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Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y O r i g i n a l R e s e a r c h

Park et al.
US-Guided Transvaginal Core Biopsy of Pelvic Masses

Vascular and Interventional Radiology


Original Research

Ultrasound-Guided Transvaginal
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Core Biopsy of Pelvic Masses:


Feasibility, Safety, and Short-Term
Follow-Up
Jung Jae Park1 OBJECTIVE. The purpose of this study was to evaluate the diagnostic accuracy and safe-
Chan Kyo Kim1,2 ty of ultrasound (US)guided transvaginal core biopsy of pelvic masses.
Byung Kwan Park1 MATERIALS AND METHODS. Fifty-five pelvic masses in 55 consecutive women who
underwent US-guided transvaginal core biopsy were enrolled in our study. All lesions were de-
Park JJ, Kim CK, Park BK tected on CT or MRI before biopsy. The procedure was performed with local anesthesia using
a transvaginal US probe equipped with a guide and an 18-gauge needle with an automatic bi-
opsy gun. We evaluated the diagnostic accuracy and complication rate of the procedure.
RESULTS. All acquired specimens were adequate for the histopathologic analysis. The
overall diagnostic accuracy of US-guided transvaginal core biopsy was 93% (51/55). Of the
55 lesions, 46 (84%) were confirmed to be either benign or malignant tumors, and five (9%)
were diagnosed as active or chronic inflammatory lesions. Four lesions (7%) were not histo-
pathologically diagnosed after biopsy: two were confirmed as fibrothecoma and leiomyosar-
coma after surgery, and the remaining two were clinically determined to be recurrent cancer.
In terms of minor complications, vaginal bleeding occurred in 10 patients (18%), and gross
hematuria occurred in two patients (4%). These complications resolved spontaneously in all
patients without further workup or treatment.
CONCLUSION. US-guided transvaginal core biopsy seems to be safe and reliable pro-
cedure for the histopathologic diagnosis of pelvic masses.

he use of pelvic CT and MRI in the of complex nerves and vessels covering the bi-

Keywords: complications, diagnosis, image-guided


T detection and diagnosis of various
primary and metastatic malignan-
cies in the pelvic cavity has in-
opsy window [9]. Another useful technique is
ultrasound (US)guided transvaginal biopsy.
Transvaginal US provides improved imaging
biopsy, pelvic mass, ultrasound creased [14]. Despite substantial develop- quality for gynecologic organs because of the
ments in imaging modalities, nonsurgical proximity between targeted lesions and the
DOI:10.2214/AJR.15.15702 pathologic diagnosis is still essential in various probe [10, 11]. Accordingly, guidance using
clinical situations, such as for neoadjuvant che- transvaginal US may provide a useful route
Received October 13, 2015; accepted after revision
December 9, 2015. motherapy for cytoreduction, malignant lesions for the approach in deep pelvic masses.
of unknown origin seen on imaging, and sus- Although US-guided transvaginal biopsy
Based on a presentation at the Radiological Society of pected recurrence after definitive treatment. has been described as a useful method for
North America 2014 annual meeting, Chicago, IL. However, a deep pelvic lesion is a diagnos- the nonsurgical diagnosis of pelvic masses in
1
Department of Radiology and Center for Imaging Science,
tic challenge for nonsurgical tissue confirma- the literature, few studies have examined its
Samsung Medical Center, Sungkyunkwan University tion because of the risk of injury to space-oc- technical feasibility and advantages [12, 13].
School of Medicine, 50 Ilwon-dong, Gangnam-gu, cupying organs, such as bowel and urinary Therefore, the aim of our study was to ret-
Seoul135-710, Republic of Korea. Address correspondence bladder. In addition, a feasible biopsy route rospectively evaluate the diagnostic accura-
to C. K. Kim (chankyokim@skku.edu).
may be limited because of the vessels, nerves, cy and safety of US-guided transvaginal core
2
Department of Medical Device Management and and bony structures covering the pelvic cavity. biopsy of pelvic masses that were identified
Research, SAIHST, Sungkyunkwan University, Seoul, Thus, various biopsy techniques with different at prebiopsy CT or MRI.
Republic of Korea. guiding modalities and approaches have been
used to overcome these anatomic barriers [5]. Materials and Methods
AJR 2016; 206:877882 CT images provide reliable information about Subjects
0361803X/16/2064877
the location of a targeted lesion and an acces- The institutional review board of Samsung
sible biopsy route [68]. However, anatomic Medical Center approved this study, and the re-
American Roentgen Ray Society and technical limitations still remain because quirement for informed consent was waived be-

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Park et al.

