ª Springer Science+Business Media New York 2016 Abdom Radiol (2016)
Abdominal
Radiology
Percutaneous biopsy in the abdomen and
pelvis: a step-by-step approach
George A. Carberry,1,2 Meghan G. Lubner,1 Shane A. Wells,1 J. Louis Hinshaw1
1
University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
2
Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/342 Clinical Science Center, 600
Highland Ave., Madison, WI 53792-3252, USA
Abstract
Percutaneous abdominal biopsies provide referring physi-
cians with valuable diagnostic and prognostic information
that guides patient care. All biopsy procedures follow a
similar process that begins with the preprocedure evalua-
tion of the patient and ends with the postprocedure man-
agement of the patient. In this review, a step-by-step
approach to both routine and challenging abdominal
biopsies is covered with an emphasis on the differences in
biopsy devices and imaging guidance modalities. Adjunc-
tive techniques that may facilitate accessing a lesion in a
difficult location or reduce procedure risk are described.
An understanding of these concepts will help maintain the
favorable safety profile and high diagnostic yield associ-
ated with percutaneous biopsies.
Key words: Percutaneous—Biopsy—Abdomen
Image-guided percutaneous biopsy is a critical part of
any radiology practice and provides tremendous value to
our referring physicians. The indications for biopsy are
broad and include the diagnosis and staging of malig-
nancy, confirmation of benign disease, and immunohis-
tochemical/genetic subtyping of cancer. With current
technology and techniques, we can safely biopsy targets
within any solid abdominal organ, as well as mesenteric/
omental masses, lymphadenopathy, and even the bowel.
For all of these reasons, image-guided biopsy is one of
the most common procedures performed by radiologists.
This paper is designed to provide both basic and
advanced information on successfully performing routine
and challenging biopsies in the abdomen and pelvis, from
the beginning to the end of the process. We cover pre-
Correspondence to: George A. Carberry; email: gcarberry@uwhealth.
org
DOI: 10.1007/s00261-016-0667-1
procedure topics, including the proper selection of biopsy
candidates and which imaging guidance modality and
biopsy devices to use. Next, we describe adjunctive
techniques that can be used during the biopsy procedure
to optimize patient safety and diagnostic yield, and we
end with a discussion on selected postprocedure issues.
Procedure planning
Preprocedural planning is critical for positive biopsy
outcomes. We will focus our review on (1) selecting pa-
tient candidates (2) choosing a biopsy target (3) deciding
on the optimal imaging guidance modality, and (4)
enhancing patient positioning and comfort to facilitate
the procedure.
Patient selection
Determining if a patient is appropriate for biopsy is a
complex process. The most important question to ask is,
does the patient actually need a biopsy? Many potential
targets can be characterized with modern imaging tech-
niques, and thus the risk of biopsy may be avoided.
Good examples include adrenal nodule characterization
with computed tomography (CT) [1], magnetic resonance
(MR) imaging [2, 3] and patient biochemical data; liver
lesion characterization with modern MR imaging tech-
niques and hepatobiliary contrast agents [4, 5], although
many more examples exist.
The patient referred for percutaneous biopsy should
also be considered for any lower risk biopsy alternatives. An
excellent example is pancreatic masses. While it is techni-
cally feasible to perform percutaneous pancreatic biopsies,
upper endoscopy with endoscopic US-guided biopsy has
become the preferred technique for most of these patients.
The lowest risk and highest yield target should also be
identified in each patient. For example, indeterminate
liver lesions are often the preferred targets for patients
with possible metastatic disease since the result will
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
provide both diagnostic and staging information. In
another example, sampling of a supraclavicular node in a
patient with a lung mass might be favored as this would
give staging information as in the prior example, but is
also a safer target without the additional risk of pneu-
mothorax associated with biopsy of a target in the lung.
Thus, determining if the patient is appropriate for biopsy
requires a thorough evaluation of all available imaging
and potential target sites, and an associated under-
standing of the diagnostic implications of each.
Determining if a patient is ‘‘safe’’ for a biopsy is a
complex process as well, but assessment of coagulation
parameters and bleeding risk is critical since hemorrhagic
complications are the most common adverse outcome. A
prolonged discussion is beyond the scope of this article,
but it should be noted that the historical norms are in the
process of changing. Many institutions are moving to-
ward more lenient coagulation parameters and decreased
blood product administration as evidence is mounting
that it is both safe and less costly to do so (Table 1) [6–8].
Renal failure is an often under-appreciated risk factor for
procedure-related hemorrhage because of its effects on
platelet function and the coagulation cascade [9], and the
increased risk of bleeding in these patients is often not
reflected by routine preprocedure lab values. Several
prior articles, as well as the article by Kohli, et al. in this
special issue on abdominal intervention, review the latest
literature and further discuss the associated risks of
blood product administration.
In addition to coagulation parameters, the patient’s
clinical status must be weighed against the urgency and
potential utility of the biopsy. For example, ill inpatients
who are hypotensive or profoundly anemic prior to
biopsy may not have the reserve to tolerate a complica-
tion like bleeding, and a safer strategy may be to delay
the biopsy until acute issues are resolved.
Selection of image guidance modality
The main imaging modalities used to guide biopsy in the
abdomen and pelvis are CT and ultrasound (US). There
are many advantages to the use of US guidance for
Table 1. Coagulation cut-offs for percutaneous procedures at the University of Wisconsin
Percutaneous procedure
FNA/core biopsy of solid organ
FNA/core biopsy of deep or intraperitoneal structures
FNA/core biopsy of superficial structures (e.g., thyroid, lymph node)
Paracentesis
Paracentesis on warfarin
Thoracentesis
Lung biopsy
For inpatients, INR and platelet count are required within 1 week of procedure. For outpatients, INR and platelets are required within 6 months, if
previously normal, otherwise a repeat INR and platelet count are drawn. If the patient is on warfarin therapy, an INR is required the day of the
procedure
FNA, fine needle aspiration
percutaneous abdominal biopsies, and US is the pre-
ferred modality at our institution for the majority of
these procedures if feasible.
The superior soft tissue contrast compared with non-
contrast CT is a tremendous advantage when targeting
lesions in the solid organs, and the real-time visualiza-
tions of both the needle and the target lesion with US
facilitate procedures that are both safe and expeditious.
In contradistinction to CT guidance where the operator
is restricted to an axial or near-axial approach, the US
transducer can be angled in any plane, allowing a more
flexible approach. The US guidance allows patients to
remain semi-upright for a biopsy, if required by their
clinical condition (Fig. 1). Color Doppler allows the
detection of blood vessels/vascularity and aids in opti-
mizing the needle trajectory. The portability, lack of
ionizing radiation, and lower cost of capital equipment
compared to CT are additional advantages. Limitations
of US include the inability to penetrate air-filled struc-
tures or bone, as well as the impact of body habitus,
operator experience, and appropriate acoustic window
on target visualization. Some locations may be more
accessible with CT guidance, including adrenal,
retroperitoneal, lung, and pelvic sidewall targets that
may be obscured by air, heavy paraspinal musculature,
or bone.
