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Ultrasound-guided fine-needle aspiration and biopsy from the pelvis


Medical editor Gunnar B. Kristensen MD
Gynecological Oncologist
Oslo University Hospital

General

MRI or CT is often used to assess possible spreading of different cancer types. A cytological or histological assessment of a tumor is often needed. If the lesion can be seen by vaginal ultrasound, ultrasound-guided biopsy is the optimal method for this. For localized tumor, for example a well-limited ovarian tumor without sign of spreading, the risk for spread in connection with the biopsy procedure must be taken into consideration. For probable stage I ovarian cancer, biopsy is generally contraindicated due to the risk of spread. For suspicion of sarcoma, the indication must be done by a sarcoma treatment specialist. For cytological examination, it is possible to obtain the result already the same or the following day while a histological examination requires a few days.

Indication 

  • Unknown type of lesion in the pelvis

Goal

  • To confirm or exclude metastases from suspect lesions in the pelvis.

Equipment

  • Ultrasound specimen with transducer for the procedure
  • Syringe (20 ml and syringe holder)
  • Needle for cytology material. (22 G B&D spinal needle)
  • 4 slides for the specimen

For histological biopsy (pistol biopsy) this is used in addition:

  • Separate 18 G or 16 G needle + gun
  • Slide for fixing histology material (formalin, Ringer solution, McCoy, dry glass for freezing etc. - depending on tentative diagnosis)
  • Sterile condom for ultrasound probe
  • Gel

Preparation

Depending on the localization of the lesion and availability, routine blood tests must be ordered regarding bleeding parameters (hemoglobin, thrombocytes, possibly INR).

  • Make sure the patient is well situated on the examination table.
  • Inform the patient during the procedure.

Implementation

Ultrasound-guided biopsy from the pelvis is taken usually under general anesthesia, but fine-needle aspiration for cytology examination can be taken without anesthesia.

Cytology sample (fine-needle aspiration)

  • Wash the vagina with chlorhexidine 1 mg/ml
  • Localize the lesion with the ultrasound probe
  • Determine the best point of puncture and direction. Use a puncture line.
  • Puncture the spinal needle quickly through mucous membrane.
  • Insert the needle into the lesion using ultrasound.
  • Pull out the mandrin.
  • Insert the needle into the lesion.
  • Aspirate while the needle moves back and forth 2-3 times per second until the material is visible in the upper part of the needle.
  • Retract the suction and pull the needle out.
  • Deposite the specimen onto the slide

Spread for cytology

  • Spread the specimen onto the slide.
  • Dry the specimen under a fan or hairdryer.
  • Alternative 1: send the specimen unfixed to the cytologist.
  • Alternative 2: Immediate staining and assessment.
    • Fixation solution with methanol + haemacolor + rinse in water
    • 5 dips in fixer. Allow the solution to drip off onto paper.
    • 3 dips in stain solution 1.
    • 6 dips in stain solution 2. Allow the solution to drip onto paper.
    • Rinse in 2 baths of clean water.
  • Examine the specimen under the microscope with 10x or 20x objective.
  • Microscopic assessment of the cell material should be done by a cytologist to determine if supplementary samples are needed. 

Histological biopsy (pistol biopsy)

  • For pistol biopsy, general anesthesia is used.
  • Insert the biopsy needle up to the lesion and insert slightly, depending on the size and type of the tissue in front and behind the lesion.
  • The needle moves 2.5 cm forward when released.
  • Retract the pistol such that the sample is taken.
  • Retrieve the needle out and open it.
  • Place the piece of tissue on a slide with transfer medium, for example formalin.  

Follow-up

  • After uncomplicated biopsies, outpatients must remain at the hospital for 1 hour before going home.
  • Depending on localization of the lesion and nature, bleeding may occur after biopsy procedure.
  • For intense pain or bleeding, the patient must be observed at the post or intensive unit dending on severity while necessary measures are taken.

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