Interventional Radiology Biopsy PDF

Biopsy  Objectives of the lecture By the end of lecture students should be: ▀Summarize the basic information concerning biopsy procedure ▀ Develop the ability of performance biopsy procedure ▀ Illustrate the purpose, indication, and necessary patient preparation for each type of biopsy proced...

Biopsy  Objectives of the lecture By the end of lecture students should be: ▀Summarize the basic information concerning biopsy procedure ▀ Develop the ability of performance biopsy procedure ▀ Illustrate the purpose, indication, and necessary patient preparation for each type of biopsy procedure Needle Biopsy Of Lung (Chest) Nodules REVIEW The lungs are the organs of respiration. They are large conical- shaped structures that extend up to or slightly above the level of the 1st rib at their apex and down to the dome of the diaphragm at their concave- shaped bases.  A lung nodule is relatively round lesion, or area of abnormal tissue located within the lung, are most often detected on a chest x-ray and do not typically cause pain or other symptoms.. Needle biopsy Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This "stereotactic" equipment helps them pinpoint the exact location of the abnormal tissue. Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality  Types of needle biopsy A fine needle aspiration, a fine gauge needle and a syringe withdraw fluid or clusters of cells. In a core needle biopsy, the automated mechanism is activated, moving the needle forward and filling the needle trough, or shallow receptacle, with ‘cores’ of tissue. The outer sheath instantly moves forward to cut the tissue and keep it in the trough.  1 2 3 4 Advantages of needle biopsy include: With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided. The patient is spared the pain, scarring and complications associated with open surgery. Recovery times are usually shorter and patients can more quickly resume normal activities. Patient positioning and instruction The patient should be positioned prone or supine dependent on the skin entry site chosen.  Indications For Lung Biopsy 1.Patients with lesions on the chest radiograph 2.Multiple nodules in a patient not known to have malignancy or who has prolonged remission or more than one Primary malignancy. 3.Persistent focal infiltrates ,either single or multiple ,for which no diagnosis has been made by sputum or blood culture, or bronchoscope. 4.Hilar mass CONTRA INDICATIONS TO LUNG BIOPSY *Abnormalities of lung function ,respiratory failure (including mechanical ventilation) – *Arterial and venous pulmonary hypertension. *Coagulation abnormalities. Benefits Risks 1-Simple method to obtain 1-Infection. tissue samples to tell if 2-Cough blood nodule is cancer or not. during and after 2-It is less invasive. procedure. 3-Recovery time is short. 3-Pneumothorax. Breast Needle Biopsy Definition Breast needle biopsy is the removal of a sample of breast tissue using a needle. The sample is examined in a lab. There are different types of breast needle biopsies: 1-Fine needle aspiration 2-Ultrasound-directed needle biopsy 3- Stereotactic core needle biopsy 4- Magnetic resonance imaging (MRI)-guided breast biopsy 5-Vacuum-assisted device biopsy Procedure : 1- Fine Needle Aspiration The skin over the area will be cleaned. A small needle will be inserted into the breast tissue. Fluid and/or tissue will be removed. The needle may be removed and re-inserted more than one time. After this is done, the doctor will apply pressure to the area and cover the spot with a bandage 2-Ultrasound-directed Needle Biopsy An ultrasound device is used to locate the area where the biopsy needs to be taken. An ultrasound uses sound waves to create an image of the breast tissue on a monitor. After the location is found, a small needle will be inserted in the breast tissue. Samples of fluid and/or tissue will be removed. A bandage will be applied after the needle is removed 3-Stereotactic Core Needle Biopsy The doctor may have you lie down on your stomach or sit depending on the equipment being used. Mammogram or ultrasound images will be taken to locate the suspicious area. The doctor will make a tiny cut in your breast and insert a special probe. Using the probe, the doctor will remove several core samples of breast tissue from the area. After this is done, the area will be covered with a bandage.  4-MRI-guided Breast Biopsy  How is the procedure performed?  In most cases, you will lie face down on a moveable exam table and the affected breast or breasts will be positioned into openings in the table.  Gadolinium will be given intravenously.  Your breast will be gently compressed between two compression plates  Using computer software, the radiologist measures the position of the lesion and calculates the position and depth of the needle placement.  