Thoracic Biopsy – What Can We Do Using Percutaneous Ultrasound - SD

Introduction

Hello everybody. I'm Al Hami radiologist from Georgia.
I work at Pel State Medical University.
Pel is the capital of Georgia.
Today we'll have a talk about possibilities of ultrasound in thoracic biopsies, thoracic biopsy.

Percutaneous Ultrasound in Thoracic Biopsies

What can we do using percutaneous ultrasound?
We are focusing on percutaneous application of ultrasound because ultrasound might be used endoscopically also.
But today we're talking about percutaneous application.
What can we assess by biopsy device under ultrasound guidance?

Of course, when we are talking about the thorax, it's a little bit problematic for ultrasound because of certain reasons.
When we are talking about thoracic wall tissues, of course, all those tissues are possible to assess by ultrasound guidance, by the way, including bone pathology if cortical bone is interrupted.
Because if the cortical bone is interrupted, we can nicely image it on ultrasound.

But what about pleura? What about lung? What about mediastinum?
It's possible if ultrasound imaging is possible using either intercostal or subcostal approach.
If we take a look at this anatomy picture, we can understand that of course we can assess all the soft tissue, masses which might be seen in thoracic wall, including the interruption of the problems, sometimes problems in the bone tissue also.

Pleural Assessment

But when we are talking about pleura, what can we assess by ultrasound?
Of course, when we are talking about the pleural masses, we are talking about the coastal surface of the pleura.
This surface of pleura, which touches diaphragm or touches mediastinum, usually is not accessible by the ultrasound.

Pulmonary Tissue Assessment

What about the pulmonary tissue?
Of course, normal lung tissue is not accessible for ultrasound imaging because of air, which contains the normal lung tissue contains.
But what if some mass is located somewhere in the periphery of the lung and there is no air.
We can image of course, those masses, and so we can perform the ultrasound guided biopsy also.

Mediastinal Assessment

And finally, what about the mediastinum?
Mediastinum seems from this on the anatomic image seems the most problematic for US guided ultrasound guided puncture.
But we should keep in mind that we are dealing with mediastinal masses.
They may bulge out from the sternum or spine if it's posterior mediastinum and touching the intercostal thoracic wall in the intercostal area.
And in such cases, we can assess it by ultrasound.

Methodological Aspects

Anesthesia

First of all, anesthesia.
We don't need the general sedation. General anesthesia.
We will use conscious sedation with local anesthesia imaging guidance.

Ultrasound Guidance Techniques

We perform using percutaneous ultrasound with different type transducers.
It might be the convex for deeper tissue.
And usually we use attached needle guide for biopsy or linear array might be used for superficial tissue.
Usually free hand technique is preferred in such cases.

Safety Issues

Safety issues. So the safe puncture site and trace should be selected, first of all, when we do it by ultrasound, using doppler, of course, to avoid the major vessels and intercostal vessels.
Also, especially important is when we are talking about the upper thorax near the clavicle.
Keeping in mind that there are a lot of major vessels post procedure monitoring for bleeding and pneumothorax should be performed.

Approaches

Different approaches might be used any intercostal area, or in some limited cases, subcostal approach might be used.
All this depends on the target location and procedure monitoring is performed in real time by ultrasound.

Devices

Which devices we can use If we perform fine needle biopsy, we usually use 22 gauge diameter, achieve a needle, but for core biopsy, we need 18 to 16 gauge diameter devices, which might be either hand manipulating or automatic.

You can see here the hand manipulating device with for instance, type needle.
When we are moving this needle back and forth in the target, the same time the syringe is connected to the needle, creating the constant negative pressure aspirating the cut tissue into the needle.

This is automatic device, so-called biopsy gun.
This is a true cut system.
First, the internal needle fires, and then the outer canula fires.
And when you open this biopsy device, you see the tissue over here.

Case Examples

This now we can see the couple of cases.
This mass arises from the pleura.
You can see it in a CT image and the posterior aspect of the thorax.
You can see the sagittal reconstruction image.
So as soon as this mass is located near the intercostal space touching the thoracic wall, we succeed to assess it.

This mass using ultrasound, we are measuring this mass.
This is the mass itself, and this is the lung surface.
And finally the needle tip.
You see it moves under the real time control that it fires and biopsy gun fires, and we take out the sample.

In this case, we are dealing with pulmonary masses.
This one is bigger, but it's not seen on ultrasound.
It's not accessible by ultrasound.
But this one, which is located adjacent to sternum, is nicely imaged on ultrasound.
Because of this, we decided to perform this procedure and the ultrasound guidance.

This is the rib, and you saw how the needle, the biopsy got fired and that we took out the sample.

Another example is the mediastinal mass.
This mass arises from anterior mediastinum pushing the lung tissue laterally and reaching the intercostal space adjacent to the sternum.
On the right side, we perform it on the ultrasound guidance.
You see the blood vessels.
Here we are, the needle is already moving towards the into the mass in the distal portion of it.
In the middle portion of it, it fires.
And we took the sample.

Fallback to CT Guidance

So what should we do if we fail to image the target on ultrasound?
We switch to ct. This is the CT image.
And you see here the target, you see here, the markers placed on the skin and the needle inserted in a certain depths beyond the pleura.
We see that the direction is not adequate.
We correct the direction, detect is documented on the city image.
Then they insert the needle deep towards the target.
We did more document the needle tip position beyond the target.
And finally, when the biopsy gun fires, we document the adequate position biopsy device into the target.

Advantages of Ultrasound vs. CT

Imaging guidance for thoracic biopsy. What's better?
We can just mention the advantages of ultrasound.
This is a possibility of needle movement, realtime control, using needle guide or freehand technique, possibility of realtime blood flow imaging by doppler, it's non invasiveness.
It's not connected with ionizing radiation.
And finally, it cost effectiveness of this technique.

What's advantage of ct?
And the great advantage, of course, that we can image any thoracic structure of any location.

Conclusion

So what can we say?
In conclusion, perform your thoracic interventions under real time ultrasound guidance.
It's safe and efficient, of course, if you can image your target adequately.
Thank you for your attention.