Liver and biliary tract
Jetra i bilijarni traktARCH GASTROENTEROHEPATOL 2001; 20 ( No 1 – 2 ):
Editorial
Da li je i kada slepa biopsija jetre slepom iglom potrebna ?
Goran Jankovic
Clinic for Gastroenterology and Hepatology, Clinical Centre of Serbia, Belgrade
( accepted June 25th , 2001 )
Abbreviations used in this article: FNLB, fine needle liver biopsy; US, ultrasound
Address correspondence to: Doc. Dr Goran Jankovic, Clinic for Gastroenterology and
Hepatology, Clinical Centre of Serbia, K. Todorovica 6, YU-11000 Belgrade, Tel. +
381 11 3615587; E-mail: [email protected]
…………………… ………………….
The advent and development of imaging methods make possible to detect early focal liver lesions of diverse aetiologies, prognosis and treatment. Sometimes their differentiation is difficult due to similar clinical and imaging characteristics. With the development of guided fine needle liver biopsy (FNLB) it became possible to get an adequate tissue sample for diagnosis with the minimal trauma. Table 1 and 2. Indications for the guided FNLB are all atypical focal liver lesions, as well as diffuse diseases processes suspected for malignancy, except when hepatic surgery is indicated ( 19,29).
Before liver biopsy it is essential to perform abdominal ultrasound (US) examination to prevent failure in obtaining adequate tissue sample, and unnecessary complications (34). In order to avoid pointless biopsy, in the absence of indication it is important to detect focal lesion s. Difficulties in liver size assessment and localisation by percussion may arise from the emphysema, or liver displacement due to other intraabdominal pathological processes. Aneurysm or subcapsular tumours, particularly hemangioma and hepatocellular carcinoma, are contraindications for direct biopsy even with fine needle (35, 36). Moreover, biliary peritonitis due to inadvertent puncture of dilated bile duct should be avoided (36).
The use of continuous guidance or even positioning of the needle by US before the procedure improve accuracy and safety of liver biopsy ( 1,37,38,39 ). Precise lesion targeting along with avoidance of non-malignant necrotic or fibrous tumour areas, and synchronous aspiration enable high sensitivity of guided FNLB (6, 14). Newer imaging techinques make possible to target lesions which are less than 10 mm in diameter and located deeply withint the liver. The influence of necrosis on the diagnostic value of FNLB can be prevented by avoiding their puncture, and better vascularised, proper tissue material from the peripheral parts of the lesion ( large tumours ) can be obtained. In order to prevent aspiration of the blood and subsequent coagulation of the sample, the puncture of the vessels has to be avoided and the aspiration discontinued before the needle is withdrawn from the lesion. Right time for the start of aspiration prevents tissue aspiration originating out of the liver. Possibility to track position of the needle preclude laceration of the capsule due to rough penetration asynchronous with respiratory movements.
Guided FNLB has very low rate of complications since it is easy to ensure safe route for needle penetration keeping device away from neibouring organs and blood vessels. Fatal outcome is extremely rare, and reported mostly in patients with already present and recognized risk factors. The analysis of the data from 214 hospitals on 63108 FNAB revealed 27 clinically significant haemorrhage (3 deaths), 4 cases of biliary peritonitis, 16 generalised infections, 51 biliary leaks, and 3 cases of tumour dissemination (40). In a multicentric Italian study of 10766 US guided FNAB of various abdominal organs morbidity was 0.18% (36).
The choice of the biopsy guidance modality depends on the doctor's personal affinity, the possibility of the visualisation of lesion (size, localisation, patient's constitution), the cost and availability of method (29). For this purpose fluoroscopy is rarely used (6). Advantages of CT are gas-unlimited visualisation and precisely planned needle direction (29, 41,42, 43). Disadvantages of the CT are: irradiation, high cost, immobility, requirement for radiologist, absence of continuous guidance, long duration of examination with long placement of the needle in the patient, necessity to hold the breath during the examination to obtain the same level of scans (14, 29, 43, 44). Since the introduction of open magnets and short-bore closed magnets, and the availability of fast imaging sequences (T1-weighted gradient-echo techniques or fast single-shot T2- weighted spin-echo sequences), NMR became a excellent tool for guidance of percutaneous procedures (45,46,47,48). Indications for liver biopsies include subdiaphragmatic lesions, and lesions poorly visible on US or contrast-enhanced CT (47, 48).