Ultrasound guidance. It is important to visualize and
track the needle throughout its entire biopsy trajectory.
Although free-hand method is a common and successful
US technique, strong consideration should be given to
utilizing a transducer needle guide for these procedures.
This has been shown to be associated with fewer biopsy
passes and more efficient needle positioning, both of
which decrease the likelihood of complications [10]. It
simplifies the process of maintaining the needle and
central US beam in a parallel plane, thus allowing one to
target a lesion primarily by ‘‘aiming’’ the transducer ra-
ther than having to manipulate the transducer and the
needle independently. The main limitation of this tech-
nique is that guides are limited in the variety of angles
that they can provide, but transducer guides are effective
and safe for most biopsies. If the needle deviates from the
INR Platelet count
<2.0 >25,000
<3.0 >25,000
Any Any
<3.0 >25,000
<2.0 >25,000
<2.0 >25,000
<2.0 >25,000
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 1. Percutaneous biopsy of a large anterior mediastinal
mass (A, arrows) in a 19-year-old female who was unable to
tolerate supine positioning for the procedure. The patient be-
Fig. 2. Effect of ultrasound beam steering on needle visu-
alization in ex vivo cow liver. In A, no beam steering is ap-
plied, resulting in an angle of insonation of approximately 45°
with the needle shaft (arrowheads). In B, the beam is steered
expected course, then the transducer can be manipulated
to correct for the deviation, or the needle can be released
from the guide, and the remainder of the procedure can
be completed using free-hand technique.
At times, needle visualization is challenging even
when oriented in the same plane as the transducer. Some
techniques for improving visualization include utilizing
electronic beam steering (possible with linear array
transducers) to replicate the optimal angle of insonation
(Fig. 2); turning off spatial compounding to eliminate
artifacts; ‘‘pumping’’ air into the coaxial needle; bounc-
ing the needle with B-mode or color Doppler imaging;
came short of breath when lying flat, so US-guided biopsy (B)
was performed to allow the patient to remain upright during the
procedure (arrow mass). Pathology revealed lymphoma.
toward the needle shaft (arrowheads), resulting in improved
reflection of sound waves and better needle visualization.
Note the angled edges of image B (arrows) which signifies the
implementation of beam steering.
and gently scoring the needle tip with a rough Kelly
clamp.
Appropriate machine settings are important for
optimal visualization. For example, the highest-fre-
quency transducer that will provide adequate sono-
graphic depth should be used to improve spatial
resolution. A high-frequency linear transducer can
sometimes even be used for left hepatic lobe lesions or
other more superficial targets. The overall gain and TGC
curves should be appropriately adjusted to the target
lesion, and the US focal zones should be placed at the
level of the target, keeping in mind that increasing the
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 3. Use of color Doppler ultrasound (US) to detect
postintervention solid organ bleeding in three different
patients. Transverse US image A in the Patient 1 demon-
strates a small jet of color Doppler signal at the periphery of
the liver (arrow) following biopsy (‘‘patent track sign’’). Note
the small amount of associated hyperechoic blood product
accumulating along the capsule (arrowhead). Longitudinal
US image B in the Patient 2 following percutaneous biopsy
number of focal zones will improve spatial resolution but
reduce temporal resolution. Harmonic imaging impairs
visualization of deep lesions and can be turned off for
those biopsies. The tint map and dynamic range on the
US monitor can also be adjusted to see if lesion visibility
can be improved. Finally, US contrast can be adminis-
tered to increase tissue conspicuity and is discussed under
adjunctive techniques below.
When utilizing US for guidance, consider using color
Doppler US both prior to and after the procedure.
Doppler prior to the biopsy allows the identification of
of a renal graft demonstrates color Doppler signal along the
biopsy tract, compatible with active hemorrhage (arrows).
Axial CT postcontrast image C of the Patient 3 demonstrates
a blush of active extravasation following percutaneous
ablation. Duplex Doppler evaluation D reveals a linear area
of color Doppler signal (arrowhead) which has hepatic
venous waveforms (thin arrow), compatible with hemorrhage
from a hepatic vein.
blood vessels, which can then be actively avoided during
needle advancement. This technique is useful for both
intra-organ vessels (e.g., portal vein and hepatic artery
branches) and abdominal wall vessels (e.g., venous col-
laterals in cirrhotic patients and the inferior epigastric
vessels in the lower abdominal quadrants). After the
biopsy is performed, Doppler can evaluate the target
organ for signs of hemorrhage. The identification of ei-
ther a ‘‘patent track’’ or a hemorrhagic jet at the con-
clusion of the study has been shown to be predictive of
post-biopsy bleeding (Fig. 3) [11]. Subcapsular or extra-
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
capsular accumulation of fluid is also a concerning sign.
Both findings may warrant at least 5 min of direct
manual pressure followed by repeat Doppler evaluation.
Utilizing US for guidance requires one to be facile
with US imaging and have reasonable eye–hand coor-
dination. One approach to simplify the process is to
adopt a two-person technique where the sonographer
holds the transducer and the radiologist advances the
needle. The sonographer provides imaging expertise and
allows the radiologist to concentrate on needle place-
ment. This method requires teamwork and communica-
tion, but can simplify challenging procedures and
provide much needed consistency and safety, particularly
important in a training environment.
CT guidance. CT has high spatial resolution and a
large field of view, which facilitates preprocedure plan-
Fig. 4. Use of a CT with a wide gantry aperture (‘‘large
bore’’) to facilitate percutaneous biopsies. Photographs of the
same 450-lb patient in CT scanners with a standard bore (A)
vs. a large bore (B) demonstrate increased working space
(arrows) for needle manipulation between the patient and
gantry in the large bore CT scanner. Images in a second 550-
lb patient (C–E) demonstrate how this extra working space
allows a renal mass biopsy to be performed. The pre-biopsy
planning CT (C) demonstrates a large right renal mass
(arrow) which was unable to be safely visualized during
ning of needle trajectory and provides the ‘‘global over-
view’’ missing with US. In addition, gas and calcification
do not interfere with lesion visualization, critical for
some cases. Pelvic sidewall, retroperitoneal, and adrenal
gland targets are common indications where CT is the
preferred modality.
Most radiologists are familiar with the fundamentals
of CT guidance, but we would like to briefly describe the
utility of both CT fluoroscopy and large-bore CT scan-
ners for percutaneous procedures. First, CT fluoroscopy
is a very powerful imaging technique that can allow
successful needle placement in even small, mobile targets.
