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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Management
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▶ Because MR-compatable biopsy devices are made from nonferrous metals, including nickel, titanium,
and chromium, they are more pliable and less sharp than their traditional ferromagnetic stainless steel
counterparts.
▶ MR aords the ability to image in multiple planes using a variety of sequences to maximize lesion and needle
conspicuity.
Further Reading
Schwartz HS, Spengler DM. Needle tract recurrences aer closed biopsy for sarcoma:three cases and review of the literature.
Ann Surg Oncol. 1997; 4(3):228–236.
Weiss CR, Nour SG, Lewin JS. MR guided biopsy:Areview of current techniques and applications. J Magn Reson Imaging.
2008; 27:311–325.
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History
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▶ Pancreatic Cancer with Intractable Back Pain
Figure 17.1
Case 17
Figure 17.2
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Case 17 Celiac Plexus Neurolysis
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Figure 17.3
Figure 17.5
Figure 17.4
Findings
▶ Contrast-enhanced abdominal computed tomography (CT) image shows the level of the celiac plexus, which
lays anterior to the aorta just below the origin of the celiac axis. Note the so tissue attenuation around the
proximal celiac axis (Fig.17.3, arrow) representing tumor inltration from a pancreatic cancer.
▶ With the patient in the prone position, bilateral 22-gauge needles have been advanced to the celiac plexus
(Fig.17.4). Contrast-opacied ethanol has been injected for neurolysis (arrows) and is seen posterior to the
diaphragmatic crus.
▶ In a dierent patient, unilateral cryoablation was used to perform celiac neurolysis (Fig.17.5). e iceball can
be seen as a low-density oval structure forming around the distal end of the cryoprobe (arrows).
Teaching Points
▶ “Neurolysis” refers to permanent destruction of nerve, whereas “nerve block” refers to temporary interruption
of nerve signaling by steroids or anesthetics.
▶ Visceral pain related to pancreatic cancer arises via visceral aerent nerves that coalesce at the celiac plexus.
Debilitating pain from intra-abdominal malignancies, most notably pancreatic cancer, can greatly limit quality
of life. In many patients, neurolysis can provide relief.
▶ e celiac plexus receives stimuli from the distal esophagus to the transverse colon, including the pancreas.
With high-quality imaging, the ganglia can be identied more oen than not. e right ganglia may be discoid
so tissue attenuation between the inferior vena cava and crus of the diaphragm.
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Management
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▶ Celiac neurolysis may be achieved with endoscopic ultrasound guidance or percutaneously with CT guidance.
CT has the advantage of being able to visualize the distribution of the injectate accurately—which should
ideally be both antecrural and retrocrural.
▶ Most commonly used for malignancy, neurolysis has also been used to treat the pain associated with chronic
pancreatitis.
▶ Ethanol is the most common agent used for neurolysis. On CT scan, ethanol is seen as fat density. Contrast
mixed with an anesthetic may be injected prior to ethanol to conrm free diusion of the injectate.
▶ Other approaches, including anterior and decubitus, have been described for patients who cannot maintain a
prone position.
▶ Compliations include pain, orthostatic hypotension, and diarrhea due to splanchnic vasodilation.
Further Reading
Kambadakone A, abet A, Gervais DA, etal. CT-guided celiac plexus neurolysis:a review of anatomy, indications, technique
and tips for successful treatment. Radiographics. 2011; 31(6):1599–1621.
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Case 18
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History
▶ A47-Year-Old Female Presented with a History of Breast Cancer. Computed Tomography Was Performed for
Abdominal Pain.
Figure 18.1
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Case 18 Liver Biopsy
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Figure 18.2
Figure 18.3
Figure 18.4
Findings
▶ Figure 18.2 demonstrates multiple hypodense lesions in the liver suspicious for metastasis. Alesion in segment
2/3 was targeted for biopsy (black arrow). It is important to choose a area to biopsy with the least amount of
necrosis to increase yield.
▶ Ultrasound demonstrates the le hemiliver (Fig. 18.3, black arrow). When possible, choosing a path that
traverses normal liver parenchyma may decrease the risk of bleeding.
