Original post, lightly edited for flow bit.ly/3KNUDyF
The patient is an 81-year-old female with underlying dementia who presented with recurrent fever, chills, cough and generalized weakness. Clinical labs and imaging cannot narrow the differential of splenic lesions. An IR consult was requested for biopsy. Would you biopsy these lesions? Any input is appreciated about fine needle aspiration versus core and needle gauge size.
Author background and current practice preferences for splenic lesion biopsy?
Avinash Medsinge, MD: I am an assistant professor and core faculty of interventional radiology at University of Pittsburgh Medical Center and have been in practice for almost 10 years.
Consults for splenic lesion biopsy are less common than other viscera in the body. Most of the splenic biopsies I have done so far have been for discrete, large splenic masses. I still consider splenic biopsy as a high bleeding risk procedure and a last-ditch effort when I cannot get tissue elsewhere in the body. I usually perform them as an outpatient procedure with conscious sedation. I order pre-procedure coagulation labs along with CBC and am very particular about INR<1.5 and platelets >50K.
Please elaborate on the specific patient background and presentation in this case.
AM: An 81-year-old female with a history of dementia, hypertension, diabetes, and recently treated pneumonia presented for evaluation of recurrent fever, chills, cough and generalized weakness after completing antibiotic treatment. CT of the abdomen/pelvis showed multiple small, hypoenhancing non-specific splenic lesions. Contrast enhanced MRI did not narrow the differential. The impression on the MR study was: the splenic lesions are nonspecific and unlikely to represent lymphoma (expected to have T2 isointensity), sarcoid (expected to have T2 hypointensity) and metastases (which should remain visible as discrete lesions following contrast). Multiple hemangiomas and micro abscesses cannot be excluded. Hence IR was consulted for biopsy.
Which specific methods or techniques do you find useful in performing a splenic lesion biopsy?
AM: Most of the time I use ultrasound guidance unless the patient’s body habitus limits visualization of the lesion. I position the patient in supine/right lateral decubitus position (though literature suggests doing in left lateral decubitus position to reduce left lung expansion).
I use a coaxial technique with 17 G trocar and 18 G needle. After achieving local anesthesia up to a splenic capsule, I introduce the trocar. I prefer an 18 G full core biopsy needle (Biopince) over side cutting device. Typically, I get one to three cores. The biopsy throw length depends on the lesion dimension and morphology. After obtaining cores, I usually embolize the tract using a thick Gelfoam slurry.
What would be your preferred biopsy approach, and what prompted you to reach out regarding this topic?
AM: I chose a subcostal approach after scanning the patient. Due to the broad differential and diffuse, nonspecific lesions throughout the spleen, I needed multiple random focal versus non-focal tissue cores and the longest throw possible without compromising safety. I used a trocar to reduce multiple punctures of the splenic capsule.
Also, one of the differential considerations was hemangiomas so I was worried about increased risk of bleeding, which prompted me to reach out about this case.
What post or posts were most valuable to you and why? Will you, or have you changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering.
AM: Several of the posts were very helpful, particularly the posts from Drs. Worthington-Kirsch and Walworth. These made me more relaxed, as core biopsy seemed less invasive than fragmenting the splenic parenchyma as described. Suggestions for post-procedure bed rest in left lateral decubitus position and additional special procedures, such as tract embolization, also alleviated my concerns. The article link given by Dr. Walsworth also made it easy for me to read the article in my go-to journal, Seminars in IR.
In cases where I am on the fence whether to proceed or not, as happened with this case, this kind of feedback helped the decision-making process and made me comfortable during the procedure. Also, my comfort level regarding future splenic lesions biopsy consults increased.
