(Radiology. 1999;212:594-597.)
© RSNA, 1999
Bowel Lesions: Percutaneous US-guided 18-gauge Needle Biopsy-Preliminary Experience1
Gareth R. Tudor, FRCR,
Peter M. Rodgers, FRCR and
Kevin P. West, FRCPath
1 From the Departments of Radiology (G.R.T., P.M.R.) and Histopathology (K.P.W.), Leicester Royal Infirmary NHS Trust, Infirmary Square, Leicester LE1 5WW, England, UK. Received March 10, 1998; revision requested May 7; final revision received November 30; accepted March 2, 1999. Address reprint requests to P.M.R.
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Abstract
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Ultrasonography-guided percutaneous biopsy was performed with local anesthesia and an 18-gauge needle in 10 patients with bowel-wall lesions. All patients underwent clinical review within 1 month. Biopsy was diagnostic in all patients. There were no complications, and all patients tolerated the procedure well. The technique appears to be safe and had an excellent diagnostic yield in our series.
Index terms: Biopsies, technology, 74.1261, 75.1261 • Intestines, biopsy, 74.1261, 75.1261 • Ultrasound (US), guidance, 74.1261, 75.1261, 74.12985, 75.12985
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Introduction
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Infiltration of the bowel wall by neoplastic or inflammatory cells may reveal the "target or pseudokidney appearance" at ultrasonography (US) (1–3). This appearance is nonspecific, and clinical management often requires histologic diagnosis. If the lesions are endoscopically inaccessible, patients may have to undergo laparoscopy or laparotomy to obtain a tissue diagnosis. Percutaneous US-guided fine-needle aspiration biopsy of bowel-wall lesions has been reported in several cases, which mostly involved gastric lesions (4–6). There can be problems when only cytologic examination is performed, however, particularly in reaching a definitive benign diagnosis (7–10). This study was performed to evaluate whether a diagnostic biopsy can be safely performed percutaneously with an 18-gauge biopsy needle to obtain a satisfactory sample for histologic examination in patients with bowel-wall lesions discovered at US.
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Materials and Methods
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US-guided percutaneous biopsy was performed in 10 patients (seven men and three women; age range, 30–77 years; mean age, 54 years) with bowel-wall lesions. Four of the patients had been treated for a primary malignancy, results in three were positive for human immunodeficiency virus (HIV), and three had no relevant medical history. The bowel-wall lesions were discovered at either US or computed tomography (CT), although one patient was found to have a thick-walled lesion at US after a stricture had been demonstrated at enteroclysis (Table). Each patient was believed to have high surgical risk for open biopsy. Informed consent was obtained individually after consultation on a case-by-case basis with the patient's physician and surgeon.
Platelet count, hemoglobin level, and coagulation screen (prothrombin time) were obtained prior to biopsy. Patients were restricted to nothing by mouth prior to the biopsy, and we did not use any bowel preparation or antibiotic prophylaxis. All biopsies were performed with a 3.5- or 5-MHz curvilinear probe (Masters Diasonics Sonotron, Milpitas, Calif). With color Doppler US, the route to the lesion and the target site were selected to avoid large vessels.
Percutaneous biopsy was performed by using standard aseptic technique with local anesthesia (5–10 mL of 1% lidocaine hydrochloride). The 18-gauge biopsy needle, with a throw of 1 cm, was mounted in an automated needle (Biopty Gun, Manan promag 2.2; Bard, Northbrook, Ill) that can be operated with one hand, which allowed US to be performed simultaneously. The biopsy needle was advanced until the lesion was seen to be indented, and then the trigger mechanism was fired and the needle was withdrawn. An average of two specimens were obtained for each patient. These specimens were fixed in formalin for histologic examination (n = 10) or sent fresh to the pathology department for microbiologic examination (n = 3). All patients were observed overnight and followed up clinically for possible complications.
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Results
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Diagnostic biopsy samples were obtained in all patients. The lesions were all accessible to biopsy with US guidance, and no procedure was abandoned because of poor access. One of the biopsy specimens revealed malignant cells, the exact nature of which was unclear histologically. This patient later underwent small-bowel resection, and the histologic findings from this specimen showed high-grade histiocytoma. The Table shows the histologic findings in the biopsy specimens: high-grade non-Hodgkin lymphoma in four cases, adenocarcinoma in two cases, metastatic melanoma in one case, high-grade sarcoma in one case, and atypical tuberculosis (Mycobacterium avium-intracellulare) in one case. Histologic examination in one of the biopsy specimens showed normal mucosa although it was believed that abnormal bowel had been biopsied. This patient later underwent laparotomy and open biopsy of macroscopically abnormal small bowel, and histologic findings were again normal. No major complications occurred, but in one patient a small hematoma was discovered incidentally during laparotomy at the site of biopsy. This patient's abdominal symptoms resolved after 3 months, and she was followed up clinically for 2 years by her general practitioner without recurrence of symptoms. Some examples of the lesions sampled at biopsy together with the relevant histologic findings are shown in Figures 1–3.
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Patient 9. US image of thick-walled small bowel in a patient with non-Hodgkin lymphoma. The biopsy needle (C) can be seen in the thickened wall (A--B).