Ultrasound is fast, portable, safe, low-cost and widely available guidance method, which enables continued tracking during needle penetration (29, 43). Disadvantages of US are difficult examination in the presence of meteorism, requirement of experienced ultrasonographer, and the possibility that flexible fine needle may get out of the echo-beam, when it is not visible (29, 43). An in-and-out jiggling motion of the needle or the stylet improves the visibility of the needle due to the deflection of the soft tissues adjacent to the needle, or the air bubbles in the needle. Teflon coating or scoring of the surface minimally improve the reflectivity of the needle (29). Decision analysis model suggested that US-guided liver biopsy is cost-effective (49).
Free-hand technique is fast and convenient as special US probe is not required, but vast experience is required (2,14). Probes with central channel provide precise and continuous guidance of the needle (50). Lack of the crystal where the needle channel penetrates the face of the transducer, which causes vertical defect of the ultrasound image, may be overcomed by the use of the triangle guide for angled direction of the needle (14). Attachable stretcher guides which can be fitted to the existing transducers enabling the use of ordinary probes, although the visualisation of the needle in the first couple of centimetres may be difficult. Endoscopic US-guided FNLB should be considered as a procedure of choice in selected patients (51).
In the most cases of percutaneous liver biopsy, pre-biopsy US examination provides enough information for correct needle positioning even without permanent echo-guidance. This improves diagnostic accuracy and safety of the biopsy (52, 53, 54). Avoided structures could explain decrease in pain when ultrasound is applied (55). Puncture site and needle track direction are of particular interest in correct needle positioning. In a cases of atypical position of the liver and small cirrhotic organ, in order to obtain an adequate sample multiple penetrations are therefore prevented (52, 55).` The advantage of this method is also in recognising the distance between the skin and liver surface, giving the information concerning the moment of the puncture of liver capsule. It can also be used for FNLB.
Biopsy needles can be grouped into fine (£ 1 mm) and coarse. According to the obtained sample there are histologic needles with the cutting tip for providing tissue particles, and cytological needles with a sharp bevelled tip which obtain cells for the examination (14). Cytological biopsy is less invasive, safe, fast and inexpensive technique, but inconclusive when necrotic material, degenerated forms of cells or cells from the surrounding structures are obtained. In addition, in the case of well differentiated adenocarcinoma, toumour cells are similar to reactively changed benign cells ( 15,56 ). There is also a variability of cells in one tumour, and similarity among different types of tumours.
Histologic examination may additionally explore the interrelations of the cells and the surrounding structures in the tissue. Its disadvantage is higher degree of invasiveness and technical complexity (16, 29, 57, 58). According to retrospective studies concerning needle diameter, less serious complications occur with fine biopsy needle compared with standard coarse needles (59, 60,61 62). To prevent hypervascular tumour or right lobe hydatid cyst US examination is mandatory before the biopsy (29). In order to provide correct positioning of the needle, US just before (without permanent echo-guidance) percutaneous liver biopsy has to be performed
Flexibility of the fine needles require the use of the guide needle with the tip located in the subcutaneous tissue. This provides better fine-needle visualisation, and directioning in cases of deep lesions (14, 63). In addition, multiple punctures with only one skin penetration and probably lower risk of needle tract tumour seeding are ensured. The use of the “Biopty” gun where Tru-cut needle is fired by fast spring mechanism, which is operated with one hand, reduces the risk of needle deflection, and increases the rate of adequate samples (59). US-guided liver biopsy with an automated needle is safer, more comfortable and only marginally more expensive than blind Trucut biopsy (63)
To detect and differeentiate malignant cells experienced and skilfull attending cytopathologist is very important. False positive results are uusally caused by insufficient number of cells for analysis what is particularly frequent in high density tissues like benign lesions or sarcoma, or by the presence of skin or epithelial cells in the sample due to the continuous aspiration during the needle withdrawal (16,19, 64). Cytological assessment of the aspirate quality during the procedure decreases the number of unnecessary punctures and inadequate samples (4, 5, 28, 29, 40, 43, 56, 65). Limitation of the method is that sample may be non-diagnostic in spite of sufficient content of cells, due to the presence of pathological processes which require examination of the whole tissue. Fine cutting needle biopsy may overcome this problem in some cases (66). According to our experience, the limiting rate factor in guided FNLB is availability of cytopathology, although sample transfer to other institution with this facility is possible.
