Transvaginal Ultrasound-Guided Biopsy of Deep Pelvic Masses: How We Do It

Comparison of the application value of transvaginal ultrasound and transabdominal ultrasound in the diagnosis of ectopic pregnancy

BACKGROUND

Ectopic pregnancy (EP) is one of the most common acute abdominal diseases in gynecology. Once the condition of EP is delayed, it may lead to massive hemorrhage, shock, and even death in a short time, seriously threatening the patient’s life. Early diagnosis is the key to preventing and improving the prognosis of EP. Transabdominal ultrasound (TAS) and transvaginal ultrasound (TVS) are the main diagnostic methods for abdominal diseases. The purpose of this study is to explore the application value and effect of TAS and TVS in the diagnosis of EP, hoping to provide more valuable references for the diagnosis of EP.

AIM

To explore the application value of TAS and TVS in the diagnosis of EP and to improve the level of clinical diagnosis.

METHODS

A total of 140 patients with EP admitted to our hospital from July 2018 to July 2020 were selected for this study. All patients were divided into two groups according to the examination methods. 63 patients who underwent abdominal ultrasound examination were set as the TAS group, while 77 patients who underwent TVS examination were set as the TVS group. We compared the diagnostic accuracy and misdiagnosis rates between the two types of ultrasound examinations, as well as the postoperative pathological results of the two diagnostic methods for different types of ectopic pregnancies. We also analyzed the sonograms for the presence of mixed ectopic masses, adnexal masses, ectopic gestational sacs, the presence or absence of visible embryo and fetal heart in the ectopic sac shadow, and the detection of fluid in the rectal fossa of the uterus, such as the adnexal area, yolk sac, and embryo, etc. In addition, the diagnosis time, days of gestational sac appearance, operation time, endometrial thickness, and blood flow resistance index were compared as well.

RESULTS

After performing both types of ultrasound examinations in 140 patients with EP, we found that the diagnostic accuracy of TVS was significantly higher than that of TAS, and the misdiagnosis rate was significantly lower than that of TAS. The differences were statistically significant (P < 0.05). In addition, the detection rate of TVS was better than that of TAS for the presence of mixed masses, adnexal masses, ectopic gestational sacs, the presence or absence of visible embryo and fetal heart in the shadow of the ectopic sac, and sonograms such as the adnexal area, yolk sac, and embryo, etc. The coincidence rate of its postoperative pathological examination results was significantly higher than those of TAS. The diagnosis time and the days of gestational sac appearance by TVS were significantly shorter than that by TAS, and the operation time was earlier than that by TAS. What’s more, the detection rates of the endometrial thickness £ 1.5 mm and blood flow resistance £ 0.5 were significantly higher in TVS diagnosis of EP than in TAS. All differences were statistically significant (P < 0.05).

CONCLUSION

Compared with TAS, TVS has the advantages of high detection accuracy and good sonogram performance.

Ultrasound-guided transvaginal biopsies of pelvic lesions: diagnostic yield, safety profile, and technical considerations over a 20-year experience

PURPOSE

To evaluate diagnostic yield, safety profile, and specific technical considerations of transvaginal ultrasound (TVUS) guided biopsy/aspiration.

MATERIALS/METHODS

TVUS guided biopsy (core, FNA) procedures with pre-procedure CT/MRI imaging at a single institution between 2001 and 2021 were reviewed. Relevant patient demographic data was extracted via the Electronic Health Record (EMR), technical details of the biopsy procedure were collected, and distance to target via transvaginal and transabdominal biopsy approach was measured on pre-procedure imaging. Surgical pathology was reviewed and assessed for concordance. Complications were assessed. Statistical analysis was performed using SPSS.