A local anesthetic will be injected into the breast  The radiologist then inserts the needle  Tissue samples are then removed using one of three methods:  a fine needle aspiration  a core needle biopsy,  With a vacuum-assisted device  After this sampling, the needle will be removed.  This procedure is usually completed within 45 minutes  5-Vacuum-assisted Device Biopsy The doctor will insert a needle and use pressure from a vacuum to pull tissue from the mass through the needle. The tissue is then placed into a sampling chamber Equipment : 1-Ultrasound 2- x-ray (mammogram) 3- MRI  Tools 1- Biopsy needle for soft tissues 2- Local anesthetic 3- sheet 4- apron 5- ultrasound machine MULTI RAM Semi-automatic disposable device with a double shooting system, for soft tissue biopsy.  OMNI-RAM  Semi-automatic disposable device with a double shooting system, for soft tissue biopsy. SPEEDY-RAM Disposable automatic gun, for soft tissue biopsy. 1-Fine needle aspiration 2-Ultrasound-directed needle biopsy 3- Stereotactic core needle biopsy 4- MRI-guided breast biopsy  Benefits  Breast needle biopsy is accurate when done by an experienced radiologist. It is also quick and does not involve surgery. Plus, there is only a small chance of infection or bruising. If breast cancer is found, the tissue removed gives important information including:  Tumor type  Tumor grade  Hormone receptor status Risk effect : Complications are rare, but no procedure is completely free of risk:  which may include:  Bleeding  Infection  Bruising  Some factors that may increase the risk of complications include:  Obesity  Smoking  Poor nutrition  Chronic illness (eg, diabetes)  Bleeding disorder https://www.youtube.com/watch?v=ink1nyRCnDQ Video MRI-Guided Breast Biopsy What is MR-Guided Breast Biopsy? Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous. A breast biopsy is performed to remove some cells—either surgically or through a less invasive procedure involving a hollow needle—from a suspicious area in the breast and examine them under a microscope to determine a diagnosis. Image-guided needle biopsy is not designed to remove the entire lesion, but most of a very small lesion may be removed in the process of biopsy. Image-guided biopsy is performed when the abnormal area in the breast is too small to be felt, making it difficult to locate the lesion by hand (called palpation). In MRI-guided breast biopsy, magnetic resonance imaging is used to help guide the radiologist's instruments to the site of the abnormal growth. What are some common uses of the procedure? An MRI-guided breast biopsy is most helpful when MR imaging shows a breast abnormality such as: @a suspicious mass not identified by other imaging techniques @an area of distortion @an area of abnormal tissue change MRI guidance is used in four biopsy procedures: Fine needle aspiration (FNA), attached to a syringe, smaller than needles typically used to draw blood ,which uses a very small needle to extract fluid or cells from the abnormal area. Core needle (CN) also called an automatic, spring-loaded needle, which consists of an inner needle connected to a trough, or shallow receptacle, covered by a sheath and attached to a spring-loaded mechanism. Which uses a large hollow needle to remove one sample of breast tissue per insertion. Vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion. a vacuum-powered instrument that uses pressure to pull tissue into the needle. A thin guide wire, which is used for a surgical biopsy. Other sterile equipment involved in this procedure includes syringes, sponges, forceps, scalpels and a specimen cup or microscope slide. Prior to a needle biopsy, you should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia. Your physician will advise you to stop taking aspirin or a blood thinner three days before your procedure. Also, inform your doctor about recent illnesses or other medical conditions. You may want to have a relative or friend accompany you and drive you home afterward. This is recommended if you have been sedated. There are other important guidelines for patients to follow prior to undergoing MR imaging. For a list of these and a review of all preparations that should be made prior to MR imaging. What does the equipment look like? The traditional MRI unit is a large cylinder-shaped tube surrounded by a circular magnet. You will lie on a moveable examination table that slides into the center of the magnet. Some MRI units, called short-bore system, are designed so that the magnet does not completely surround you; others are open on the sides (open MRI). These units are especially helpful for examining patients who are fearful of being in a closed space and for those who are very obese. Newer open MRI units provide very high quality images for many types of exams; however, open MRI units with older magnets may not