CT and UltrasoundGuided Biopsies and Interventions

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CT- and Ultrasound-Guided Biopsies and
Interventions

• Peter Loud, M.D.
• Director of Body Imaging, Roswell Park Cancer
  Institute

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Image-Guided Procedures

• Primarily body imaging applications (not breast
  or neurologic imaging applications)
• Primarily cancer related procedures but most are
  done in any large hospital setting because cancer
  is unfortunately common
• Begin with focus on lung biopsy as a
  representative CT-guided biopsy

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CT-guided interventional procedures

• Biopsies primarily lung and mediastinum,
  retroperitoneum (pancreas, kidney, lymph nodes,
  sarcomas), and bone
• Drainages of thoracic or abdominal fluid
  collections
• Pre-operative needle localization
• Tumor ablation

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Tools of the trade

• Biopsies Fine needle aspiration vs. core
  samples.
• Drainages Fluid aspiration vs. indwelling
  catheter placement.
• Needle localization
• Ablation

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Core biopsy gun
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Core biopsy
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Cause and Effect
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Indications for lung biopsy

• Diagnosis of suspected malignancy, either primary
  lung cancer or metastatic disease
• Size, shape, growth, PET positivity, clinical
  scenario
• Suspected atypical infection
• Patient not a surgical candidate

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Contra-indications to lung biopsy

• Uncorrectable coagulopathy
• Inability to cooperate (lie still, hold breath)
• Risks outweigh benefits
• Dont touch lesions
• One lung (relative)

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Alternatives to percutaneous biopsy

• Observation
• VATS
• Bronchoscopic biopsy
• Open resection

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Percutaneous lung biopsybefore you begin

• Experienced technologists
• On-site cytology available (FNA)
• Excellent nursing (monitoring, conscious
  sedation, record keeping, post-procedure
  recovery)
• Ready to deal with complications

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CT-guided lung biopsy

• Position patient as comfortably as possible
• Conscious sedation if needed (monitoring)
• Scan and mark skin over lesion

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CT-guided lung biopsy

• Prep, drape, anesthetize, and place coaxial
  needle
• Confirm position and place biopsy needle
  (quickly, during suspended respiration!)

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Female with multiple brain metastases and 1 cm
lung nodule
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Small Cell Lung Carcinoma
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CT-guided lung biopsy

• Biopsy and confirm pathology
• Check for complications (post-bx scan, CXR,
  monitoring)
• Deal with complications

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PneumothoraxRisk factors during biopsy

• Emphysema
• Cooperation
• Needle size
• Depth of lesion
• Pleural punctures of biopsies (avoid
  fissures, make your first shot count)

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Pneumothorax What to do

• Common 10-30 of lung biopsies
• BUT, most (90) are small and self-limited
• So, stay calm and assess the situation
• Early 0-1 hr. and delayed 2-4 hr. CXR
• If small, stable, and asymptomatic, D/C with
  careful instructions. PTX will resolve in days

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Pneumothorax what to do

• Treatment indicated for large (gt20), growing, or
  symptomatic PTX
• Can try to avoid chest tube by aspirating PTX on
  the CT table
• If unsuccessful, insert a small bore chest tube
  with a heimlich valve and observe with serial CXR

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Aspiration of PTX
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Aspiration of pneumothorax
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Aspiration of pneumothorax
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Pulmonary Hemorrhage
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Mediastinal Biopsy
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Pulmonary Hamartoma
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Pulmonary AVM
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Pulmonary infarcts
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Trans-hepatic pancreas biopsy
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Liposarcoma
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CT-guided bone biopsy
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CT-guided maxillary biopsy
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CT-Guided Localization
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CT-Guided Localization
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CT-Guided Localization
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Ultrasound Guided Procedures
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Pancreas mass small liver nodule
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Metastatic Pancreatic Carcinoma
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Ultrasound-Guided Interventional Procedures

• Biopies Any lesion that can be seen
  sonographically, but primarily liver, kidney,
  pancreas, thyroid, superficial lymph nodes, soft
  tissue masses.
• Drainages Thoracentesis, paracentesis,
  pericardiocentesis, abscesses (when not obscured
  by lung, bone, bowel, fat).
• Tumor ablation (liver and kidney)

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Advantages of US-guided procedures

• Fast
• Multiplanar approaches are easy
• Doppler to identify vessels
• Doesnt tie up a CT scanner
• No radiation exposure
• Probe compresses and displaces tissues

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Ultrasound-guided Biopsy
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Ultrasound-guided mediastinal biopsy
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Drainage Catheter
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Drainage Catheter
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Pericardial Effusion
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Image-Guided Tumor Ablation

• Ablation Destruction of tumor deposits using
  heat, cold, chemical or biologic agents
• Minimally invasive Percutaneous radiofrequency
  ablation typically performed as an outpatient
  procedure
• Ethanol ablation (hepatocellular carcinoma)
• Cryoablation (renal tumors, prostate cancer)
• Radiofrequency ablation (liver, kidney, bone,
  lung)

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Radiofrequency Ablation
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Radiofrequency Ablation
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Summary

• CT and US-guided interventional procedures are
  minimally invasive and play a large and growing
  role in modern medical care.
• Image-guided procedures require a team approach
  with technologist, nurse, and physician working
  closely together with the goal of maximal success
  and minimal patient discomfort.
• Different procedures utilize the strengths of
  different imaging modalities and must be tailored
  to the patient and particular problem at hand.

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Thank You!!