RESULTS

96 TVUS procedures (mean age, 58.7 ± 15.2 years; mean BMI, 27.4) were reviewed. TVUS guided approach decreased the distance to target (mean, 1.1 cm vs 8.6 cm transabdominal; p < 0.0001) and created a safe path not otherwise available in two patients. Average lesion size was 4.0 ± 2.1 cm (IQR 2.5, 5.2 cm) and targets at or above the vaginal cuff (0.9 ± 1.5 cm) and up to 0.5 ± 1.0 cm above the acetabular roof were accessible. 75 (78%) cases were core biopsies (18G; median, 2 passes) and 21 were FNA. Conscious sedation was used in 84.4% (n = 81) of cases and local anesthetic was also used in 84.4% (n = 81) of cases. Overall diagnostic yield was 98.9% (n = 94) with 94.7% (n = 89) cases confirmed as concordant diagnoses, including 57.4% (n = 54) malignant. Complications occurred in eight patients (8.3%), all minor. No post-biopsy infections were encountered regardless of administration of pre-procedure antibiotics (n = 14, 14.6%,), documentation of sterile prep (n = 92, 95.8%), or speculum use (n = 19, 19.8%). 50% (n = 48) had a prior hysterectomy, with no association with adequacy or complications (p = 0.9).

CONCLUSION

Transvaginal biopsy of pelvic lesions offers excellent diagnostic yield and favorable safety profile, and can dramatically decrease distance to target.

CLINICAL RELEVANCE

Ultrasound-guided transvaginal approach offers a safe and effective way to biopsy pelvic lesions in women.

Contribution of Outpatient Ultrasound Transvaginal Biopsy and Puncture in the Diagnosis and Treatment of Pelvic Lesions: A Bicenter Study

BACKGROUND

The use of transvaginal ultrasound guided biopsy and puncture of pelvic lesions is a minimally invasive technique that allows for accurate diagnosis. It has many advantages compared to other more invasive (lower complication rate) or non-invasive techniques (accurate diagnosis). Furthermore, it offers greater availability, it does not radiate, enables the study of pelvic masses accessible vaginally with ultrasound control in real time, and it is possible to use the colour Doppler avoiding puncturing large vessels among others. The main aim of the work is to describe a standardized ambulatory technique and to determine its usefulness.

METHODS

This is a retrospective study of ultrasound transvaginal punctures (core needle biopsies and cytologies) and drainages of pelvic lesions performed on an outpatient basis during the last two years. The punctures were made with local anesthesia, under transvaginal ultrasound guidance with an automatic or semi-automatic 18G biopsy needle with a length of 20-25 cm and a penetration depth of 12 or 22 mm. The material obtained was sent for anatomopathological, cytological and/or microbiological study if necessary.

RESULTS

A total of 42 women were recruited in two centers. Fifty procedures (nine punctures, seven drains, and 34 biopsies) were performed. In five cases the punction and drain provided clinical relief in benign pelvic masses. Regarding material of the biopsies performed, 15 were vaginal in women previously histerectomized, finding 10 carcinomas, eight were ovarian tumours in advanced stages or peritoneal carcinomatosis obtaining the appropriate histology in each case, seven were suspicious cervical biopsies finding carcinomas in five of them, three were myometrial biopsies including one breast carcinoma metastasis in the miometrium and a benign placental nodule, and a periurethral biopsy was performed on a woman with a history of endometrial cancer confirming recurrence. The pathological diagnosis was satisfactory in all cases, confirming the nature of the lesion (25 malignant-ten vaginal recurrences of previous gynaecological cancers, eight cases of primary ovarian/peritoneal carcinoma, four new diagnosis of cervical malignant masses, one cervical metastasis of lymphoma, one periurethral recurrence of endometrial carcinoma and one recurrence of breast cancer in the myometrium-and 23 benign). The tolerance was excellent and no complications were detected.

CONCLUSION

The ambulatory ultrasound transvaginal puncture and drainage technique is useful for obtaining a sample for pathological and microbiological diagnosis with excellent tolerance that can be used to rule out the recurrence of malignant lesions or progression of the disease, diagnose masses not accessible to gynecological exploration (vaginal vault, myometrium or cervix) and for early histologic diagnosis in cases of advanced peritoneal carcinomatosis or ovarian carcinoma as well as drainage and cytological study of cystic pelvic masses.

