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Image-guided Percutaneous Needle Biopsy: An Overview.

Image-guided percutaneous needle biopsy (IGPNB) is a valuable tool for diagnosis of nonpalpable or deep-seated lesions that cannot be characterized definitively with diagnostic imaging alone. The procedure entails inserting a needle through the skin into an area of suspected pathology under the guidance of various imaging techniques to retrieve a sample of tissue or fluid for analysis. This article discusses the historical development, indications, contraindications, patient preparation, equipment and possible complications of IGPNB, with particular attention to biopsies of the thorax, breast, abdominal organs, head and neck and the musculoskeletal system.

This article is a Directed Reading. See the quiz at conclusion.

A middle-aged smoker experiences a nagging, right-sided chest pain. He tries to dismiss it as a pulled muscle or pleurisy, but it won't go away. A visit to the family physician yields an unremarkable physical exam, but chest radiographs are taken. The radiographs reveal a right hilar mass. The patient is referred for bronchoscopy, which is negative.

A postmenopausal woman keeps the appointment for her annual screening mammogram. She felt no lumps on breast self-exam and the clinical breast exam was unremarkable. However, the mammogram demonstrates a dense, irregular mass in her left breast near the chest wall.

A college-age man with prostate cancer complains of pain in his right buttock area. An osteolytic lesion, inconsistent with prostatic metastasis, is seen in the right ischium on a pelvis radiograph. There is a corresponding area of increased uptake on a radionuclide bone scan.

These 3 people have very different medical problems. However, they have one thing in common -- all are candidates for image-guided percutaneous needle biopsy (IGPNB).

In general terms, a percutaneous needle biopsy (PNB) procedure entails inserting a needle through the skin and into an area of suspected pathology to retrieve a sample of the tissue or fluid for analysis. The procedure is considered a closed biopsy, as opposed to an open or surgical biopsy. The needle insertion can be nondirected (ie, performed without direct visualization of the target tissue during insertion) or image-guided, using diagnostic imaging to demonstrate the needle placement in the tissue to be sampled. The nondirected technique is used frequently when the lesion is palpable, whereas PNB is performed with image guidance when the lesion is deep-seated and nonpalpable.

Image-guided percutaneous needle biopsy is divided into 2 procedural areas, fine-needle aspiration biopsy (FNAB) and percutaneous core needle biopsy (PCNB), that differ in both process and product. FNAB, also called fine-needle aspiration cytology, is used when cellular specimens are collected from a lesion for cytologic or microbiologic analysis. Small fragments of tissue can be provided by an FNAB, but these fragments often are insufficient for histology purposes. PCNB, also called core needle biopsy, percutaneous core biopsy or percutaneous cutting needle biopsy, is performed when a tissue specimen is required for histologic evaluation. Although the IGPNB procedure is common in current radiologic practice, there has been historical resistance to the procedure as a viable alternative to open, surgical biopsy.[1]

History

Techniques for PNB have been described in the literature since the mid 19th century.[2-4] However, uses of these techniques in the United States were not published until the 1930s.[5-8] During that period, open surgical biopsy was the established method, so these early articles had little effect on the practice of tumor diagnosis.[9]

The progress of IGPNB has paralleled advances in imaging techniques. By the end of the 1930s, radiographic and fluoroscopic guidance had become a more important part of the IGPNB procedure in the chest and abdomen.[10-12] The development of image intensification for fluoroscopy allowed continued refinement of IGPNB techniques[13,14] to the point that, in 1972, Lalli[15] believed that it no longer was necessary to perform PNB in an operating suite. As new imaging techniques were developed, they were applied to IGPNB guidance. Ultrasound first was applied in the late 1960s,[16] computed tomography (CT) in the mid 1970s[17,18] and magnetic resonance imaging (MR) in the mid 1980s.[19,20]

Advances in biopsy needles and percutaneous biopsy system design have improved the safety and tissue yield of these procedures. Smaller diameter needles with improved tissue-cutting features allow multiple passes into a lesion with minimal complications and retrieval of quantities of lesion material sufficient for both histologic and cytologic evaluations.[21] In addition, the diagnostic quality of aspirated specimens has improved with inclusion of a cytotechnologist or cytopathologist on the IGPNB team. Adequate cellularity of the specimen can be assessed immediately and the cytology personnel can gather pertinent clinical information.[22,23] Although IGPNB procedures have been performed in the United States since the late 1920s,[5] they have been common only in the past 20 to 30 years.[24,25]

Indications

Image-guided PNB has developed into a valuable tool for diagnosis of nonpalpable or deep-seated lesions that cannot be characterized definitively by their appearance on diagnostic images. If the lesion is easily palpable or clearly warrants surgical intervention, IGPNB often is unnecessary. The IGPNB procedure is useful to differentiate a malignant from a benign condition and to provide material for cytologic, microbiologic, histologic and chemical analyses. The techniques and materials used depend on the location, characteristics and visibility of the lesion.[24]

The principal goals of IGPNB are to decrease the need for surgical biopsy and to determine the nature of a lesion before nonsurgical treatment. This practice is driven by the desire for minimally invasive diagnostic procedures and by economic forces. An IGPNB is easier on the patient and costs less. Even if the cost of the procedure were the same as for a surgical biopsy, hospitalization is usually unnecessary for IGPNB, thus decreasing the overall cost of patient management.[26]

Contraindications

There are few absolute contraindications to IGPNB, especially if fine needles are used. Because bleeding is a common complication of these procedures, patients with uncorrectable bleeding diatheses may not be good candidates, especially for IGPNB using large cutting needles. A patient's inability to suspend respiration, control movement such as coughing or jerking or lie in the required position also may be contraindications to IGPNB. In addition, the IGPNB procedure may be contraindicated when there is no clear, safe path to the lesion. However, many intestinal structures may be penetrated by fine needles with only rare complications.[24] Warnings have been published against IGPNB of certain parasitic masses (eg, hydatid cyst),[27] vascular masses[25] and catecholamine-producing adrenal masses (eg, pheochromocytoma).[28]

The majority of complications reported in the literature are related to the organ or structure punctured, so they are most appropriately discussed in the sections covering the IGPNB technique for each anatomical region. Complication rates can be minimized with adequate patient preparation and prebiopsy planning.

Patient Preparation and Management

The IGPNB patient should be questioned regarding known coagulation disorders, easy bruising and recent use of aspirin or other medications that decrease platelet function.[29,30] Coagulation studies and platelet counts frequently are included in the prebiopsy assessment to screen for inadequate clotting. Common tests include prothrombin time (PT or ProTime), partial thromboplastin time (PTT) and platelet count. The activity of the clotting factors measured by the PT and PTT may be affected by medications or by a physiologic condition. In addition to the common tests, a bleeding time may be included because some medications can prolong bleeding by preventing platelet aggregation, even when the platelet count is considered normal.[25] Acceptable limits for these tests are institution specific, because the normal values may differ between laboratories. Coagulation abnormalities should be corrected before attempting IGPNB.

Patients who will receive potentially nephrotoxic, iodinated contrast media during the procedure should be assessed for adequate renal function. Blood urea nitrogen (BUN) and creatinine levels are measured for this purpose. Acceptable limits for these tests are institution specific.

Before beginning an IGPNB procedure, the process, benefits, all possible procedural risks and reasonable alternative diagnostic procedures should be fully discussed with the patient. The physician who presented the information, the patient and at least one witness who will not participate in the procedure must sign the procedural consent form.[31] The consent form should be signed by the patient before any medications are administered that may alter lucidity.

The patient should be monitored throughout the procedure for signs of distress, especially if sedation, narcotics or tranquilizers are administered. These medications, especially in combination, can adversely affect the cardiovascular and respiratory systems. The physician performing the IGPNB should have a thorough understanding of the potential effects of the medications used and the interventions needed to treat them.[25]

Outpatients may be observed for 1 to 4 hours following the procedure, depending on the institution, the patient and the procedure. The standard time period may be extended if larger caliber needles are used or if the patient experiences a complication, such as a pneumothorax or protracted bleeding that requires treatment. Patients undergoing dialysis may be observed for an extended period because they are more prone to bleed.[24]

There is a misconception that if a complication occurs, the radiologist is not required to be an active participant in the treatment. Spies and Berlin[32] contend that the interventional radiologist's patient care responsibilities have increased as procedures have become more invasive. They recommend that the radiologist initiate immediate treatment when a complication occurs while the patient is in the imaging suite. In addition, the radiologist should play an active role in managing the patient after transfer to the appropriate care unit. This includes offering differential diagnoses and suggesting additional diagnostic imaging procedures.

Image Guidance For Percutaneous Needle Biopsy

Imaging techniques used to guide IGPNB include radiography, fluoroscopy, sonography, CT and MR. Radionuclide imaging has seen limited use, primarily in bone and in the breast. Several authors agree that the choice of technique often is based on personal preference and previous experience.[25,33,34] Lesion characteristics such as visibility, size and location influence the choice of guiding technique. Cost, safety and availability are additional considerations.[33]

Indirect guidance and localization can be accomplished using radiography. Currently, use of radiographs is limited to visualization and approximate location of lesions. Mammography is used for placement of marking needles to direct surgical biopsy and may be used to guide FNAB or PCNB.

Although the majority of IGPNB procedures are guided with sonography or CT, fluoroscopy still is used for peripheral pulmonary lesions, for structures in the abdomen that can be opacified by an appropriate contrast medium[35] and for some skeletal lesions. Fluoroscopy has the advantages of low cost and wide availability but is limited by poor visibility of soft tissues and lack of multiplanar imaging, unless C-arm or biplane units are used.[24]

Sonography is widely used as a guidance technique for IGPNB. Advantages include accurate demonstration of anatomy, fast procedure time, real-time needle visualization similar to fluoroscopy, guidance in multiple imaging planes and portability.[25,33] Same-day availability and lower cost are considered additional advantages, although these are relative advantages that may vary by institution. A major disadvantage of sonography is the inability to image structures containing air or bone, which limits its use in the chest, cranium, mid-abdomen and pelvis.[25] Needle visibility can be a problem in hyperechoic structures such as retroperitoneal fat or breast parenchyma. Sonographically guided PNB is difficult for deep lesions and in obese patients.[33] A variety of techniques have been devised to improve sonographic visibility of needles including jiggling during insertion, Teflon coating and etching the needle surface. Sonography is amenable to both manual and mechanically guided needle insertions. Transducer modifications and add-ons have been developed to aid in needle guidance.

Computed tomography is well developed as an image guidance technique for IGPNB of all body regions. Excellent spatial resolution of lesions is a major advantage of CT. A wide range of tissue densities can be demonstrated (air, fluid, soft-tissue, bone), allowing visualization of all structures in the needle path. The needle tip can be tracked consistently and accurately in the axial plane. Because the CT image displays a 360o view of structures surrounding the lesion, a number of alternate needle paths can be considered and the safest one selected.[34] CT is an excellent choice for needle biopsy of deep lesions in the thorax, abdomen, pelvis, retroperitoneum and skeleton.[33] Critical areas such as those adjacent to major vessels, the hilum of the spleen and the mediastinum also are well suited to CT-guided PNB. Complications associated with the use of large cutting needles can be reduced with CT by avoiding uninvolved adjacent tissues in the sample and by excluding areas of increased vascularity.[34]

A disadvantage of CT is the lack of continuous needle visualization during insertion and biopsy. However, scan times have been greatly reduced through the application of helical CT to IGPNB,[36] and dynamic needle imaging became possible with development of real-time CT fluoroscopy.[37] If radiation exposure is contraindicated, sonography may be a better choice for image guidance. Cost and convenient availability of the scanner may be other disadvantages.[34]

MR guidance for IGPNB is appropriate for lesions that are not visible on other techniques. Some lesions, such as certain prostate cancers, liver metastases[38] and breast lesions,[39] are visible only on MR. MR's high flow sensitivity allows demonstration of vascular structures without use of a contrast medium.[40] Images can be acquired in multiple planes, allowing easier needle tip localization within the imaging plane. MR may replace CT for IGPNB in the head and neck for several reasons: needle placement is more precise in relatively inaccessible areas; there are no beam-hardening artifacts in the skull base; and contrast medium is not needed.[40] Major disadvantages to the use of MR for IGPNB guidance have been slow image acquisition and poor access to the patient. However, open-bore systems with MR fluoroscopy are a promising new development.[41,42] (See Fig. 1.)

