sampling are taken.     

超声引导下经皮肝穿刺活检220例临床分析

目的讨论肝穿活检病理组织学特点,分析肝穿病检结果中疾病分布情况,研究肝穿活检对临床诊断的参考意义。方法对本院近2年各科室送检的220例超声引导下肝脏穿刺活检病理切片标本进行回顾性分析,总结其l临床诊断和病理诊断的疾病分布情况。结果所有病例均成功穿刺,无并发症发生。因肝脏占位送检病例中,有63．9％为恶性肿瘤,且以肝细胞癌为主;因HBV-DNA〉10^4拷贝／ml、转氨酶轻度升高而送检的慢性乙肝患者中,有41．5％炎症活动度大于2级,需接受抗病毒治疗;23例不明原因肝损害者经肝穿刺活检均明确病因。结论超声引导下肝脏穿刺活检安全性高,是肝脏疾病诊断的重要辅助手段。     

Interventional breast procedures

The capability to provide histologic diagnoses of nonpalpable lesions by performance of percutaneous needle biopsy has revolutionized breast imaging in the past decade. The radiologist who performs percutaneous breast biopsies assumes an increased level of responsibility for the patient regarding patient selection, lesion selection, performance of the biopsy procedure, interpretation of results, and patient follow-up. With variable and increasingly numerous options for the biopsy of breast lesions, careful attention must be paid to the selection of patients and types of lesions for different procedures. Critical technical considerations affect whether biopsy of a lesion can be optimally performed percutaneously, and these considerations must be factored into the recommendations for patient treatment. In addition, a limited preprocedural clinical assessment of the patient will allow a safer procedure to be performed expeditiously. Most breast abnormalities classified by using the ACR Lexicon as 4 (suggestive) or 5 (highly suggestive, likely malignant) are suitable for either percutaneous breast needle biopsy or needle localization and excisional biopsy. In general, those lesions classified as 3 (probably benign) carry a recommendation for early follow-up and not biopsy, because the likelihood of malignancy is small. A particular advantage of percutaneous biopsy is in the diagnosis of multicentric breast cancer. Core biopsy is less invasive and less costly than surgical biopsy, and it can be used to demonstrate multicentric disease, saving the patient a two-step surgery. However, several lesions are better treated by excision than by percutaneous biopsy. Among these are architectural distortion or loosely arranged, segmental or regional microcalcifications. For nonpalpable breast lesions visualized on mammography, sonography, or both, imaging-guided localization is required for precise needle placement either for wire localization or for percutaneous breast biopsy. The selection of which modality to use for guidance depends on (1) the adequacy of visualization of the lesion by the modality used, (2) the position of the lesion, (3) the ease of positioning the patient, (4) the skill of the operator, (5) the need to reduce radiation exposure, (6) the overall patient condition, and (7) size of the lesion. Fine-needle aspiration biopsy (FNAB) has a high sensitivity and specificity in the diagnosis of palpable breast lesions when the procedure is properly performed and interpreted. Variable results have been achieved with FNAB of nonpalpable breast lesions under imaging guidance. Three critical components are necessary to achieve reliable results by using FNAB. These include the following: (1) accuracy in needle placement, (2) skill in performance of FNAB, and (3) expert cytopathologic analysis. Accurate preoperative needle localization of nonpalpable breast lesions allows the radiologist to guide the surgeon performing an open biopsy and helps to ensure that the surgical procedure can be performed quickly and can be accomplished with the best possible cosmetic result for the patient. Lesions selected for needle localization and biopsy should undergo a complete tailored imaging evaluation before the needle localization is scheduled. Specimen radiography should be performed for all nonpalpable lesions. Once the lesion has been identified on specimen radiography, the radiologist can assist the pathologist in identifying the lesion microscopically by marking the lesion within the surgical specimen. We cover the technical and interpretative aspects of percutaneous breast biopsy and needle localization for surgical biopsy.     

Duplex Doppler sonography of small (<3 cm diameter) liver tumours: intralesional arterial flow does not exclude cavernous haemangioma

In small liver lesions (<3 cm diameter), detection of internal arterial flow with duplex Doppler sonography is thought to virtually exclude the diagnosis of cavernous haemangioma. We retrospectively reviewed 114 consecutive small lesions confirmed or suspected to be haemangiomas. Doppler sonography revealed intralesional arterial flow in four lesions for which correlative imaging studies were diagnostic of haemangioma, and for which stability was documented with follow-up sonography. We conclude that intralesional arterial flow should not be interpreted as conclusive evidence that a small liver lesion is not a haemangioma. If the presence of arterial flow within a small liver lesion prompts concern that the lesion is not a haemangioma, our findings suggest that a correlative imaging study should be considered before percutaneous biopsy is performed.     