Additional commentary
Percutaneous image-guided intra-abdominal biopsies are safe, effective and considered one of the most common interventional radiology procedures.1,2,3,4 The indications for intra-abdominal biopsies include the diagnosis of primary malignancy and other entities such as cysts and infection, tissue sampling for suspected metastases, and malignancy staging. The spleen is commonly affected in intra-abdominal multiorgan disease; it is an uncommon region for intra-abdominal biopsy relative to the other solid intra-abdominal organs, in part due to perceived hemorrhage risks.4,6 Procedural alternatives historically included open splenectomy and laparoscopic splenic biopsy requiring general anesthesia.4 Recent literature—including a systematic review and meta-analysis on the diagnostic accuracy of percutaneous splenic lesion biopsy—found the use of percutaneous biopsy technique to represent a safe and effective alternative to splenectomy when the spleen was the only site available for biopsy, such as in the case above.5
The choice of imaging modality is based on the anatomic location, size and depth of the lesion of interest, body habitus, and safety of percutaneous access.1,2,3,4 CT and ultrasound are both effective modalities for lesional characterization and performing biopsy under image guidance.1 Ultrasound is benefitted by real-time imaging and lack of ionizing radiation exposure.2,4 CT provides cross-sectional anatomical detail and is performed using an overlying grid over the area of interest while measuring shortest distance trajectories from skin entry site to lesion.2,4 For both modalities, it is important to avoid significant transpleural transgression and minimize the number of passes that are made into the splenic capsule to prevent pneumothorax, pleural space infection, hematoma formation and pain.4 Positioning the patient in left lateral decubitus position can help displace the ipsilateral lung away from the spleen, creating a safer window for biopsy.4 A breath hold technique can also bring the lesion into the field of view and mitigate movement that occurs from respiratory motion.1,6 Several needle biopsy tricks may also be utilized for optimal placement into splenic lesions, including organ hydrodissection and the use of side or end cutting needles with a curved distal end.2
Clinically significant hemorrhage is a feared, albeit rare, complication of intra-abdominal biopsies, particularly splenic biopsy, and is found in less than 2% of biopsies.1 Thus, many prior studies have traditionally employed a 20 to 22-gauge for fine needle aspiration or core needle biopsy in order to obviate the risk of hemorrhage.6 The use of 18-gauge side-cutting core needle biopsies has been described as safe and accurate in a large, recent case series with bleeding rates comparable to kidney and liver lesional biopsies.6 A safety check of vital signs and full pre-procedure evaluation of labs including complete blood count and INR should be performed prior to lesional biopsy.1,6 Additional considerations to decrease risk of hemorrhage include reducing ascites with paracentesis or diuretics or correcting any underlying coagulopathies when evident.7 Plugging the biopsy tract with an absorbable gelfoam slurry, which can absorb up to 45 times its weight with whole blood and has minimal risk of non-target embolization, may be employed in patients with higher bleeding risk or when coaxial technique is used.1,7 Polyvinyl alcohol foam, microfiliary collagen, embolization coils and autologous clot may also be used at the skin entry site and have also been previously described.1,8 Additional quick nontract embolization techniques, including pressure or tamponade on the percutaneous biopsy skin site, may be performed with the patient lying down on their ipsilateral side.1 In the future, randomized trials assessing the efficacy of these techniques in providing hemostasis for core and fine needle biopsies may help us better understand their role in preventing bleeding complications.
References
- Sainani NI, Silverman SG. “Percutaneous abdominal biopsy.” Handbook of Interventional Radiologic Procedures. Kandarpa K, et al. 2016:453-459.
- Sainani NI, Arellano RS, Shyn PB, Gervais DB, Mueller PR, Silverman SG. The challenging image-guided abdominal mass biopsy: Established and emerging techniques. If you can see it, you can biopsy it. Abdom Imaging. 2013;38(4):672–96. doi.org/10.1007/s00261-013-9980-0.
- Gupta S, Wallace MJ, Cardella JF, Kundu S, Miller DL, Rose SC. Quality improvement guidelines for percutaneous needle biopsy. JVIR. 2010;21(7): 969–75. doi.org/10.1016/j.jvir.2010.01.011.
- Sammon J, Twomey M, Crush L, Maher MM, O’Connor OJ. Image-guided percutaneous splenic biopsy and drainage. Sem Interv. 2012;29(4):301. doi. org/10.1055/s-0032-1330064.
- McInnes MD, Kielar AZ, Macdonald DB. Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accuracy. database of abstracts of reviews of effects (DARE): Quality-assessed Reviews. Centre for Reviews and Dissemination (UK), 2011. ncbi.nlm.nih.gov/books/NBK91784/.
- Nirav P, Dawe G, Tung K. Ultrasound-guided percutaneous splenic biopsy using an 18-G core biopsy needle: Our experience with 52 cases. Br J Radiol Suppl. 2015;88(1055): 20150400. doi.org/10.1259/bjr.20150400.
- Tsang WK, Luk WH, Lo AXN. Ultrasound-guided plugged percutaneous biopsy of solid organs in patients with bleeding tendencies. Hong Kong Med J. 2013. doi.org/10.12809/hkmj133972.
- Handke NA, Koch DC, Muschler E, Thomas D, Luetkens JA, Attenberger UI, Kuetting D, Pieper CC, Wilhelm K. Bleeding management in computer tomography-guided liver biopsies by biopsy tract plugging with gelatin sponge slurry. Scientific Reports. 2021;11(1):24506. doi.org/10.1038/ s41598-021-04155-1.
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