Korean J Radiol.  2017 Apr;18(2):361-369. 10.3348/kjr.2017.18.2.361.

Practical Guidelines for Ultrasound-Guided Core Needle Biopsy of Soft-Tissue Lesions: Transformation from Beginner to Specialist

• Kim SY
• Chung HW
• Oh TS
• Lee JS

• KMID: 2427948
• DOI: http://doi.org/10.3348/kjr.2017.18.2.361

Abstract

Ultrasound-guided core needle biopsy (US-CNB) is an important step in the diagnosis of musculoskeletal soft-tissue lesions. To maximize efficacy and minimize the complications of US-CNB, it is critical to collaborate with a multidisciplinary team and to understand the particular considerations of US-CNB for these lesions. The purpose of this article is to provide a systematic review and step-by-step tips for using US-CNB to diagnose musculoskeletal soft-tissue lesions.

Keyword

Ultrasound; Core needle biopsy; Soft tissue; Image-guided biopsy; Soft tissue neoplasms

MeSH Terms

Aged
Aged, 80 and over
*Biopsy, Large-Core Needle
Female
Humans
Image-Guided Biopsy
Middle Aged
Musculoskeletal Diseases/*pathology
Practice Guidelines as Topic
Soft Tissue Neoplasms/*pathology
Ultrasonography

Figure

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  Fig. 1 67-year-old female patient with mass in her right posterior thigh. A. Longitudinal US image showing mass with well-defined, ovoid margins (white arrowheads). Proximal portion of mass (yellow arrow) shows heterogeneous hyper-echogenicity, and distal portion (red arrow) shows homogeneous hypoechogenicity. Deciding proper target is deliberate process for successful US-CNB. B-D. Sagittal T1-weighted MR image (B), enhanced T1-weighted MR image (C), and positron emission tomography (PET) image (D). Proximal portion of mass (yellow arrows) shows high signal intensity with multiple septations on sagittal T1-weighted MR image. This portion does not demonstrate enhancement on enhanced T1-weighted image, thus suggesting fat component. In contrast, distal portion (red arrows) shows homogeneous, intense enhancement on enhanced T1-weighted image and hypermetabolic activity on PET image. When we consider proper targeting, distal portion (red arrow) is best. E. On longitudinal US image, US-CNB was performed at distal hypoechoic area, and this mass was confirmed as well-differentiated liposarcoma. US = ultrasonography, US-CNB = ultrasound-guided core needle biopsy

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  Fig. 2 55-year-old female patient with mass in her right anterior thigh. A. Longitudinal US image shows multi-lobulated mass. Most proximal portion of mass (red arrow) shows homogeneous hypoechogenicity, and just distal portion (yellow arrow) shows heterogeneous hyperechogenecity; lower portion (white arrow) shows homogeneous hyperechogenecity. It was difficult to determine proper target by considering only ultrasonographic appearance. B, C. On sagittal enhanced T1-weighted MR (B) and PET images (C), most proximal portion of mass (red arrows) enhanced well and revealed hypermetabolic activity. Just distal portion (yellow arrows) shows mild enhancement on enhanced T1-weighted image; however, this portion does not show significant metabolic activity on PET image. Lower portion (white arrows) reveals nonenhancing cystic area with hemorrhagic component. Proper target is most proximal portion (red arrow). D. On longitudinal US image, US-CNB was performed at most proximal portion of mass, and this mass was confirmed as undifferentiated pleomorphic sarcoma. PET = positron emission tomography, US = ultrasonography, US-CNB = ultrasound-guided core needle biopsy

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  Fig. 3 67-year-old female patient with mass in her right posterior thigh. On radiographic image and actual picture of right upper leg, approximate margin of mass is marked with dark line (white arrows), and there are number of predicted entry points for US-CNB (shown as blue and red dots). Blue dots are located within margins of mass and are included on planned incision line for surgery (red arrows); these are proper needle entry points. In contrast, red dots are located outside of margins of mass, and these are poor needle entry points that could lead to unnecessary resection. US-CNB = ultrasound-guided core needle biopsy