Small (< or = 2-cm) breast cancer treated with US-guided radiofrequency ablation: feasibility study

PURPOSE: To determine the feasibility and safety of ultrasonographically (US) guided percutaneous radiofrequency (RF) ablation in the local treatment of invasive breast carcinomas 2 cm or less in greatest diameter. MATERIALS AND METHODS: RF ablation of 21 malignant lesions was performed in 20 patients immediately before their scheduled lumpectomy or mastectomy. A 15-gauge needle electrode was placed in the lesions, and the prongs of the needle electrode were deployed with real-time US guidance. A temperature of approximately 95 degrees C was maintained for 15 minutes at the tips of the prongs. Histopathologic examination of the resected specimens included use of nicotinamide adenine dinucleotide in its reduced form-diaphorase stain, which is specifically used to confirm thermal cell injury and lack of viability. The desired outcome of the procedure was ablation of the tumor and of an adequate margin around it, as confirmed by the absence of viable tissue in the surgical specimen. RESULTS: In all 21 cases, complete ablation of the target lesion was visualized at US. In one patient, who had undergone preoperative chemotherapy for a mass that was initially judged to be a T2 tumor but who was found to have a small residual tumor at mammography and US performed at the time of ablation, the target lesion was ablated but residual in situ mammographically and US occult invasive carcinoma was found at histopathologic examination. There were no adverse effects. CONCLUSION: US-guided percutaneous ablation of small invasive breast carcinomas is feasible and safe.     

A fatal case of hemoperitoneum after ultrasound-guided liver biopsy in a patient with intravascular large B-cell lymphoma

An autopsy case of fatal complication of percutaneous liver biopsy targeting a rare type of large B-cell lymphoma is presented. A 79 year-old man was referred to the hematology unit of a hospital because of anemia with thrombocytopenia and hepatosplenomegaly. Results of inguinal lymph node biopsy were inconclusive. To investigate a mass lesion in the liver visualized by ultrasonography, image-guided liver biopsy was performed following platelet infusion. The patient became unresponsive 6h post procedure because of hypotension due to intraperitoneal hemorrhage of undetermined origin. Autopsy revealed hemoperitoneum but failed to identify any macroscopic intra- or extrahepatic vascular injuries. Histopathological investigation disclosed infiltration of atypical lymphocytes into the systemic organs including the lymph nodes, spleen, liver, and lungs. Prominent hemophagocytosis was also noted. The lymphoma cells were exclusively accumulated within vascular and sinusoidal structures, and diagnosed with immunohistochemistry as Asian variant of intravascular large B-cell lymphoma. Massive blood extravasation was presumed to originate directly from the markedly dilated liver sinusoids filled with erythrocytes, macrophages and tumor cells, under the condition of impaired hemostasis. Although the biopsy was thought to have been correctly performed, this case would be instructive for evaluation of the indications and risks associated with liver biopsy.     

Percutaneous Cryoablation of Small Hepatocellular Carcinoma with US Guidance and CT Monitoring: Initial Experience

The purpose of this study was to retrospectively determine the safety and effectiveness of percutaneous cryoablation, monitored with computed tomography (CT) and ultrasonographic (US) guidance, for the treatment of hepatocellular carcinoma (HCC). Four patients with small HCCs underwent one percutaneous cryoablation treatment session monitored with CT and US guidance. All patients underwent pretreatment blood chemistry testing and imaging evaluation. We treated lesions with simultaneous insertion of multiple 17-G cryoprobes (two or three) and defined technical success when the extension of a visible iceball was beyond 5 mm from the tumor margin. Intralesional enhancement or tumoral size increase was defined as local progression compared with that on images obtained immediately after ablation. We evaluated complications and follow-up (at 1, 3, and 6 months). All patients survived without short- or long-term complications. Cryoablation was technically successful in all patients at the end of the procedure. During follow-up two patients developed disease recurrence. One patient developed local tumor progression on the margin of the lesion; the other, a new HCC. In the case of local tumor progression a new elevation of α-fetoprotein (αFP) levels occurred at first follow-up control. In the other case levels of αFP remained stable during the first 3 months after the procedure, then demonstrated a progressive increase in αFP levels beginning at the fourth month, without tumor evidence during CT control at 3 months. We conclude that percutaneous cryotherapy with US guidance and CT monitoring is a feasible, safe, and effective for treatment of HCC. If local ablative procedures of hepatic lesions are to be performed, percutaneous cryoablation, not laparotomic, should be discussed as an alternative therapeutic measure. Longer follow-up should provide proof of the effectiveness of this technique.     