[Figure 1 ILLUSTRATION OMITTED]

Biopsy Needles

A variety of needles are available for IGPNB, some with broad applicability and some very specialized. They can be categorized in several ways -- either by diameter or by type of tissue specimen obtained. Fine or "skinny" needles generally are considered those 20 gauge or smaller, with most 20 or 22 gauge.

A variety of needle-tip configurations have been devised to improve the quality and quantity of specimen retrieved. They vary in bevel angle, tip shape and ability to cut the specimen with the end or side of the needle. The commonly used Chiba[43] needle has an acutely angled (24 [degrees]) beveled tip and is used primarily to obtain aspiration biopsies of cellular components for cytologic evaluation. Other acutely beveled needles include the Menghini[44] and Turner.[45] A beveled needle with a corkscrew stylet (Rotex) has seen limited use.[46] Circumferentially sharpened needles with no bevel (90 [degrees]) include the Greene[47] and Madayag.[48] The Franceen[49] needle has a serrated, 3-point tip for increased tissue cutting. The Westcott[50] needle contains a tissue-cutting side slot. The cutting tips of these fine needles are designed to allow retrieval of cellular aspirates and small pieces or cores of tissue that may be adequate for histologic assessment. (See Fig. 2.)

[Figure 2 ILLUSTRATION OMITTED]

Andriole and associates[51] assessed the tissue-cutting capabilities of various biopsy needles and concluded that for fine needles of the same caliber, acutely angled bevels yielded the greatest amount of tissue. However, they didn't assess the small caliber, slotted Westcott needle that has been shown to consistently retrieve adequate cores of tissue.[50]

Larger diameter (18 gauge or greater) cutting needles are designed to retrieve cores of tissue suitable for histologic analysis. These cutting needles may be introduced manually or incorporated into an automated device. Manual cutting needles can be end cutting, such as the Turner and Menghini, or side cutting, such as the TruCut. The automated devices, commonly called biopsy guns, "throw" the needle several centimeters into the lesion, preventing the problem of lesion displacement by the needle tip that is sometimes encountered with a manual technique. (See Fig. 3.)

[Figure 3 ILLUSTRATION OMITTED]

Biopsy guns primarily use a TruCut-type slotted needle, although biopsy guns with end-cut needles have been introduced more recently. Available TruCut-type biopsy guns include the Biopty (Bard Urological, Covington, Ga), the Monopty (Bard Urological, Covington, Ga), the Ultra-Cut (Medical Device Technologies, Gainesville, Fla) and the ASAP 18 (Microvasive/Boston Scientific, Watertown, Mass). A performance study of these side-cutting devices by Mladnich and associates[52] found no significant difference in the quality or quantity of specimens collected. Examples of end-cut biopsy guns include the Autovac (Argon Medical, Sugarland, Tex), the Ultra-Vac (MD Tech, Gainesville, Fla) and the Full-Core (Amedic AB, Sollentuna, Sweden). A comparison of these end-cutting models with the Biopty instrument found that although the end-cut needles obtained high-quality tissue cores, they had a significantly greater percentage of zero biopsies (no tissue retrieved) than the Biopty device. However, the authors mention that a recently improved model of the Full-Core instrument appears to have a greatly reduced zero biopsy rate.[53]

A variety of specialized needles have been developed. Trephine (sawtooth or serrated tip) needles are available for biopsy of lesions deep within intact cortical bone, reducing the need for predrilling.[24] In addition, needles have been adapted for use with particular imaging techniques. Teflon coating, surface etching[54] and corkscrew stylets[55] improve sonographic visibility of the biopsy needle. Increasing the percentage of copper in stainless steel needles reduces metal artifacts on MR images.[56] More recently, Steiner and colleagues[57] added a receiving coil to the needle tip of their prototype MR needle.

IGPNB Techniques

Techniques for performing IGPNB differ by the type of instrument used to retrieve the sample and the type of tissue specimen needed for diagnosis of the suspected lesion. Either a single needle or a coaxial technique can be used to aspirate cellular material for cytologic assessment or to cut a core of tissue for histologic analysis.

The single-needle technique, as the name implies, is performed with a single needle that is used to puncture the lesion and interposed tissues. The skin hole created is frequently smaller than with a coaxial system and the needle is in the tissue a shorter time. However, multiple needle passes require the repuncture of interposed tissues for each insertion into the lesion. These multiple needle punctures carry a varying amount of complication risk, depending on the type of tissues penetrated. For example, an increase in the number of pleural punctures is associated with an increased incidence of pneumothorax.[58]

The coaxial system was developed to allow multiple needle insertions into a lesion without the need to repuncture the skin and other interposed tissues. However, these systems create a larger skin hole and remain in the body longer than a single needle. A basic system consists of an outer needle guide and an inner biopsy needle. The guide needle is inserted to contact the surface of the lesion and then the biopsy needle is advanced into the lesion. Systems have been developed for both FNAB and PCNB. For IGPNB in the thorax, Tarver[59] recommends a coaxial system for smaller lesions and those that require extended imaging procedures for proper needle placement. In addition, the coaxial technique is preferred when on-site cytology service is available because multiple specimens can be retrieved and screened without reimaging the patient.

Regardless of the needle insertion technique used, a 10 mL or 20 mL syringe usually is attached to the biopsy needle, unless a biopsy gun is used. A vacuum is created by pulling back on the syringe plunger, either manually or with the aid of a syringe holder, such as a Cameco syringe pistol (Precision Dynamics, San Francisco, Calif). While the vacuum is maintained, the needle is moved up and down within the lesion to dislodge cells and draw them into the lumen. (See Fig. 4.)

[Figure 4 ILLUSTRATION OMITTED]

Standard procedures, such as patient assessment, informed consent, sedation, analgesia, anesthesia, proper positioning for site exposure, site preparation and image guidance method, are usually the same regardless of the needle introduction system.

Specimen Handling, Preparation and Analysis

The final step in performing an IGPNB is proper handling, preparation and analysis of the specimen. A flawlessly performed retrieval can be negated if the specimen is damaged. Adherence to strict specimen handling and preparation procedures is especially critical for FNAB because of the limited amount of material collected.[60] Even when a specimen has been successfully aspirated, it may not be suitable for interpretation if there are an insufficient number of cells, if the cells of interest are obscured by too many red blood or inflammatory cells, or if drying or degeneration distorts the cells.[9] If an on-site cytology team is not available, the physician performing the IGPNB procedure should be familiar with slide preparation and fixation techniques.[61]

A cytotechnologist and cytopathologist prepare and analyze FNAB specimens. Because time is an important factor, both for the biopsy procedure and for specimen preservation and fixation, it is highly recommended that a cytology team attend the procedure.[60] They will be able to prepare the specimen for preservation and fixation immediately after removal from the patient. (See Fig. 5.) In addition, they will be able to perform appropriate stains, determine the adequacy of the sample and request additional specimens when needed.

[Figure 5 ILLUSTRATION OMITTED]

The presence of a cytology team also is important for gathering pertinent clinical information directly from the radiologist. Some information, such as age, gender, clinical history and diagnosis, should be in the patient record, but lesion location and appearance are best obtained from the radiologist performing the needle biopsy procedure. Accurate cytologic analysis requires correlation with clinical data because the cytopathologist must determine if the specimen appearance is consistent with the clinical diagnosis.[62]

Specimen handling and preservation also are important for tissue samples obtained by PCNB. Care should be taken to avoid unnecessary tissue damage as the specimen is removed from the biopsy needle and the specimen should be placed immediately into a fixative solution, usually 10% neutral buffered formalin[63] or sterile saline. A pathologist is not present to assess the tissue sample because the histologic preparation and treatment of the specimen are time consuming and are not done at the site of the procedure. The more rapid frozen section technique, used for surgical biopsy, is not customarily used for tissue cores retrieved from a PCNB procedure.[64]

Although the procedural aspects discussed above represent the general IGPNB procedure, there are variations in technique for different body regions and organs. For purposes of discussion, the body will be divided into 5 regions, including the thorax, breast, abdomen, head/neck and the musculoskeletal system. Each of these regions requires modifications to the standard procedures. In addition, specialized equipment has been developed to optimize specimen retrieval from varied tissues.

Thorax

Currently, there are 4 methods of obtaining lung tissue for cytologic, histologic and microbiologic evaluation. These include surgical biopsy, video-assisted thorascopic biopsy, transbronchial bronchoscopic biopsy and transthoracic needle biopsy (TNB). Choice of technique is determined by the location, size and suspected nature of the lesion. A surgical biopsy is appropriate if there is a high suspicion of malignancy that will require surgical resection. The thorascopic technique is used for peripheral pulmonary lesions near the pleural surface.[59] Lesions beyond the pleural surface may not be visible to the thoracoscopist, but can be marked with a mammographic localization wire to guide the thorascopic biopsy.[65] A bronchoscopic biopsy is preferred for more centrally located lesions with endobronchial involvement. A brush biopsy or transbronchial Wang needle biopsy may be performed through the bronchoscope.

The first transthoracic needle biopsy was reported by Leyden[66] in 1883. However, it wasn't until the mid 1960s that image-intensified fluoroscopy was applied to FNAB in the lung.[67] As imaging and interventional techniques improved, TNB gained popularity as an effective method for evaluating thoracic lesions.

Transthoracic needle biopsy is appropriate under a number of conditions and may be the first choice in patients who are not surgical candidates because of known metastasis, an invasive tumor and poor pulmonary or overall physical condition.[68] It is an established diagnostic technique for indeterminate solitary nodules in several categories of patients, including those with a risk for lung cancer, with extrathoracic malignancy or suspected metastatic disease and immunocompromised patients with suspected infectious lesions.[58,59] A TNB may be used to assess a mediastinal mass[68] or to further evaluate a hilar mass or solitary nodule after a negative or indeterminate bronchoscopy.[69] In addition, the technique can be used to establish the benign nature of a lesion.[68] TNB may not be warranted when the probability for cancer is high or biopsy results are unlikely to affect treatment.

As with many interventional procedures, the contraindications to TNB are related to the associated procedural complications. There are no absolute contraindications, but some patients are at greater risk for complications. Relative contraindications to TNB include compromised pulmonary function (eg, severe chronic obstructive pulmonary disease [COPD], pneumonectomy, mechanical ventilation), bullae or emphysema in the path of the needle, patient inability to cooperate (eg, maintain a position or hold breath), intractable cough, a bleeding diathesis (clotting abnormality), pulmonary hypertension, vascular lesions and echinococcal (hydatid) cyst.[58,59,68]

The most common complications of TNB are pneumothorax and hemoptysis (spitting up blood). The reported incidence of pneumothorax varies from 10% to 60%,[68,70] with an average rate of 20% to 30%.[58] Factors increasing the risk of pneumothorax include large needles ([is greater than] 18 gauge), deep-seated lesions, increasing numbers of pleural punctures, presence of emphysema or COPD, patient movement or coughing, advanced age and operator inexperience.[70] However, with improvements in needle biopsy techniques, these risk factors may change. For instance, recent research indicates that advanced age may not increase the likelihood of pneumothorax.[71] Hemoptysis, indicating a pulmonary hemorrhage, occurs in 5% to 15% of TNB procedures.[68,70] Patients with an uncontrolled bleeding diathesis, pulmonary hypertension, vascular lesions, uncontrolled cough or an inability to remain still are at an increased risk for bleeding.

