(':u-diovasc lntervent Radiol (19N6) 9:65-68

CardioVascular and Interventional ~:~ Springer-Verlag New York Inc. 1986

Percutaneous Needle Biopsy of Deep Pelvic Masses: A Posterior Approach J o r g e O. P a r d e s , I M o r t o n S c h n e i d e r , J u n e K o i z u m i , Ivy A. Engel, Y o n g H o A u h , and William R u b c n s t c i n Departments of Radiology and Pathology. New York Hospital-Cornell Medical College. Ne~ York. New York 10021, USA

Abstract. T h e c l a s s i c a l a p p r o a c h for the fine-needle a s p i r a t i o n b i o p s y o f d e e p pelvic m a s s e s has been through the l o w e r a n t e r i o r a b d o m i n a l wall. With this a p p r o a c h , an d using e i t h e r C T or s o n o g r a p h i c g u i d a n c e , b o w e l o r b l a d d e r m a y be u n a v o i d a b l y trav e r s e d to r e a c h the mass. We h a v e b e e n using a p o s t e r i o r a p p r o a c h t h r o u g h the sciatic notch, which is a safe and s i m p l e p r o c e d u r e , with g o o d results. T h e b i o p s y is d o n e with the patient in a p r o n e position, using a 22-gauge b i o p s y needle.. With this technique we h a v e s u c c e s s f u l l y b i o p s i e d v a r i o u s neoplastic p e l v i c e n t i t i e s . K ey words: C T , p e l v i s - - U l t r a s o u n d , opsy, p e l v i s - - T u m o r s , p e l v i s - - P e l v i s

pelvis--Bi-

M o s t d e e p p e l v i c m a s s e s c a n r e p r e s e n t a diagnostic d i l e m m a s o l v e d o n l y by tissue analysis (cytologicalhistological). T h e classical a p p r o a c h for the finen e e d l e a s p i r a t i o n ( F N A ) b i o p s y through the [ower a n t e r i o r a b d o m i n a l wall c a n be c u m b e r s o m e , painful, and t e c h n i c a l l y difficult w h e n there has b e e n p r e v i o u s s u r g e r y a n d / o r r a d i a t i o n in the area, bec a u s e o f the e x t e n s i v e fibrotic r e a c t i o n that can be p r e s e n t . U s e o f the p o s t e r i o r a p p r o a c h has facilitated p e r f o r m i n g t h e s e b i o p s i e s in o u r e x p e r i e n c e .

Materials and Methods Eleven patients with deep pelvic masses seen on previous CT and/or ultrasound (US) examinations were biopsied with this Present address: Department of Radiology, Booth Memorial Medical Center, Flushing, NY 11355. USA Address reprint requests to: Jorge G. Pardes, M.D., I)epartment of Radiology, Booth Memorial Medical Center, Main Street al Booth Memorial Avenue, Flushing, NY 11355. USA

technique. The patients were biopsied in a prone position using the sciatic notch as a window. CT guidance was used in 7 patients using eilher a GF 88(X) or a GE 98111)CT scanner (GE, Milwaukee, Wisconsin. USA). 9.6 and 2.0 sec scanning time, respectively. Sonographic guidance was used in 4 patients using a Picker 80-L articulated arm scanner (Picker Corp.. H ighhmd Heights. ()hit>, USA). with a 2.25- or 3.5-MHz medium-focus transducer. In our experience, this scanher allowed easier visualizalion of the mass and guidance than sector real-time equipment for this particular biopsy technique. The patients were biopsied in a fairly standard fashion, using CT guidance as described in the literature [1, 2]. We used either the Greene (Cook Inc., Bloomington. Indiana, USA) or Westcott (Becton-Dickinson, Rutherford. New Jersey, USA) needles, 10 and 15 cm long. Tandem technique was found useful when dealing with small masses. Using t'S guidance, the patient is scanned prone Ir:msgluteally in both longitudinal and transverse phmes. The puncture site, angulation, and depth are determined, and the procedure is also done in a standard fashion.

Case Reports Case 1 A 79-year-old man. who had an abdominoperineal resection (APR) I year ago for adenocarcinoma of the rectum. Now he presents with rectal type pain. CT shows a presacral solid mass (Fig. IA). Sonogram shows a ,solid echopoor mass (Fig. IB). FNA biopsy revealed recurrent tumor (Fig. ICE. Case 2 A 65-year-old marl with a history of AF'R for rectal adenocarcinoma 2~ years ago. Now he has rectal pain. CT shows ,'~ small, Iobulated soft-tissue mass in the presacral space (Fig. 2). FNA biopsy was done twice and was negative fl'w malignancy. The patient remained clinically disease flee 6 months later, as also

documented by follow-up CT.

('ase 3 A 63-year-old woman with a history of pelvic angiosarcoma resected and radiated 14 years ago. The present symptom,; :_ire

66

J.G. Parties el al.: Needle Biops.,, of Pelvic Mu,~ses pressure. CT shows a low-density relrorectal pelvic ma~,s {Fig. 4A). Sonogram shows a wcll-de[incd mass with mulliplc imt:rnal echoes (Fig. 4B). FNA biopsy revealed benign sacrococcyge~d teratoma thai was confirmed ~1 surgery.

