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1. Ultrasound Guided Biopsies Wendy Blount, DVM Free PowerPoint Templates

2. Indications for US Guided Biopsy • Solid soft tissue masses visible by ultrasound • If mixed echo pattern, go for a solid spot • Take care aspirating fluid filled structures in body cavities • Aspirate the gall bladder only if you are prepared to do interventional surgery onsite • Aspirate GB only under sedation & with informed consent • Be prepared for interventional surgery for hypoechoic lesions in liver, spleen & other internal organs Free PowerPoint Templates

3. Indications for US Guided Biopsy • FNA of fluid filled uterus is never recommended • Percutaneous draining of local peritonitis, pancreatic abscesses, perinephric cysts can be attempted • Septic contamination of the peritoneal cavity less likely with these • Scanners with needle guides and needle path screen guides are nice • Take 2-3 samples for better results Free PowerPoint Templates

4. Indications for US Guided Biopsy • FNA of fluid filled uterus is never recommended • Percutaneous draining of local peritonitis, pancreatic abscesses, perinephric cysts can be attempted • Septic contamination of the peritoneal cavity less likely with these • Scanners with needle guides and needle path screen guides are nice Free PowerPoint Templates

5. Bob Stout – Nacogdoches TX Free PowerPoint Templates

6. Indications for US Guided Biopsy • FNA of fluid filled uterus is never recommended • Percutaneous draining of local peritonitis, pancreatic abscesses, perinephric cysts can be attempted • Septic contamination of the peritoneal cavity less likely with these • Scanners with needle guides and needle path screen guides are nice Free PowerPoint Templates

7. Patient & Equipment Preparation • Clip fur and do alcohol prep (no gel!) • If you are going to touch the entry site with your fingers, don sterile gloves for FNA • Don sterile gloves for core biopsies, and place a sterile glove or probe cover over the probe • Use sterile surgical lube under the probe cover as well as on the patient • May or may not need sedation for FNA • Sedation required for core biopsy • Consider scheduling all FNA/biopsies in the AM Free PowerPoint Templates

8. Patient & Equipment Preparation • Pre-Sampling Lab work – within 24 hours • CBC confirming platelets >50,000/ul • HCT >30% for dogs, HCT >25% for cats being sedated • Buccal Mucosal Bleeding Time (BMBT) <2 minutes Jorvet - Surgicutt Triplett – Fisher Scientific Free PowerPoint Templates

9. Patient & Equipment Preparation • Pre-Sampling Lab work • Buccal Mucosal Bleeding Time (BMBT) <2 minutes • Lift the upper lip (gauze muzzle) • Remove the device safety tab • Place the device on the mucosa • Push the device trigger button • Dab dripping blood every 15 • seconds, but don’t touch the clot • 6. BMBT = when bleeding stops Free PowerPoint Templates

10. Patient & Equipment Preparation • Pre-Sampling Lab work • Buccal Mucosal Bleeding Time (BMBT) <2 minutes • If liver disease, PT/PTT • Any preanesthetic lab work or other diagnostics indicated for safe anesthesia • Sterilize Needle Guide, if used • Some are disposable • Some gas sterilized, autoclaved or gluteraldehyde Free PowerPoint Templates

11. Patient & Equipment Preparation • Supplies • FNA needles – 22-25g for internals, any size for peripherals • 1-1/2 inch, 3 inch spinal needles • Sterile core biopsy needles 18g – 14g • Can re-autoclave until dull • Measure and label needle throw path • 5-12cc syringes for aspiration • Glass slides, stains, decent cytology microscope • Formaldehyde cups & cassettes for core biopsies • 25g x 5/8” needles for teasing core biopsies out of needle Free PowerPoint Templates

12. Tips for US Guided FNA/Biopsy • Choose the shortest direct path between skin and the target • Try not to pass through more than one body cavity, and not more than one organ • Separate needle for each location • Indirect guidance – use US to find a good place, and then do a blind needle pass • Draping usually not necessary • Stab incision needed for core biopsy, but not FNA Free PowerPoint Templates

13. Free Hand vs. Needle Guide • Needle guides usually have a fixed angle of entry • Adjust the needle angle if freehand • Superficial structures best done freehand or with indirect guidance • Cover needle hub with finger to • prevent cells from inadvertently • entering the needle • When you reach lesion edge, • uncover hub and advance into the lesion Free PowerPoint Templates

14. Free Hand vs. Needle Guide • Fill syringe full of air • *then* attach needle filled with sample • Forcefully expel contents of needle onto the slide • Gently perform vertical pull • apart slides with pressure of • weight of slide only • Horizontal preps for bone marrow • or mesenchymal tumors • Make 5-10 slides of each lesion Free PowerPoint Templates

15. FNA vs. Core Biopsy • FNA probably better for vascular areas • Core biopsy for large solid lesions • Check your FNA cytology, and if non-diagnostic, consider a core • Sacrifice a core biopsy for cytology to make sure you have a good sample Free PowerPoint Templates

16. FNA vs. Core Biopsy • FNA probably better for vascular areas • Core biopsy for large solid lesions • Check your FNA cytology, and if non-diagnostic, consider a core • Sacrifice a core biopsy for cytology to make sure you have a good sample Needle throw length Free PowerPoint Templates

17. Tips for FNA • Try a “core” FNA first with no attached syringe • Less hemodilution • Attach air filled 10cc • syringe and propel • needle contents onto • a slide • Prep, dry and stain as • usual Free PowerPoint Templates