Rare complications of TNB include air or tumor embolism, bronchopleural fistula, lung torsion, tumor seeding along the needle track and significant bleeding incidents, such as massive hemoptysis, hemothorax or cardiac tamponade.[68] Although massive hemorrhage is rare, it is hard to control and is considered the cause of most fatalities associated with TNB.[70]

Prebiopsy patient assessment and preparation for TNB follow standard protocol, with emphasis on assessing the patient for contraindications or for conditions that may require changes to the planned procedure. Choice of imaging technique for guidance is based on the size and location of the lesion, availability of the desired technique and the preference and experience of the radiologist. Fluoroscopy, CT and, less frequently, sonography are used. Fluoroscopy is particularly useful for smaller, peripheral lesions, especially in the lower third of the lungs where greater respiratory movement occurs.[59] Fluoroscopic TNB of small, central lesions has been found to result in decreased diagnostic accuracy.[72,73]

CT is recommended over fluoroscopy for TNB of small lesions near vascular structures or lesions that are difficult to see on fluoroscopy.[74] Another advantage of CT is the ability to accurately document the needle tip within the nodule, especially when cytologic evaluation is benign or indeterminate and additional work-up is being considered.[75,76] The reported accuracy of CT is not equal to fluoroscopy,[73] but this may be related to the selection of more difficult lesions for CT-guided biopsy.[77]

Sonography is useful for biopsy of peripheral pleural consolidation and nodules adjacent to the pleura.[78-80] Biopsy of anterior mediastinal masses using sonography for guidance has been reported.[81,82]

Both aspiration and core cutting needles are used for TNB. Small-diameter needles such as the Chiba and Greene commonly are used for aspiration biopsy.[58,59] The Chiba type is used for the single-needle technique, whereas the Greene needle is a coaxial system consisting of a 19- or 22-gauge ultra-thin-walled outer needle with a smaller gauge inner needle. The single pass needle technique is appropriate for large, easily accessible lesions. Coaxial needle systems are best for smaller, more remote lesions that may require multiple needle passes or a lengthy biopsy procedure.[59] (See Figs. 4 and 6.)

[Figure 6 ILLUSTRATION OMITTED]

Cutting needles are needed when the aspiration biopsy technique cannot provide sufficient tissue for a definitive diagnosis, when lymphoma is suspected, for the diagnosis of benign lung nodules and when immediate cytopathologic assessment of biopsy specimens is unavailable.[83,84] A variety of cutting needles are used for TNB, including manual devices such as the Franseen or Westcott needles and automated devices such as the Biopty biopsy gun. The lesion size and proximity to vascular structures limit use of cutting needles, especially biopsy guns.[68] Biopsy of the parietal pleura requires cutting needles designed for that purpose, such as the Abrams or Cope needle.

Patient management after TNB should focus on detecting the presence and limiting the consequences of common complications -- pneumothorax and hemorrhage. The patient should be positioned so that the biopsy site is dependent, thus reducing the leakage of air from the lung into the pleural space by approximating the visceral pleura against the parietal pleura.[85] Blood pressure and oxygen saturation should be monitored and the patient should be observed for signs of respiratory distress or extended hemoptysis.

If the patient remains asymptomatic, an uptight full-expiration chest radiograph usually is taken after 20 minutes[59] to 1 hour.[58] Outpatients remain in the observation area until another chest radiograph is taken after 3 to 4 hours. Inpatients usually return to the ward after the first hour, until it is time for the second chest radiograph.[59] Small pneumothoraces are common and, if found, the patient will remain in the department several additional hours. However, patients may be released once it has been established that the pneumothorax is stable because 98% to 100% of pneumothoraces large enough to require treatment occur within the first hour after the biopsy procedure.[58] Pneumothoraces requiting treatment frequently can be managed with small caliber (6 to 9 French) pleural drainage catheters and one-way Heimlich valves. Use of suction or large-bore chest tubes is usually unnecessary.[68]

Breast

Breast cancer screening programs have been developed to detect early changes in breast tissue that indicate malignancy. When positive mammographic findings are identified, the breast tissue may be examined further using additional imaging studies, such as a sonogram. If the image of the lesion suggests malignancy, a biopsy may be warranted. The gold standard for breast biopsy is surgical excision of all or part of the lesion.[86] However, techniques for IGPNB of the breast have been developed to reduce the need for surgical biopsy in some categories of abnormalities identified on breast imaging studies.

In 1995, the American College of Radiology (ACR) published the Breast Imaging Reporting and Data System (BI-RADS).[87] This is a standardized system for the description of mammographic findings. A national task force, consisting of representatives from the ACR, the American College of Surgeons and the College of American Pathologists, published a 1997 report[64] recommending stereotactic core needle breast biopsy for BI-RAD category 4 lesions (suspicious abnormality), many category 5 lesions (highly suggestive of malignancy) and, under certain conditions, category 3 lesions (probably benign findings). The report indicated that PCNB is most appropriate for category 4 lesions. The histologic evaluation of PCNB tissue cores can differentiate lesions that require surgical excision from those that can be followed with mammography and clinical assessment.

Both FNAB and PCNB are used for breast biopsy, with core needle biopsy more frequently chosen. Fine-needle aspiration biopsy has not gained the wide acceptance in the United States that it has in Europe for several reasons: a trained cytopathologist is required, disagreement exists over the accuracy of the procedure, the rate of insufficient samples is high and the current medicolegal environment is unfavorable to FNAB.[88-90] However, FNAB has been an accepted method for breast cancer diagnosis since 1970[91] and still is regarded as a valuable diagnostic tool by some practitioners.

The major advantages of FNAB are related to needle caliber. The fine (22- to 25-gauge) needles used result in relatively little pain or bleeding. Hematoma is uncommon and tumor seeding along the needle track has not been reported for breast FNAB.[86] Significant disadvantages to the procedure include the high number of insufficient biopsies[92] and the need for a pathologist experienced in evaluating the aspirates.[88]

PCNB can be used as the primary method of IGPNB in the breast or as an adjunct to FNAB when findings are equivocal. Advantages of PCNB are primarily related to the volume of intact tissue retrieved. These advantages include ease of pathologic evaluation, differentiation of benign processes and differentiation of invasive from intraductal or in situ carcinoma.[93,94] Several authors who compared PCNB before surgical excision with wire-localized surgical excision contend that use of PCNB results in decreased need for re-excision during surgery, increased frequency of negative margins in the specimen and an increased number of one-stage surgeries.[95,96] Relative contraindications to PCNB using stereotactic mammography guidance include patients too large to be accommodated by the biopsy equipment, breasts with an insufficient compressed thickness to allow the needle throw of biopsy guns, lesions too close to the skin, vague tissue characteristics or diffuse calcifications and inability of the patient to remain still between localization and needle placement in the lesion.[64]

The choice of imaging technique for IGPNB of the breast is based on characteristics of the lesion, such as visibility, location or presence of calcifications, and experience or preference of the practitioner.[94] Mammography, stereotactic mammography, sonography, CT, MR and radionuclide scanning have been used successfully as guidance techniques, with stereotactic mammography the most popular.

Stereotactic mammography systems may be add-on devices for upright mammography units or freestanding prone stereotactic tables. Incorporating a digital imaging system makes it unnecessary to take and process mammograms during the procedure, thus reducing the procedure time.[94] The add-on devices are less expensive, work with existing equipment and allow more flexibility in patient positioning.[97] The prone stereotactic table requires a dedicated room but alleviates the need to stop diagnostic mammography during a biopsy procedure. The more recently developed stereotactic breast biopsy systems use the prone stereotactic table.

Sonography has several advantages as a guidance technique. As mentioned previously, it is widely available, portable and relatively inexpensive. The real-time capabilities of sonography allow continuous visualization of needle advancement into the lesion. Patients may lie supine and the breast need not be compressed.[98] (See Figs. 7 and 8.) Some lesions are visible only with sonography. When sonography is used as a guidance technique for IGPNB of the breast, high-frequency (7.5 MHz or higher) transducers are recommended.[86]

[Figures 7-8 ILLUSTRATION OMITTED]

Sonographic guidance also has drawbacks. Although up to 77% of mammographically suspicious lesions are demonstrable with sonography, those with isolated clusters of microcalcifications are not visible.[99] In addition, some radiologists find the coordination of simultaneous transducer manipulation and needle placement difficult to master.[98]

Although stereotactic mammography and sonography guide the majority of IGPNB procedures in the breast, other techniques have been used successfully. CT has been used for FNAB or PCNB of lesions that are difficult to localize with mammography or sonography.[86,100] MR with and without contrast media enhancement has been used successfully for guidance of IGPNB and localization wire placement in breast lesions visible with MR alone[101,102] Stereotactic (framed[103,104] and frameless[105]) and freehand[106,107] techniques for needle placement have been developed. Scintimammography (radionuclide imaging of the breast using technetium Tc 99m sestamibi) has been used for needle localization prior to surgical biopsy of lesions exhibiting abnormally increased uptake.[108]

Prebiopsy patient assessment should include screening for significant coagulopathy or incidents of syncopy during needle placement, because bleeding and vasovagal reactions are complications of IGPNB in the breast.[92] Depending on the needle guidance method used, the patient should be screened to determine the ability to cooperate and assume the required position. For example, arthritis and spinal fusion may limit the patient's ability to lie prone on a biopsy table.[94] As with all invasive diagnostic procedures, informed patient consent is necessary. Standard protocol for obtaining consent should be followed.

Choice of equipment for IGPNB may be related to the radiologist's preference or the characteristics of the lesion. If FNAB is elected, fine-gauge aspiration needles, such as the Chiba, will be used. When PCNB is selected, either biopsy guns or other automated needle biopsy systems may be applied. The biopsy guns, first introduced for breast biopsy in 1990,[109] often use a TruCut-type needle and may be directed manually or with the aid of a stereotactic device.

Directional, vacuum-assisted breast biopsy systems such as the Mammotome (Ethicon Endo-Surgery Inc, Cincinnati, Ohio) have been developed to improve calcification retrieval and reduce underestimation of lesions containing atypical ductal hyperplasia or ductal carcinoma in situ.[110,111] (See Figs. 9 and 10.) Fourteen-gauge needles were used initially, but 11-gauge needles have been introduced to improve diagnostic yield[112] and allow placement of a localizing clip after small lesions have been completely excised.[113] Retrieval of 5 specimens is recommended to ensure a high degree of accuracy, but 10 or more specimens may be required if calcifications are present in the lesion.[114,115]

[Figures 9-10 ILLUSTRATION OMITTED]

Specimen handling for IGPNB of breast lesions is essentially the same as for other body regions. The presence of a trained cytopathologist during a breast FNAB is strongly recommended.[94] Tissue cores from PCNB may be submitted to pathology in one container if a solitary lesion was biopsied, but samples from multiple lesions must be submitted separately and clearly labeled.[64] If the lesion contains calcifications, the tissue cores retrieved through PCNB should be mammographed to ensure that the calcifications are included.[116] (See Fig. 11.)

[Figure 11 ILLUSTRATION OMITTED]

Postbiopsy patient management is related to the technique used. Complications are similar for FNAB and PCNB, but bleeding increases with use of larger caliber needles and may be increased when vacuum-assisted breast biopsy is performed.[111] Application of ice and direct pressure stop bleeding in most cases. However, more aggressive measures may be used for hemostasis after 11-gauge vacuum-assisted biopsy, including administration of a local anesthetic with epinephrine for deep anesthesia and wrapping the chest for 24 hours.[117]

Abdomen

IGPNB of the abdomen is performed on a variety of solid organs and masses, located in both the abdominopelvic cavity and in the retroperitoneal space. Frequently examined organs include the liver, pancreas, kidney, adrenal gland and pelvic structures such as the prostate and ovaries. In addition, enlarged abdominal lymph nodes and pelvic masses may be examined. The IGPNB technique for each organ, region or structure will be discussed separately because the indications, contraindications, complications and procedural aspects may differ.