TABLE 1: Results of Nine Patients Without Tumors on Biopsy


Patient Mass Size Histopathologic Final
No. Underlying Malignancy (cm) Result Follow-Up Decision
1 Endometrial cancer 1.3 Fibrous tissue Size increase during 6 months (clinically regarded Nondiagnostic
asrecurrence)
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2 Ovarian mucinous borderline tumor 1.7 Suture granuloma No change for 2 years Diagnostic
3 Endometrial cancer 1.0 Chronic inflammation Disappearance Diagnostic
4 Endometrial cancer 1.3 Active inflammation Disappearance Diagnostic
5 Ovarian serous adenocarcinoma 1.6 Fibrous tissue Size increase after 3 months (clinically regarded Nondiagnostic
asrecurrence)
6 Uterine leiomyosarcoma 2.5 Fibroadipose tissue Surgery (confirmed as recurrence) Nondiagnostic
7 None 2.7 Chronic inflammation Size decrease over 1 year Diagnostic
8 None 3.4 Normal ovary Surgery (confirmed as fibrothecoma) Nondiagnostic
9 None 1.7 Active inflammation Disappearance Diagnostic

cause of its retrospective design. We reviewed the on prebiopsy CT or MRI. The distance of the bi- (78%) underwent the biopsy because of sus-
medical records of 55 consecutive patients (mean opsy was defined as the gap between the tip of the picion of recurrence or metastasis from an
age, 58 years; range, 2587 years) who underwent probe and the target lesion, and it was retrospec- underlying primary malignancy of the cervix
US-guided transvaginal core needle biopsy for a tively measured on the acquired US images using (n= 17; Fig. 2), ovary (n= 8), endometrium
pelvic mass between March 2009 and May 2014 our PACS (Centricity Radiology RA 1000, GE (n= 7), myometrium (n= 4), bladder (n= 2),
at our single institution. Among the enrolled pa- Healthcare). The number of biopsy cores obtained pancreas (n= 2), vulva (n= 1), anus (n= 1),
tients, all targeted lesions were already detected at from each patient was also recorded. or lung (n= 1). Of these 43 lesions, 37 (86%)
CT or MRI before biopsy. None of the 55 patients Biopsy results were analyzed according to were confirmed by biopsy to be either recur-
was excluded from this study because they all met pathologic reports. If a benign or malignant tumor rent or metastatic lesions. The remaining 12
the following inclusion criteria: proper CT or MRI was identified on biopsy, the procedure was deter- lesions (22%) were initially detected without
examination performed within 1 month before bi- mined to be diagnostic. If tumors were not identi- an underlying primary malignancy. Of these
opsy, clinical and pathologic information avail- fied on biopsy, the results of the clinical and radio- 12 lesions, nine (75%) were confirmed to be
able for analysis, and an adequate clinical and ra- logic follow-up were considered to be a possible lymphoma (n= 3), cervical squamous cell
diologic follow-up period ( 6 months), especially false-negative biopsy. Biopsy-related complica- carcinoma (n= 1), leiomyosarcoma (n= 1),
if the biopsy results were inconclusive. tions were classified as either major or minor. Ma- invasive urothelial carcinoma (n= 1), granu-
jor complications were defined as abnormal post- losa cell tumor (n= 1; Fig. 3), malignant neu-
Biopsy Procedure procedural conditions, such as bleeding, infection, rogenic tumor (n= 1), and extrauterine ad-
Each biopsy was performed by one of two geni- organ injury, and persistent pain that required fur- enomyoma (n= 1). Thus, the histopathologic