Similar to conventional fluoroscopy, CT fluoroscopy
allows the operator to actively image the patient, while
the patient is in the gantry and the operator is in the
room. Depending on the vendor, this can allow real-time
attempted US-guided biopsy. A photograph during biopsy (D)
shows the utility of having extra space between the patient
and gantry for needle guidance. In a standard CT gantry, the
patient would contact the edges of the gantry aperture leaving
no room for needle manipulation. An image acquired with CT
fluoroscopy (E) is impaired by photon starvation artifact and
excessive noise related to patient body habitus; image quality
can be improved by increasing tube current (arrow biopsy
needle, M renal mass).
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 5. CT gantry angulation. Photographs show the ability of the CT gantry to tilt 30° in the cranial or caudal dimension (A).
The use of the CT laser guide (arrow) is helpful for guiding needle placement along the oblique transverse plane (B).
or near-real-time visualization of both the needle and the
target. Removing the delay between imaging and needle
manipulation increases the likelihood of appropriate
needle positioning, decreases the risk of collateral dam-
age to adjacent structures, and decreases procedure time
compared to conventional CT guidance [12, 13]. The
main disadvantage is radiation exposure to the medical
personnel. However, with appropriate shielding, appro-
priate scanner settings (low mA/high noise index) and
minimal, intermittent fluoroscopy acquired only prior to
and after a needle adjustment, the radiation exposure can
be minimized. Radiation dose in CT-guided procedures
is reviewed in greater detail in this special issue by
Lambda et al.
Second, a large-bore CT scanner can be very helpful
when performing biopsies that are deep within the body,
or if the patient has a large body habitus, where extra
gantry space is needed for placement and manipulation
of the biopsy needles. Any biopsy practice will encounter
these patients and a large-bore CT scanner can facilitate
biopsies that otherwise would be impossible (Fig. 4).
One of the limitations of CT is that CT-guided ap-
proaches are generally limited to the axial plane, an ap-
proach that may or may not be appropriate for the
associated anatomy. However, many CT scanners do
allow gantry angulation up to 30 degrees from vertical
(Fig. 5). Making this adjustment can optimize the needle
path to avoid nontarget structures, such as the lung bases
during an adrenal biopsy (Fig. 6). A series of cases re-
ported by Hussein et al. demonstrated that 96% of
adrenal nodules were successfully biopsied using CT
gantry angulation [14]. If angling the gantry still does not
allow access to the lesion, repositioning the patient or
using a nontraditional approach can also be helpful, such
as a trans-organ needle path, which is discussed below.
Occasionally a ‘‘dead reckoning’’ technique must be used
where the needle is angled out of the plane of the gantry
and carefully advanced while monitoring the position of
the tip (Fig. 7).
Other imaging guidance modalities. While US and CT
guidances are most commonly used for percutaneous
abdominal biopsies, MR imaging, and positron emission
tomography (PET) have useful attributes for procedure
guidance but also important limitations. The use of MR
guidance provides excellent soft tissue contrast with a
lack of ionizing radiation, but there is a paucity of MRI-
compatible biopsy instruments and many facilities lack
an appropriate open ‘‘interventional’’ MRI scanner. The
result is limited capacity, and because of the utility of US
and CT guidance, limited demand. However, one
potential indication for routine use of MR guidance is
prostate biopsies, especially in the patients with a nega-
tive transrectal US-guided biopsy, as MR imaging
guidance for these patients provides cancer detection
rates ranging from 30% to 59% [15–17]. MR–US fusion
software is a developing technique that may improve
these results and also allow more precise US-guided
biopsies in this setting [18]. Venkatesan, et al. describe
the use of fusion software in more detail in this special
edition of the Journal.
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 6. Use of CT gantry angulation to biopsy a new adrenal
nodule in a patient with a history of lung cancer on warfarin
therapy. Axial T2W fat-suppressed MR image (A) demon-
strates a rounded hyperintense lesion in the left adrenal gland
(arrow). Transverse CT image obtained prior to biopsy (B)
shows pleura (arrow) between the skin and target lesion. To
PET-guided biopsy is a technique that may have
particular benefits when the biopsy target is partly or
mostly necrotic, or otherwise obscured on conventional
imaging (e.g., tumor recurrence within an area of radi-
ation fibrosis). The commonest technique is to perform a
‘‘cognitive’’ biopsy where the operator mentally fuses the
preprocedural PET images with the cross-sectional ima-
ges he/she is using for real-time needle guidance in order
to target the portion of the lesion that will be most likely
to provide a diagnostic result [19]. Alternatively, there
are software packages that allow the PET images to be
fused with the intraprocedural imaging using image
registration to map the most hypermetabolic region of
the mass [20]. It is even feasible to perform a biopsy with
‘‘real-time’’ PET imaging, but specialized equipment is
needed [21].
avoid transgression of the pleura, the CT gantry was angled in
the cranial direction (C). This angulation created a needle
path (D, arrow) that provided access to the lesion without
crossing the lung (D). The biopsy specimen revealed no
malignant cells, and the lesion decreased in size, consistent
with hematoma.
Selection of biopsy devices
The choice of biopsy device depends largely on the vol-
ume and composition of tissue sample needed by the
pathologist to make a confident diagnosis. The two most
commonly used tissue sampling methods are core needle
biopsy (CNB) and fine needle aspiration biopsy (FNAB).
CNB devices are designed to obtain a cylindrical or semi-
cylindrical ‘‘core’’ of cellular material from the target
tissue. Because tissue architecture of the sample is pre-
served, complete pathologic analysis of the tissue can be
performed. FNAB, on the other hand, results in the
acquisition of individual cells or small groups of cells.
These cells and tissue fragments can be dried, fixed, and
stained immediately after collection for both rapid
assessment and final diagnosis.
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 7. Use of the ‘‘dead reckoning’’ technique to safely biopsy
an indeterminate adrenal nodule. Transverse unenhanced pre-
procedure CT image (A) demonstrates lung in the projected
needle path to the left adrenal nodule (arrow) despite left lateral
decubitus positioning of the patient. An axial slice several cen-
timeters caudal to the lesion (B) was selected for needle entry
There are two advantages to FNAB: it can be per-
formed through smaller needles and thus is less invasive,
and the cytologist is able to evaluate the samples rapidly
and provide intra-procedural feedback regarding the
adequacy of the sample. FNAB is most often useful with
small lesions, very necrotic tumors or biopsy targets in
close proximity to vulnerable structures where the pri-
mary objective is to define the presence or absence of
metastatic disease. However, because the volume of tis-
sue obtained during FNAB is low, the diagnostic testing
that can be performed on the tissue is limited. Because of
the larger volume of tissue provided by CNB, this is the
most common technique used at our institution if feasi-
ble. However, the most accurate assessment is a com-
bined cytological and histopathological assessment [22–
25], so there are rare occasions where both techniques
(FNAB, CNB) may be performed.