Liver

There are currently 3 nonsurgical approaches to liver biopsy, including laparoscopy, the transvenous approach and the percutaneous route. Laparoscopy, by virtue of direct peritoneal visualization, is very effective for staging a variety of intra-abdominal malignancies. This technique is useful for biopsy in the cirrhotic liver and for diagnosis and staging of hepatocellular carcinoma.[118] The transvenous approach for liver biopsy, with access through the internal jugular or common femoral vein, is a viable alternative for patients with uncorrectable coagulopathy. Diffuse parenchymal disease may be evaluated by transvenous forceps biopsy from a hepatic vein.[27] The percutaneous route for liver biopsy, including both FNAB and PCNB, is less invasive than laparoscopy and more broadly applicable than the transvenous approach.

Although percutaneous liver biopsy first was performed in 1883,[1] it was not until the introduction of the "1-second technique" by Mengini[44] in 1958 that needle biopsy of the liver gained popularity. Currently, the liver is the most frequently biopsied abdominal organ.[119] Broad indications for IGPNB of the liver include diffuse parenchymal diseases, focal lesions and tissue viability after transplantation.[118] (See Figs. 3 and 12.)

[Figure 12 ILLUSTRATION OMITTED]

Contraindications to IGPNB of the liver include uncorrectable bleeding diatheses, absence of a safe route to the lesion,[119] patient uncooperativeness, suspected echinococcal (hydatid) disease, hemangioma, significant ascites and infection in the liver region.[120] The most frequent complications associated with hepatic IGPNB are pain (right upper quadrant or right shoulder) and hemorrhage (intraperitoneal, intrahepatic or subcapsular hematoma, hemobilia).[118] In addition, infections, bile peritonitis, various pleural cavity complications (eg, pneumothorax, hemothorax), reaction to anesthesia, needle breakage, biopsy of other organs, malignant tract seeding and death have been reported.[119,120,121]

Prebiopsy patient assessment and consent follow standard protocol. Choice of technique for image guidance is based on several factors, including the clinical situation, the visibility of the lesion and operator preference. As with most IGPNB procedures, sonography and CT are used most frequently. Sonography is desirable for real-time observation during needle insertion, but is limited by intervening air or gas and by difficulty imaging lesions under the anterior dome of the diaphragm. CT is chosen when the needle path or lesion is demonstrated more clearly.[119] (See Fig. 13.) MR-guided PNB is under development for lesions best demonstrated on MR. Both closed bore and open bore magnet systems have been used.[42,122,123]

[Figure 13 ILLUSTRATION OMITTED]

Both FNAB and PCNB are performed for diagnosis in the liver. Needle choice varies, depending on the radiologist's preference, the type of sample needed and the potential for complications. When core biopsy of vascular lesions is necessary, an 18-gauge cutting needle provides a sufficient tissue sample[124] and results in complication rates no greater than 21-gauge fine needles[33] as long as the length of interposing liver parenchymal track is not less than 1 cm.[125] When larger needles are used on high-risk patients, embolization of the needle track with geltoam[126] or steel coils[127] is recommended.

Postbiopsy patient management should include assessment for complications. Most occur within 2 hours of the procedure and nearly all occur within 24 hours. Although pain is a common complaint, it is usually mild and of short duration. Severe abdominal pain of extended duration may indicate more severe complications, such as hemorrhage or peritonitis.[118]

Pancreas

Three nonsurgical techniques for tissue biopsy have been applied to the pancreas, including endobiliary brush biopsy, endoscopic ultrasound-guided FNAB and IGPNB. Endobiliary brush biopsy of the pancreas, performed through a cholangiopancreatic endoscope, retrieves cellular specimens for cytologic evaluation and is limited to lesions involving the pancreatic ductal system.[128] Endosonographically guided FNAB, by virtue of high-resolution visualization of small pancreatic tumors and lymph nodes, has shown promise for needle aspiration biopsy of lesions within 2 to 3 cm of the stomach or duodenal wall.[129,130]

Indications for IGPNB of the pancreas include suspected carcinoma of the body or tail, unresectable carcinoma of the head, peripancreatic lymphadenopathy, characterization of some benign lesions, evaluation of pancreatic allo-graft and staging of a suspected or known malignancy for presurgical planning.[131,132] The only contraindications are uncorrectable bleeding diatheses and uncooperative patients. Reported complications include pancreatitis, vasovagal reaction, sepsis, hemorrhage, hematoma, peritonitis and needle-tract seeding. [129,133,134]

Procedural considerations, including patient assessment, needle selection and guidance technique, are similar to those for the liver. An anterior or posterior approach may be used, with sonographic or, most commonly, CT guidance. Lees[129] states that the pancreas is the most dangerous abdominal organ to biopsy. Needle puncture of dilated biliary or pancreatic ducts should be avoided and fine needles should be used if intestine is interposed. Complications can be reduced by using the smallest possible needle size and minimizing the number of needle passes.

Kidney

In 1951 Iverson and Brun[135] reported their early experience with IGPNB using intravenous pyelography as the guidance technique to assess diffuse parenchymal disease in the kidney. The next year, Lindblom[136] added fluoroscopy to the use of IV contrast media to extend IGPNB to diagnosis of renal cysts and tumors. Currently, sonography and CT are used most frequently for guidance. Choice of technique depends on availability, preference of the practitioner, visibility of the lesion and contraindication to use of iodinated contrast media.

IGPNB of the kidney is used to differentiate a primary renal tumor from a metastatic or retroperitoneal tumor, or to provide tissue for histologic evaluation of diffuse parenchymal diseases. In addition, renal IGPNB can be used to characterize a suspected malignant lesion in patients who are poor surgical risks and to evaluate masses in patients on extended hemodialysis.[27,137,138]

Although FNAB is used extensively in Europe, the current use of fine needles in the United States is controversial for all but cystic lesions and cases unsuitable for PCNB.[137] Because hemorrhage is a common occurrence, especially following PCNB, patients on dialysis require special consideration because they are more likely to bleed. Patients with a urinary tract infection or pyelonephritis should not undergo IGPNB until the infection has been treated. Needle-tract seeding is a rare complication, but is more likely with transitional cell carcinoma than with parenchymal adenocarcinoma.[138]

Most procedural considerations follow standard protocols for abdominal IGPNB. Both fine and cutting needles are used, depending on the location and type of lesion. The trend has been toward smaller gauge (18-gauge) biopsy guns, as opposed to the larger gauge (14-gauge) manual-cutting needles. Tissue sampling has been found equivalent for diagnosis of both diffuse parenchymal disease[139] and renal allografts,[140] with a decrease in complications.

Adrenal

Asymptomatic patients with a small ([is less than] 5 cm) adrenal mass or those with a known malignancy are candidates for IGPNB of the adrenal gland.[27] MR may allow differentiation between an incidental, nonfunctioning adenoma and a metastatic lesion in some cases.[24] However, when imaging is equivocal, IGPNB can be used to provide histologic evidence of malignancy for tumor staging and determining the appropriateness of surgery.[138]

CT is the common guidance technique, but sonography may be used. Although FNAB is used successfully for adrenal gland biopsy,[141] PCNB is more common in the United States. Eighteen-gauge biopsy guns or 20-gauge cutting needles such as the Franseen[138] or Turner are used. The route of needle insertion is chosen to avoid crossing the pleura or passing through the pancreas or spleen. Avoidance of these structures will decrease the incidence and severity of common complications, such as pneumothorax and bleeding.[138]

Pelvic Masses and Organs

IGPNB may be used in the diagnosis of pelvic masses and lesions in organs such as the ovaries or prostate. The IGPNB technique is useful for staging genitourinary and gastrointestinal malignancy[27] for documenting recurrence after surgical resection[33] and for evaluating non-neoplastic masses.[142] Approach to the lesion may be percutaneous, transvaginal, transcystic or transrectal, depending on the safest or shortest route.[27]

Both FNAB and PCNB techniques are used, with core biopsy preferred. CT is used frequently, but transabdominal sonography can be used when bowel gas does not interfere with visualization of the lesion.[138] Endosonography is standard for lesions that can be reached transvaginally or transrectally. For example, IGPNB of the prostate is carried out most frequently with endorectal guidance by the transrectal route using an 18-gauge automatic biopsy gun.[138,143] Complications from IGPNB in the pelvis are infrequent and usually are limited to local bleeding and pain.[24]

Lymph Nodes

Discrete lymph node enlargement or a lymph node mass in the retroperitoneum or pelvis can be subject to IGPNB. The technique is useful for diagnosis of lymphoma and for tumor staging to establish the presence of metastatic involvement. FNAB and PCNB are used for lymph node biopsy, and both provide sufficient material for diagnosis of primary and metastatic disease. However, PCNB often is necessary to provide sufficient tissue for histologic subtyping of lymphoma.[144]

Head and Neck

IGPNB may be performed in nearly all areas of the head and neck. FNAB may be performed with or without image guidance. Palpable, easily accessible masses may be biopsied without a guidance technique and may be performed with or without vacuum aspiration (ie, needle only).[145] Cutting-needle biopsy is performed customarily with image guidance. IGPNB of brain lesions requires stereotactic localization and guidance to achieve sufficiently precise needle placement. Sonography, CT and MR are the common guidance techniques, with fluoroscopy used occasionally. Sonography is chosen frequently, especially for masses that are more superficial.[146] CT provides better detail of deep neck structures and those within the cranium.[147] Either CT or MR may be used for stereotactic brain biopsy, depending on visibility or location of the lesion.[148,149] With the development of interventional MR scanners, head and neck lesions outside the cranium are now sampled by MR-guided PNB.[40,150]

Lesions in the thyroid or salivary glands, enlarged cervical lymph nodes and intracranial lesions are frequently subject to IGPNB. In addition, masses arising in and around the oral, nasal, orbital and pharyngeal cavities can be assessed. These mass lesions may result from primary processes or may represent metastasis.

Thyroid nodules occur in about 4% of the U.S. population. Most are associated with benign processes such as goiter or thyroiditis. The incidence of thyroid cancer is small, occurring in approximately 40 persons per million.[151] FNAB has become important in the assessment of thyroid nodules. (See Figs. 14 and 15.) The FNAB technique is useful to distinguish between benign and suspicious or clearly malignant conditions. It also is useful to diagnose malignancy in patients considered unsuitable for surgery.[152] When surgery is indicated, Dovoudi[153] states that tissue evaluation by FNAB may replace intraoperative frozen section as an indicator of the extent of thyroid resection needed. FNAB is not recommended for patients who have been treated with low-dose radiation therapy to the neck, because 40% of nodules contain cancer and surgery is indicated.[151] Fine needles (23 to 25 gauge) are recommended for thyroid biopsy because of the vascularity of the gland, but Taki[154] has used an 18-gauge, short-throw biopsy gun with no significant increase in complications. Use of the biopsy gun improved the diagnostic yield for lesions [is greater than] 10 mm. Reported complications from FNAB of the thyroid are infrequent and include local bleeding, vasovagal episodes and tracheal puncture.[152]

[Figures 14-15 ILLUSTRATION OMITTED]

Salivary gland lesions may be examined using IGPNB. Both major and minor glands are examined, although the parotid gland is biopsied most frequently because 80% of salivary gland malignancies occur there.[155] IGPNB of a salivary gland is helpful to differentiate between inflammatory and malignant conditions, aid in therapy planning when a suspected malignancy is confirmed, document recurrence of a prior malignancy and diagnose malignancy in patients with inoperable disease, metastasis or lymphoma.[156,157] FNAB may be performed with sonography or without image guidance, using either an aspiration or a capillary (needle only) technique.[145,156] In addition, sonographically guided CNB has been successfully performed on parotid gland masses.[146] The only reported complications resulting from salivary gland IGPNB have been small hematomas.[158]