Core biopsy of the bowel wall: efficacy and safety in the clinical setting

OBJECTIVE: The purpose of this study was to evaluate the efficacy and complications of percutaneous 18-gauge core biopsies of lesions of the bowel wall using CT and sonographic guidance. A retrospective study was made of 15 biopsy procedures performed on 12 patients with suspected neoplasia of the gastrointestinal tract. The biopsies were performed when there were no sites of metastatic disease more readily accessible to biopsy and the lesion was inaccessible to endoscopic techniques or when the endoscopic biopsy findings were negative. CONCLUSION: Three biopsy procedures provided inadequate samples and the biopsies were repeated, giving a total of 15 biopsy procedures. A tissue diagnosis was made in all 12 patients. All procedures were well tolerated, and no immediate or delayed complications occurred. Percutaneous core biopsy of bowel wall masses is a safe technique that allows a histologic diagnosis to be obtained in difficult cases when other methods cannot provide an adequate tissue sample.     

Real-time MR Imaging Guidance for Percutaneous Core Biopsy of US- and CT-negative Lesion

Biopsies traditionally are performed under ultrasound (US), computed tomography (CT), or fluoroscopic guidance. In situations in which lesions are difficult to visualize with US or CT guidance, magnetic resonance (MR) imaging often can provide better imaging results. The authors describe a case in which a recurrent calf mass not well visualized under fluoroscopy, CT, or US was identified on MR imaging. In the absence of real-time needle visualization, percutaneous interventions under MR guidance have been limited by prohibitively long imaging times. A novel guidance system providing real-time MR guidance of needle position was used to procure a core biopsy specimen of the lesion.     

Musculoskeletal neoplasms: biopsy and intervention

Percutaneous core needle biopsy and fine-needle aspiration are safe and cost-effective methods and can be important steps in the workup of a bone or soft tissue lesion. These procedures should be performed in collaboration with the orthopedic oncologist who performs the definitive surgery. In the extremities, attention to compartmental anatomy is paramount. With frozen section evaluation at the time of biopsy, the chances of a nondiagnostic specimen necessitating rebiopsy are minimized. The principles underlying the percutaneous approach to various lesions are valuable and can be applied to minimally invasive percutaneous therapy for bone and soft tissue lesions.     

Liver biopsy with guidance in scanning A preliminary report.

A method to improve the accuracy of obtaining biopsy material of a lesion detected at liver scanning is presented. The site of the lesion is determined in two orthographic projections during scintigraphy and indicated on the patient's skin. With guidance of indicator fluoroscopy in two perpendicular projections percutaneous biopsy from any part of the liver may be performed.     

Contrast-enhanced harmonic ultrasound imaging in ablation therapy for primary hepatocellular carcinoma

The success rate of percutaneous radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) depends on correct targeting via an imaging technique. However, RF electrode insertion is not completely accurate for residual HCC nodules because B-mode ultrasound (US), color Doppler, and power Doppler US findings cannot adequately differentiate between treated and viable residual tumor tissue. Electrode insertion is also difficult when we must identify the true HCC nodule among many large regenerated nodules in cirrhotic liver. Two breakthroughs in the field of US technology, harmonic imaging and the development of second-generation contrast agents, have recently been described and have demonstrated the potential to dramatically broaden the scope of US diagnosis of hepatic lesions. Contrast-enhanced harmonic US imaging with an intravenous contrast agent can evaluate small hypervascular HCC even when B-mode US cannot adequately characterize tumor. Therefore, contrast-enhanced harmonic US can facilitate RF ablation electrode placement in hypervascular HCC, which is poorly depicted by B-mode US. The use of contrast-enhanced harmonic US in ablation therapy for liver cancer is an efficient approach.     