Core needle biopsy devices. Both end-cutting (‘‘cylin-
drical’’) and side-cutting (‘‘side notch’’) biopsy devices
are available from different manufacturers in a variety of
lengths and gages. The cylindrical core biopsy needles are
fully automated with a spring-loaded mechanism and are
advantageous because they obtain a larger volume of
tissue with each pass (Fig. 8). Cylindrical CNB devices
(arrow needle tip). Sequential CT fluoroscopic images (C–F)
demonstrate progressive advancement of the needle in the
cephalad direction, keeping only the tip of the needle (arrow) in the
axial plane with the CT table adjustments. Image (F) demon-
strates the needle tip in the target lesion without traversing the
lung. This can be a very technically challenging biopsy method.
are available with both fixed and adjustable core throw
lengths. The advantage of the adjustable throw device is
that it allows the size of the tissue sample to be adjusted
based upon the target lesion size (Fig. 9), but also allows
a large volume sample for nontargeted liver biopsies and
other indications. A single pass is often adequate with
these devices. In our practice, we use these devices almost
exclusively in the abdomen, with a preference for an 18-
gage automated end-cutting needle. It is important to
warn patients that this device may make a sudden
clicking or snapping sound, as it can be startling if the
patient is not aware and lead to unwanted patient mo-
tion.
Side-notch needles are available with automated,
semi-automated, and manual firing modes. Both the
automated and semi-automated devices rely on spring-
loaded deployment of the stylet, cutting cannula, or
both, whereas the manual devices require the operator to
physically advance the tissue-cutting component of the
needle over the stylet. The semi-automated and manual
devices are lightweight and less expensive but are limited
in their ability to penetrate hard lesions and all of these
devices obtain smaller volume tissue samples. One
advantage of a side-notch device is that the cutting nee-
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 8. Comparison of the firing mechanisms of side-cut vs.
end-cut core needle biopsy devices. In (A), the sample
chamber of the side-cut needle is open, allowing the target
tissue to fill the chamber. In (B), the cutting cannula has been
either automatically or manually advanced over the sampling
chamber, cutting the target tissue. Note the semi-cylindrical
Fig. 9. US-guided biopsy of an expansile rib lesion in a
woman with metastatic breast cancer. 99-m-technicium-MDP
planar bone scan (A) demonstrates a new area of increased
radiotracer uptake in the posterolateral left ninth rib. This lesion
was easily visualized with US given its expansile soft tissue
gross morphology of the sample which provides less volume
of tissue per throw length than does an end-cut core needle
device. In (C), the tip of the end-cut needle stylet abuts the
target tissue. After firing the device, the inner coring cannula
advances forward into the tissue, over a predetermined throw
length.
component (B, arrows). Measurement of the lesion length
during preprocedure planning allowed the operator to maximize
the throw length of the adjustable core needle biopsy device.
The lesion was successfully biopsied with US guidance (C) with
no postprocedure pneumothorax or other complication.
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
dle can be advanced prior to firing the cutting cannula
over the sampling chamber (Fig. 8). This allows defini-
tive visualization of the needle tip prior to cutting the
tissue, which is potentially useful for confirming exact
sampling location and in cases where there are vulnerable
structures along the deep margin of the target.
Fine needle aspiration needles. Needles used for
FNAB are available in a variety of gages and up to
20 cm in length. In general, 20–25-gage needles with ei-
ther a bevel tip (e.g., Chiba needle) or crown-point/cut-
ting tip (e.g., Franseen needle) are used in the abdomen
(Fig. 10). The Greene needle with the coring tip and lack
of serrations is preferred by some operators, which may
reduce the incidence of local bleeding, but these needles
are more frequently used in the lung.
The tip of the needle has implications for needle
tracking. Some coaxial fine needles have a diamond tip
stylet, which favors minimal deviation of the needle in
tissue during advancement. Bevel tip needles, on the
other hand, tend to deviate away from the side of the
bevel, and thinner diameter (higher-gage) needles have
been shown to deviate more than those with wider
Fig. 10. Photograph of commonly used fine needles for
abdominal biopsies. Their stylets have been removed to re-
veal the shapes of their sampling surfaces. (A) Chiba, (B)
Greene, (C) Franseen, and (D) Spinal.
Fig. 11. Transhepatic adrenal nodule biopsy. Transverse CT
image (A) demonstrates a partially calcified right adrenal nod-
ule (arrow). In (B), intervening lung is present in the planned
needle path (arrow). A transhepatic needle route was taken to
diameter needles [26]. This attribute can be used to the
operator’s advantage when fine needle control is needed
within tissue. Most FNAB needles also have an echo-
genic tip for improved sonographic visualization and an
adjustable stopper ring that can be placed along the hash
marks of the needle to prevent over-excursion.
Introducer needles. The coaxial technique is almost
essential when using CT guidance and can be used with
US guidance. There are advantages to a coaxial tech-
nique when it is possible. Because the introducer needle
has a larger caliber, it is easier to visualize and deviates
less from the planned needle trajectory in tissue. In
addition, a single puncture possible with an introducer
needle decreases the bleeding and tumor seeding risk
compared to repeat punctures [27] (Fig. 11). Utilizing an
introducer needle also allows track hemostasis, as dis-
cussed below.
However, there are several reasons to utilize a direct
puncture technique when using US guidance. First, many
biopsies are adequate after a single pass as they produce
at least a 2 cm tissue core, with few biopsies requiring
more than two passes. Thus, the increased invasiveness
of a larger bore introducer needle, while minimal, is not
justified. In addition, most of the targeted lesions are
within solid organs that move during patient respiration.
Placing and leaving an introducer needle in place during
respiration does increase the risk of hemorrhagic com-
plications and nontarget sampling if the needle moves
between placement and sampling. Thus, we prefer to
perform needle placement and sampling during a single
breath hold if at all possible.
Patient positioning and comfort
Positioning. Patient positioning can be very helpful in
target visualization, and repositioning can be a simple
problem-solving technique. Adrenal and upper pole renal
biopsies can be challenging with both US and CT guid-
ance. When using US guidance, placing the patient in the
contralateral decubitus position (e.g., left lateral decu-
avoid the pleura with successful sampling of the mass (C). An
introducer needle (C, arrow) was used to decrease the bleeding
risk associated with multiple punctures and to avoid seeding of
the biopsy tract if the mass was malignant.
