Ultrasound (US)-guided percutaneous core biopsy of pancreatic tumor:tips and tricks to ensure safe and effective biopsy

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1 Ultrasound (US)-guided percutaneous core biopsy of pancreatic tumor:tips and tricks to ensure safe and effective biopsy Poster No.: C-2368 Congress: ECR 2014 Type: Scientific Exhibit Authors: J. W. Kim, S. M. Kim, S. S. Shin, S. H. Heo, Y. Y. Jeong, H K. Kang ; Jeollanamdo/KR, Gwangju/KR, Jeollanam-do/KR, 4 5 Jeonnam/KR, Kwang-ju/KR Keywords: Pancreas, Ultrasound, Biopsy, Education and training DOI: /ecr2014/C-2368 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 34

2 Aims and objectives The purpose of this exhibit is to review the US-guided percutaneous core biopsy of pancreatic tumor (USPPB) including indications, approach paths, tips of needle handling, contraindications, and potential complications, with emphasis on how to decide safe needle pathway using video clips and illustrations. Fig. 1 Page 2 of 34

3 Fig. 2 Page 3 of 34

4 Fig. 3 Page 4 of 34

5 Methods and materials Fig. 4 General overview of USPPB A. indications The first indication is to confirm suspected malignancy in the pancreas. According to NCCN guidelines for pancreatic adenocarcinoma, histopathological confirmation is strongly recommended because all patients with unresectable pancreatic cancer should have confirmation before non-surgical treatment (1). The second is to determine nature of indeterminate lesion in the pancreas, and the last is to confirm mass suspected to be benign but in which benignity must be established. B. Contraindications Page 5 of 34

6 USPPB should be avoided in patients with uncorrectable coagulopathy, poor cooperation, and lack of safe path for biopsy. In case of poor cooperated patient, uncontrolled motion or irritability can occurs during USPPB, which may increase risk of injury. Lack of safe path for biopsy can be associated with high risk of overlying vascular injury around target lesion. However, biopsy path extending through liver, spleen or bowel is possible and safe. In case of mild coagulopathy secondary to aspirin use, USPPB can be performed at least 5 days later after discontinuation of aspirin, with confirmation of normal result on platelet function test. Sometimes, administration of appropriate blood product needs to be considered for USPPB. C. Preparation NPO should be done in a patient during 6 hours before biopsy. The operator should check patient's condition such as coagulopathy, medical history including taking an aspirin, prothrombin time (PT), activated partial thromboplastin time (aptt) and platelet count (6). Premedication (including sedatives & analgesics) is usually not necessary. Informed consent should be obtained regarding the process of procedure, risks, alternatives and benefit, before USPPB. Intravenous access may be established before biopsy, because parenteral administration of sedatives, analgesics, or other medications or fluid could be required during or after the biopsy procedure (5). In addition, in patient with increased risk of bleeding, a larger or second intravenous access site should be considered. D. Training of How to breathe Deep breathing should be avoided during USPPB, especially when trans-hepatic or trans-splenic approach path is selected for biopsy (Fig.3). Because migration distance of peritoneal organ along craniocaudal direction is longer during deep breathing than during shallow breathing, the risk of laceration of vital organs could be increased during USPPB. In fact, as a result of deep breathing during USPPB, vertical laceration of liver or spleen sometimes occurs along craniocaudal direction by inserted biopsy needle. Thus, shallow breathing during USPPB should be strongly recommended. The operator should make patients understand the importance of shallow breathing during USPPB and warn the risk of vital organ injury during deep breathing. How to decide approach path according to location of pancreatic tumors Proper planning of percutaneous needle approach path Anatomy of the pancreas Page 6 of 34

7 Fig. 5 Page 7 of 34

8 Fig. 6 Position Change of Surrounding Anatomy Peritoneal organs such as liver, stomach, jejunum, and colon can be movable during respiration and change of patient position (Fig.3). Factors affecting peritoneal organ movement are as follows; Respiration state (resting or expiration), NPO, compression by probe, and patient position. However, retroperitoneal organ is not movable. Page 8 of 34

9 Fig. 7 Planning of USPPB path Location of target Page 9 of 34

10 Fig. 8 Planning of Safe path Location of target lesions within pancreas is the most important factor to decide safe path for biopsy. The biopsy paths should be decided according to the location of target lesions within pancreas. The planning of USPPB firstly needs to be established with crosssectional images (CT or MRI) for seeking a safe path to target lesions and avoiding injury of important peritoneal structures such as major vessels, colon, small bowel, stomach, spleen and liver. And then, feasibility of biopsy path, which was pre-determined on CT or MRI must be confirmed by US before biopsy. Color Doppler US can be helpful to localize important vessels around pancreas that should be avoided (7, 8). If planned biopsy path on CT or MRI is considered to be inadequate for biopsy on US, another safe path should be sought using US. The less important vessels are visualized through biopsy path, the more biopsy path becomes safe. Page 10 of 34

11 Results Fig. 9 Page 11 of 34

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23 Fig. 21 Technical tips and tricks for safe and effective USPPB How to select biopsy needle Selection of adequate biopsy needle is very important for successful USPPB. It affects successful acquisition of adequate target tissue. A variety of needles with broad spectrums of calibers, lengths, and tip design are commercially available for percutaneous biopsy. Needle caliber is important factor for successful USPPB. In general, small caliber needles (20 to 25 gauge) are used primarily to obtain specimens for cytologic analysis and large caliber needles (14 to 19 gauge) can be used to obtain greater amount of material for more thorough histologic analysis (7). Recently, among large caliber needles, commercially available automated, spring-loaded biopsy gun with 18 gauge needle has been preferable for abdominal biopsy. Page 23 of 34