Transvaginal Ultrasound-Guided Fine-Needle Aspiration Biopsy of Pelvic Lesions

OBJECTIVES

To assess adequacy of transvaginal ultrasound-guided fine-needle aspiration biopsy (TVUS-FNAB) for pathologic diagnosis of pelvic masses performed using onsite cytopathology consultation.

METHODS

In this Institutional Review Board approved, Health Insurance Portability and Accountability Act (HIPAA) compliant study, radiology records were retrospectively queried to identify patients who underwent TVUS-FNAB of a pelvic mass over a 11-year duration. TVUS-FNAB adequacy was determined by correlating cytopathology results with transvaginal ultrasound-guided core-needle biopsy (TVUS-CNB) or surgical pathology results when available, and with clinical diagnostic confidence when additional pathology confirmation was not available. Secondary analysis included patient age, history of hysterectomy, or pelvic malignancy. Target-specific features analyzed included mass size, depth, location, and final pathologic diagnosis.

RESULTS

Sixty patients underwent TVUS-FNAB of pelvic masses, 43 of which underwent FNAB only and 17 underwent both TVUS-FNAB and TVUS-CNB during the same procedure. TVUS-FNAB alone was adequate for diagnosis in 51 (85%) cases and addition of core-needle biopsy (CNB) achieved a diagnosis in additional 4 patients, increasing overall diagnostic accuracy to 92% (55/60). FNAB inadequacy had statistically significant association with increasing mass depth, occurrence of a minor intraprocedural complication, and decision to perform a CNB (P <.05). Number of FNAB passes, mass size, history of hysterectomy, and final diagnosis were not statistically significant predictors of FNAB adequacy.

CONCLUSION

TVUS-FNAB has a high specimen adequacy rate when performed with an onsite cytopathologist and can be considered first-line approach for image-guided sampling of pelvic lesions with option to add CNB if preliminary cytopathologic review does not confirm sample adequacy.

Transvaginal Ultrasound-Guided Core Biopsy-Experiences in a Comprehensive Cancer Centre

Simple Summary

Adequate histological diagnosis defines the treatment in gynaecologic oncology. Although transvaginal ultrasound (TVUS) has widespread use in the diagnosis of pelvic tumours, TVUS-guided core biopsy is not a common procedure. In this study we summarize our experience in TVUS-guided biopsies performed in a comprehensive cancer centre, discussing the results of 303 patients who underwent this procedure. In addition, we compare the histological results of the biopsies with subsequent surgical histological results in 94 cases. Our study demonstrates that TVUS-guided core biopsy is a safe and effective histological sampling procedure providing adequate tissue for pathological evaluation in 99% of cases. Compared to surgically obtained histology, this procedure can reliably guide therapy, as its performance is satisfactory. In our opinion, TVUS-guided core biopsy is an effective diagnostic method providing possible benefits to patients referred for suspicion of gynaecological malignancy.

Abstract

In this paper, we report our experience of transvaginal ultrasound (TVUS)-guided core biopsies involving 303 patients referred to the gynaecological ultrasound unit of our national comprehensive cancer centre. Adequate histologic specimens were obtained in 299 patients (98.7%). The most common sites of biopsy sampling were the adnexa (29.7%), the vaginal stump or wall (13.5%), the uterus (11.6%) and the peritoneum (10.2%). Malignancy was confirmed in two-thirds of patients (201/303) and a primary malignancy was diagnosed in 111 of the 201 histologically verified malignant cases (55.2%). Interestingly, 23.9% (48/201) of malignant tumours were proven to have a non-gynaecological origin. Among them, gastrointestinal tumours occurred the most frequently (31/48 patients). Three abscesses were discovered following the biopsy procedure, resulting in a complication rate of 1%. In 94 (31%) patients, subsequent surgery allowed the comparison of the ultrasound-guided and surgically obtained histologic results. We found inaccuracy in 12 cases (12.8%), which is discussed in this paper in detail. Sensitivity, specificity, PPV and NPV to diagnose malignancy was 94.8%, 94.1%, 98.7% and 80.0%, respectively. This is the largest study reported to date about the efficacy and safety of TVUS-guided core biopsy in evaluating pelvic lesions giving rise to a suspicion of gynaecological cancer.

