Percutaneous Transhepatic Biopsy Research Articles

Percutaneous Transhepatic Biopsy for Extrahepatic Lesions

Abstract Purpose The purpose was to assess the diagnostic accuracy and safety of percutaneous transhepatic biopsy for extrahepatic lesions. Materials and Methods Between January 2008 and December 2019, 26 patients (17 men and 9 women; median age, 60 years) underwent percutaneous transhepatic needle biopsy for extrahepatic lesions at our institution. Transhepatic biopsy was deemed appropriate compared with other biopsy routes or methods (i.e., endoscopic or surgical). The lesions were in the porta hepatis (n = 9), retroperitoneum (n = 6), right adrenal gland (n = 4), right kidney (n = 3), lesser omentum (n = 2), duodenum (n = 1), pleura (n = 1), and inferior vena cava (n = 1). The median maximal diameter of the lesions was 45.5 mm (range, 18–148 mm). Core-needle biopsy was performed in all patients. Eighteen-gauge and 21-G needles were used in 25 and one patient, respectively. Ultrasound was used for biopsy in 21 patients, and CT fluoroscopy was used in five patients. Postbiopsy tract embolization was performed in three patients. Technical success and diagnostic accuracy of the biopsy were evaluated. Complications were recorded using the systemic inflammation response (SIR) criteria. Results The pathological results of biopsy were carcinoma (n = 10), lymphoma (n = 9), and other diagnoses (n = 7). Technical success was obtained in all patients. The accurate diagnosis was achieved in 24 of the 26 patients (92.3%). A major complication, a bladder tamponade, was observed in one patient (3.8%) after biopsy of a right kidney lesion. A hematoma caused by iatrogenic renal injury likely obstructed the bladder outlet. Minor complications were observed in three patients (11.5%). Conclusions Percutaneous transhepatic biopsy for extrahepatic lesions is feasible with acceptable safety.

Percutaneous transhepatic cholangiobiopsy.

Most tumors of the biliary tract are too small to have specific imaging characteristics or for percutaneous puncture to provide sufficient material for diagnosis. Percutaneous transhepatic biliary drainage, in addition to being a well-established technique in the treatment of obstructive jaundice, provides adequate access for sampling obstructive lesions. In cases of biliary lesions, percutaneous transhepatic biopsy of the biliary tract has proven to be a useful diagnostic technique, with a reported accuracy of over 90% at some referral centers.

Cavernous Sinus Syndrome as the Presentation of Systemic Non-Hodgkin’s Lymphoma

Background: Cavernous sinus (CS) involvement has rarely been reported in malignant lymphoma. CS syndrome is uncommon as an initial presentation of non-Hodgkin’s extra nodal lymphomas. Case report: A 57-year-old man presented with a one-month history of headache, ocular pain and diplopia. Neurological examination revealed incomplete palsy of the left III and right VI nerves, and sensory loss of the first division of the left trigeminal nerve. Initial Magnetic Resonance Imaging (MRI) suggested left CS thrombosis. Despite optimal anticoagulation therapy, he developed right oculomotor nerve palsy, with ptosis and mydriasis of the left eye and bilateral sensory loss of the first and second division of the trigeminal nerves. MRI demonstrated a homogenous tissue lesion occupying the CS with moderate gadolinium enhancement. A body scan showed hepatosplenomegaly with hepatic and splenic nodules. The patient underwent percutaneous transhepatic biopsy and the lesion was histologically diagnosed as non-Hodgkin’s lymphoma, diffuse large B-cell type. Tumor cells were positive for CD20, CD79a and Ki67. Following four cycles of intravenous and intrathecal chemotherapy, the right oculomotor nerve palsy was completely resolved. There was partial improvement of enhancing lesion noted on follow-up MRI. Conclusion: CS syndrome is a rare presentation of malignant non-Hodgkin lymphoma. The diagnosis rests largely on imaging and biopsy results. It is associated with poor prognosis and Aggressive combined modality treatment appears to improve survival.

