Sonographically guided percutaneous biopsy of gastrointestinal tract lesions

Malignant transformation of rectal endometriosis: Preoperative diagnosis by endorectal ultrasound guided biopsy

The prevalence of malignant transformation of endometriotic lesions is estimated between 0.3% and 1%. Malignant transformations of endometriosis occur in the colorectum is rarer, accounting for 0.25%. Because the malignant transformation of colorectal endometriosis rarely involves mucosa, it is difficult to obtain abnormal tissue by routine endoscopic biopsy. In this case, we evaluated a patient with a rectal mass by endorectal ultrasound (ERUS) and performed endorectal ultrasound-guided biopsy (EGB). Malignant transformations of endometriosis were confirmed by histological result. For patients with rectal tumors but with negative findings on colonoscopy and biopsy, ERUS and EGB contribute to preoperative diagnosis.

Ultrasound-guided biopsy of challenging abdominopelvic targets

Percutaneous ultrasound-guided biopsies have become the standard of practice for tissue diagnosis in the abdomen and pelvis for many sites including liver, kidney, abdominal wall, and peripheral nodal stations. Additional targets may appear difficult or impossible to safely biopsy by ultrasound due to interposed bowel loops/vasculature, deep positioning, association with the bowel, or concern for poor visibility; however, by optimizing technique, it is often possible to safely and efficiently use real-time ultrasound guidance for sampling targets that normally would be considered only appropriate for CT guided or surgical/endoscopic biopsy.

Assessment of the clinical usefulness of ultrasound-guided cytological specimens obtained from gastrointestinal lesions in dogs and cats

OBJECTIVES

Cytological biopsies are an integral additional test to an abdominal ultrasound when a lesion is identified, but there is little published on factors that that may impact achieving a clinically useful sample of gastrointestinal lesions obtained by ultrasound-guided fine-needle cytologic biopsy. This retrospective, descriptive study aimed to assess factors that may influence the clinical usefulness of submitted cytological samples collected from gastrointestinal lesions by ultrasound-guided percutaneous fine-needle cytologic biopsy.

MATERIAL AND METHODS

Gastrointestinal cytological samples obtained from 25 dogs and 19 cats over 2.5 years were reviewed and determined as clinically useful or clinically useless as per the cytology report. Variables dependent on the ultrasound exam that were used in the analysis included lesion location, lesion thickness, loss of gastrointestinal layering, and the number of slides submitted.

RESULTS

Thirty (30/44) of the submitted cytological samples were considered clinically useful. Factors associated with achieving a clinically useful sample in univariable models included the number of slides submitted and the thickness of the lesion. However, these two variables appear inter-related, as a weak correlation existed between them. Where histologic biopsies were obtained, a clinically useful sample had a partial or complete agreement with histology in three of 12 and eight of 12 cases, respectively.

CLINICAL SIGNIFICANCE

Ultrasound-guided fine-needle cytological biopsies of gastrointestinal masses provided a clinically useful sample in two-third of the cases, especially if more slides were provided to the cytologist and thicker lesions were sampled.

Transabdominal ultrasonographic features in the diagnosis of gastrointestinal lymphoma

Background

Gastrointestinal (GI) lymphoma is a challenging disease. We aimed to study and characterize the different endoscopic and transabdominal ultrasonography (TUS) features of gut lymphoma and to assess whether TUS has a complementary role to endoscopy in the diagnosis of GI lymphoma.

Methods

This study was conducted on 21 patients with GI lymphoma, attending the GI endoscopy and liver unit, Endemic Medicine Department and Oncology Department in Kasr El Aini Hospital, Cairo University. Patients were subjected to GI endoscopy (upper endoscopy & colonoscopy) and transabdominal ultrasonography. The diagnosis was finally based on histopathology of core biopsies (obtained either endoscopically or by ultrasonography) and immuno-histochemistry.

Results

In all 21 patients with GI lymphoma included in this study, TUS could accurately determine the site of disease affection compared to endoscopy which is considered the gold standard for site localization. The main TUS pathologic features detected were increased wall thickness of the affected bowel segment with a mean value of (15.6±5.9 mm) and loss of layering pattern in 16 patients (76%). While the most common endoscopic features were ulcers and mass lesions accounting for 38% of the patients for each. Diffuse large B-cell lymphoma was found in 19 patients (90%). Because of endoscopic biopsies were conclusive in 14 patients (67%), TUS guided biopsy was resorted to in 7 patients and was diagnostic in all of them.

Conclusions

Transabdominal ultrasonography is a useful tool in the diagnosis of GI lymphoma that is complementary to conventional diagnostic endoscopic procedures.

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

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.