▶ In Figure 18.4 the biopsy needle (white arrow) is seen within the target lesion (black arrow). When core biopsy
is planned, it is important to take the throw of the biopsy needle (usually from 1 to 2cm) into account to avoid
injury to structures deep to the biopsy target.
Teaching Points
▶ Image-guided liver biopsies are performed in a targeted fashion for focal lesions and in a nontargeted fashion
to evaluate for parenchymal disease (see Case 14).
▶ For targeted liver lesions, the presence of on onsite cytopathology increases the diagnostic rate. If a
cytopathologist is unavailable, three core biopsies allow for diagnosis in ~90% of cases.
▶ In a 2009 position paper, the American Association for the Study of Liver Diseases recommends a 16-gauge
core biopsy be obtained to allow diagnosis, grading, and staging of diuse, nonneoplastic parenchymal
disease. In practice, many practitioners obtain 18- to 20-gauge core specimens.
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Management
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▶ Patients are observed in a recovery area for 2 to 4 hours. e majority of complications manifest within the
rst 2 hours.
▶ e most frequent major complication is bleeding that requires therapy—including transfusion, overnight
observation, or embolization. Patients with major bleeding will manifest with pain refractory to pain
medications with associated tachycardia, hypotension, and/or drop in hematocrit. ere should be a low
threshold to obtain urgent noncontrast computed tomography (CT) imaging of the abdomen if there is
concern for bleeding.
Further Reading
Applebaum L, Kane RA, Kruskal JB, etal. Focal hepatic lesions:US guided biopsy—Lessons from review of cytologic and
pathologic examination results. Radiology. 2009; 250:453–458.
Vijayaraghavan GR, David S, Bermudez-Allende M, etal. Image-guided parenchymal liver biopsy:How we do it. J Clin
Imaging Sci. 2011; 1:1–8.
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History
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▶ A25-Year-Old Female with Cold Intolerance. Workup for Hyperthyroidism Included an Ultrasound.
Case 19
Figure 19.1
Figure 19.2
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Case 19 Thyroid Biopsy
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Figure 19.3 Figure 19.4
Findings
▶ Ahypoechoic lesion (white arrow) is seen in the le thyroid lobe (Fig. 19.3) demonstrating vascularity (not shown).
▶ A25-gauge biopsy needle (white arrow) has been advanced into the lesion (Fig. 19.4).
Teaching Points
▶ Dierent techniques have been used to obtain samples from thyroid biopsies, namely aspiration using suction
or capillary action. Neither has proven to be superior and both are used clinically.
▶ Because of the small working area, it is easy to contaminate the specimen with ultrasound gel; to avoid this
problem, either saline or betadine can be used as a coupling agent.
▶ When lesions are mixed cystic and solid, the solid component should be targeted for biopsy.
Management
▶ While the decision to biopsy certain thyroid nodules remains controversial, in 2009 the American yroid
Association suggested certain guidelines in choosing which nodules to biopsy:
1. In patients without risk factors for thyroid cancer:
■ All solid nodules greater than 1cm in size with suspicious ultrasound characteristics.
• Suspicious characteristics include the following:
• Microcalcications
• Irregular borders or ill-dened margins
• Cold on scintigraphy
■ Mixed cystic and solid nodules without suspicious ultrasound features that are greater than 2.0cm.
2. For patients with risk factors for thyroid cancer, nodule size threshold for biopsy decreases to 0.5cm.
Further Reading
Frates MC, Benson CB, Charboneau JW, etal; Society of Radiologists in Ultrasound. Management of thyroid nodules detected
at US:Society of radiologists in ultrasound consensus conference statement. Radiology. 2005; 237:794–800.
Nixon IJ, Ganly I, Hann LE, etal. Nomogram for selecting thyroid nodules for ultrasound-guided ne-needle aspiration biopsy
based on a quantication of risk of malignancy. Head Neck. 2013; 35(7):1022–1025.
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Case 20
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History
▶ A69-Year-Old Female with Hepatocellular Carcinoma
Following multiple embolizations, residual and enlarging focus of viable disease is seen anteriorly in segment
VIII. What is the procedure being performed?
Figure 20.1
Figure 20.2
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