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 12. Use of patient positioning to prevent pleural trans-
gression during adrenal nodule biopsy. Transverse CT
images demonstrate a left adrenal nodule (A, arrow) with lung
tissue (B, arrowhead) in the path of the planned needle
Fig. 13. Transhepatic renal mass biopsy. Transverse CT
image (A) shows a solid mass in the upper pole of the right
kidney (arrow). Given its medial location, a transhepatic
needle path was chosen (dashed arrow). Longitudinal
sonographic image (B) shows the 18-gage core needle
bitus for a right-sided mass), can be helpful. This posi-
tion results in compensatory hyperinflation of the ipsi-
lateral lung, displacing the liver, right adrenal gland, and
kidney caudally. This downward shift of the organs is
often sufficient to improve the sonographic window and
therefore, the chance of a successful biopsy. Valsalva or
inspiration may also be needed. This decubitus posi-
tioning may also cause adjacent bowel to fall out of the
way of the needle trajectory. Bolstering under the hips
may also improve visualization of renal lesions and move
them closer to the transducer.
In contrast, when utilizing CT guidance for upper
abdominal biopsies, prone or ipsilateral decubitus posi-
tioning is more effective. Prone positioning with gantry
angulation and end expiration is often successful. If this
does not provide a safe needle path that avoids traversing
trajectory. By having the patient lie in the left lateral decubitus
position (C), the lung base ascended, creating a direct soft
tissue path for the needle in the transverse plane.
coursing through the liver parenchyma with its tip at the
periphery of the renal mass (L liver, K kidney). Note the use of
distance markers on the transducer needle guide software
overlay in (B).
the lung, then ipsilateral decubitus positioning will usu-
ally work. This position results in atelectasis in the down-
side lung, creating a window for needle placement for all
but the most superior targets (Fig. 12). Of note, almost
all liver lesions can be approached with a subcostal or
intercostal US window, even when they are located in the
hepatic dome or lateral liver. Although transpulmonary
approaches, with or without adjuncts like a ‘‘protective
pneumothorax’’ have been described [28] and can work,
in our experience, they are almost never needed.
Finally, patient comfort is critical, and US is more
flexible in the type of positioning it can allow compared
with CT. For example, in the patients with large medi-
astinal masses or large retroperitoneal masses, lying flat
can be very uncomfortable. When US guidance is used,
these patients can potentially be biopsied with their
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 14. Transhepatic biopsy of a new perihepatic nodule in
a 38-year-old woman with a history of partial hepatectomy for
metastatic colorectal cancer. Axial post-gadolinium T1WI (A)
demonstrates a small enhancing nodule near the cut surface
of the liver (arrow). The presence of aerated lung (B, arrow)
Fig. 15. Transplenic microwave ablation of a small renal
mass. Transverse contrast-enhanced CT image (A) demon-
strates an enhancing 2.1-cm mass in the upper pole of the left
kidney. Right lateral decubitus images from CT fluoroscopy
heads elevated or sitting up which may improve their
comfort and ability to tolerate a biopsy (Fig. 1). With
CT, a large bore gantry may facilitate elevating the head
slightly as well.
Sedation/analgesia. Appropriate analgesia and seda-
tion are critical components of any successful biopsy,
both to alleviate patient anxiety and improve the safety
and the efficacy of the procedure itself. Conscious
sedation should be strongly considered for all ‘‘deep’’
intra-abdominal biopsies. Level 2 sedation (whereby the
patient responds purposefully to verbal commands or
light touch) is often sufficient to calm the patient and
expedite the procedure without the added risk that is
associated with deeper sedation. For local anesthesia,
utilization of Lidocaine with epinephrine can decrease
perfusion related dispersion of the lidocaine, increasing
both the half-life of the analgesic effect and the local
along the planned needle path necessitated a transhepatic
route to biopsy this lesion (C). Note use of left lateral decu-
bitus patient positioning to shorten the needle path through
the liver parenchyma.
(B) and (C) show splenic transgression with the microwave
antenna (B, arrow) to safely ablate the renal mass (C, arrow).
No splenic hemorrhage occurred during or after the proce-
dure.
efficacy and decrease the risk of hemorrhagic complica-
tions. Buffering the lidocaine with bicarbonate to de-
crease the burning associated with the injection is
another common technique, but the true efficacy of this
is less clear.
Adjunctive biopsy techniques
Transorgan approaches
Solid organs. The liver, spleen, and kidneys can be safely
traversed when needed to perform an image-guided
biopsy in the abdomen. Introducer needles should be
strongly considered for these biopsies in order to avoid
repeat passes through the organ.
Transhepatic biopsies are probably the most common
and may be necessary for biopsies of right adrenal masses
(Fig. 11), masses in the upper pole of the right kidney
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 16. Illustration of a kidney in the transverse plane (A)
demonstrating a region in the renal parenchyma relatively
void of large blood vessels (Brodel’s avascular plane).
Corresponding axial contrast-enhanced CT image (B)
Fig. 17. Transgastric biopsy of a duodenal lesion in an 80-
year-old woman with stage 3 colon cancer and a new duo-
denal mass. Transverse CT image (A) demonstrates a
pedunculated, enhancing mass along the second portion of
the duodenum (arrow). Endoscopic US (B) confirms the
(Fig. 13), or in cases of high retroperitoneal or perihep-
atic lymph nodes/soft tissue nodules (Fig. 14). If the
mass is not well visualized with US, CT guidance can be
considered, but the liver often provides an excellent
sonographic window for these procedures. The needle
path should avoid the liver hilum and gallbladder if
possible. If avoidance of these structures is impossible,
FNAB can be performed to minimize the risk of com-
plication.
A transplenic needle path may be necessary for
biopsies of the left adrenal gland, pancreatic tail, and/or
superior pole of the left kidney (Fig. 15). No large series
demonstrating the location of the avascular plane (green box)
which spans the cranial to caudal aspect of the kidney. Per-
cutaneous biopsies of lesions in this location have a theo-
retical lower risk of bleeding complications.
mass; no biopsy was performed due to unfavorable endo-
scopy angles which precluded FNAB. Two 18-gage core
samples were obtained of the hypoechoic mass (arrow)
through the gastric lumen (C). The dashed arrow in (A) shows
the transgastric needle path.
are available in the literature evaluating risk of hemor-
rhage or other complication during transplenic biopsies
but extrapolation from splenic mass biopsy data reveals
that the major complication rates of splenic biopsies are
no different than percutaneous liver or renal biopsies
when an 18-gage or smaller needle is used [29]. Similar to
splenic mass biopsies, minimizing the amount of normal
splenic parenchyma the needle has to traverse, utilizing
color Doppler US, and avoiding the splenic hilum is
recommended [30].