tourinary radiologists (with at least 10 years of ex- ther workup or treatment. Minor complications results were conclusive for 46 lesions with ei-
perience in genitourinary imaging and interven- were defined as abnormal findings that resolved ther a benign or malignant tumor identified
tions) using one of two US scanners (HDI 5000 or spontaneously without sequelae [14]. on biopsy. In the nine lesions without any
iU22, Philips Healthcare). All patients were placed tumors present, four spontaneously disap-
in the lithotomy position, and transvaginal US was Statistical Analysis peared or decreased in size during the fol-
performed before the biopsy to localize the target- The Mann-Whitney U test was used to compare low-up period without treatment, and one
ed lesion. After local anesthesia with 1% lidocaine tumor size and biopsy distance between diagnos- was identified as a suture granuloma that did
(Daihan Lidocaine, Dai Han Pharm) via a 21-gauge tic and nondiagnostic biopsy groups. Statistical not change for 2 years. Accordingly, the re-
15-cm Chiba needle (Cook Medical), an 18-gauge analyses were performed using the PASW soft- sults of these biopsies were regarded as diag-
20-cm Tru-Cut needle (Cardinal Health) with an ware (version 20.0, SPSS). A two-sided p< 0.05 nostic. However, the remaining four lesions
automatic biopsy gun (Acecut, TSK Laboratory) was considered to indicate statistical significance. were regarded as nondiagnostic, with two le-
was inserted parallel to the transvaginal US probe sions confirmed to be tumors after surgery
through an attached needle guide. A prophylac- Results and two clinically regarded as recurrent can-
tic antibiotic was not used, and the vagina was not In 55 pelvic lesions of 55 patients, the mean cers from underlying malignancies because
prepared before the biopsy. During the procedure, (SD) tumor size was 4.3 3.4 cm (range, of substantial increases in size on short-term
conscious sedation was not performed. All patients 117 cm). The mean distance of the biopsy follow-up imaging (Table 1). Finally, 51 of
were hospitalized for at least 1 day after the biopsy was 1.6 cm (range, 03.8 cm). The median the 55 biopsy lesions (93%) were determined
for monitoring of procedure-related complications. number of biopsy cores obtained from each to be diagnostic.
patient was three (range, 26 cores). In all The mean tumor size was smaller in the
Data Analysis cases, the acquired specimens were adequate nondiagnostic biopsy group (2.2 0.9 cm)
Patients demographic information was ac- for the histopathologic diagnosis. than in the diagnostic biopsy group (4.5 3.4
quired from the medical records. A radiologist in- A schematic flowchart of biopsy result cm), and the mean biopsy distance was lon-
dependently measured the maximum tumor size is shown in Figure 1. Of the 55 lesions, 43 ger in the nondiagnostic biopsy group (2.3

878 AJR:206, April 2016


US-Guided Transvaginal Core Biopsy of Pelvic Masses

logic confirmation of pelvic masses and can


Biopsy for pelvic mass be an alternative to invasive surgical biopsy.
n = 55 To date, few studies have reported the pre-
liminary results of US-guided transvaginal
biopsy with a limited number of cases. Volpi
Underlying malignancy (positive) Underlying malignancy (negative) et al. [12] first reported the diagnostic accu-
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n = 43 n = 12 racy of US-guided transvaginal biopsy to be


