Ultrasound Guided Abdominal Biopsies: Lessons Learned - Part 3

Splenic Biopsies

Splenic biopsies usually have to be performed in the right decubitus position using a left intercostal approach or subcostal approach.

If the spleen is big, we're generally going after a splenic mass, and the suspicion obviously would be, it could be a metastatic lesion or a lymphoma.

Again, in counter distinction to the theory that you should not biopsy a vascular mass on a liver surface, you can biopsy a splenic mass on the surface of the spleen.

I would reference the article below to make this point.

In this instance here, we have a mass within the spleen, as you can see on the CT scan on the left.

And then with the patient in the decubitus position going through the intercostal space, we can easily perform a biopsy of this lesion, again, using a coaxial needle for obtaining FNAs and cores.

Melanoma obviously is a lesion that can go to the spleen.

In this instance, I biopsy this lesion again with the patient in the right decubitus position.

But unfortunately following the surgery, the patient hemorrhaged and needed a transfusion.

Renal Biopsies

Parenchymal Disease Biopsies

Again, we're doing it either for parenchymal disease and somebody with renal failure, or we would be looking at a mass in the kidney to be biopsied.

Usually we have the patient in the prone position with a pillow underneath the abdomen to kind of stop the kidney from moving back and forth with breathing, and also to make it more approximate to the posterior abdominal wall.

Again, we like to use a subcostal approach.

In some very obese patients where the kidney is very deep, it may not be possible to do the biopsy with the patient in the prone position, in which case I will actually put the patient in the decubitus position and then scan the upside and try and identify the kidney.

Because when you do this, what actually happens is the kidney will actually move downwards and forward and actually will be closer to the skin.

In patients like this who are very obese, if that technique does not work, one may have to go through the intercostal approach, but that really I don't like to do.

The other reason is if you use the intercostal approach, you often end up in the mid portion of the kidney, which always raises the possibility of the needle entering into the renal sinus in increasing the risk of bleeding.

So anyway, when we were doing a biopsy for parenchymal disease, again, I will use my coaxial needle technique.

I will bring the coaxial needle down to the capsule of the lower pole of the kidney, and I will obtain upwards of four cores.

Obviously, again, I will have the patient suspend the respiration and withdraw the needle because obviously you don't want to be firing the needle off into a moving kidney.

This is just an example of the scan plane that we would use to get down to the kidney, and this is an example of where we would fire the needle off into the kidney right through the lower pole cortex.

As I said already, you don't want to go up too high because you don't want to have the needle end up into the renal sinus where all the blood vessels are, which is obviously increase your risk of having bleeding in a patient like this.

But bleeding does happen.

Usually the hemorrhage from the kidney is usually self-limited, does not require treatment on occasion.

However, you may have to do embolization if the bleeding does not stop in a timely manner.

Renal Mass Biopsies

So in terms of doing a biopsy of a renal mass, well, usually you're trying to distinguish first of all, if the patient, let's say, has a lung cancer and then you discover a mass in the kidney, the question always would be, well, is this mass in the kidney in metastasis or does it represent a second primary, such as the renal cell carcinoma?

Also, we biopsy renal masses when we have a mass in the kidney and the metastatic disease where the patient would not be a candidate for a surgical removal of the renal mass.

Also, we do biopsies of these small solid lesions that prior to ablation or focal resection, and there's also debate out there whether we should do a Bosniak two F or the three biopsies, but that's a discussion for another day.

Again, just like for the liver, when we have a mass, we take our coaxial needle, we insert it down to the mass, we insert the cutting needle through the coaxial needle and then fired off after suspending the respiration.

This is just an example of a large renal lesion, quite easily seen with the patient into the decubitus position.

And you can see the lesion over here where we, this is our plane of the entry into the lesion and we can easily do a biopsy.

Here's another example of another lower pole mass here.

Because of the size of the mass you do, you'd want to go towards this periphery if you could, as we did in this case here.

All another technical point here.

As we look at this CT scan, we can see that this lesion is in the front portion of the kidney.

It's got small bowel draped over it.

And you can see that if we were to try and go from the back of this patient, we would end up going through the renal sinus and also through the pelvicalyceal system, which we'd want to avoid.

So when we're using our CT scan in terms of planning our approach, we would now see that putting the patient in the right decubitus position and using ultrasound to approach him from the side would be the way to go because in this instance, you would avoid entering into the renal sinus of this patient's kidney.

Adrenal Biopsies

Adrenal biopsies nowadays are not very commonly needed because they really can be characterized as either being an adenoma by CT or MRI or by being metastatic disease if there is CT PET.

Occasionally, however, we do end up with a case where we can't determine whether the mass in the adrenal is a metastatic lesion or not, or where it could in fact represent adrenal cortical cancer.

Obviously, we do not wish to biopsy adrenal masses that are pheochromocytomas and so patients should be worked up appropriately to exclude that diagnosis if that is a consideration.

And adrenal biopsies, again, the same technique.

Now obviously most of these lesions are small and cannot be seen by ultrasound, but if they are sonographically visible, it's quite easy to do a biopsy usually with the patient in a lateral decubitus position.

And here we often would have to go through the intercostal approach because of its position high above the kidney.

Obviously you could use a subcostal approach if it would allow that, and basically you'd have to angle up to avoid the lung and the liver if it's on the right side.