Long-term outcome of autologous peripheral blood CD34+ hematopoietic stem cell transplantation in the treatment of advanced liver cirrhosis

Objective To investigate the long-term outcome of autologous peripheral blood CD34+ hematopoietic stem cell transplantation in the treatment of advanced liver cirrhosis. Methods The retrospective cross-sectional study was adopted. The clinical data of 42 patients with advanced liver cirrhosis who were admitted to the Sichuan Provincial People's Hospital between July 2010 and July 2015 were collected. The patients underwent autologous peripheral blood CD34+ hematopoietic stem cell transplantation. The 5 μg/kg colony-stimulating factors were injected subcutaneously daily for 3-5 days. The peripheral blood stem cells were collected and detected by flow cytometry, showing (1.8±1.7)×106/kg of CD34+ cell. Transfemoral superselective hepatic arterial implantation or catheterization via right gastroepiploic venous to main portal vein (PV) was performed by digital subtraction angiography (DSA) at 2 days after collection, and intraoperative portal venous pressure (PVP) was monitored. PVP was reduced after operation and liver and renal functions were protected. The patients underwent anticoagulation therapy at 3 days for preventing PV thrombosis. Observation indicators included (1) treatment: the basic conditions of patients after CD34+ hematopoietic stem cell transplantation and postoperative complications, (2) follow-up: survival rate of patients, Child score, model for end-stage liver disease (MELD) score, result of biopsy, Knodell score and health related quality of life (HRQL) score. The follow-up using outpatient examination, telephone interview and Email was performed to detect the liver and renal functions and coagulation function up to July 2015. Peritoneal effusion of patients was detected by B ultrasound and computed tomography (CT) examination. The patients received liver function Child-Pugh score, MELD score, percutaneous transhepatic biopsy guided by B ultrasound and HRQL score. Measurement data with normal distribution were presented as ±s, comparison between groups was analyzed by the matched t test. The survival curve was drawn by the Kaplan-Meier method. Measurement data with skewed distribution were presented as M (range). Results (1) Treatment: the symptoms of spirit, sleep, appetite, urination and defecation in 42 patients were improved after autologous peripheral blood CD34+ hematopoietic stem cell transplantation. Ten patients had postoperative complications, including 3 with upper gastrointestinal hemorrhage, 3 with grade I of hepatic encephalopathy, 2 dying of hepatorenal syndrome at postoperative month 1 and 3, 1 with PV thrombosis at postoperative month 6 and 1 with spontaneous peritonitis. Other patients were cured or improved by symptomatic treatment. (2) Follow-up situations: 42 patients were followed up for a median time of 57 months (range, 1-60 months), with 5-year survival rate of 95.23%. The Child score and MELD score were 7.1±1.1 and 14±4 at postoperative year 5, 9.4±1.8 and 19±5 before operation, respectively, with statistically significant differences (t=1.672, 3.773, P<0.05). The result of liver biopsy showed that disordered hepatic lobule structures were cut by fibers and ground-glass hepatic cells showed symptoms of edema and degeneration with spotty and piecemeal necrosis. Necrosis from portal regions to bridge connection were found, proliferation of fibrous tissue, invasion of moderate amount of lymphocytes and monocytes inside portal regions were also detected, and pseudolobule was formed. At postoperative year 5, hepatic lobule was increased obviously and the distribution tended to normal. Hepatic cells showed symptoms of edema and degeneration with small amounts of spotty necrosis and without piecemeal necrosis. Proliferation of fibrous tissue inside portal regions was improved markedly, fibrous tissues were obviously reduced and stain was significantly fade. Knodell score at postoperative year 5 and before operation was 9.9±2.7 and 14.1±4.1, showing a statistically significant difference (t=4.142, P<0.05). HRQL score at postoperative year 5 and before operation was 167±21 and 134±15, with a statistically significant difference (t=3.142, P<0.05). Conclusion Autologous peripheral blood CD34+ hematopoietic stem cell transplantation can effectively improve liver function and pathological histology of hepatic cirrhosis as well as quality of life in patients with advanced liver cirrhosis. Key words: End-stage liver diseases; Liver cirrhosis; Autologous peripheral blood CD34+ stem cell; Model for end-stage liver disease score; Health related quality of life score

Major complications due to transjugular liver biopsy: Incidence, management and outcome

