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

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

AJR:206, April 2016 877

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

878 AJR:206, April 2016

 US-Guided Transvaginal Core Biopsy of Pelvic Masses
Biopsy for pelvic mass
n = 55
Underlying malignancy (positive) Underlying malignancy (negative)
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n = 43 n = 12
Recurrence metastasis No tumor Recurrence metastasis
(positive) n = 37 n=9 (negative) n = 9
Follow-up Nondiagnostic
surgery biopsy n = 4
Diagnostic biopsy
n = 51
Fig. 1Schematic flowchart shows biopsy results.
0.5 cm) than in the diagnostic biopsy group sy. However, these symptoms also resolved
(1.6 0.9 cm). However, the differences in within a few hours after the procedure with-
tumor size and biopsy distance between the out the need for treatments. No patient had
two groups were not statistically significant signs or symptoms of infection.
(p= 0.12 and 0.09, respectively).
During or after the biopsy, no patient had Discussion
major complications that required specif- Our results show that US-guided transvag-
ic workup or treatment. In terms of minor inal biopsy has an excellent diagnostic accu-
complications, 10 patients (18%) had vaginal racy of approximately 93% for histopatho-
bleeding immediately after the biopsy, al- logic diagnosis in women with pelvis masses.
though none received transfusion or under- Moreover, no major complications after the
went CT angiography because the bleeding procedure were noted. These findings indi-
spontaneously resolved in all patients. Two cate that US-guided transvaginal biopsy is a
patients (4%) had gross hematuria after biop- safe and effective procedure for histopatho-
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.
AJR:206, April 2016 879
logic confirmation of pelvic masses and can
be an alternative to invasive surgical biopsy.
To date, few studies have reported the pre-
liminary results of US-guided transvaginal
biopsy with a limited number of cases. Volpi
et al. [12] first reported the diagnostic accu-
racy of US-guided transvaginal biopsy to be
approximately 95% in 21 patients. Howev-
er, the prebiopsy workup was accomplished
by US or physical examination, and all of
the enrolled patients had underlying gyneco-
logic malignancies. Sheth and Angirish [15]
also reported the potential of the procedure
in patients with pelvic masses, although the
number of enrolled cases was only five. In the
study of Faulkner et al. [16], the diagnostic
accuracy of US-guided transvaginal biopsy
was 86%. However, the enrolled lesions were
limited to the palpable masses around the va-
gina in the patients with provisional diagno-
sis of ovarian cancer. Walker [13] described
22 cases in which US-guided transvaginal bi-
opsy was successfully used to confirm myo-
metrial lesions and revealed equivocal US
findings before uterine artery embolization.
Two recent studies using image-guided tech-
niques have reported the feasibility of US-
guided transvaginal biopsy for various pelvic
masses [17, 18]. However, these studies ad-
opted variable guiding modalities and route-
approaching techniques; accordingly, the
utility of only US-guided transvaginal biopsy
seemed limited.
In contrast, the present study evaluated
the utility of US-guided transvaginal tech-
nique for 55 pelvis masses, which is a rela-
(Fig. 2 continues on next page)
 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
previous studies. The diagnostic accuracy of
US-guided transvaginal technique was ap-
proximately 93%, which is comparable with
results from previous studies, regardless of
biopsy method used [12, 17, 18]. The reliable
and accurate diagnostic performance of the
procedure might be explained by the abili-
ty to advance the needle parallel to the lon-
gitudinal axis of the transvaginal probe us-
ing an attached guide similar to that used in
transrectal prostate biopsy. This can allow an
easy and consistent approach to a targeted le-
sion, enabling diagnostic biopsy regardless
of the operators skill if the targeted lesion is
appropriately identified on US.
US guidance has several benefits com-
pared with CT guidance with respect to ra-
diation exposure and cost effectiveness, in
addition to its ability to perform noninvasive
real-time imaging. Although US is relatively
inferior to CT for localizing lesions because
of its low spatial resolution and variable ar-
tifacts, these limitations can be partly com-
pensated for by the coregistration of prebi-
opsy CT or MR images for estimating the
location of the target lesion. In addition, pre-
biopsy imaging may be useful for determin-
ing the optimal guidance and approach route.