provide this same quality. Certain types of exams cannot be performed using open MRI. For more information, consult your doctor. The computer workstation that processes the imaging information is located in a separate room than the scanner. The majority of MRI-guided breast biopsies are currently performed in closed MRI systems with a specially modified exam table. This moveable examination table allows your breasts to hang freely into cushioned openings, which contain wire coils that send and receive radio waves to help create the MR images. How does the procedure work? Unlike conventional x-ray examinations and computed tomography (CT) scans, MRI does not depend on ionizing radiation. Instead, while in the magnet, radio waves redirect the axes of spinning protons, which are the nuclei of hydrogen atoms, in a strong magnetic field. The magnetic field is produced by passing an electric current through wire coils in most MRI units. Other coils, located in the machine and in some cases, placed around the part of the body being imaged, send and receive radio waves, producing signals that are detected by the coils. A computer then processes the signals and generates a series of images each of which shows a thin slice of the body. The images can then be studied from different angles by the interpreting physician. Overall, the differentiation of abnormal (diseased) tissue from normal tissues is often better with MRI than with other imaging modalities such as x-ray, CT and ultrasound. Using MRI guidance to calculate the position of the abnormal tissue and to verify the placement of the needle, the radiologist inserts the biopsy needle through the skin, advances it into the lesion and removes tissue samples. If a surgical biopsy is being performed, MRI may be used to guide a wire into the mass to help the surgeon locate the area for excision. How is the procedure performed? Image-guided, minimally invasive procedures such as MR- guided breast biopsies are most often performed by a specially trained breast radiologist. Breast biopsies are usually done on an outpatient basis. You will lie face down on a moveable exam table and the affected breast or breasts will be positioned into openings in the table. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm and the contrast material gadolinium will be given intravenously. Your breast will be gently compressed between two compression plates (similar to those used in a diagnostic MRI exam), one of which is marked with a grid structure. Using computer software, the radiologist measures the position of the lesion with respect to the grid and calculates the position and depth of the needle placement. A local anesthetic will be injected into the breast to numb it. A very small nick is made in the skin at the site where the biopsy needle is to be inserted. The radiologist then inserts the needle, advances it to the location of the abnormality and MR imaging is performed to verify its position. Depending on the type of MRI unit being used, you may remain in place or be moved out of the center or bore of the MRI scanner. Tissue samples are then removed using one of three methods: In a fine needle aspiration, a fine gauge needle and a syringe withdraw fluid or clusters of cells. In a core needle biopsy, the automated mechanism is activated, moving the needle forward and filling the needle trough, or shallow receptacle, with 'cores' of breast tissue. The outer sheath instantly moves forward to cut the tissue and keep it in the trough. This process is repeated three to six times. With a vacuum-assisted device (VAD), vacuum pressure is used to pull tissue from the breast through the needle into the sampling chamber. Without withdrawing and reinserting the needle, it rotates positions and collects additional samples. Typically, eight to 10 samples of tissue are collected from around the lesion. After this sampling, the needle will be removed. If a surgical biopsy is being performed, a wire is inserted into the suspicious area as a guide for the surgeon. A small marker may be placed at the site so that it can be located in the future if necessary. Once the biopsy is complete, pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing. No sutures are needed. A mammogram may be performed to confirm that the marker is in the proper position. This procedure is usually completed within 45 minutes. What will I experience during and after the procedure? You will be awake during your biopsy and should have little or no discomfort. Most women report little or no pain and no scarring on the breast. Some women find that the major discomfort of the procedure is from lying on their stomach for the length of the procedure, which can be reduced by strategically placed cushions. When you receive the local anesthetic to numb the skin, you will feel a slight pin prick from