The purpose of this study was to retrospectively evaluate the incidence of intraperitoneal bleeding and other major complications of transjugular liver biopsy (TJLB) and analyze their outcome and management. The clinical files of 341 consecutive patients who had TJLB were retrospectively analyzed. There were 237 men and 104 women (mean age: 51.38±12.8 years; range: 17-89 years). All patients had TJLB because standard percutaneous transhepatic biopsy was contraindicated. Patients' files were reviewed to search for major and minor procedure-related complications during or immediately after TJLB. TJLBs were technically successful in 331/341 patients (97.07%; 95%CI: 94.67-98.58%). Major complications consisted exclusively of intraperitoneal bleeding due to liver capsule perforation and were observed in 2/341 patients (0.59%; 95%CI: 0.07-2.10%). They were treated using transcatheter arterial or venous embolization with a favorable outcome. The most frequent minor complications were abdominal pain (35/341; 10.26%; 95%CI: 7.25-13.99%) and supraventricular arrhythmia (15/341; 4.40%; 95%CI: 2.48-7.15%). No cases of inadvertent injury of the carotid artery were observed. Major complications during TJLB are extremely rare and can be managed using arterial or venous embolization with a favorable outcome. Our results reinforce the general assumption that TJLB is a safe and well-tolerated technique.

Transjugular liver biopsy using ultrasonographic guidance for jugular vein puncture and an automated device for hepatic tissue sampling: a retrospective analysis of 200 consecutive cases

We retrospectively evaluated the value of the combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for transjugular liver biopsy. Transjugular liver biopsy was performed with ultrasonographic guidance for right internal jugular vein puncture and an automated device for hepatic tissue sampling (Quick-Core) in 200 consecutive patients in whom percutaneous transhepatic biopsy was contraindicated. Histopathologic specimens were reviewed for adequacy and complications related to the procedure were analyzed. Biopsies were technically successful in 198 of 200 (99%) patients. The two cases of technical failure were due to an acute angle between right hepatic vein and inferior vena cava (1%). Adequate gross hepatic tissue specimens (mean length, 11. 0 mm +/- 5.3; range, 5.0-20.0 mm) were obtained in 198 (99%) patients, allowing definitive histological diagnosis in 196 of 198 patients, for an overall success rate of 98%. Neither cases of inadvertent injury of the carotid artery nor life-threatening intraperitoneal bleeding were observed. Minor complications were noted in 24/200 (12%) patients. The combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for tissue sampling is recommended for transjugular liver biopsy as it results in a safe, well-tolerated, and efficient technique.

A Sister Mary Joseph Node

A 64 year old man with previous medical history of hypertension and cholelithiasis was admitted to the hospital due to a non-healing umbilical ulcer. The ulcer was first noted one month prior to admission, and continued to increase in size despite the use of antibiotics. Our patient described a constant right upper quadrant abdominal pain and a 20 pound weight loss associated to anorexia, sporadic nausea and dizziness. He also noted several episodes of unquantified fever and chills prior to the admission. He denied increased abdominal girth, pruritus, or mental status changes. He also denied dark urine, pale stools or jaundice. Laboratory data showed evidence of leukocytosis with left shifting, high alkaline phosphatase and normal bilirubin and aminotransferase levels. [figure 1]An abdominal ct scan was performed on arrival showing an advanced gallbladder lesion with associated hepatic invasive changes and metastatic implants throughout the abdominopelvic cavity. Small stones were noticed within the gallbladder and a metastatic node was present at the umbilical region. A percutaneous transhepatic biopsy was performed, revealing a poorly differentiated adenocarcinoma with extensive necrosis. Patient's hospital course was complicated with the presence of deep venous thromboses, with subsequent bleeding after anticoagulation and posterior death less than one month after the diagnosis. Gallbladder cancer (GBC) is a rare but highly fatal malignancy with fewer than 5000 newly diagnosed cases each year in the U.S. In this patient, it was found incidentally, the only suspicious findings for malignancy were the presence of a Sister Mary Joseph node, abdominal pain and weight loss. Although a Sister Mary Joseph node has been mainly associated to gastric cancer, GBC should be considered in the differential diagnosis whenever it is identified. [figure 2]FigureFigure