Cervical lymph nodes may be involved in both metastatic and lympho-proliferative disease. Evaluation of enlarged or suspicious lymph nodes with IGPNB assists in determining prognosis and appropriate treatment. The location of involved nodes often is indicative of cancer in particular locations. For example, adenocarcinoma in the middle third or upper third of the cervical nodes usually originates in the thyroid, whereas epidermoid carcinoma in these nodes is commonly from a primary malignancy of the upper aerodigestive tract.[159] Nodal involvement isolated to the lower third of the neck frequently is associated with primary tumors arising below the clavicle.[159]

When cervical nodes are not palpable, diagnostic imaging techniques, including sonography, CT and MR are used to screen for suspicious nodes. Sonography is used most frequently for PNB guidance in the neck, except for retropharyngeal and periesophageal nodes, when CT is more effective.[147] Fine needles provide sufficient material for diagnosis of malignancy and metastasis, but there are concerns regarding the diagnostic value of FNAB for lymphoma. Use of biopsy guns for PCNB of suspicious lymph nodes has proven superior to FNAB, with no increase in complications.[146] Reports of complications related to IGPNB of cervical lymph nodes are primarily concerned with changes in tissue architecture that may impact postsurgical histologic evaluation.[160]

Intracranial lesions can be assessed with IGPNB, commonly aided by stereotactic localization. Either FNAB or PCNB can be performed, depending on the type of lesion.[148] CT and MR are used for image guidance, with the choice depending on lesion visibility. For example, a lesion near the skull base may be obscured by beam-hardening artifacts on CT, so MR may demonstrate the lesion more clearly.[34] Guidance of the biopsy needle to the lesion frequently is accomplished with the aid of a stereotactic frame attached to the patient's head.[161] Frameless stereotactic systems also are under development. These systems direct the needle trajectory without a frame by monitoring the spatial location of the biopsy needle and overlaying the needle location on the image of the lesion.[40] Stereotactic systems have been designed for use with CT and MR, so these directed biopsies can be accomplished with the imaging technique that demonstrates the lesion most clearly.[149]

Stereotactically directed needle biopsies are performed when:

* The risk of a craniotomy is too great.

* The lesion is deep or near vital structures.

* Open surgical resection is not required for treatment.

* Identification of the lesion is desired before open surgery is performed.[148]

Reported complications from stereotactic needle biopsy include skin infection or dehiscence (splitting open) at the puncture site, varying degrees of parenchymal hemorrhage, subtle neurologic deficits and fatal perioperative pulmonary embolism.[161]

Musculoskeletal

Musculoskeletal lesions are amenable to IGPNB, although its accuracy does not equal that of open, surgical biopsy. However, IGPNB is faster, safer, less expensive and more convenient for the patient. The major disadvantage is the smaller amount of tissue retrieved compared with surgical biopsy.[162] The primary indication for musculoskeletal biopsy is to confirm metastasis from a known primary tumor. This is especially important when the lesion appears atypical for the type or stage of primary tumor, or when a lesion is found many years after treatment of the primary disease.[163]

The most common origins for skeletal metastasis are the lung, breast, prostate, kidney and thyroid, in that order.[159] When there are multiple primary tumors, IGPNB can aid in establishing the origin of the metastatic skeletal lesions. In addition, the IGPNB technique is helpful when bony lesions are suspicious for metastasis, but a primary tumor has not been found. Characterization of the malignant cells can aid in locating the primary lesion.[162] Lesions evident on radionuclide bone scans or MR, but not on CT or radiographs, may be sampled by IGPNB to differentiate a benign from malignant process.[164] In addition, metabolic diseases, infections in bone or joints, and other conditions such as Paget disease, fibrous dysplasia, eosinophilic granuloma and sarcoidosis may be examined using IGPNB techniques.[162]

Contraindications to IGPNB of the musculoskeletal system include uncorrectable bleeding diatheses and infection in the tissues along the needle track. Sites considered inaccessible to IGPNB include sclerotic lesions in the anterior portion of the thoracic vertebral bodies next to the thoracic aorta, lesions of the odontoid process and lesions in the anterior arch of the first cervical vertebra.[164]

The most common imaging techniques used for guidance of musculoskeletal PNB are fluoroscopy and CT. Biplane fluoroscopy is recommended over conventional fluoroscopy to improve confirmation of needle depth. CT is used almost exclusively for the upper thoracic and cervical spine, as well as the skull base and facial bones.[163] Several authors[165,166] found that, compared with fluoroscopy, CT significantly improved the accuracy of IGPNB and permitted access to otherwise inaccessible lesions by allowing selection of a safe puncture route and identification of susceptible adjacent structures. Radionuclide scanning has been used as a PNB guidance technique for lesions not seen on other imaging exams.[167] However, the biopsy has been more successful when the lesion is visible with both nuclear medicine and radiography.[162]

Both fine and cutting needles are used for IGPNB in the musculoskeletal system. Needle choice depends on the nature and location of the lesion. Intact bony cortex overlying the lesion requires use of a bone-cutting needle, whereas an osteolytic lesion that has thinned or destroyed the cortex can be reached with an aspiration needle or a soft-tissue cutting needle. Aspiration needles may be 18- to 23-gauge spinal or aspiration-cutting types.[163] TruCut needles have been used for soft-tissue masses, for osteolytic lesions extending beyond the cortex and for medullary lesions after cortical penetration by drill or bone-cutting needle.[164] An 18-gauge biopsy gun also has been used for medullary tissue sampling after cortical penetration.[168]

There are varieties of bone-cutting needle systems for penetrating the intact bony cortex. The common features are a trochar for penetration and a trephine (serrated edge) for cutting.[169] They can be single pass (such as the Jamshidi), or coaxial (such as the Kormed, Craig and Ackermann).[164] The cutting cannulas have relatively large handles to facilitate trephine needle rotation and application of pressure to the needle tip. (See Fig. 16.) Modifications and refinements continue to be made to these needle systems. Recently, Kruyt[170] developed a hybrid technique for musculoskeletal IGPNB using a power drill for cortical penetration, followed by a coaxial needle system consisting of an outer cannula and an inner, apple-corer shaped cutting needle with a side slot for specimen removal.

[Figure 16 ILLUSTRATION OMITTED]

Approach to the musculoskeletal lesion varies with location and intervening structures. Long bones of the extremities usually are approached anteriorly or laterally to avoid the neurovascular bundles.[171] The shortest path is chosen if there are no important intervening structures. An exception to this would be for thin or flat bones, when a needle path traversing the long axis of the lesion would be safer and more productive. In addition, a less direct route may be desirable to place the needle track within the planned surgical incision when resection is necessary.[163]

In the pelvis, an anterior approach is used for the pubis, while a posterior approach is used for the ilium, ischium and sacrum. (See Figs. 17 and 18.) In the spine, the spinous processes and laminae are biopsied from a posterior approach. A posterolateral approach is used for the transverse processes, pedicles, thoracic vertebral bodies and lumbar vertebral bodies. The first thoracic through fourth cervical vertebral bodies are punctured with a lateral approach. An anterior, transpharyngeal approach through the open mouth may be applied for IGPNB of the upper 3 cervical vertebrae.[171]

[Figures 17-18 ILLUSTRATION OMITTED]

There have been few serious complications reported as a result of IGPNB in the musculoskeletal system. The most frequent complication is mild pain primarily related to inadequate anesthesia and negative pressure or needle manipulation within the medullary canal.[163] Neurologic damage and paraplegia are the most serious complications reported with any significant frequency. Pneumothorax has been associated with IGPNB of the thoracic spine and ribs.[171] Hemorrhage may result from vascular injury, such as aortic puncture,[172] or from biopsy of vascular lesions.[162] Other extremely rare complications include foot drop, pneumonia, pneumoretroperitoneum, meningitis and death.[162] Overall, IGPNB has been found to be a safe and effective alternative to open, surgical biopsy for diagnosis of musculoskeletal tumors.

Conclusion

IGPNB has developed into a valuable tool for diagnosis of nonpalpable or deep-seated lesions that cannot be characterized definitively by their appearance on diagnostic images. Principal goals for the use of IGPNB are to decrease the need for surgical biopsy and to determine the nature of a lesion before nonsurgical treatment. This practice is driven by economic forces and the desire for minimally invasive diagnostic procedures.

IGPNB techniques are safe and effective alternatives to open surgical biopsy for diagnosis of a variety of lesions. Advances in biopsy needles and percutaneous biopsy system design have improved the safety and tissue yield of these procedures. Smaller diameter needles with improved tissue-cutting features allow multiple passes into a lesion with minimal complications and retrieval of sufficient material for both histologic and cytologic evaluation.

References

[1.] Hopper KD. Percutaneous, radiographically guided biopsy: a history. Radiology. 1995;196:329-333.

[2.] Kun M. A new instrument for the diagnosis of tumors. Mon J Med Sci. 1847;7:853.

[3.] Lebert H. Traite Practique des Maladies Cancereuse et des Affections Curables Confoundues Avec le Cancer. Paris: J.B. Bailiere; 1851.

[4.] Paget J. Lectures on Tumors. London: Langman; 1853.

[5.] Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg. 1930;92:169-181.

[6.] Coley BL, Sharp GS, Ellis EB. Diagnosis of bone tumors by aspiration. Am J Surg. 1931;13:215-224.

[7.] Stewart FW. The diagnosis of tumors by aspiration. Am J Pathol. 1933;9:801-812.

[8.] Martin HE, Stewart FW. The advantages and limitations of aspiration biopsy. AJR Am J Roentgenol. 1936;35:245-247.

[9.] Nguyen G, Kline TS. Essentials of Aspiration Biopsy Cytology. New York, NY: Igaku-Shoin; 1991:1-13.

[10.] Blady JV. Aspiration biopsy of tumors in obscure or difficult locations under roentgenoscopic guidance. AJR Am J Roentgenol. 1939;42:515-524.

[11.] Craver LF, Binkley JS. Aspiration biopsy of tumors of the lung. J Thorac Surg. 1939;8:436-463.

[12.] Dean AL. Treatment of solitary cyst of kidney by aspiration (abstr). Trans Am Assoc Genitourin Surg. 1939;32:91.

[13.] Lusted LB, Mortimore GE, Hopper J. Needle renal biopsy under image amplifier control. AJR Am J Roentgenol. 1956;75:953-955.

[14.] Edholm P, Fernstrom I, Lindblom K, Seldinger SJ. Roentgen television in practice with special regard to puncture examination. Acta Radiol. 1962;216(suppl):l

[15.] Lalli AF. The direct fluoroscopically-guided approach to renal, thoracic, and skeletal lesions. Curt Probl Radiol. 1972;2:3-49.

[16.] Joyner CR, Herman RJ, Reid JM. Reflected ultrasound in the detection and localization of pleural effusion. JAMA. 1967;200:399-402.

[17.] Alfidi RJ, Haaga J, Meaney TF, et al. Computed tomography of the thorax and abdomen: a preliminary report. Radiology. 1975;117:257-264.

[18.] Haaga JR, Alfidi RJ. Precise biopsy localization by computed tomography. Radiology. 1976;118:603-607.

[19.] Mueller PR, Stark DD, Simone JF, et al. MR-guided aspiration biopsy: needle design and clinical trials. Radiology. 1986;161:605-609.

[20.] Lufkin R, Teresi L, Hanafee W. New needle for MR-guided aspiration cytology of the head and neck. AJR. 1987;149:380-382.

[21.] Westcott JL. Lung Biopsy. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers; 1990:9-17.

[22.] Garcia FU. General cytologic pitfalls. In: Atkinson BF, Silverman JF, eds. Atlas of Difficult Diagnoses in Cytopathology. Philadelphia, Pa: WB Saunders; 1998:7-8.

[23.] Labadie M, Liaras A. Cytology. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers Inc; 1990:2-8.

[24.] Turner AF. Radiographically guided techniques of biopsy. In: McKenna RJ, Murphy GP, eds. Cancer Surgery. Philadelphia, Pa: JB Lippincott; 1994:21-33.