the needle. You may feel some pressure when the biopsy needle is inserted. The area will become numb within a short time. You must remain still while the biopsy is performed. As tissue samples are taken, you may hear clicks from the sampling instrument. If you experience swelling and bruising following your biopsy, you may be instructed to take an over-the-counter pain reliever and to use a cold pack. Temporary bruising is normal. You should contact your physician if you experience excessive swelling, bleeding, drainage, redness or heat in the breast. If a marker is left inside the breast to mark the location of the biopsied lesion, it will cause no pain, disfigurement or harm. You should avoid strenuous activity for 24 hours after returning home, but then usually will be able to resume normal activities. Manufacturers of intravenous contrast indicate mothers should not breast feed their babies for 24-48 hours after contrast medium is given. However, both the American College of Radiology (ACR) and the European Society of Urogenital Radiology note that the available data suggest that it is safe to continue breast-feeding after receiving intravenous contrast. The Manual on Contrast Media from the ACR states: Review of the literature shows no evidence to suggest that oral ingestion by an infant of the tiny amount of gadolinium contrast medium excreted into breast milk would cause toxic effects. We believe, therefore, that the available data suggest that it is safe for the mother and infant to continue breast-feeding after receiving such an agent. If the mother remains concerned about any potential ill effects, she should be given the opportunity to make an informed decision as to whether to continue or temporarily abstain from breast-feeding after receiving a gadolinium contrast medium. If the mother so desires, she may abstain from breast-feeding for 24 hours with active expression and discarding of breast milk from both breasts during that period. In anticipation of this, she may wish to use a breast pump to obtain milk before the contrast study to feed the infant during the 24-hour period following the examination." What are the benefits vs. risks? Benefits The procedure is less invasive than surgical biopsy, leaves little or no scarring and can be performed in less than an hour. MRI is a noninvasive imaging technique that does not involve exposure to ionizing radiation. MRI-guided breast biopsy using a core needle is considered both safe and accurate. The speed, accuracy and safety of MRI-guided vacuum-assisted breast biopsy are as good as MR-guided wire localization without the associated complications and cost of surgery. Compared with stereotactic biopsy, the MRI-guided method avoids the need for ionizing radiation exposure. MRI-guided breast biopsy, using either the core needle method or the vacuum-assisted device, takes less time than surgical biopsy, causes less tissue damage, and is less costly. Recovery time is brief and patients can soon resume their usual activities. Risks Because the vacuum-assisted device removes slightly larger pieces of tissue than other types of needles, there is a risk of bleeding and forming a hematoma, or a collection of blood at the biopsy site. The risk, however, appears to be less than one percent of patients. An occasional patient has significant discomfort, which can be readily controlled by non-prescription pain medication. Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000. Doing a biopsy of tissue located deep within the breast carries a slight risk that the needle will pass through the chest wall, allowing air around the lung that could collapse a lung. This is a rare occurrence. What are the limitations of MRI-Guided Breast Biopsy? MRI-guided tissue sampling is limited by the position of the abnormality in the breast. Breast lesions located in the back of the breast or small abnormalities can be difficult or impossible to accurately target using MR. Breast biopsy procedures will occasionally miss a lesion or underestimate the extent of disease present. If the diagnosis remains uncertain after a technically successful procedure, surgical biopsy will usually be necessary. The MR-guided breast biopsy method cannot be used unless the mass can be seen on an MRI exam. Calcifications within a cancerous nodule are not shown as clearly with MR as with x- rays. Small lesions may be difficult to target accurately by MR- guided breast biopsy. The widespread use of this technique is limited by its high cost, availability, and length of the procedure. MR-guided biopsy should not be considered if the lesion can be seen on mammography or on ultrasound, where the biopsy can be performed more easily with less patient discomfort. In those cases, stereotactic biopsy or ultrasound-guided biopsy are the more appropriate methods of tissue sampling.