approximately 95% in 21 patients. Howev-
er, the prebiopsy workup was accomplished
Recurrence metastasis No tumor Recurrence metastasis by US or physical examination, and all of
(positive) n = 37 n=9 (negative) n = 9 the enrolled patients had underlying gyneco-
logic malignancies. Sheth and Angirish [15]
also reported the potential of the procedure
Follow-up Nondiagnostic in patients with pelvic masses, although the
surgery biopsy n = 4 number of enrolled cases was only five. In the
study of Faulkner et al. [16], the diagnostic
accuracy of US-guided transvaginal biopsy
Diagnostic biopsy was 86%. However, the enrolled lesions were
n = 51 limited to the palpable masses around the va-
gina in the patients with provisional diagno-
Fig. 1Schematic flowchart shows biopsy results. sis of ovarian cancer. Walker [13] described
22 cases in which US-guided transvaginal bi-
0.5 cm) than in the diagnostic biopsy group sy. However, these symptoms also resolved opsy was successfully used to confirm myo-
(1.6 0.9 cm). However, the differences in within a few hours after the procedure with- metrial lesions and revealed equivocal US
tumor size and biopsy distance between the out the need for treatments. No patient had findings before uterine artery embolization.
two groups were not statistically significant signs or symptoms of infection. Two recent studies using image-guided tech-
(p= 0.12 and 0.09, respectively). niques have reported the feasibility of US-
During or after the biopsy, no patient had Discussion guided transvaginal biopsy for various pelvic
major complications that required specif- Our results show that US-guided transvag- masses [17, 18]. However, these studies ad-
ic workup or treatment. In terms of minor inal biopsy has an excellent diagnostic accu- opted variable guiding modalities and route-
complications, 10 patients (18%) had vaginal racy of approximately 93% for histopatho- approaching techniques; accordingly, the
bleeding immediately after the biopsy, al- logic diagnosis in women with pelvis masses. utility of only US-guided transvaginal biopsy
though none received transfusion or under- Moreover, no major complications after the seemed limited.
went CT angiography because the bleeding procedure were noted. These findings indi- In contrast, the present study evaluated
spontaneously resolved in all patients. Two cate that US-guided transvaginal biopsy is a the utility of US-guided transvaginal tech-
patients (4%) had gross hematuria after biop- safe and effective procedure for histopatho- nique for 55 pelvis masses, which is a rela-

A B
Fig. 269-year-old woman who underwent radical hysterectomy for uterine cervical cancer 1 year earlier.
A and B, Contrast-enhanced axial (A) and coronal (B) CT images show 3.8-cm mass (arrowheads) involving left posterior wall of urinary bladder and ipsilateral distal
ureter. Before biopsy, catheter (arrow) was inserted in left ureter to relieve obstruction.
(Fig. 2 continues on next page)

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Park et al.
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C D
Fig. 2 (continued)69-year-old woman who underwent radical hysterectomy for uterine cervical cancer 1 year earlier.
C, Transvaginal ultrasound (US) shows features consistent with periureteral mass (arrowheads).
D, During US-guided transvaginal biopsy, tip of biopsy needle is located within target (open arrow) beside ureter, presenting as echogenic line due to catheter (solid
arrow). Distance of biopsy (between open arrowheads) was 1.0 cm. Lesion (solid arrowheads) was confirmed to be recurrent cervical cancer.

tively large number of cases compared with of the operators skill if the targeted lesion is ing the optimal guidance and approach route.
previous studies. The diagnostic accuracy of appropriately identified on US. The transvaginal approach may also be bet-
US-guided transvaginal technique was ap- US guidance has several benefits com- ter than a percutaneous approach for deep
proximately 93%, which is comparable with pared with CT guidance with respect to ra- pelvic lesions in several locations. One pos-
results from previous studies, regardless of diation exposure and cost effectiveness, in sible explanation is that a transvaginal US
biopsy method used [12, 17, 18]. The reliable addition to its ability to perform noninvasive probe can be closely positioned near a lesion,
and accurate diagnostic performance of the real-time imaging. Although US is relatively which can be further highlighted by pushing
procedure might be explained by the abili- inferior to CT for localizing lesions because the probe in the direction of the targeted le-
ty to advance the needle parallel to the lon- of its low spatial resolution and variable ar- sion. In our study, the mean gap between the
gitudinal axis of the transvaginal probe us- tifacts, these limitations can be partly com- probe and the targeted lesion was only 1.6
ing an attached guide similar to that used in pensated for by the coregistration of prebi- cm. The short distance of the biopsy route
transrectal prostate biopsy. This can allow an opsy CT or MR images for estimating the may explain the safety and accuracy of the
easy and consistent approach to a targeted le- location of the target lesion. In addition, pre- procedure, although a significant difference
sion, enabling diagnostic biopsy regardless biopsy imaging may be useful for determin- between diagnostic and nondiagnostic biop-