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  Fig. 4 76-year-old male patient with mass in his left lateral thigh. A, B. On axial (A) and sagittal enhanced T1-weighted images (B), there is heterogeneously enhancing, solid mass that involves vastus intermedius and vastus lateralis muscles. Broadly, two biopsy routes can be considered (as shown by blue and red arrows). Blue route traverses and violates unaffected posterior compartment, but red route crosses only anterior compartment and thus is proper route. C. On longitudinal US image, US-CNB was performed on this mass via red route. D. In actual picture of left upper leg, biopsy entry point was within intended field of surgery and on planned surgery incision line. Imaginary blue biopsy route is marked with blue dots (blue arrow). This mass was confirmed as undifferentiated pleomorphic sarcoma. US = ultrasonography, US-CNB = ultrasound-guided core needle biopsy

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  Fig. 5 81-year-old female patient with mass in her left upper arm. On axial enhanced T1-weighted image, there is homogeneously enhancing, solid mass that involves biceps brachii muscle. Three biopsy routes can be considered, as shown by blue, green, and red arrows. Blue route crosses uninvolved muscle, and green route could violate median nerve (star) and brachial artery (cross) within mass. Red route does not traverse uninvolved muscular structure and is relatively safe in terms of not violating neurovascular bundle: this is proper route for US-CNB. US-CNB was performed on this mass via red route, and this mass was confirmed as lymphoma. US-CNB = ultrasound-guided core needle biopsy

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  Fig. 6 Compartments of arm and leg. A. Compartments of upper leg. Anterior compartment (red) includes quadriceps muscle group, iliopsoas, sartorius, and tensor fascia lata muscles, and iliotibial band. Medial compartment (green) includes adductor muscle group and gracilis muscle. Posterior compartment (blue) includes hamstring muscle group. B. Compartments of lower leg. Anterior compartment (red) includes tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles. Lateral compartment (green) includes peroneus longus and brevis muscles. Posterior compartment (blue) includes soleus, gastrocnemius, plantaris, flexor digitorum longus, tibialis posterior, flexor hallucis longus, and popliteus muscles. Posterior compartment can be separated into superficial and deep compartments by transverse intermuscular septum (white dotted line). C. Compartments of upper arm. Anterior compartment (red) includes biceps, brachialis, and coracobrachialis muscles, and posterior compartment (blue) includes triceps muscle. D. Compartments of forearm. In two-compartment description, anterior or flexor compartment (red) is separated from posterior or extensor compartment (blue) by radius, ulna, and intermuscular septum. Using three-compartment classification, three muscles–brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis–are considered lateral compartment (green).

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  Fig. 7 Two types of core biopsy needle. A. Automated core biopsy needle (Acecut; TSK Laboratory, Tochigi, Japan) has both single and two-stage firing options. B. Semiautomated biopsy needle (Stericut; TSK Laboratory). Inner needle of this biopsy system can be introduced by hand for added safety and tactile sensitivity, and needle can be delivered in combination with coaxial introducer needle. C. Manual advancement of inner stylet of semiautomated biopsy needle allows for more delicate control; however, there is higher probability of distally displacing lesion, and thus cannula may partially cut lesion; as result, rest of core tissue would be only adjacent normal tissue.

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  Fig. 8 Conceptual diagram for ultrasonographic visualization of biopsy needle. A. Biopsy needle is better visualized when US beam is steered as close to perpendicular to needle as possible. B. Visualization becomes poor at steep insertion angles because echoes are reflected away from the transducer. C. Heel-and-toe maneuver is performed to bring transducer face into parallel arrangement with needle shaft. US beam will hit perpendicular to needle shaft, thus producing optimal visualization. US = ultrasonography

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  Fig. 9 Conceptual diagram for US-CNB for small soft tissue lesion. Traversing lesion with core needle may be difficult when lesion is small and mobile. Aiming at center of lesion rather than periphery is helpful for traversing it. US-CNB = ultrasound-guided core needle biopsy

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  Fig. 10 56-year-old female patient with soft-tissue mass in her left knee. A, B. On axial enhanced T1-weighted (A) and sagittal T2-weighted MR images (B), there is ovoid mass in subcutaneous fat layer of lateral aspect of left knee. This lesion was movable and measured < 0.6 cm in diameter. C. On longitudinal US image, US-CNB was successfully performed via center of lesion, and this lesion was confirmed as myopericytoma. US = ultrasonography, US-CNB = ultrasound-guided core needle biopsy

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