Comparison of a coaxial versus non-coaxial liver biopsy technique in an oncological setting: diagnostic yield, complications and seeding risk.
Nicos Fotiadis, Katja N. De Paepe, Lawrence Bonne,Nasir Khan, Angela Riddell, Nicholas Turner, Naureen Starling, Marco Gerlinger , Sheela Rao, Ian Chau, David Cunningham & Dow-Mu Koh
Eur Radiol 30, 6702–6708 (2020).
https://doi.org/10.1007/s00330-020-07038-7
Interventional radiology skills form workload for many gastrointestinal radiologists. The complexity of oncological therapies continues to increase, requiring routine sophisticated tumour analysis for molecular and genomic analysis, such as for deficient mis match repair in colorectal carcinoma, which indicates chemotherapy resistance of tumours to 5-FU based chemotherapy.1 Since the liver is a common site for metastasis the optimal method for tissue sampling must be considered. While CIRSE has issued guidance on percutaneous needle biopsy in 2017, no specific guidance was issued regarding the optimal needle combination (Coaxial vs Non-coaxial).2 However they noted that coaxial systems have no increase in complications and may reduce procedure time compared with non-coaxial techniques.
The Royal Marsden research group (London, UK) performed this important comparative study to assess the optimal technique for coaxial needle biopsy of the liver, comparing diagnostic yield, safety and seeding risk with a coaxial percutaneous liver biopsy (C-PLB) and a non-coaxial (NC-PLB) liver biopsy technique in a cancer patient cohort.
The group evaluated the outcomes in 741 patients undergoing 932 liver biopsies with 9.1% under CT guidance with the remaining 90.9% using ultrasound with patients given fentanyl and optional midazolam for comfort. Patients had a full range of malignancies, with the commonest being Colorectal (20.4%), Breast (15.5%) and Lung (9%). The operator was able to choose the type of needle and the diameter (C-PLB 15G or 17G vs NC-PLB 16G or 18G) depending on preference and clinical situation. In the group undergoing C-PLB all patients had gelatin pledgets inserted along the needle track for haemostasis at the end of the procedure. All patients without complications were observed for 4 hours prior to discharge. Outcomes and complications were assessed by follow up of patient records and imaging studies.
C-PLB was most commonly performed (72.9% vs 27.1% for NC-PLB) with 18G biopsy diameter selected in 69.1% and 85% respectively. Diagnostic yield was high (92.6%) with no significant difference in diagnostic yield between C-PLB and NC-PLB or differences in needle diameter. However more cores were obtained in the C-PLB group (median 4 vs 2 in NC-PLB, p<0.001).
While the overall complication rate was 9.3%, complications were lower with C-PLB (8.2% vs 12.3% in NC-PLB; p = 0.024), with pain and sepsis/fever featuring more commonly in the NC-PLB group. While the 1.8% tumour seeding rate was low, this was significantly higher in the NC-PLB group (3% compared with 1.3% in C-PLB,P=0.021). Seeding rate was noted to be higher in melanoma, GIST and cholangiocarcinoma tumour subtypes and were only detected as small lesions on retrospective review of the imaging in all 13 cases. However, the overall tumour seeding rate was lower than expected in colorectal cancer where rates of up to 16% have been published, compared to 2% in this group. The team hypothesise that this is related to single puncture of the liver capsule and that the outer coaxial needle does not contact the tumour metastasis.
While the group recognises drawbacks in the study design including selection bias and retrospective design, overall some important messages come from this large study. This reflects a ‘routine’ oncology workload and shows that C-PLB with track plugging is a safe technique with a lower complication rate and lower risk of tumour seeding then NC-PLB. Perhaps it is time to consider this as the optimal method for tumour sampling in the liver?
References:
1.Kawakami H, Zaanan A, Sinicrope FA. Implications of mismatch repair-deficient status on management of early stage colorectal cancer. J Gastrointest Oncol. 2015;6(6):676-684. doi:10.3978/j.issn.2078-6891.2015.065
2. Veltri A, Bargellini I, Giorgi L, Almeida PAMS, Akhan O. CIRSE Guidelines on Percutaneous Needle Biopsy (PNB). Cardiovasc Intervent Radiol. 2017 Oct;40(10):1501-1513. doi: 10.1007/s00270-017-1658-5.
Dr. Damian Tolan is a gastrointestinal radiologist from St James’s University Hospital (Leeds, UK) specialising in luminal gastrointestinal imaging with a particular clinical and research interest in colorectal cancer, inflammatory bowel disease and perianal disease. He is a regular faculty member at ESGAR conferences and a member of guideline groups and the Education committee of ESGAR.
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