Certain kidney and adrenal lesions may require a
trans-renal biopsy approach. The area of renal par-
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 18. Use of an artificial pneumothorax to avoid trans-pul-
monary adrenal mass biopsy. Prone axial CT images (A), (B),
and (C) demonstrate the creation of a small pneumothorax at the
enchyma with the lowest density of blood vessels, and
therefore the favored needle path when possible, lies
along the posterior aspect of the lateral convex contour
of each kidney where the branches of the renal arteries
meet, an area known as the Brodel avascular plane
(Fig. 16). Conversely, the highest concentration of ves-
sels is at the renal hilum. FNAB are preferred for deep
hilar biopsies, whereas a CNB can be performed through
the peripheral renal parenchyma, utilizing the avascular
plane when possible.
Stomach and bowel. Transgastric biopsies, which are
similar in concept to endoscopic ultrasound (EUS)-gui-
ded biopsies that necessitate traversing the stomach wall,
may be indicated for biopsies of pancreatic, duodenal
(Fig. 17) or left adrenal lesions [31, 32]. The thick,
muscular wall of the stomach and its relative sterility
make transgastric biopsies generally safe [33, 34]. A study
involving the placement of 18-gage automated core
needles through the stomach of rabbits found no risk of
bleeding, leakage or peritonitis [35]. This matches our
clinical experience and the experience with EUS-guided
biopsies.
Small bowel can also be safely traversed, but for these
cases, use of a smaller-gage needle may be prudent, such
as 21- or 22-gage fine needles (37), or if necessary, a 20-
gage CNB device. When a cystic lesion or focal fluid
collection is the target, transenteric biopsy is not rec-
ommended due to the risk of contaminating the fluid
collection [32, 34, 36].
The safety of transcolonic punctures is less clear.
While several studies have reported no significant com-
plication [37, 38], creating a mucosal defect in a bacteria-
base of the left pleural space (arrow) (A) through which the biopsy
needle was advanced (B, arrow). In (C), the pneumothorax has
been aspirated with successful re-expansion of the lung.
rich viscera almost certainly predisposes to leakage and
possible peritonitis. Avoid transcolonic biopsies unless
absolutely necessary, and perform only with a needle
smaller than 21-gage if possible, and never with a drain.
As with colonic surgeries, a cleansing bowel preparation
may be beneficial, and prophylactic antibiotics are rec-
ommended by some authors [39]. Similar to other
transenteric biopsies, there is a risk of superinfection of
cystic lesions and fluid collections with a transcolonic
approach.
Lung and pleura. The pleural space is frequently tra-
versed when performing liver and upper abdominal
biopsy requiring an intercostal approach. This approach
is completely safe unless the target lesion is a potential
abscess, in which case it should be avoided to minimize
the chances of introducing the infectious agent into the
pleural space.
Alternatively, traversing the lung itself should be
avoided if at all possible to reduce the risk of pneu-
mothorax. Even high lateral liver dome lesions can
usually be accessed with US guidance without necessi-
tating a transpulmonary approach. If a hepatic dome or
other high abdominal lesion is difficult to visualize with
US, the introduction of artificial ascites into the abdo-
men has been shown to improve conspicuity [40, 41].
If CT guidance is used or the lesion cannot be reliably
visualized with US, a transpulmonary approach may be
helpful [28]. In these cases, the risk of pneumothorax will
be at least as high as the risk inherent to lung biopsies as
a result of the double pleural puncture. One technique
that can obviate some of that risk is the introduction of a
‘‘protective’’ pneumothorax. By displacing the lung with
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 19. Transvaginal biopsy of a new pelvic mass in an 82-
year-old woman with a history of endometrial cancer. Trans-
verse contrast-enhanced CT image (A) demonstrates a roun-
ded, septate mass in the lower pelvis. Biopsy was initially
attempted with CT guidance with the patient in the prone
air, it is sometimes possible to then access the target le-
sion without actually traversing lung parenchyma
(Fig. 18). Most authors use either a 5F Yueh needle-
catheter system or a Veress needle system to enter the
pleural space and insufflate room air or carbon dioxide,
although any 18- to 22-gage spinal needle can be effective
(Fig. 10). The benefit of using a Yueh catheter system is
that the catheter can be left in place, facilitating aspira-
tion of the air following the procedure.
Transvaginal, transrectal, transperineal, and transg-
luteal approaches. For lesions in the central pelvis in fe-
male patients, particularly below the level of the
acetabuli, a transvaginal approach can be a useful
method of targeting (Fig. 19). This approach may re-
position (B) but the needle path to the lesion was obstructed by
the pelvic bones. The mass was easy to visualize and target
sonographically using a transvaginal approach (C, arrows)
which allowed safe core needle biopsy of the lesion (D, arrow).
The mass was found to be recurrent endometrial cancer.
quire intracavitary application of betadine, more
aggressive sedation, and use of both lidocaine jelly and a
submucosal injection of lidocaine. Administration of a
single dose of preprocedure antibiotics (e.g., cipro-
floxacin 500 mg) is recommended 1 h prior to the pro-
cedure, with two additional doses administered 12 and
24 h after the procedure.
Similarly, a transrectal approach can be used for
prostate or central pelvic lesions in male patients with
similar considerations and antibiotic regimen. As with
the transenteric approach, both intracavitary approaches
may introduce infection into cystic lesions or fluid col-
lections. For patients with no rectum (e.g., for patients
treated with abdominoperineal resection) but who have
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 20. Transperineal prostate biopsy. A prostate biopsy
was required in a 77-year-old man with a history of
abdominoperineal resection for rectal cancer, so a percuta-
neous transperineal approach was taken under US guidance
to successfully biopsy the prostate. Note the use of a trans-
ducer needle guide to direct the core biopsy needle (arrow) to
the hypoechoic prostate gland (P).
need for a pelvic biopsy, a transperineal approach can
also be considered (Fig. 20), although this technique may
require general anesthesia.
For lesions higher in the pelvis, or if the above ap-
proaches are not feasible, a transgluteal approach with
CT guidance can be used. Knowledge of pelvic anatomy
is helpful to safely use this approach. The sacral plexus
runs along the anterior surface of the piriformis muscle
and continues inferiorly as the sciatic nerve. The superior
and inferior gluteal arteries are located anterior and
cephalad to the piriformis. The sacrospinous ligament
runs from the sacrum to the ischial spine and marks the
inferior aspect of the greater sciatic foramen. All major
vascular and neural structures are located cephalad to
this ligament (Fig. 21).
To use this approach, the patient can be positioned
prone, oblique, or full decubitus, and if possible the
needle should start at the level of the sacrospinous liga-
ment (below the piriformis) as close to the sacrum as
possible (Fig. 22). For higher lesions, gantry angulation
in the cephalic direction may allow the puncture site to
start at the level of the sacrospinous ligament and course
superiorly [42, 43].