[25.] McGahan JP, Brant WE. Principles, Instrumentation, and Guidance Systems. In: McGahan JP, ed. Interventional Ultrasound. Baltimore, Md: Williams & Wilkins; 1990:1-20.

[26.] Dicato M, Freilinger J, Dondelinger RF, Kurdziel JC. Economic considerations. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers Inc, 1990:64-66.

[27.] Higgins JL, Letourneau JG. Percutaneous biopsy Techniques. Part 1. Radiologic biopsy of abdominal masses. In: Castaneda-Zuniga WR, ed. Interventional Radiology. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997:1691-1718.

[28.] Casola G, Nicolet V, vanSonnenberg E, et al. Unsuspected pheochromocytoma: risk of blood-pressure alterations during percutaneous adrenal biopsy. Radiology. 1986;159:733-735.

[29.] Silverman SG, Mueller PR, Pfister RC. Hemostatic evaluation before abdominal interventions: an overview and proposal. A JR Am J Roentgenol. 1990;154:233-238.

[30.] Rapaport SI. Preoperative hemostatic evaluation: Which tests, if any? Blood. 1983;61:229-231.

[31.] Obergfell AM. Law and Ethics in Diagnostic Imaging and Therapeutic Radiology. Philadelphia, Pa: WB Saunders; 1995.

[32.] Spies JB, Berlin L. Complications of percutaneous needle biopsy. AJR Am J Roentgenol. 1998;171:13-17.

[33.] Charboneau JW, Reading CC, Welch TJ. CT and sonographically guided needle biopsy: current techniques and new innovations. AJR Am J Roentgenol. 1990;154:1-10.

[34.] Haaga JR. Interventional CT-guided procedures. In: Haaga JR, Lanzieri CF, Sartoris DJ, Zerhouni EA, eds Computed Tomography and Magnetic Resonance Imaging of the Whole Body. 3rd ed. St. Louis, Mo: Mosby; 1994:1572-1610.

[35.]Otto RC, Donlinger RF, Kurdziel JC. Abdominal biopsy. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers Inc; 1990:33.

[36.] Silverman SG, Bloom DA, Seitzer SE, Tempany CMC, Adamus DF. Needle-tip localization during CT-guided abdominal biopsy: comparison of conventional and spiral CT. AJR Am J Roentgenol. 1992;159:1095-1097.

[37.] Katada K, Kato R, Anno H, et al. Guidance with real-time CT fluoroscopy: early clinical experience. Radiology. 1996;200:851-856.

[38.] Silverman SG. Biopsy of the liver and abdomen. In: Jolesz FA, Young IR, eds. Interventional MR: Techniques and Clinical Experience. St. Louis, Mo: Mosby; 1998:225-236.

[39.] Schnall MD. MR-guided breast biopsy: US experience. In: Jolesz FA, Young IR, eds. Interventional MR: Techniques and Clinical Experience. St. Louis, Mo: Mosby; 1998:209-213.

[40.] Bittner C, Anzai Y, Curran J, Lufkin RB. MR-guided biopsy of the head, neck and brain. In: Jolesz FA, Young IR, eds. Interventional MR: Techniques and Clinical Experience. St. Louis, Mo: Mosby; 1998:195-207.

[41.] Schenck JF, Jolesz FA, Roemer PB, et al. Superconducting open configuration MRI system for image-guided therapy. Radiology. 1995;195:804-814.

[42.] Silverman SG, Collick BD, Figueira MR, et al. Interactive biopsy in an open configuration MRI system. Radiology. 1995;197:175-181.

[43.] Okuda K, Tanikawa K, Emura T, et al. Nonsurgical, percutaneous transhepatic cholangiography: diagnostic significance in medical problems of the liver. Dig Dis. 1974;19:21-36.

[44.] Menghini G. One-second biopsy of the liver. Gastroenterol. 1958;35:190-199.

[45.] Turner AF Sargent EN. Percutaneous pulmonary needle biopsy. A JR Am J Roentgenol. 1968;104:846-850.

[46.] Nordenstrom B. New instrument for biopsy. Radiology. 1975;117:474-475.

[47.] Greene R, Szyfelben WM, Isler RJ, Stark P, Jantsch H. Supplementary tissue-core histology from fine-needle transthoracic aspiration biopsy. AJR Am J Roentgenol. 1985;144:787-792.

[48.] Madayag MA. Combined hepatic angiography and percutaneous aspiration biopsy in the evaluation of primary hepatic neoplasm. Gastrol Radiol. 1982;7:159-163.

[49.] Franceen CC. Aspiration biopsy with a description of a new type of needle. N Engl J Med. 1941;224:1054-1058.

[50.] Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology. 1980;137:31-35.

[51.] Andriole JG, Haaga JR, Adams RB, Nunez C. Biopsy needle characteristics assessed in the laboratory. Radiology. 1983;148:659-662.

[52.] Mladinich CRJ, Ackerman N, Berry CR, Buergelt CD, Longmate J. Evaluation and comparison of automated biopsy devices. Radiology. 1992;184:845-847.

[53.] Hopper KD, Abendroth CS, Sturtz KW, Matthews YL, Hartzel JS, Potok PS. CT percutaneous biopsy guns: comparison of end-cut and side-notch devices in cadaveric specimens. A JR Am J Roentgenol. 1995;164:195-199.

[54.] McGahan JP. Laboratory assessment of ultrasonic needle and catheter visualization. J Ultrasound Med. 1986;5:373-377.

[55.] Reading CC, Charboneau JW, James EM, Hurt MR. Sonographically guided percutaneous biopsy of small (3 cm or less) masses. AJR Am J Roentgenol. 1988;151:189-192.

[56.] Lufkin R, Teresi L, Hanafee W. New needle for MR-guided aspiration cytology of the head and neck. AJR. 1987;149:380-382.

[57.] Steiner P, Erhart P, Heske N, et al. Active biplane MR tracking for biopsies in humans. AJR Am J Roentgenol. 1997;169:735-741.

[58.] McLoud T. Interventional techniques. In: McLoud TC. Thoracic Radiology: The Requisites. St. Louis, Mo: Mosby; 1998:515-523.

[59.] Tarver RD, Conces DJ. Interventional chest radiology. Radiol Clin North Am. 1994;32:689-709.

[60.] Atkinson BF, Silverman JF. Atlas of Difficult Diagnoses in Cytopathology. Philadelphia: WB Saunders Co; 1998:1-27.

[61]. Lieu D. Fine-needle aspiration: technique and smear preparation. Am Fam Physician. 1997;55:839- 846.

[62.] Labadie M, Liaras A. Cytology. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers Inc; 1990:3.

[63.] Hopwood D. Fixation and fixatives. In: Bancroft JD, Stevens A, eds. Theory and Practice of Histologic Techniques. New York, NY: Churchill Livingstone; 1990:21-42.

[64.] Bassett L, Winchester DP, Caplan RB, et al. Stereotactic core-needle biopsy of the breast: a report of the joint task force of the American College of Radiology, American College of Surgeons, and College of American Pathologists. CA Cancer J Clin. 1997;47:171-190.

[65.] Shah RM, Spirn PW, Salazar AM, et al. Localization of peripheral pulmonary nodules for thorascopic excision: value of CT-guided wire placement. A JR Am J Roentgenol. 1993;161:279.

[66.] Leyden OO. Uber infectiose pneumoniae. Stech Med Wochenschr. 1883;9:52.

[67.] Dahlgren S, Nordenstrom B, eds. Transthoracic Needle Biopsy. Stockholm: Almquist and Wiksell;1966.

[68.] Hansell DM. Interventional techniques. In: Armstrong P, Wilson AG, Dee P, Hansell DM, eds. Imaging of Diseases of the Chest. 2nd ed. St. Louis, Mo: Mosby; 1995:894-912.

[69.] Yankelevitz DF, Henschke CI, Koizumi J, Libby DM, Topham S, Altorki N. CT-guided transthoracic needle biopsy following indeterminate fiberoptic bronchoscopy in solitary pulmonary nodules. Clin Imag. 1998;22:7-10.

[70.] Radley SPG, Flower CDR. Complications of percutaneous intervention in the thorax. In: Ansell G, Bettman MA, Kaufman JA, Wilkins RA. Complications in Diagnostic Imaging and Interventional Radiology. 3rd ed. Cambridge, Mass: Blackwell Science; 1996:473- 482.

[71.] Brown TS, Kanthapillai P. Transthoracic needle biopsy for suspected thoracic malignancy in elderly patients using CT guidance. Clin Radiol. 1997;53:116-119.

[72.] Berquist TH, Bailey PB, Cortese DA, Miller WE. Transthoracic needle biopsy: accuracy and complications in relation to location and type of lesion. Mayo Clin Proc. 1980;55:475-481.

[73.] Layfield LJ, Coogan A, Johnston WW, Patz EF. Transthoracic fine needle aspiration biopsy -- sensitivity in relation to guidance technique and lesion size and location. Acta Cytol. 1996;40:687-690.

[74.] Gardner D, VanSonnenberg E, D'Agostino HB, Casola G, Taggart S, May S. CT-guided transthoracic needle biopsy. Cardiovasc Interven Radiol. 1991;14:17-23.

[75.] Westcott JL. Needle biopsy of the chest. In: Tavares J, Ferrucci J, eds. Imaging-Diagnosis-Intervention. Vol 1. Philadelphia, Pa: Lippincott; 1993:1-13.

[76.] Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology. 1997;202:97-103.

[77.] Yankelevitz DF, Henschke CI, Koizumi JH, Altorki NK, Libby D. CT-guided transthoracic needle biopsy of solitary pulmonary nodules. Clin Imag. 1997;21:107-110.

[78.] Chang DB, Yang PC, Luh KT, et al. Ultrasound-guided leural biopsy with Tru-cut needle. Chest. 1991;100:1328-1333.

[79] ang PC, Chang DB, Yu CJ, et al. Ultrasound-guided core biopsy of thoracic tumors. Am Rev Respir Dis. 1992;146:763-767.

[80.] Yuan A, Yang PC, Chang DB. Ultrasound-guided aspiration biopsy of small pulmonary nodules. Chest. 1992;101:926-930.

[81.] Sawhney S, Jain R, Berry M. Tru-cut biopsy of mediastinal masses guided by real-time ultrasound. Clin Radiol. 1991;44:16-19.

[82.] Takkakoski T, Lohela P, Leppanen M, et al. Ultrasound-guided aspiration biopsy of anterior mediastinal masses. J Clin Ultrasound. 1991;19:209-214.

[83.] McLoud TC. Should cutting needles replace needle aspiration of lung lesions? Radiology. 1998;208:569- 570.

[84.] Staroselsky AN, Schwarz Y, Man A, Marmur S, Greif J. Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions. Chest. 1998;113:1522-1525.

[85.] Moore EH, Shepard JO, McLoud TC, et al. Positional precautions in needle aspiration lung biopsy. Radiology. 1990;175:733.

[86.] Kopans DB. Breast Imaging. Philadelphia, Pa: Lippincott-Raven Publishers; 1998:637-720.

[87.] American College of Radiology. Breast Imaging Reporting and Data System (BI-RADS). 2nd ed. Reston, Va: American College of Radiology; 1995.

[88.] Jackson VP, Bassett KW. Stereotactic fine-needle aspiration biopsy for nonpalpable breast lesions. AJR Am J Roentgenol. 1990;154:1196-1197.

[89.] Kopans DB. Fine-needle aspiration of clinically occult breast lesions. Radiology. 1989;170:313-314.

[90.] Pisano ED, Fajardo LL, Tsimikas J, et al. Rate of insufficient samples for fine-needle aspiration for nonpalpable breast lesions in a multicenter clinical trial. Cancer. 1998;82:679-688.