A B
Fig. 379-year-old woman who underwent simple hysterectomy for uterine leiomyoma 30 years ago.
A and B, Sagittal T2-weighted (A) and corresponding contrast-enhanced T1-weighted (B) images show 13-cm pelvic mass (asterisk) containing soft-tissue area with
enhancement mainly located in deep pelvic cavity.
(Fig. 3 continues on next page)

880 AJR:206, April 2016


US-Guided Transvaginal Core Biopsy of Pelvic Masses
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C D
Fig. 3 (continued)79-year-old woman who underwent simple hysterectomy for uterine leiomyoma 30 years ago.
C, Transvaginal US shows concordant feature of pelvic lesion (asterisk).
D, During US-guided transvaginal biopsy, tip of biopsy needle (arrow) is properly located within target. Distance of biopsy (between open arrowheads) was 0.6 cm. Lesion
(asterisk) was identified as granulosa cell tumor on both biopsy and at examination of surgical specimen.

sies was not found in our study. Furthermore, guided transvaginal biopsy can be performed ly kept clinicians informed of the procedure
US guidance via the transvaginal approach is in outpatient clinics, and overnight hospital- and its satisfactory outcomes. Both radiolo-
less affected by the abundant subcutaneous ization seems not to be mandatory if the pro- gists and clinicians need to know the utili-
fat seen in obese patients, as is the case with cedure is successfully completed without im- ty of US-guided transvaginal biopsy to mini-
percutaneous procedures. mediate complications. mize invasive surgical biopsy.
In our study, none of the cases was compli- At our institution, the clinicians, such as There are several limitations to our study.
cated by serious hemorrhage requiring treat- gynecologic oncologists, urologists, and ra- First, although we had a relatively large study
ment. US-guided transvaginal biopsy mini- diation oncologists, refer the patients to population compared with previous studies,
mizes biopsy-related hemorrhage because us for image-guided biopsy if they want to this study was still performed with a small
the transvaginal approach avoids most of the pathologically confirm any pelvic lesions. number of patients and a retrospective de-
great pelvic vessels that are located along the Then, we determine the optimal guiding mo- sign. Further large-scale studies will be
pelvic wall [9]. In addition, color Doppler US dality and route for the biopsy by reviewing needed. Second, in our study, the results of
provides crucial real-time information about available CT and MR images. To improve the biopsies for nine patients with specimens
blood flow around the target lesion. For he- the efficiency of the management process, that did not reveal tumors were determined
mostasis, the transvaginal probe can be used we have tried to include the technical feasi- according to clinical and radiologic findings.
to provide compression adjacent to the bleed- bility of image-guided interventions in radio- Although all patients seemed to have appro-
ing focus. With regard to postbiopsy infection, logic reports for CT and MRI examinations priate follow-up, we cannot completely ex-
transvaginal biopsy also seems to be safer before clinicians requests if we think that clude the possibility of false-negative inter-
than the transrectal approach. To our knowl- the procedure will be necessary for diagno- pretations. Finally, the feasibility of biopsy in
edge, no studies have reported infectious com- sis and treatment, although the final decision all enrolled patients was already determined
plications after US-guided transvaginal biop- is made by the clinicians. At our institution, on prebiopsy imaging. This might have led to
sy [12, 13, 15, 17, 18]. In our study, no patient the dedicated genitourinary radiologists per- potential selection bias.
showed signs or symptoms of infection af- form almost all of the diagnostic interven- In conclusion, US-guided transvaginal
ter the biopsy, which was performed without tions for the genitourinary systems. Among core biopsy seems to be a safe and reliable
vaginal preparation or prophylactic antibiot- the variable procedures, an understanding of procedure for the histopathologic diagnosis
ics. All patients enrolled in our study were ad- pelvic anatomy and US findings seems to be of pelvic masses.
mitted after the biopsy for monitoring com- crucially important, especially for US-guid-
plications. However, considering our results ed transvaginal biopsy because the proce- References
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