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Patient 10. (a) US image shows eccentric thickening (A--B) of the cecum. (b) Photomicrograph from the lesion in a shows sheets of malignant cells: adenocarcinoma-forming glandular structures (arrows). (Hematoxylin-eosin stain; original magnification, x25.)
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Patient 10. (a) US image shows eccentric thickening (A--B) of the cecum. (b) Photomicrograph from the lesion in a shows sheets of malignant cells: adenocarcinoma-forming glandular structures (arrows). (Hematoxylin-eosin stain; original magnification, x25.)
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Patient 7. (a) Image obtained during enteroclysis with barium and methylcellulose shows a stricture (arrow). (b) US scan shows thickened small-bowel wall (A--B) at the site of the stricture in a. (c) Photomicrograph from the lesion in b shows multiple small dysplastic cells (arrows), revealed to be non-Hodgkin lymphoma at immunocytochemical testing. (Hematoxylin-eosin stain; original magnification, x25.)
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Patient 7. (a) Image obtained during enteroclysis with barium and methylcellulose shows a stricture (arrow). (b) US scan shows thickened small-bowel wall (A--B) at the site of the stricture in a. (c) Photomicrograph from the lesion in b shows multiple small dysplastic cells (arrows), revealed to be non-Hodgkin lymphoma at immunocytochemical testing. (Hematoxylin-eosin stain; original magnification, x25.)
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Patient 7. (a) Image obtained during enteroclysis with barium and methylcellulose shows a stricture (arrow). (b) US scan shows thickened small-bowel wall (A--B) at the site of the stricture in a. (c) Photomicrograph from the lesion in b shows multiple small dysplastic cells (arrows), revealed to be non-Hodgkin lymphoma at immunocytochemical testing. (Hematoxylin-eosin stain; original magnification, x25.)
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Discussion
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Although there have been advances in imaging techniques for the investigation of bowel-wall lesions, there is still a need in many cases to make a definitive diagnosis with histologic findings. Percutaneous US-guided biopsy with a fine (22-gauge) needle has been reported as safe (6). Percutaneous biopsy of other abdominal structures has also been shown to be a safe and cost-effective method of obtaining samples for histologic analysis with 18-gauge needles (11–13). The risks and costs of surgical biopsy and anesthesia can be avoided by using percutaneous biopsy methods. In our group of patients, surgical biopsy was avoided in eight of the 10 patients.
There has been some debate in the literature regarding the adequacy of sample material and complication rates with either 18-gauge or fine biopsy needles. Biopsy material must be of a sufficient quality to allow a correct diagnosis. Support has been given by many authors for the use of cutting needles, which generally provide adequate samples (14–17). The biopsy gun we use is a rapid firing system that reduces fragmentation and crush artifacts in the samples obtained. With 18-gauge needles, the percentage of inadequate samples obtained has been reported at 3%–10% (17–19). With fine needles, the percentage of insufficient samples has been reported at 20% and 24% (11,20). It would appear, therefore, that 18-gauge cutting needles acquire an acceptable specimen in more than 90% of biopsies. If there is close cooperation between the radiology and pathology departments, the adequacy of the biopsy specimen can be assessed at the time of the procedure. This may not be possible in all institutions because of staffing implications, but it should reduce the number of biopsy passes necessary to obtain an adequate sample.
It has been claimed that use of fine needles is the safest way to obtain tissue samples (21). Findings in several studies have shown that there is a marginally lower complication rate with 22-gauge compared with 18-gauge needles, but the differences were not statistically significant (22,23). In a review of the literature, however, Smith (21) found no evidence to support the suggestion that cutting needles less than 19 gauge cause more complications than do aspiration needles.
In our series, there was only one known complication, a very small hematoma noticed incidentally at the biopsy site in a patient who later underwent laparotomy.
There is little in the literature about percutaneous bowel-wall biopsy, and we know of no authors who have used 18-gauge cutting needles to obtain samples from the bowel wall. There are several references in the literature that claim no complications arise when bowel is traversed at biopsy of other abdominal masses.
We found that a diagnostic biopsy can be safely performed percutaneously with an 18-gauge biopsy needle to obtain a satisfactory sample for histologic examination in patients with bowel-wall lesions discovered at US. The role of this technique in bowel lesions has not been established. Although we realize this is a small series to determine a meaningful complication rate, there were no clinically important complications, and the diagnostic yield was excellent. We did not have to abandon any biopsy attempts because of poor access. The patients, because of their generally poor physical condition, were good candidates for US in most cases. None of the patients in this group had ascites, which might make performance of biopsy more difficult. In cases in which lesions are identified with US, this technique has the advantage over CT guidance because the operator is able to fix the bowel loop by means of compression with the US probe. The use of color flow Doppler US allows avoidance of larger mesenteric vessels. Laparotomy was obviated in eight of our 10 patients, in whom laparotomy was believed to be inappropriate or unacceptable risk.
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Footnotes
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Abbreviation: HIV = human immunodeficiency virus
Author contributions: Guarantors of integrity of entire study, G.R.T., P.M.R.; study concepts and design, G.R.T., P.M.R.; definition of intellectual content, G.R.T., P.M.R.; literature research, G.R.T.; clinical studies, P.M.R., K.P.W.; data acquisition, G.R.T.; data analysis; manuscript preparation, editing, and review, G.R.T., P.M.R., K.P.W.
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Abstract
Introduction