Osteoid osteoma: percutaneous treatment with radiofrequency energy

PURPOSE: To report our experience with technical success, complications, and long-term clinical success of radiofrequency (RF) ablation of osteoid osteoma. MATERIALS AND METHODS: After needle biopsy, computed tomography (CT)-guided percutaneous RF ablation was performed with general or spinal anesthesia. With an RF electrode, the lesion was heated to 90 degrees C for 6 minutes. Patient age and sex, lesion size and location, biopsy results, and complications were recorded. Clinical success was assessed at a minimum of 2 years after the procedure. Significance of patient age and sex and lesion location and size as a predictor of biopsy result was tested by means of chi2 analysis. In addition, effects of patient age and sex, lesion location and size, and biopsy results on clinical success were tested with the Fisher exact test. RESULTS: During an 11-year period, 263 patients who were suspected of having osteoid osteoma underwent 271 ablation procedures. All procedures were technically successful. There were two anesthesia-related complications (aspiration, cardiac arrest) and two minor procedure-related complications (cellulitis, sympathetic dystrophy). Results at biopsy were positive in 73% (197 of 271 biopsies). Two-year follow-up data were available for 126 procedures. The other procedures had been performed more recently or the patients could not be contacted. There was complete relief of symptoms after 112 of the 126 procedures (89%). For procedures performed as the initial treatment, the success rate was 91% (107 of 117 procedures). Procedures for recurrent lesions had a significantly lower success rate (six of 10 procedures [60%], P <.001). Clinical outcome was not dependent on biopsy result, patient age or sex, or lesion size or location. CONCLUSION: CT-guided percutaneous RF ablation of osteoid osteoma is a safe and effective technique.     

Vacuum-assisted breast biopsy on digital stereotaxic table of nonpalpable lesions non-recognisable by ultrasonography

The aim of this study was to evaluate accuracy of 11 G vacuum-assisted percutaneous biopsy (VAPB) carried out on digital stereotaxic table, on breast non-palpable lesions (NPLs), non-visible by US. Prospective study on 132 consecutive NPLs (126 patients) not reliably found by US; 82% showed microcalcifications. Surgical confirmation was obtained in all malignant cases and when VAPB reported atypical lesion (ductal or lobular), radial scar or atypical papillary lesion. All patients with benign results were included in a mammographic follow-up programme. Two cases could not be dealt with due to technical difficulties. One to 26 cylinders were obtained from the remaining 130 NPLs. Sixty-four lesions were surgically confirmed. Forty-six of the 47 malignancies were correctly diagnosed. In one case of a malignant tumour, an atypical lesion was classified with VAPB. All cases of histologically verified lobular carcinoma in situ, atypical ductal or lobular hyperplasia, radial scar or atypical papillary lesion were correctly diagnosed preoperatively. The remaining lesions were benign in VAPB, and after 1 year of follow-up, no false negative has been found. Based on this short-term follow-up, absolute sensitivity was 97.9%, absolute specificity 84.3% and accuracy was 99.2%. For predicting invasion, accuracy was 89.1%. Vacuum-assisted percutaneous biopsy is a very accurate technique for NPLs which are not detectable by US. It can replace approximately 90% of DSB with no important complications, avoiding scars and providing a higher level of comfort.     

Ultrasound-guided core needle biopsy of non-palpable breast lesions: a prospective analysis in 204 cases

Purpose: To assess the diagnostic value of ultrasound (US)-guided 14 G core needle breast biopsy in non-palpable suspicious breast lesions.

Material and Methods: From August 1997 to April 2001, 198 patients with 204 suspicious non-palpable breast lesions underwent US-guided large core needle biopsy. Biopsies were performed with a free-hand technique using US equipment with a 7.5 MHz linear-array transducer; a minimum of three cores were obtained from each lesion. Pathological findings in US-guided core biopsy were correlated to findings in subsequent surgery or long-term (more than 2 years) imaging follow-up.

Results: Among the 204 non-palpable breast lesions for which histopathological findings were obtained by US-guided core biopsy, 118 were malignant (114 carcinoma, 2 metastasis, 1 lymphoma, and 1 malignant phyllodes tumor) and 86 were benign (4 carcinoma and 82 benign lesions confirmed at surgery or after at least 2 years of follow-up). Sensitivity, specificity, positive predictive value, and negative predictive value for diagnosis of malignancy in our series were 97%, 100%, 100%, and 95%, respectively. Diagnostic yield with 1, 2, 3, and 4 specimens per lesion was 73.5%, 88%, 94%, and 97.5%, respectively.

Conclusion: US-guided core needle biopsy is a sensitive percutaneous biopsy method for diagnosing non-palpable breast lesions. To achieve a high diagnostic yield, a minimum number of three cores per lesion is advisable.