18. Tips for FNA • Try a “core” FNA first with no attached syringe • Less hemodilution • If that fails, add aspiration with syringe • 2cc saline in syringe for • better recovery on firm • lesions that produce scant • samples • Spin down & prep slides from • sediment Free PowerPoint Templates

19. Tips for FNA • Try a “core” FNA first with no attached syringe • Less hemodilution • If that fails, add aspiration with syringe • 2cc saline in syringe for better recovery on firm samples that produce scant samples • Spin down & prep slides from sediment • If that fails try a larger needle if deemed safe • Or a needle with stylet (spinal needle), followed by aspiration Free PowerPoint Templates

20. FNA/Biopsy of Liver • Difficult to impossible in deep chested dogs with small livers • Use the ultrasound to avoid pleural cavity when using intercostal approach • Liver biopsy/FNA for diffuse disease – left lobe • Use US to avoid GB and vessels • Penetrate through the capsule before deploying the Trucut to minimize bleeding Free PowerPoint Templates

21. FNA/Biopsy of Liver • Indirect Ultrasound Guidance • Notch between xyphoid and costal arch • Choose needle length sufficient to penetrate • falciform ligament (at least 1-1/2“) • Check for liver presence with the US probe • Clip & surgically prep the area • Penetrate the skin and pause • Pass needle to the hub into the liver • Direct needle 45o to table, toward head • Do not redirect – straight in, straight out • Core first, then add aspiration if needed X Free PowerPoint Templates

22. FNA/Biopsy of Liver • Indirect Ultrasound Guidance • Notch between xyphoid and costal arch • Choose needle length sufficient to penetrate • falciform ligament (at least 1-1/2“) • *Quickly* squirt needle contents onto a slide • Prep, dry and stain as usual • Confirm that you have hepatocytes on the slide • Big purple cells – granular cytoplasm Free PowerPoint Templates

23. FNA/Biopsy of Spleen • Very low risk of bleeding for diffuse disease and solid tumors • Significant hemorrhage risk for cystic structures • Indirect ultrasound guidance often sufficient for diffuse disease Free PowerPoint Templates

24. FNA/Biopsy of Kidneys • Can do blindly by palpating the kidney with one hand and aspirating or biopsying the • caudal pole cortex with the other • Or ultrasound guided • freehand for diffuse disease • Penetrate renal capsule • Measure needle throw with calipers, to avoid renal artery, aorta and caudal vena cava • Deploy biopsy needle, remove biopsy needle, apply pressure • Harvest biopsy sample for histopathology and/or cytology Free PowerPoint Templates

25. Diane DeBruyn – Mission TX Free PowerPoint Templates

26. FNA/Biopsy of Prostate • If smallish masses cannot be accessed transabdominally, they can be accessed rectally using a Franzen needle for FNA Free PowerPoint Templates

27. FNA/Biopsy of Prostate • If smallish masses cannot be accessed transabdominally, they can be accessed rectally using a Franzen needle for FNA Free PowerPoint Templates

28. FNA of Bone Lesions • I use an 18g needle, add aspiration if needed • Sedation or at least pain meds on board normal bone cortex metastatic bone lesion Free PowerPoint Templates

29. FNA of Lung Lesions • Difficult to differentiate collapsed lung from mass • Lung more wedge shaped, with “hepatized” pattern • Needle 19g or smaller - fewer complications • No FNA with needle only – attach syringe and maintain negative pressure to prevent pneumothorax • Extension set between needle & syringe (or butterfly) • Maintains negative pressure • Prevents trauma during aspiration Free PowerPoint Templates

30. FNA of Lung Lesions • Difficult to differentiate collapsed lung from mass • Lung more wedge shaped, with “hepatized” pattern • Linear probe best for this • Needle 19g or smaller - fewer complications • No FNA with needle only – maintain negative pressure to prevent pneumothorax • Extension set between needle & syringe (or butterfly) • Maintains negative pressure • Prevents trauma during aspiration Free PowerPoint Templates

31. Pitfalls of FNA & Biopsy • FNA/biopsy of adrenals &pancreas often non-diagnostic • Most helpful when ruling out neoplasia, or organ source of mid-abdominal mass • Characteristics of malignancy are • unreliable • Adrenals are highly vascular • and tend to bleed • Neuroendocrine cells in an • unusual location indicate • metastasis Free PowerPoint Templates

32. FNA & Biopsy Complications • Bleeding – watch for this with the US probe for 5 minutes after last stick (<1% hemorrhage risk) • If bleeding is a concern, stick to a smaller needle • Use Doppler to identify and avoid large vessels • Small amount of self limiting bleeding is no problem (5%) • Asymptomatic pneumothorax after lung FNAno problem • Rupture of fluid filled structure - problem • Gall bladder – bile peritonitis • Abscess or gut – sepsis • Urinary tract - uroabdomen Free PowerPoint Templates

33. FNA & Biopsy Complications • Seeding of neoplasia • Highest risk is with transitional cell carcinoma • Get informed consent prior to aspiration • Hematuria after kidney biopsy often resolves in a few days Free PowerPoint Templates

34. Summary • PowerPoint – Ultrasound Guided Fine Needle Aspirates and Biopsies • .pdf of PowerPoint – (1 and 6 slides per page) • Protek disposable needle guides • Oncura FNA Training Module

35. Acknowledgments Robert Fulton Chapter 8: Focused or COAST3 – ReproductiveFocused Ultrasound Techniques for the Small Animal PractitionerEditor Greg Lisciandro Thomas Nyland, John Mattoon, Eric Herrgesell, Erik Wisner Chapter 3: Ultrasound Guided BiopsySmall Animal Diagnostic UltrasoundEditors Nyland and Mattoon – 3rd Edition 2014