High-Frequency Ultrasonic Forceps for the In Vivo Detection of Cancer During Breast-Conserving Surgery

A major aim in the surgical management of soft tissue cancers is to detect and remove all cancerous tissues while ensuring noncancerous tissue remains intact. Breast-conserving surgery provides a prime illustration of this aim, since remaining cancer in breast margins results in multiple surgeries, while removal of too much unaffected tissue often has undesirable cosmetic effects. Similarly, resection of benign lymph nodes during sentinel lymph node biopsy can cause deleterious health outcomes. The objective of this study was to create an intraoperative, in vivo device to address these challenges. Instant diagnostic information generated by this device could allow surgeons to precisely and completely remove all malignant tissue during the first surgery. Surgical forceps based on Martin forceps were instrumented at the tips with high-frequency ultrasonic transducers composed of polyvinylidene difluoride, a thickness-sensing rotary potentiometer at the base, and a spring to provide the appropriate restoring force. Transducer wires within the forceps were connected to an external high-frequency pulser-receiver, activating the forceps' transmitting transducer at 50 MHz and amplifying through-transmission signals from the receiving transducer. The forceps were tested with tissue-mimicking agarose phantoms embedded with 58–550 μm polyethylene microspheres to simulate various stages of cancer progression and to provide a range of measurement values. Results were compared with measurements from standard 50 MHz immersion transducers. The results showed that the forceps displayed similar sensitivity for attenuation and increased accuracy for wave speed. The forceps could also be extended to endoscopes and laparoscopes.

The Management of Women's Health Care by Internists With a Focus on the Utility of Ultrasound

Adult women require routine care for the acute and chronic health problems found in both sexes, and they require specialized care for women's health problems, including disease prevention, disease screening, and disease management. Internists should direct primary care and participate in specialized care and to the extent possible follow guidelines published by various professional organizations. They should understand the use of ultrasound in breast cancer screening, the management of pregnancy, and other gynecologic problems, including vaginal bleeding, pelvic pain, and investigation for pelvic malignancy. Finally, all management decisions need discussions on the potential benefit or harm in each step of a woman's care with an emphasis on personal preferences.

Role of transvaginal ultrasound-guided biopsy in gynecology

BACKGROUND

Ultrasound-guided biopsy is an easy technique for obtaining tissue samples. It is commonly used for different types of tumors, such as breast and prostate cancers, in order to plan early and adequate treatment.

OBJECTIVE

To evaluate the indications, adequacy, and safety of transvaginal ultrasound-guided biopsy in women with pelvic lesions suspected of gynecologic malignancy.

METHODS

A retrospective study including all patients who had undergone transvaginal ultrasound-guided biopsy between April 2015 and May 2018 was carried out at the division of gynecologic oncology. Inclusion criteria were the presence at imaging of abdominal or pelvic tumors in patients considered not ideal candidates for primary gynecological surgery, or the origin and/or nature of the tumor was unclear and further management required histological verification. Patients with planned surgery were excluded from the study. Transvaginal biopsies were performed with a 18 G/25 cm core-cut biopsy needle and histology was obtained. Tru-cut biopsies were performed using an automatic bioptic gun with a 18 G/25 cm core-cut biopsy needle. Results are presented as absolute frequency (percentage) for nominal variables and as median (range) for continuous variables.

RESULTS

A total of 62 women were analyzed. An adequate sample for histological analysis was obtained in all cases. Histopathological examinations showed 24 (38.7%) benign lesions (fibrosis, inflammation, uterine or ovarian myoma) and 38 (61.3%) malignant tumors, distributed as follows: 34 (89.5%) malignant gynecological lesions and 4 (10.5%) non-gynecological malignant tumors. Among the malignant lesions, there were 12/38 (31.6%) primary tumors, 24/38 (63.2%) recurrent tumors, and 2/38 (5.3%) metastases from non-genital cancer. Ten patients eventually underwent surgery. Final histology was not in agreement with the results from transvaginal ultrasound-guided biopsy in 2 of 10 patients (20%); in particular, benign disease at transvaginal ultrasound-guided biopsy was malignant at final histology (two cases of recurrence of cervical cancer). Three patients (4.8%) had pain during the procedure, which was controlled by oral analgesic therapy and lasted for no longer than 10 min. No major complications were registered.