[91.] Webb AJ. The diagnostic cytology of breast carcinoma. Br J Surg. 1970;57:259-263.

[92.] Levin E, Sadowsky N. Complications of interventional procedures in the breast. In: Ansell G, Bettman MA, Kaufman JA, Wilkins RA, eds. Complications in Diagnostic Imaging and Interventional Radiology. 3rd ed. Cambridge, Mass: Blackwell Science; 1996:603-611.

[93.] Acheson MB, Patton RG, Howlsey RL, Lane RF, Morgan A. Histologic correlation for imaging-guided core biopsy with excisional biopsy of nonpalpable breast lesions. Arch Surg. 1997;132:815-821.

[94.] McCombs MM, Bassett LW, DeBruhl N, Jahan R, Fu YS. Imaging-guided needle biopsy of the breast. In: Bassett LW, Jackson VP, Jahan R, Fu YS, Gold RH, eds. Diagnosis of Diseases of the Breast. Philadelphia, Pa: WB Saunders Co; 1997:251-261.

[95.] Liberman L, Dershaw DD, Rosen PP, Cohen MA, Hann LE, Abramson AF. Stereotaxic core biopsy of impalpable speculated breast masses. A JR Am J Roentgenol. 1995;165:551-554.

[96.] Kaufman CS, Delbecq R, Jacobson L. Excising the reexcision: stereotactic core-needle biopsy decreases need for reexcision of breast cancer. World J Surg. 1998;22:1023-1028.

[97.] Pile-Spellman ER. Stereotactic core needle biopsy. In: Kinne DW, ed. Multidisciplinary Atlas of Breast Surgery. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:7-17.

[98.] Reynolds HE, Jackson VP. Sonographically guided interventional procedures. In: Bassett LW, Jackson VP, Jahan R, Fu YS, Gold RH, eds. Diagnosis of Diseases of the Breast. Philadelphia, Pa: WB Saunders Co; 1997:263-274.

[99.] Ciatto S, Catarzi S, Morrone D, Roselli del Turco M. Fine needle aspiration cytology of non-palpable breast lesions: US versus stereotactic guidance. Radiology. 1993;188:195-198.

[100.] Parker SH, Lovins JD, Jobe WE, et al. Non-palpable breast lesions: stereotaxic automated large-core biopsies. Radiology. 1991;180:403-407.

[101.] Orel SG, Schnall MD, Newman RW, Powell CM, Torosian MH, Rosario EF. MR-imaging-guided localization and biopsy of breast lesions: initial experience. Radiology. 1994;193:97-102.

[102.] Fischer U, Vosshenrich R, Bruhn H, Keating D, Raab BW, Oestmann JW. MR-guided localization of suspected breast lesions detected exclusively by post-contrast MRI. J Conput Assist Tomogr. 1995;19:63-66.

[103.] Fischer U, Vosshenrich R, Keating D, et al. MR-guided biopsy of suspected breast lesions with a stereotaxic add-on device for surface coils. Radiology. 1994;192:272-273.

[104.] Kuhl CK, Elevelt A, Leutner CC, Gieseke J, Pakos E, Schild HH. Interventional breast MR imaging: clinical use of a stereotactic localization and biopsy device. Radiology. 1997;204:667-675.

[105.] DeSouza NM, Coutts GA, Puni RK, Young IR. Magnetic resonance imaging guided breast biopsy using a frameless stereotactic technique. Clin Radiol. 1996 ;51:425-428.

[106.] Brenner RJ, Shellock FG, Rothman BJ, Giuliano A. Technical note: magnetic resonance imaging-guided preoperative breast localization using "freehand technique." Br J Radiol. 1995;68:1095-1098.

[107.] Daniel BL, Birdwell RL, Ikeda DM, et al. Breast lesion localization: a freehand, interactive MR imaging-guided technique. Radiology. 1998;207:455-463.

[108.] Khalkhali I, Mishkin FS, Diggles LE, Klein SR. Radionuclide-guided stereotactic prebiopsy localization of nonpalpable breast lesions with normal mammograms. J Nuc Med. 1997;38:1019-1022.

[109.] Parker SH, Levin JD, Jobe WE, et al. Stereotactic breast biopsy with a biopsy gun. Radiology. 1990;176:741-747.

[110.] Burbank F. Stereotactic breast biopsy of atypical ductal hyperplasia and ductal carcinoma in situ lesions: improved accuracy with directional, vacuum-assisted biopsy. Radiology. 1997;202:843-847.

[111.] Liberman L, Smolkin JH, Dershaw DD, Morris EA, Abramson AF, Rosen PR. Calcification retrieval at stereotactic, 11-gauge, directional, vacuum-assisted breast biopsy. Radiology. 1998;208:251-260.

[112.] Jackman RJ, Burbank FH, Parker SH, et al. Atypical ductal hyperplasia diagnosed by 11-gauge, directional, vacuum-assisted breast biopsy: how often is carcinoma found at surgery? (abstr) Radiology. 1997;205:325.

[113.] Liberman L, Dershaw DD, Morris EA, Abramson AF, Thornton CM, Rosen PP. Clip placement after stereotactic vacuum-assisted breast biopsy. Radiology. 1997;205:417-422.

[114.] Liberman L, Dershaw DD, Rosen PP, et al. Stereotaxic 14-gauge breast biopsy: how many core biopsy specimens are needed? Radiology. 1994;192:793-795.

[115.] Brenner RJ, Fajardo L, Fisher PR, et al. Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy. A JR Am J Roentgenol. 1996;166:341-346.

[116.] Lagios MD, Bennington JL. Protocol for the pathologic examination and tissue processing of the mammographically directed breast biopsy. In: Bennington JL, Lagios MD, eds. The Mammographically Directed Biopsy. Vol 1. Philadelphia, Pa: Hanley and Belfus; 1992:23-45.

[117.] Burbank F. Stereotactic breast biopsy: comparison of 14- and 11-gauge Mammotome probe performance and complication rates. Am Surg. 1997;63:988-995.

[118.] Reddy KJ, Jeffers LJ. Evaluation of the liver: liver biopsy and laparoscopy. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. Vol 1. 8th ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1999:245-265.

[119.] Brown SD, vanSonnenberg E, Mueller PR. Interventional imaging of the liver and biliary system: interventional radiology in the liver, biliary tract, and gallbladder. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. Vol 1. 8th ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1999:343-365.

[120.] Reddy KR, Schiff ER. Complication of liver biopsy. In: Taylor MB, Gollan JL, Wolfe MM, eds. Gastrointestinal Emergencies. 2nd ed. Baltimore, Md: Williams & Wilkins, 1997:959-968.

[121.] Pieters PC, Bettman MA. Complications of transhepatic biliary procedures. In: Ansell G, Bettman MA, Kaufman JA, Wilkins RA. Complications in Diagnostic Imaging and Interventional Radiology. 3rd ed. Cambridge, Mass: Blackwell Science; 1996:503-505.

[122.] Rofsky NM, Yang BM, Schlossberg P, Goldenberg A, Teperman LW, Weinreb JC. MR-guided needle aspiration biopsies of hepatic masses using a closed bore magnet. J Comput Assist Tomogr. 1998;22:633-637.

[123.] Lu DSK, Lee H, Farahani K, Sinha S, Lufkin R. Biopsy of hepatic dome lesions: semi-real-time coronal MR guidance technique. AJR Am J Roentgenol. 1997;168:737-739.

[124.] Heilo A, Stenwig AE. Liver hemangioma: US-guided 18-gauge core-needle biopsy. Radiology. 1997;204:719-722.

[125.] Ch Yu S, Metreweli C, Lau WY, Leung WT, Liew CT, Leung NWY. Safety of percutaneous biopsy of hepatocellular carcinoma with an 18 gauge automated needle. Clin Radiol. 1997;52:907-911.

[126.] Chuang UP, Alspaugh JP. Sheath needle for liver biopsy in high risk patients. Radiology. 1988;166:261-262.

[127.] Allison DJ, Adams A. Percutaneous liver biopsy and track embolization with steel coils. Radiology. 1988;169:261-263.

[128.] Layfield LJ, Wax TD, Lee JG, Cotton PB. Accuracy and morphologic aspects of pancreatic and biliary duct brushings. Acta Cytol. 1993;39:8-11.

[129.] Lees WR. Percutaneous needle aspiration and cytology. In: Beger HG, Warshaw AL, Buchler MW, et al, eds. The Pancreas. Cambridge, Mass: Blackwell Science; 1998:260-263.

[130.] Cahn M, Chang K, Nguyen P, Butler J. Impact of endoscopic ultrasound with fine-needle aspiration of pancreatic carcinoma. Am J Surg. 1996;172:470-472.

[131.] Neiman HL. Radiologic observations and techniques. In: Frias-Hidvegi D. Guides to Clinical Aspiration Biopsy: Liver and Pancreas. New York, NY: Igaku-Shoin; 1988:1-16.

[132.] Drachenberg CB, Papadimitriou JC, Klassen DK, et al. Evaluation of pancreas transplant needle biopsy: reproducibility and revision of histologic grading system. Transplantation. 1997;63:1579-1586.

[133.] Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Radiology. 1994;178:253-258.

[134.] Linder S, Blasjo M, Sundelin P, vonRosen A. Aspects of percutaneous fine-needle aspiration biopsy in the diagnosis of pancreatic carcinoma. Am J Surg. 1997;174:303-306.

[135.] Iverson P, Brun C. Aspiration biopsy of the kidney. Am J Med. 1951;11:324-330.

[136.] Lindbloom K. Diagnostic kidney puncture in cysts and tumors. AJR Am J Roentgenol. 1952;68:209-215.

[137.] Suen KC. Kidneys and urinary tract. In: Suen KC. Guides to Clinical Aspiration Biopsy: Retroperitoneum and Intestine. 2nd ed. New York, NY: Igaku-Shoin; 1994:247-286.

[138.] Cronan JJ. Percutaneous biopsy. Radiol Clin North Am. 1996;34:1207-1223.

[139.] Kim D, Kim H, Shin G, et al. A randomized, prospective, comparative study of manual and automated renal biopsies. Am J Kidney Dis. 1998;32:426-431.

[140.] Kovalik EC, Schwab SJ, Gunnells JC, Bowie D, Smith SR. No change in complication rate using spring-loaded gun compared to traditional percutaneous renal allograft biopsy techniques. Clin Nephrol. 1996;45:383-385.

[141.] Suen KC. Adrenals. In: Suen KC. Guides to Clinical Aspiration Biopsy: Retroperitoneum and Intestine. 2nd ed. New York, NY: Igaku-Shoin; 1994:213-246.

[142.] Nadji M, Ganjei P. Fine-needle aspiration cytology of the ovary. In: Bonfiglio TA, Erozan YS, eds. Gynecologic Cytopathology. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:157-164.

[143.] Rifkin MD. Biopsy techniques. In: Rifkin MD. Ultrasound of the Prostate: Imaging in the Diagnosis and Therapy of Prostatic Disease. 2nd ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:237-262.

[144.] Gothlin JH. Percutaneous lymph node biopsy. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers; 1990:53-57.

[145.] Zajdela A, Zillhardt P, Voillemot N. Cytologic diagnosis by fine needle sampling without aspiration. Cancer. 1987;59:1201-1205.

[146.] Elvin A, Sundstrom C, Larsson SG, Lindgren PG. Ultrasound-guided 1.2-mm cutting-needle biopsies of head and neck tumours. Acta Radiol. 1997;38:376-380.

[147.] Righi PD, Kopecky KK, Caldemeyer KS, Ball VA, Weisberger EC, Radpour S. Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection. Head Neck. 1997;19:604-610.

[148.] Burger PC, Nelson JS. Stereotactic brain biopsies: specimen preparation and evaluation. Arch Pathol Lab Med. 1997;121:477-480.

[149.] Kondziolka D, Dempsey PK, Lunsford LD, et al. A comparison between magnetic resonance imaging and computed tomography for stereotactic coordinate determination. Neurosurgery. 1992;30:402-407.