Transgastric biopsy of a submucosal gastric tumour

Endoscopic biopsy is thought to be the best method to obtain biopsy samples of the gastrointestinal tract. In our case, however, an endoscopic forceps biopsy failed to confirm malignancy of an intramural gastric tumour. Since the tumour, about 4 cm in diameter, was well delineated on the CT scan, the patient was referred for a percutaneous CT-guided needle biopsy, which confirmed a gastrointestinal stromal tumour.

Difficult biopsy and drainage: just say yes

Abdominal radiologists are often asked to perform difficult percutaneous chest, abdomen, and pelvis biopsies and drainages with imaging guidance. Many of these procedures involve small target lesions far from the skin surface, in close proximity to critical structures. Organ location is changeable due to respiration, peristalsis, and pulsation, further complicating the planning process. High-level three-dimensional spatial awareness is critical to mastery of complex image-guided procedures. A comprehensive grasp of anatomy and expected changes can be exploited in certain cases to target lesions within a solid organ or to avoid injury to sensitive structures during biopsy, drain placement, or thermal ablation. In this article, we will use illustrative cases to explore the use of anatomic knowledge and the ability to synthesize this three-dimensional data dynamically during planning and execution of difficult CT- and ultrasound-guided procedures. We will discuss unusual biopsy requests-such as bowel biopsies-and the benefits of using ultrasound guidance for certain procedures in the chest. Additionally, we will describe multiple special techniques, including out of standard plane angulation and endocavitary techniques, in order to maximize chances of success.

A safe and simpler diagnosis of gastric schwannomas

Although gastric schwannomas usually are nonmalignant, these tumors can undergo malignant transformation. For diagnosis, endoluminal routes are believed to decrease the chance of cancerous cell dissemination. We present a case where a percutaneous route was utilized with supporting evidence for the safe use of this method for diagnosis.

Ultrasound-guided percutaneous biopsy for diagnosis of gastrointestinal lesions

BACKGROUND AND AIMS

Endoscopical examination is not always sufficient for the diagnosis of gastrointestinal masses. This study assessed the diagnostic accuracy and safety of ultrasound-guided percutaneous biopsy of gastrointestinal lesions.

METHODS

This retrospective study evaluated 114 patients who underwent ultrasound-guided biopsy of gastrointestinal masses with a 18G needle. Thirty-two of these patients underwent a 22G fine-needle biopsy for cytology. Histology was compared with a composite standard of reference for diagnosis (i.e. post-surgery histological evaluation in 73 cases and computed tomography or magnetic resonance scan findings, together with a compatible clinical follow-up for at least 24 months, in the remaining 41 cases). Safety was assessed by recording side effects for up to 4h after the procedure.

RESULTS

Of the 114 lesions evaluated, 112 were malignant (98.2%) and 2 benign (1.8%). Specimens were adequate for histology in all but one case. Specimens were obtained from the stomach (n=38; 33.3%), small bowel (n=36; 31.6%) and colon (n=40; 35.1%). Diagnosis was correct in 113/114 cases (99.1%). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 99.1%, 100%, 100%, 66%, and 99%, respectively. One of the 114 patients (0.9%) bled from a gastric GIST.

CONCLUSIONS

Ultrasound-guided percutaneous biopsy of gastrointestinal lesions is a valid alternative when diagnosis of a gastrointestinal mass cannot be obtained with an endoscopical procedure.

Ultrasound-guided biopsies in the abdomen and pelvis

Ultrasound-guided biopsies in the abdomen and pelvis are generally more effective, safer, faster, and cheaper than those performed under computed tomography guidance. This manuscript will discuss multiple aspects of sonographic biopsies performed between the diaphragm and the symphysis pubis. We begin with systems issues, patient preparation (including bleeding profile and anticoagulant use), pain management, and infection precautions. The procedure itself is then analyzed, including needle guidance, the role of the sonographer, image optimization, patient positioning, core- versus fine-needle aspiration, coaxial versus individual pass, needle technique, and postprocedure management. Issues specific to different sites are then discussed: liver, spleen, pancreas, kidney, adrenal, bowel, retroperitoneum and mesentery, and the pelvis. We finish with a discussion of complications, future trends, and a brief summary.

Solitary gastric melanotic schwannoma: sonographic findings

Solitary gastric schwannoma is rare, and solitary melanotic schwannoma is even rarer, posing a dilemma in diagnosis and treatment. We report the case of a 69-year-old woman with gastric melanotic schwannoma who presented with nausea, vomiting, and abdominal pain. Abdominal sonographic examination revealed a 5-cm hypoechoic mass in the epigastric area that was confirmed to be a gastric submucosal tumor on endoscopic examination. The diagnosis of melanotic schwannoma was confirmed via sonographically guided percutaneous core biopsy. The tumor was resected, and no recurrence has occurred in a 3-year follow-up.