The article published in this issue of the Archives by Edoute Y et al. rises the question of necessity to perform blind FNLB in the setting of unavailable guidance technique (67). Financial aspects of this experimental method may be attractive for developing regions, but certain limitations of the study should be taken into consideration. The existence of previous imaging in some cases, attendant experienced cytopathologist who checked adequacy of samples during the procedure, opportunity to verify blood coagulation with sophisticated methods like d-dimmer, etc., are difficult to exist in the institution where biopsy guidance is unavailable. In addition, the influence of imaging-undetectable malignant tissue on the result of the biopsy should be further evaluated, as well as safety of described method. Nevertheless, these results surely emerge further studies in order to approve routine use of this method in such atypical situation. At the moment, it could be performed in some special circumstances, since US device is widely accessible today, at least for pre-biopsy assessment and positioning of the needle. Value of guidance in improving biopsy accuracy and safety is impossible to neglect in any case.
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Table 1 - History of liver biopsy
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Year Author Development
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1883 Ehrlich Study on glikogen content in diabetic liver
1895 Lucatello Diagnosis of tropical liver abscess
1907 Schupfer The first series of percutaneous biopsies
1958 Menghini One-second method for percutaneous biopsy
1971 Kratochwil A-mode ultrasound biopsy probe
1972 Holm, Goldberg B-mode ultrasound biopsy probe
1973 Haaga CT guided biopsy
1973 Rosch Transjugular biopsy
1980 Otto Ccontinued US guidance with central channel probe
1981 Isler Fine cutting needle
Table 2 - Published results of the ultrasonically guided fine - needle liver biopsy
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Author,year (ref.) No Adequacy Sensitivity Specificity Accuracy Complic.
% % % % No
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Otto,80 (1)* 141 91,6 0
Schwerk,81 (2) 60 88,2 88,9
Ho,81 (3) 40 100 93 80 90 1
Bondestam,81 (4)* 67 100 91 100 92,5 0
Bondestam,81 (5)* 100 88 100
Montali,82 (6) 126 100 92 100 94 0
Struve,82 (7) 39 88 100 89,7 0
Ranieri,83 (8) 26 92,3 73 0
Klann,83 (9) 42 95,3 100
Kasugai,84 (10) 40 100 96,2 100 0
Bret,84 (11) 322 99,7 88,6 100 91,6 4**
Wernecke,84 (12) 86 96,1 100 98,8
Tatsuta,84 (13) 41 100 100 95,7 97,6 0
Holm,85 (14) 247 99,2 94,1 100 93,1
Kasugai,85 (15) 59 100 95.0 100 0
Fischnaller,86 (16) 101 83,2 86,9 100 95,2
Limberg,86 (17) 71 100 87,7 100 91,3 1
Pandey,86 (18) 16 93,8 77,8 100 86,7 0
Sauterau,87 (19) 97 93,8 83 93 86,6 0
Limberg,87 (20) 84 100 88,5 100 92,9 1
Duvnjak,87 (21) 62 93,9 100 95,2 0
Servoll,88 (22) 153 86,5 79,5 100 87,5 0
Pinto,88 (23) 81 91 100
Celle,88 (24) 39 100 85 100 89,7 0
Xu,89 (25) 105 94,9 96,2 95,2 0
Dumas,90 (26) 260 92 100 92,5 0
Outchnikov,90 (27)* 91 93,4 87,8 96,1 92,9 0
Fornari,90 (28) 441 100 93,2 100 95 1
Charboneau,90 (29)* 1000 91,8 89,9 96 0,3%**
Ren,90 (30)* 183 84,1
Caldironi,91 (31)* 260 93,4 100 1,5%
Gilg,91 (32) 84 95 100 96
Edoute,91 (33) 492 85,6 98,4 89,7 1**
Jankovic,97 (34) 409 95,1 91,6 100 94,0 2
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* other abdominal localizations included
** one case of death