The transvaginal approach may also be bet-
ter than a percutaneous approach for deep
pelvic lesions in several locations. One pos-
sible explanation is that a transvaginal US
probe can be closely positioned near a lesion,
which can be further highlighted by pushing
the probe in the direction of the targeted le-
sion. In our study, the mean gap between the
probe and the targeted lesion was only 1.6
cm. The short distance of the biopsy route
may explain the safety and accuracy of the
procedure, although a significant difference
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,
US guidance via the transvaginal approach is
less affected by the abundant subcutaneous
fat seen in obese patients, as is the case with
percutaneous procedures.
In our study, none of the cases was compli-
cated by serious hemorrhage requiring treat-
ment. US-guided transvaginal biopsy mini-
mizes biopsy-related hemorrhage because
the transvaginal approach avoids most of the
great pelvic vessels that are located along the
pelvic wall [9]. In addition, color Doppler US
provides crucial real-time information about
blood flow around the target lesion. For he-
mostasis, the transvaginal probe can be used
to provide compression adjacent to the bleed-
ing focus. With regard to postbiopsy infection,
transvaginal biopsy also seems to be safer
than the transrectal approach. To our knowl-
edge, no studies have reported infectious com-
plications after US-guided transvaginal biop-
sy [12, 13, 15, 17, 18]. In our study, no patient
showed signs or symptoms of infection af-
ter the biopsy, which was performed without
vaginal preparation or prophylactic antibiot-
ics. All patients enrolled in our study were ad-
mitted after the biopsy for monitoring com-
plications. However, considering our results
and previous reports, we think that US-guid-
ed transvaginal biopsy is very safe and reli-
able. Furthermore, a radiologist can recom-
mend that patients need hospital admittance
by considering the possibility of any compli-
cations by reviewing prebiopsy imaging or US
findings during the procedure. Therefore, US-
guided transvaginal biopsy can be performed
in outpatient clinics, and overnight hospital-
ization seems not to be mandatory if the pro-
cedure is successfully completed without im-
mediate complications.
At our institution, the clinicians, such as
gynecologic oncologists, urologists, and ra-
diation oncologists, refer the patients to
us for image-guided biopsy if they want to
pathologically confirm any pelvic lesions.
Then, we determine the optimal guiding mo-
dality and route for the biopsy by reviewing
available CT and MR images. To improve
the efficiency of the management process,
we have tried to include the technical feasi-
bility of image-guided interventions in radio-
logic reports for CT and MRI examinations
before clinicians requests if we think that
the procedure will be necessary for diagno-
sis and treatment, although the final decision
is made by the clinicians. At our institution,
the dedicated genitourinary radiologists per-
form almost all of the diagnostic interven-
tions for the genitourinary systems. Among
the variable procedures, an understanding of
pelvic anatomy and US findings seems to be
crucially important, especially for US-guid-
ed transvaginal biopsy because the proce-
dure is methodologically simple and easy.
Therefore, we think that anyone who under-
stands imaging of the female pelvis may eas-
ily adopt the procedure. In 6 years, 55 pa-
tients underwent US-guided transvaginal
biopsy. However, the number of cases is in-
creasing every year because we have steadi-
ly kept clinicians informed of the procedure
and its satisfactory outcomes. Both radiolo-
gists and clinicians need to know the utili-
ty of US-guided transvaginal biopsy to mini-
mize invasive surgical biopsy.
There are several limitations to our study.
First, although we had a relatively large study
population compared with previous studies,
this study was still performed with a small
number of patients and a retrospective de-
sign. Further large-scale studies will be
needed. Second, in our study, the results of
the biopsies for nine patients with specimens
that did not reveal tumors were determined
according to clinical and radiologic findings.
Although all patients seemed to have appro-
priate follow-up, we cannot completely ex-
clude the possibility of false-negative inter-
pretations. Finally, the feasibility of biopsy in
all enrolled patients was already determined
on prebiopsy imaging. This might have led to
potential selection bias.
In conclusion, US-guided transvaginal
core biopsy seems to be a safe and reliable
procedure for the histopathologic diagnosis
of pelvic masses.
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