Diagnostic value of cytologic examination of gastrointestinal tract tumors in dogs and cats: 83 cases (2001–2004)

OBJECTIVE

To determine results of cytologic examination of fine-needle aspirates and impression smears of gastrointestinal tract tumors in dogs and cats.

DESIGN

Retrospective case series.

ANIMALS

38 dogs and 44 cats with histologically confirmed gastrointestinal tract tumors.

PROCEDURES

Results of cytologic examination of fine-needle aspirates (n = 67) or impression smears (31) were compared with the histologic diagnosis, and extent of agreement was classified as complete, partial, none, or undetermined.

RESULTS

For 48 of the 67 (72%) fine-needle aspirates, there was complete or partial agreement between the cytologic and histologic diagnoses. For 12 (18%) aspirates, the extent of agreement could not be determined because the cytologic specimen was considered unsatisfactory. For 29 of the 31 (94%) impression smears, there was complete agreement between the cytologic and histologic diagnoses, and for 2 (6%), there was partial agreement. None of the impression smears were considered unsatisfactory. Proportion of samples with complete agreement and proportion of samples with complete or partial agreement were significantly higher for impression smears than for fine-needle aspirates.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that there was moderate agreement between results of cytologic examination of fine-needle aspirates from dogs and cats with gastrointestinal tract neoplasia and the definitive histologic diagnosis. The agreement between results of cytologic examination of impression smears and the histologic diagnosis appeared to be higher.

Prognostic Factors of Primary Small Bowel Adenocarcinoma: Univariate and Multivariate Analysis

BACKGROUND

Adenocarcinoma of the small bowel is relatively less common than malignancies of the esophagus, stomach, and colorectum. In small bowel adenocarcinoma, various prognostic factors influence the disease-free status and overall survival rates.

MATERIALS AND METHODS

Eighty patients who were diagnosed with small bowel adenocarcinoma and treated at our institute between 1983 and 2003 were retrospectively reviewed.

RESULTS

The patients included 40 men and 40 women with an age range of 15 to 93 years (median: 62 years). Only 51.3% of patients were accurately proved preoperatively to have a malignancy by endoscopic biopsy. Sixty patients underwent surgical treatment, and 45 of those patients had curative resection. The follow-up period ranged from 2.5 to 229.7 months, with a median of 9.1 months. The cumulative 1-, 3-, and 5-year survival rates for all patients (excluding 3 patients who died in the immediate postoperative period) were 43.6%, 22.8%, and 17.5%, respectively. The cumulative 1-, 3-, and 5-year disease-free survival rate for all 43 patients with curative resection (excluding 2 patients who died in the immediate postoperative period) was 54.9%, 30.5%, and 27.4%, respectively. Meanwhile, multivariate analysis with Cox proportional hazards analysis demonstrated that earlier tumor stages (stages I and II) and curative resection were two independent factors influencing favorable overall survival. Lymph node metastasis was the only independent factor predicting poor disease-free survival in patients undergoing curative resection.

CONCLUSIONS

Poor prognosis of small bowel adenocarcinoma may be related to a delay in the diagnosis and treatment of the disease. Curative resection is the aim of surgical treatment for small bowel adenocarcinoma. Lymph node metastasis at presentation of the disease predicts tumor recurrence and distant metastasis after curative surgical treatment.

Percutaneous coaxial needle biopsy using the spacer technique: a novel and easy modification to increase procedure safety

We describe a novel but easy modification to percutaneous coaxial needle biopsy technique using readily available standard equipment to enable a predefined variable sampling length to be achieved. This technique involves the insertion of a carefully measured spacer between the coaxial cutting needle and guide needle. This can minimise the sampling length required to biopsy any given lesion, minimising the volume of traumatised tissue and preventing unnecessary penetration of tissues deep to smaller lesions, thus increasing procedure safety.

Ultrasound-Guided Biopsies: Tricks, Needle Tips, and Other Fine Points

Ultrasound (US)-guided biopsy of thyroid nodules, abdominal masses, liver masses, random core liver biopsies, as well as aspiration of abdominal or pleural fluid is now routine practice. The ability of US to guide biopsy of abnormalities seen on cross-sectional imaging studies is well recognized as an efficient and effective means of achieving a tissue diagnosis. Its use requires basic knowledge of US image analysis, but clinically useful intuitive and nonintuitive methods can enhance its strengths. The purpose of this review is to provide a practical guide to some of these tricks that may be useful in everyday clinical practice.

