Oncology
Procedure Guide
No safe percutaneous or endovascular route, e.g., completely surrounded by vessels and bowel
Uncorrected coagulopathy. However, there is a study showing no increased complications rate with INR <2 and Plt >25K.
Lesion believed to be a pheochromocytoma or carcinoid tumor - can technically premedicate and perform safely
Liver hemangioma on surface
HCC meeting imaging diagnostic criteria
Liver biopsy with massive ascites/obesity -> transjugular likely better
Lung:
85% success rate
9-19% pneumothorax, higher w/ emphysema (3xs, ~50% will get one), path crossing fissure, longer path (>4 cm), smaller nodule (<2 cm), pleural entry angle <45 (perpendicular is ideal)
4-10% Hemoptysis
Very rare: air embolism, AVF, cardiac tamponade
Liver:
76% success rate
0-6% bleeding, pneumothorax, bile injury
Kidney:
95% success rate
<2% bleeding, urinary system injury
Bone:
74-96% success rate, higher with mets
<2% bleeding, fracture
Thyroid:
84% success rate
1-9% bleeding
Pancreas:
93-98% success rate
1-8% bleeding, pancreatitis
Lymph node / soft tissue:
<1% bleeding
Very rare complications: air embolism, AVF, cardiac tamponade, needle seeding (0.005-0.009%; ~5% w/ HCC)
Plan track and positioning with imaging - need sufficient tissue to stabilize needle while avoiding vessels, bowel, gallbladder, crossing pleura (if possible; posteriorly the pleura ends at the 12th rib, lung at the 10th)
For primary bone lesions or concern for sarcoma, good to confirm path with ortho oncology to not violate certain compartments or fascial planes.
For osteomyelitis/discitis, take angled approach to get bone-disc-bone in core
Labs: Coags and CBC within 30 days
Hold coumadin/Plavix 5d, Lovenox 1d, No need to hold ASA/NSAID
Pre-scan with US, CT, MRI and mark skin. Ideally for solid organs, choose a path passing through some normal parenchyma to avoid bleeding.
If ascites present, might as well leave it. No good study showing increased risk and needle visualization is easier per Al Nemcek (NW, past JVIR editor). Others advocate for doing a paracentesis first.
Anesthetize skin and soft tissue leaving needle in place if using CT to assess proper positioning and angle
Advance introducer needle.
Most common is using a coaxial introducer needle used to introduce a biopsy device for multiple passes. Advantage is only having to access the target once for efficiency and less risk of seeding. Disadvantage is a tendency to sample the same single part of the lesion with less tissue on each pass. Can reduce by gently curving the biopsy device and directing the cannula.
Single needle technique without coaxial introducer is good for superficial lesions where there is less tissue to secure the introducer.
Tandem needle technique: smaller needle advanced to target under imaging guidance and then multiple needles are advanced along side blind. No longer used (as far as I know).
Take samples
Can have cytopathology present for confirmation of adequacy.
Single 18G pass has been shown to have higher yield than multiple 20G passes.
Need multiple FNAs if concern for lymphoma.
Good to drip saline into introducer needle to avoid introducing air with each pass and risk of air embolism for lung biopsies.
(Optional) Embolize biopsy tract
Gelfoam slurry or torpedoes are most common, particularly for solid organ biopsies. Mixed results of studies comparing embo vs no embo for liver biopsies, e.g., here’s one of the positive studies
For lung biopsies, more common to use autologous blood patch (old school) or BioSentry device (Merit). Robert Suh (UCLA) uses BioSentry, post-scan at 3-5 min after removing the needle and discharges 30 min after without CXR if no PTX.
If PTX occurs, can aspirate small PTX as needed or place a chest tube and continue biopsy. Really need to make the first pass count.
Bed rest for 2-3 hrs with biopsy site down for solid organs. Mild right shoulder pain after liver biopsy is normal. Prolonged pain >5 min can suggest bleeding (“Kehr sign”)
For lung, people vary whether they get CXRs, how many, and when. One common approach is one immediately after as a baseline and one in 2 hrs prior to discharge.
Usually best not to discuss any preliminary diagnosis with the patient and wait for final pathology result.