24 Fig. 22 Selection of biopsy needle with different sampling size depends on target size along biopsy path. Biopsy gun with broad spectrum of sampling size is commercially available. Biopsy gun with large sampling size is generally preferred when target is large and sufficiently thick for tissue cutting. In contrast, biopsy gun with small sampling size may be selected when target is small and thin. Page 24 of 34

25 Fig. 23 Selection of biopsy needle with different length depends on distance to target from skin along planned safe path. Biopsy needle with too long length is difficult to handle during biopsy. Tips for Clear Visualization of Biopsy Needle Key factors for safe and successful performance of USPPB are as follows; Clear visualization of biopsy needle during biopsy, effectively handling of biopsy needle, expertise of real-time US scanning, experience of US guided percutaneous biopsy. Page 25 of 34

26 Fig. 24 Many operators prefer "free-hand" approach in which needle is freely inserted through skin under US imaging without imaginary guiding line. Alignment of both needle tip and transducer should be parallel in free-hand technique. For accurate free-hand technique, it is very important that parallel placement of both needle and central ultrasound beam of transducer within same plane. It allows entire needle shaft to be clearly visualized. If needle was not visualized, needle might be mis-aligned. In this situation, re-alignment by fine movement of needle along perpendicular direction of transducer under fixed transducer position can be a useful tip for clear visualization of biopsy needle. Page 26 of 34

27 Fig. 25 Reflectivity of biopsy needle can affects USPPB performance. Large caliber needles are more readily visualized than small caliber needles. Thus, this is one of reasons why large caliber needle such as 18 gauge needle is more preferred for USPPB. Sometimes, needle is not visualized on US images during biopsy, even with large caliber needle used. In this situation, bobbing or in-and-out jiggling movement of biopsy needle during insertion of biopsy needle could improve needle visualization. Bobbing motion makes trajectory of needle more discernible within otherwise stationary field. Page 27 of 34

28 Fig. 26 The echotexture of structure which is being penetrated during biopsy also can affect visualization of biopsy needle. Biopsy needles are easily identified within relatively hypoechoic structures such as liver, spleen, target masses and subcutaneous fat layer. Presence of overlapping bowel gas or hyperechoic abdominal fat can render needle visualization difficult (Fig.11). Page 28 of 34

29 Fig. 27 How to effectively handle a biopsy needle Expected penetration length of biopsy needle should be carefully considered during tissue cutting. When using biopsy needle with double firing system, first, you can place needle tip at near edge of target lesion and then shoot single firing (advance inner cannula). Second, you can advance echogenic tip of inner cannula to desired depth within target for second firing of outer cutting cannula in a bid to cut target tissue. It is very useful to avoid unexpected injury of deep seated critical structure such as vessel by overpenetration of target lesion during biopsy Page 29 of 34

30 Fig. 28 Page 30 of 34

31 Conclusion Technically, US-guided percutaneous core biopsy of pancreatic tumor is still challenging. However, it could be a safe and feasible method with a full understanding of the proper methodology. We review the USPPB with various cases with video clips and illustrations: Proper planning of approach path for USPPB according to the location of pancreatic tumors Technical tips and tricks to ensure safe biopsy and to avoid potential complications Page 31 of 34

32 Personal information Jin Woong Kim, MD. PhD. Associate professor Department of Diagnostic Radiology Chonnam National University Hwasun Hospital #160 Ilsim-ri, Hwasun-eup, Hwasun-gun, Jeollanam-do, , South Korea Page 32 of 34

33 References 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. National Comprehensive Cancer Network: Fort Washington, Kliewer MA, Sheafor DH, Paulson EK, Helsper RS, Hertzberg BS, Nelson RC. Percutaneous liver biopsy: A cost-benefit analysis comparing sonographic and ct guidance. AJR Am J Roentgenol 1999;173: Sheafor DH, Paulson EK, Kliewer MA, DeLong DM, Nelson RC. Comparison of sonographic and ct guidance techniques: Does ct fluoroscopy decrease procedure time? AJR Am J Roentgenol 2000;174: Sheafor DH, Paulson EK, Simmons CM, DeLong DM, Nelson RC. Abdominal percutaneous interventional procedures: Comparison of ct and us guidance. Radiology 1998;207: Carol M. Rumack SRW, William Charboneau, Jo-Ann Johnson. Diagnostic ultrasound: Ultrasound-guided biopsy and drainage of the abdomen and pelvis. Mosby 2005;3rd Edition: Silverman SG, Mueller PR, Pfister RC. Hemostatic evaluation before abdominal interventions: An overview and proposal. AJR Am J Roentgenol 1990;154: Longo JM, Bilbao JI, Barettino MD, Larrea JA, Pueyo J, Idoate F et al. Percutaneous vascular and nonvascular puncture under us guidance: Role of color doppler imaging. Radiographics 1994;14: McGahan JP, Anderson MW. Pulsed doppler sonography as an aid in ultrasoundguided aspiration biopsy. Gastrointest Radiol 1987;12: Haaga JR, LiPuma JP, Bryan PJ, Balsara VJ, Cohen AM. Clinical comparison of smalland large-caliber cutting needles for biopsy. Radiology 1983;146: Matalon TA, Silver B. Us guidance of interventional procedures. Radiology 1990;174:43-47 Page 33 of 34

34 11. Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in europe in Ann Oncol 2007;18: Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, CA Cancer J Clin 2007;57: Kim KW, Kim MJ, Kim HC, Park SH, Kim SY, Park MS et al. Value of "Patent track" Sign on doppler sonography after percutaneous liver biopsy in detection of postbiopsy bleeding: A prospective study in 352 patients. AJR Am J Roentgenol 2007;189: Page 34 of 34