Experimentally Induced Small-Bowel Tumor in Rabbits: US-guided Percutaneous 18-gauge Core Biopsy

PURPOSE

To evaluate the safety and diagnostic yield of percutaneous 18-gauge core biopsy for an experimentally induced small-bowel tumor in a rabbit model.

MATERIALS AND METHODS

Small-bowel tumors were induced by injecting VX2 tumor into 20 rabbits. After 3 weeks, the small bowel was filled with 100 mL of 2% diluted contrast agent containing methylene blue by using a 5-F catheter. Fifty biopsy firings for small-bowel tumor were performed with ultrasonographic (US) guidance by using an 18-gauge automatic gun. Computed tomography (CT) was performed before and immediately after biopsy. Any procedure-related complications, including leakage of air or fluid, hematoma, and perforation as seen at CT and identified at laparotomy, which was performed 48 hours after biopsy, were evaluated. White blood cell (WBC), red blood cell, and platelet counts; hemoglobin and hematocrit levels; and erythrocyte sedimentation rate were also obtained before and 48 hours after biopsy. Comparison was performed with paired t test. The diagnostic yield was calculated, and the specimen was evaluated whether fragments of mucosa were included or not.

RESULTS

No contrast agent leakage or pneumoperitoneum suggesting perforation was identified at CT or laparotomy. Fluid leakage was observed with manual squeezing at two biopsy sites (4%). In two rabbits, hemoperitoneum was observed at CT or laparotomy. Hematoma larger than 3 cm was observed in six rabbits. WBC count and erythrocyte sedimentation rate slightly increased, and red blood cells, hemoglobin, hematocrit, and platelets counts had decreased slightly after biopsy but were not significant (P >.05). Definitive histologic diagnosis of tumor was obtained in 44 (88%) of 50 biopsy sites. Fragments of mucosa were observed in 13 (28%) specimens of 10 rabbits.

CONCLUSION

Core biopsies of small-bowel tumor can be performed safely with an 18-gauge gun without severe complications and allow histologic diagnosis of small-bowel tumor with a good diagnostic yield.

Gastrointestinal tract cytology: advancing horizons

Tide and ebb of interest in gastrointestinal tract cytology has followed technical advances in this field over the last 60 years. Cytologic samples can be obtained using gastric lavage, abrasive balloons, mucosal brushing, and fine needle aspiration (under percutaneous image guidance, endoscope and endoscopic ultrasound guidance). These advances now allow simultaneous performance of brushing the abnormal mucosa, obtaining fine needle aspirates and excising mucosal biopsy samples for evaluation. Use of endoscopic ultrasound guided fine needle aspirates now help to obtain diagnosis of submucosal lesions, preoperative staging of gastrointestinal tract malignancies and help determine further management of patients. Such advances have brought pathologists to the forefront of the patient management team for the treatment of gastrointestinal tract lesions. This manuscript reviews the advantages and limitations of each cytology associated technique as well as reviews the salient diagnostic features, differential diagnosis and diagnostic pitfalls of gastrointestinal tract lesions. Finally, it suggests the modalities best suited to obtain diagnosis for various gastrointestinal tract lesions.

Usefulness of sonographic guidance during percutaneous biopsy of mesenteric masses

OBJECTIVE

The objective of our study was to determine the usefulness of sonographic guidance for biopsy of mesenteric masses.

MATERIALS AND METHODS

Twenty-five sonographically guided percutaneous biopsies of mesenteric masses were performed in 23 patients. Biopsies were performed with an 18-, 20-, or 22-gauge self-aspirating needle or core biopsy device. Final pathology results and patient medical records were reviewed for biopsy accuracy and complications. A biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist or if surgical-pathologic confirmation was obtained.

RESULTS

Open surgical biopsy was performed after sonographically guided biopsy in 13 patients and led to 12 concordant diagnoses (nine true-positives and three true-negatives) and one discordant diagnosis (false-negative). Specific pathologic diagnosis was rendered for the 10 percutaneous biopsies that were not confirmed by surgical biopsy: five biopsies matched known primary malignancies, consistent with metastases; four biopsies revealed primary tumors, and one biopsy revealed chronic inflammation (nine true-positives and one true-negative). Two biopsies were nondiagnostic because of insufficient material (n = 1) and necrotic tumor (n = 1). In the biopsies with diagnostic tissue specimens, sonographically guided biopsy achieved a sensitivity of 95% (18/19) and specificity of 100% (4/4) for allowing neoplastic tissue to be distinguished from nonneoplastic tissue. Complications included a mesenteric hematoma and abdominal wall cellulitis.

CONCLUSION

Percutaneous biopsy of mesenteric masses is a useful and safe procedure.