Organ-displacement techniques
Hydrodissection. Hydrodissection refers to the instilla-
tion of fluid in order to mechanically displace adjacent
structures away from the target tissue, thus providing a
Fig. 21. Transgluteal anatomy. Transverse contrast-en-
hanced CT image (A) demonstrates the piriformis muscle (P)
at the midpoint of the greater sciatic foramen. Note the gluteal
vessels (arrow) and the sacral plexus (arrowhead) running
along its surface. More caudal transverse CT image (B)
demonstrates the sacrospinous ligament (circle), which marks
the inferior aspect of the greater sciatic foramen. Note that the
gluteal vessels (arrow) and sciatic nerve (arrowhead) are now
located lateral to a needle track kept close to the sacrum.
safer window for access. This technique is most com-
monly utilized during percutaneous thermal ablation
procedures, but it can also be used for biopsies in which
aerated lung, colon, or another vulnerable structure lies
in the projected needle path (Fig. 23). Another benefit of
hydrodissection is the improved sonographic window it
provides during US-guided procedures. If CT guidance is
used, 20 mL of a 300 mg/mL nonionic iso-osmolar
contrast agent can be added to 1 L of normal saline (2%
concentration) to provide adequate contrast between the
fluid and the adjacent soft tissues (Fig. 24) [44]. In gen-
eral, the hydrodissection is achieved by performing a
hand injection of the fluid through an 18–20-gage needle
placed in the plane of the needed displacement as the
needle is advanced.
Hydrodissection is most effective in the retroperi-
toneum. Displacement of the duodenum or the ascend-
ing/descending colon can be performed to create a safe
needle trajectory [45, 46]. When instilled in the peri-
toneum (‘‘artificial ascites’’), the fluid tends to disperse
within the peritoneal space, and this is most effective for
improving the sonographic window for hepatic dome
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 22. Percutaneous transgluteal biopsy. CT-guided trans-
gluteal biopsy was performed in this patient with rectal cancer
status post abdominoperineal resection who was found to have
increasing presacral soft tissue (A, arrow). The patient is placed
Fig. 23. The use of hydrodissection to displace colon away
from the biopsy target. A 67-year-old male with an anterior
right renal mass, seen on CT (A, arrow) and redemonstrated
on US (B, arrow). Note the proximity of the colon (C). At initial
scanning, the colon was on the back side of the lesion and
would have been the back stop for the biopsy needle. In
lesions, as discussed above, rather than for tissue dis-
placement.
Transducer pressure. An underappreciated advantage
of using US guidance for percutaneous procedures is the
ability to place manual pressure on the transducer in
order to displace mobile tissues, such as small bowel and
mesentery. This technique can be used for mesenteric and
retroperitoneal biopsies (Fig. 25). The bowel or other
viscera can usually be adequately displaced, but some-
times the tissue is just compressed. Fortunately, as dis-
cussed above, it is generally safe to traverse the collapsed
bowel to perform the biopsy. A bit more concerning is
the potential for collapsing larger blood vessels with
prone for the biopsy, with needle entry site at the level of the
sacrospinous ligament, tracking close to the sacrum to safely
target this area (B, arrowhead). Surgical pathology demon-
strated fibrous tissue with small interspersed malignant cells.
addition, during the procedure the colon was intermittently in
the needle path and partially obscuring the lesion. Hydrodis-
section fluid (F) was instilled to displace the colon (C), and the
mass (arrow) was successfully biopsied without complication
(arrowhead = needle). Surgical pathology demonstrated clear
cell renal cell carcinoma.
transducer pressure, thus limiting the utility of color
Doppler to identify these vessels. Thus, we recommend
evaluating with color Doppler prior to applying pressure
to determine if there are any large blood vessels in the
needle path. Despite this precaution, there is likely a
slightly higher risk of hemorrhage associated with these
procedures.
Utilization of a blunt needle. Inevitably, there are
times when accessing a target lesion requires a biopsy
path that closely apposes large blood vessels or bowel. A
useful technique in these situations is to use a blunt
stylet. The initial skin puncture and soft tissue penetra-
tion must be performed with the usual sharp stylet, but
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 24. Use of hydrodissection during upper abdominal
retroperitoneal lymph node biopsy. Transverse CT image (A)
shows an avidly enhancing para-aortic lymph node (short
arrow) in close proximity to the pleural of the left lung base
(arrowhead) and splenic artery (long arrow). Prone CT fluo-
when traversing tissue adjacent to the vulnerable struc-
ture, it can be replaced with a blunt stylet. Thus, even if
the needle does contact the vessel or bowel loop, it will
usually deflect rather than penetrate the lumen. This can
be useful for pelvic sidewall and retroperitoneal biopsies.
This technique is mainly performed co-axially with use of
the blunt stylet in the introducer needle.
Use of contrast agents
Contrast-enhanced ultrasound. The use of contrast-en-
hanced (CE) US in the abdomen has a long history
outside of the United States but has recently become
more prevalent in the United States. CE US has both
diagnostic and interventional applications. The current
FDA-approved vehicles are 1–4 lm in size, allowing
capillary migration and tissue perfusion and are pri-
marily intravascular agents. Thus, they have a limited
half-life in solid organs, but are generally present long
enough to provide visualization for an US-guided biop-
sy. If nothing else, they can be utilized to confirm the
presence and location of the target lesion. A special US
software package is required to perform CE US, but it is
a simple add-on for most US units. CE US is particularly
effective in discerning isoechoic liver lesions from back-
ground parenchyma (Fig. 26) as well as for identification
and characterization of small, hypoechoic renal lesions
prior to biopsy (Fig. 27).
CT contrast. The safety and accuracy of CT-guided
biopsies can, at times, be improved by the administration
of intravenous (IV) and/or enteric contrast. Iso-attenu-
ating liver or renal lesions can be made more conspicu-
ous by imaging in the portal venous or nephrographic
phase after the administration of IV contrast, respec-
tively [47] (Fig. 28). Since the contrast will usually wash
out before the biopsy can be completed, it is important to
define anatomic landmarks that can be correlated with
the intra-procedural images.
When performing retroperitoneal biopsies, it can be
useful to administer a small bolus of IV contrast if the
roscopic images (B and C) during biopsy from a paravertebral
approach show hydrodissection with a solution containing
iodinated contrast and 0.9% normal saline (arrows) which
results in displacement of the pleura (arrowhead) and splenic
artery (long arrow) away from the path of the needle.
target lesion is close to the ureters. The excreted contrast
in the ureters can be used as both a landmark and a
mechanism to avoid accidentally injuring the ureters
(Fig. 29). It is important to note that when a low tube
output is being used with CT fluoroscopy or a CT biopsy
protocol, the dense contrast may result in beam hard-
ening artifact, obscuring visualization of the adjacent
target. Transiently increasing the tube kV may be nec-
essary to reduce the streak artifact but at the cost of
decreased soft tissue contrast.