CONCLUSIONS

Transvaginal ultrasound-guided biopsy is a minimally invasive method to obtain adequate material for histological diagnosis and could avoid unnecessary surgical procedures, costly CT-guided procedures, or prolonged waiting times.

Transvaginal/transrectal ultrasound-guided aspiration biopsy for diagnosis of pelvic/pelvic floor tumors in females: A retrospective analysis

Ultrasound guidance for histological diagnosis is in real-time, convenient, and economical. The aim of this study was to determine whether transvaginal ultrasound (TVUS)- and transrectal ultrasound (TRUS)-guided aspiration biopsy allows detection of a malignant pathology of pelvic/pelvic masses. Data of 40 patients with pelvic and pelvic mass lesions by computed tomography or magnetic resonance imaging underwent TVUS- or TRUS-guided biopsy. Tissue samples obtained were assessed on suitability for histopathologic evaluation. The post-biopsy complication was monitored. All the specimens in the pelvic floor, vaginal stump, vaginal fornix, cervix, and posterior wall of the anal canal were adequate for histologic diagnosis. There were no post-biopsy complications. Transvaginal/transrectal ultrasound-guided aspiration biopsy is safe and simple. It can be used for the diagnosis and differential diagnosis of pelvic and pelvic floor lesions in women. Prospective studies are needed to test diagnostic performance across clinical scenarios.

Transrectal or transvaginal ultrasoundguided biopsy for pelvic masses: external validation and usefulness in oncologic patients

Purpose

The purpose of this study was to externally validate the diagnostic usefulness of transrectal ultrasound (TRUS) or transvaginal ultrasound (TVUS)-guided biopsy for pelvic masses, and to analyze the diagnostic performance of these methods in oncologic patients.

Methods

A consecutive series of 30 patients who underwent TRUS- or TVUS-guided biopsy for pelvic masses was included. Tissue samples were obtained using an 18-gauge core biopsy needle under local anesthesia for lesions detected on computed tomography or magnetic resonance imaging. We analyzed the rates of diagnostic biopsies upon pathologic examination and biopsy-related major complications requiring treatment. In diagnostic biopsy cases, the performance was also investigated for all patients and patients with underlying malignancy.

Results

The diagnostic biopsy rate was 93.3% (28 of 30) for all patients and 95.0% (19 of 20) for oncologic patients. No patients had major complications. In diagnostic biopsies, the sensitivity, specificity, positive and negative predictive value, and accuracy for identifying malignancy were 100% (17 of 17), 72.7% (8 of 11), 85.0% (17 of 20), 100% (8 of 8), and 89.3% (25 of 28) for all patients and 100% (14 of 14), 60.0% (3 of 5), 87.5% (14 of 16), 100% (3 of 3), and 89.5% (17 of 19) for oncologic patients, respectively.

Conclusion

This study externally validated the feasibility and safety of TRUS- or TVUS-guided biopsy. In addition, these techniques appear to enable accurate pathologic diagnoses of pelvic masses in oncologic patients to be made safely and relatively noninvasively.

Ultrasound-guided genitourinary interventions: principles and techniques

Ultrasound (US) is often used to guide various interventional procedures in the genitourinary (GU) tract because it can provide real-time imaging without any radiation hazard. Moreover, US can clearly visualize the pathway of an aspiration or biopsy needle to ensure the safety of the intervention. US guidance also helps clinicians to access lesions via the transabdominal, transhepatic, transvaginal, transrectal, and transperineal routes. Hence, US-guided procedures are useful for radiologists who wish to perform GU interventions. However, US-guided procedures and interventions are difficult for beginners because they involve a steep initial learning curve. The purpose of this review is to describe the basic principles and techniques of US-guided GU interventions.