[150.] Fried MP, Hsu L, Jolensz FA. Interactive magnetic resonance imaging-guided biopsy in the head and neck: initial patient experience. Laryngoscope. 1998;108:488-493.

[151.] Clark OH. Fine-needle aspiration biopsy and management of thyroid tumors. Am J Clin Pathol. 1997;108(4 suppl 1):S22-S25.

[152.] Powers CN, Frable WJ. Thyroid and parathyroid. In: Powers CN, Frable WJ. Fine Needle Aspiration Biopsy of the Head and Neck. Boston, Mass: Butterworth-Heinemann; 1996:49-73.

[153.] Davoudi MM, Yeh KA, Wei JP. Utility of fine-needle aspiration cytology and frozen-section examination in the operative management of thyroid nodules. Am Surg. 1997;63:1084-1090.

[154.] Taki S, Kakuda K, Kakuma K, et al. Thyroid nodules: evaluation with US-guided core biopsy with an automated biopsy gun. Radiology. 1997;202:874-877.

[155.] Shah JP, DeLacure. Head and neck surgery. In: McKenna RJ, Murphy GP, eds. Cancer Surgery. Philadelphia, Pa: JB Lippincott; 1994:515-535.

[156.] Powers CN, Frable WJ. Salivary glands. In: Powers CN, Frable WJ, eds. Fine Needle Aspiration Biopsy of the Head and Neck. Boston, Mass: Butterworth-Heinemann; 1996:22-48.

[157.] Filopoulos E, Angeli S, Daskalopoulou D, Kelessis N, Vassilopoulos P. Pre-operative evaluation of parotid tumours by fine needle biopsy. Euro J Surg Onc. 1998;24:180-183.

[158.] MacLeod CB, Frable WJ. Fine needle aspiration biopsy of the salivary gland: problem cases. Diagn Cytopathol. 1993;9:216-225.

[159.] Rush BF. Cancers with an unknown primary. In: McKenna RJ, Murphy GP, eds. Cancer Surgery. Philadelphia, Pa: JB Lippincott; 1994:719-724.

[160.] Powers CN, Frable WJ. Lymph nodes. In: Powers CN, Frable WJ, eds. Fine Needle Aspiration Biopsy of the Head and Neck. Boston, Mass: Butterworth-Heinemann; 1996:74-105.

[161.] Dyck P, Bouzaglou A, Wiseman C. Malignant brain and spinal cord tumors. In: McKenna RJ, Murphy GP, eds. Cancer Surgery. Philadelphia, Pa: JB Lippincott; 1994:701-717.

[162.] Resnick D. Needle biopsy of bone. In: Resnick D. Diagnosis of Bone and Joint Disorders. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1995:475-485.

[163.] Carrasco CH, Yasko AW. Percutaneous skeletal biopsy. In: Castaneda-Zuniga WR, ed. Interventional Radiology. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997:1719-1721.

[164.] Ghelman B. Biopsies of the musculoskeletal system. Radiol Clin North Am. 1998;36:567-580.

[165.] Dupuy DE, Rosenberg AE, Punyaratabandhu T, Tan MH, Mankin HJ. Accuracy of CT-guided needle biopsy of musculoskeletal neoplasms. AJR Am J Roentgenol. 1998; 171:759-762.

[166.] Schweitzer ME, Gannon FH, Deely DM, O'Hara BJ, Junea v. Percutaneous skeletal aspiration and core biopsy: complementary techniques. AJR Am J Roentgenol. 1996;166:415-418.

[167.] Collins JD, Bassett L, Main GD, Kagan C. Percutaneous biopsy following positive bone scans. Radiology. 1979;132:439-442.

[168.] White LM, Schweitzer ME, Deely DM. Coaxial percutaneous needle biopsy of osteolytic lesions with intact cortical bone. A JR Am J Roentgenol. 1996;166:143-144.

[169.] Laredo JD, Bellaiche L, Hamze B, Naouri JF, Bondeville JM, Tubiana JM. Current status of musculoskeletal interventional radiology. Radiol Clin North Am. 1994;32:377-398.

[170.] Kruyt RH, Oudkerk M, van Sluis D. CT-guided bone biopsy in a cancer center: experience with a new apple corer-shaped device. J Comput Assist Tomogr. 1998;22:276-281.

[171.] Carrasco CH, Charnsangavej C, Richli WR, Wallace S. Bone biopsy. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S, eds. Interventional Radiology. New York, NY: Thieme Medical Publishers; 1990:5863.

[172.] Olscamp A, Rollins J, Tao SS, Ebraheim NA. Complications of CT-guided biopsy of the spine and sacrum. Orthopedics. 1997;20:1149-1152.

Bruce W. Long, M.S., R.T.(R)(CV), is an associate professor in the radiologic sciences program at Indiana University School of Allied Health Sciences, Indiana School of Medicine, in Indianapolis.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.

[C] 2000 by the American Society of Radiologic Technologists.

Directed Reading Continuing Education Quiz
DRI0000003
Expiration Date:
April 30, 2002(*)
Approved for 2.5
Cat. A CE credits


To receive Category A continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on page 382 and then follow the directions for submitting the answer sheet to the American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at www.asrt.org.

(*) Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.
1. A percutaneous needle biopsy is considered to be
   a(n) -- biopsy.

  a. closed.
  b. open.
  c. surgical.
  d. wedge.


2. Into which 2 procedural areas is IGPNB divided?
  a. endobiliary brush biopsy and percutaneous
     core needle biopsy.
  b. transbronchial bronchoscopic biopsy and fine-needle
     aspiration biopsy.
  c. fine-needle aspiration biopsy and percutaneous
     core needle biopsy.
  d. transvenous needle biopsy and percutaneous
     core needle biopsy.


3. -- biopsy is used to collect cellular specimens from a lesion for cytologic and microbiologic analysis.
  a. Fine-needle aspiration.
  b. Percutaneous core needle.
  c. Percutaneous cutting needle.
  d. Core needle.


4. -- biopsy is performed when a tissue specimen is required for histologic analysis.
  a. Fine-needle aspiration.
  b. Endobiliary brush.
  c. Percutaneous core needle.
  d. Endoscopic fine-needle aspiration.


5. Techniques for PNB have been described in the literature since the -- century.
  a. early 19th.
  b. mid 19th.
  c. late 19th.
  d. early 20th.


6. Uses of PNB in the United States were first published in the:
  a. 1920s.
  b. 1930s.
  c. 1940s.
  d. 1950s.


7. Ultrasound was applied as an image guidance technique for PNB in the late:
  a. 1950s.
  b. 1960s.
  c. 1970s.
  d. 1980s.


8. Computed tomography was used as an image guidance technique for PNB in the mid --.
  a. 1950s.
  b. 1960s.
  c. 1970s.
  d. 1980s.


9. Magnetic resonance imaging was used as an image guidance technique for PNB in the mid --.
  a. 1950s.
  b. 1960s.
  c. 1970s.
  d. 1980s.


10. The complication common to IGPNB in all body regions is --.
  a. pneumothorax.
  b. bleeding.
  c. pneumoperitoneum.
  d. neurologic damage.


11. Which of the following tests are commonly included in the prebiopsy screening for inadequate clotting?
  1. prothrombin time (PT).
  2. blood urea nitrogen (BUN).
  3. partial thromboplastin time (PTT).

  a. 1 and 2.
  b. 1 and 3.
  c. 2 and 3.
  d. 1, 2 and 3.


12. Which of the following tests is used to assess renal function?
  a. bilirubin level.
  b. platelet count.
  c. creatinine level.
  d. leukocyte count.


13. Which of the following does not warrant extending the standard postbiopsy observation period?
  a. a large caliber needle was used.
  b. the patient complains of fatigue.
  c. pneumothorax.
  d. poorly controlled bleeding.


14. Which of the following is the most commonly used guidance technique for real-time visualization of needle placement?
  a. fluoroscopy.
  b. CT.
  c. sonography.
  d. MR.


15. Which of the following PNB needles has a serrated, 3-point tip?
  a. Westcott.
  b. Chiba.
  c. Franceen.
  d. Madayag.


16. Which of the following PNB needles has a tissue-cutting side slot?
  a. Westcott.
  b. Chiba.
  c. Franceen.
  d. Madayag.


17. The term used to describe the saw-toothed or serrated tip of bone-cutting needles is --.
  a. point.
  b. cannula.
  c. trephine.
  d. bevel.


18. A -- needle system consists of an outer needle guide (cannula) and an inner biopsy needle.
  a. single.
  b. coaxial.
  c. triaxial.
  d. side-by-side.


19. A -- cc syringe commonly is used to create a vacuum during FNAB.
  a. 5.
  b. 10.
  c. 30.
  d. 50.


20. Tissue samples from a PCNB are placed immediately into a fixation solution usually consisting of 10% --.
  a. ethyl alcohol.
  b. glacial acetic acid.
  c. gluteraldehyde.
  d. neutral buffered formalin.


21. Image-intensified fluoroscopy was applied to FNAB of the lung in the mid --
  a. 1940s.
  b. 1950s.
  c. 1960s.
  d. 1970s.


22. Which of the following is a contraindication for TNB?
  a. suspected metastatic disease.
  b. compromised immunity.
  c. severe chronic obstructive pulmonary disease
     (COPD).
  d. mediastinal mass.


23. The most common complication of TNB is:
  a. pneumothorax.
  b. air embolism.
  c. hemoptysis.
  d. hemothorax.


24. The severity of a postbiopsy pneumothorax may be reduced by the having the patient:
  a. sit upright in a chair.
  b. stand.
  c. lie with the biopsy site visible and free from
     pressure.
  d. lie with the biopsy site dependent.


25. The gold standard for breast biopsy is:
  a. FNAB.
  b. PCNB.
  c. surgical biopsy.
  d. ductal brush biopsy.


26. BI-RADS stands for:
  a. Breast Imaging Reporting and Data System.
  b. Breast Imaging Review and Diagnostic System.
  c. Bureau Internationale Radiologic Diagnostic
     Societe.
  d. Bivalent Integrated Reporting and Data System.


27. When using directional, vacuum-assisted breast biopsy systems, retrieval of 5 specimens has been recommended to ensure a high degree of accuracy, but -- or more specimens may be required if calcifications are present in the lesion.
  a. 7.
  b. 8.
  c. 9.
  d. 10.


28. The "1-second technique" for percutaneous liver biopsy was developed in 1958 by:
  a. Mengini.
  b. Madayag.
  c. Mueller.
  d. Mendelson.


29. According to Lees,[129] the -- is the most dangerous abdominal organ to biopsy.
  a. liver.
  b. pancreas.
  c. kidney.
  d. stomach.


30. Which of the following is an indication for an adrenal IGPNB?
  a. a large adrenal mass and no known malignancy.
  b. asymptomatic patient with large ([is greater than] 5 cm)
     adrenal mass.
  c. small ([is less than] 5 cm) adrenal mass and a primary lung
     tumor.
  d. MR results consistent with nonfunctioning
     adenoma.


31. FNAB is used successfully for lymph node biopsy. However, PCNB is often necessary to provide sufficient tissue for histologic subtyping of:
  a. sarcoma.
  b. adenocarcinoma.
  c. metastatic disease.
  d. lymphoma.


32. The salivary gland most frequently examined with IGPNB is the:
  a. parotid.
  b. submandibular.
  c. sublingual.
  d. assessory.


33. The most common origin of skeletal metastasis is the:
  a. thyroid.
  b. lung.
  c. prostate.
  d. kidney.


34. Which of the following is a bone biopsy needle?
  a. Chiba.
  b. Greene.
  c. Ackermann.
  d. Abrams.


Reference No. DRI0000003
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Author:LONG, BRUCE W.
Publication:Radiologic Technology
Geographic Code:1USA
Date:Mar 1, 2000
Words:15212
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