Postprocedure considerations
Biopsy track management
Biopsy track management may aid in decreasing post
procedure bleeding. One common intervention is to de-
posit thrombotic material along the needle track at the
conclusion of the biopsy. This technique requires the use
of an introducer needle and either a heterologous or
autologous injectable agent. The most commonly used
material is gelfoam, a compressed, absorbable gelatin
sponge made from porcine skin. It is usually adminis-
tered as a slurry, if distal dispersion of the gelfoam is
needed, or as a ‘‘torpedo,’’ if track plugging is needed
[47]. Alternatively, biopsy track plugging can be per-
formed using the patient’s own blood. This technique
involves allowing back-bleeding to occur up the shaft of
the introducer needle until coagulation occurs. Subse-
quently, the introducer stylet is replaced, pushing the
clotted blood out through the needle shaft into the
biopsy track as the needle is removed. However, 5 min of
direct pressure on the biopsy site after the biopsy needle
is removed may be sufficient in many cases.
Postprocedure pain control
Occasionally, even when a biopsy is optimally executed,
patients may experience postprocedure pain. It is most
important to make sure that this is not due to a com-
plication such as bleeding. Evaluation of vital signs and
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 25. Displacement of bowel and mesenteric vessels with
manual US transducer pressure in two patients. Axial fused
PET/CT image and transverse US image (images A and B,
respectively) demonstrate a new retroperitoneal mass in a 73-
year-old man with Hodgkin lymphoma. The hypermetabolic
mass (A, arrow) is surrounded by loops of small bowel (A, thin
arrows) which were successfully displaced with US transducer
pressure (B) prior to obtaining a core needle biopsy (arrowhead
imaging with US or non-contrast CT to assess for hem-
orrhage can be helpful. Large bleeds may require trans-
fusion, and angiography with embolization or surgery.
For uncomplicated post-biopsy pain, analgesia with
short-acting agents like midazolam and fentanyl can be
useful. With persistent pain, longer-acting agents may be
core biopsy needle). Axial unenhanced CT image and trans-
verse US image (images C and D) demonstrate a markedly
enlarged retroperitoneal lymph node (C, arrow) in a 45-year-old
man with metastatic testicular cancer who could not lie prone
due to pain from the lesion. The adjacent small bowel and
mesentery (C, thin arrows) were displaced with the use of US
transducer pressure prior to core needle biopsy (D, arrowhead).
This second patient was biopsied sitting up with US guidance.
needed. With liver biopsy in particular, it is possible that a
small amount of bile leaks from the biopsy track and this
can cause irritation of the peritoneum. This is seen more
commonly in the patients with biliary obstruction prior to
biopsy. Ketorolac (15 mg IV 9 1 initially, can give up to
30 mg) can be effective for controlling this type of post-
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 26. The use of contrast-enhanced US to increase
conspicuity of a liver mass. Axial contrast-enhanced CT im-
age (A) demonstrates a subtle but new 7-mm hypodensity in
the posterior right hepatic lobe in a 55-year-old man with
Fig. 27. Contrast-enhanced US for renal mass biopsy.
Longitudinal US image (A) and precontrast grayscale US
image (B, left image) demonstrates a 1-cm hypoechoic renal
mass without definitive sonographic characteristics of a cyst
procedure pain in appropriate patients without increasing
risk of bleeding [48] (caution must be used in elderly pa-
tients and in the patients with renal dysfunction). This can
be used in combination with small doses of other longer-
acting narcotic analgesics such as hydromorphone (0.2–
0.4 mg IV). Opioids may be associated with nausea, and if
severe, an anti-emetic can be useful as well.
pancreas cancer (arrow). No sonographic correlate is identi-
fied on transverse-enhanced US (B). US contrast was then
administered (C), revealing the location of the 7-mm hypoe-
choic mass (arrow) for biopsy planning purposes.
(arrow). US image following contrast administration (B, right
image) reveals diffuse enhancement of the lesion (arrowhead)
which prompted percutaneous biopsy. Final pathology
revealed a papillary renal cell carcinoma.
Conclusion
Percutaneous biopsies are among the most common
procedures that radiologists perform and follow a step-
wise process that begins with patient evaluation and ends
with postprocedure care. Knowledge of specific biopsy
tools, modalities of imaging guidance, and adjunctive
G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
Fig. 28. Use of intravenous contrast to increase conspicuity
of a small renal mass which does not deform the overlying
renal cortex making unenhanced CT-guided biopsy difficult.
Transverse CECT image (A) reveals a 2.2-cm solid renal
mass in the right kidney (arrow) which is occult on the prone
unenhanced CT image at the time of biopsy (B). Following the
administration of IV contrast, the renal mass is apparent
Fig. 29. Use of intravenous contrast to opacity ureters during
fluid sampling in a 44-year-old woman with ruptured appen-
dicitis. Transverse contrast-enhanced CT image (A) reveals a
loculated retroperitoneal fluid collection near the bifurcation of
the aorta (arrow). Prone intraprocedural transverse CT images
(C, arrow). CT-fluoroscopic image (D) in the excretory phase
of renal enhancement shows the biopsy needle in place (ar-
row). Note how the presence of contrast in the renal collecting
system creates streak artifact (arrowhead), impairing visual-
ization of the adjacent mass. Increasing the CT tube output or
lowering the noise index may have improved contrast reso-
lution.
(B and C) following administration of a small bolus of IV contrast
shows opacification of the adjacent right ureter (B, arrow) which
allowed safe needle positioning medial to the ureter (C, arrow).
The presence of positive enteric contrast in (A) helps differen-
tiate the fluid collection (arrow) from adjacent bowel.
 G. A. Carberry et al.: Percutaneous biopsy in the abdomen and pelvis
techniques will help achieve a low rate of biopsy com-
plications and high diagnostic yield.
Compliance with ethical standards
Disclosures George A. Carberry, MD and Shane A. Wells, MD have
no conflicts of interest to report.
Funding Meghan G. Lubner, MD: Grant funding from GE, Philips,
and Neuwave Medical, Inc. J. Louis Hinshaw, MD: Shareholder in
Neuwave Medical, Inc. and Cellectar Biosciences.
Research involving human participants and/or animals All procedures
performed in studies involving human participants were in accordance
with the ethical standards of the Institutional and/or National Research
Committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed consent For this type of study, formal consent is not re-
quired.
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