Results

Seventeen biopsies were performed in 11 patients. Eight of these patients had a previous diagnosis of colorectal carcinoma, one of endometrial carcinoma, another of angiosarcoma of the pelvis, and the remaining one of undiagnosed pelvic mass. The technique allowed accuratc results in 91% of biopsies (true positive: 64%: tr-ue negative: 27%). There was a 9% incidence of false-negative results. Thcrc were no complications as a result of the biopsy.

Discussion

Fig. I. A Prone pelvic CT s h o w s Iobuklted solid presacral mass (arrow). B T r a n s v e r s e prone sonogram shows solid presacral mass extending laten, lly larrows). Scaled marker indicates the path of the needle. C FNA: malignant cigar-shaped cells in glandular arrangement. Diagnosis: recurrence.

related to increasing pelvic pressure. CT shows a large, righlsided retrovesical mass involving the right piriformis muscle (Fig. 3A). Prone transverse sonogram ,;hows large solid echopot)r mass (Fig. 3B). FNA biopsy showed recurrence (Fig. 3(').

Case 4 A 44-year-old w o m a n discovered to have a pelvic mu',s during a pregnancy 14 years ago. Now she cumptains of increasing pe[,,ic

FNA biopsy has been proved as a safe and simple procedure [1] for the cytologic-histologic diagnosi,s of tumors [1,3]. Complications are rare [4]. The use of CT and US guidance for the procedure has also been well established and described in the literature [l, 5,6]. The classical anterior approach of deep pelvic masses has its disadvantages. If the biopsy is done with US guidance, a full bladder is needed to visualize the mass and it may be traversed, v/hich can be quite painful in patients who have undergone sungery and/or radiation therapy. With either CT or US guidance, deep masses can be difficult to reach. especially when they are quite caudal and posterior in location 17]. To avoid these problems, a posterior approach with the patient prone has been quite useful in our experience. This procedure mainly requires good anatomic knowledge of the area. The main anatomic facts to consider are the following (Fig. 5): The sciatic notch extends from the edge of the sacrum to the posterior ilium, acetabuhtm, and ischium. In the mid and lateral portions of the notch lie the inferior gluteal artery and sciatic nerve, respectively. The bony and soft-tissue landmarks just described are well demonstrated with CT and US. Therefore, the main technical point is to place 'the needle as close as possible to the edge of the sacrum in order to avoid these vital neurovascular structures. Our rationale for using CT versus US guidance is the following: Masses that are easily visualized sonographically are done with US guidance; smaller masses or previously unsuccessful on "'negative" biopsies are done with CT. The US-guided procedure is usually quicker but has the known disadvan-

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Fig. 2, Prone pelvic CT s h o w s bowtie shaped solid presacral mass. Needle is in place. Fig. 3. A Pelvic CT displayed prone shows ':,olid retrovesicul mass involving the right piritbrmis muscle (arrow). B Tran:.,ver:,,e pr,.me sonogram show:., large :,,olid echopo,.:,r mass (M). C FNA: malignant spindle-shaped cells fl:,rming ubn,ormal vaxcutar channels. Diagnosis: recurrence.

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J.G. Pardes el al.: Needle Biopsy of Pelvic M a s s e s

diagnostic material, since the m a s s may be predominantly fibrotic due to previous treatments or to the desmoplastic reaction associated with these tumors. In s u m m a r y , we have found this a simple, accurate, and reliable technique for the biopsy of deep pelvic masses. The ease and safety of this procedure make its use feasible on outpatients. The only prerequisite is good anatomic knowledge of the area.

References

Fig. 5. Anatomical cross-section o f the pelvis: Open arrow: edge of sacrum 1S), Black arrowhead: posterior acetabulum ~The sciatic notch extends between these two). White arrow: sciauc nerve, Curved arrow: inferior gluteal artery, F: femoral head. P: piriformis muscle tCross-section is a courtesy of Dr. Elias K a z a m New York Hospital. Cornell University Medical Center. New York. New York).

tage of not always confirming the placement of the needle. It is also important to note that the high index of repeated biopsies in patients with a history of colcrectal cancer is due to the difficulty in obtaining

I. Ferrucci JT Jr. Wittenberg J (19811 Interventional radiotog.~ of the abdomen, Williams and Wilkins. Baltimore 2, Ferrucci JT Jr, Wittenberg J, Muetler PR. et al. 11980) Diagnosis of abdominal malignancy by radiologic fine-needle aspiration biopsy. A JR 134:323-330 3, Kline TS, Neal HS '1978) Needle aspiration biopsy: Critical appraisal. Eight years and 3.267 specimens later. J A M A 239:36-39 4. Ferrucci ]T Jr, Wittenberg J. Margolies MN. Carey RW t1979) Malignant seeding of the tracl after thin-needle aspwation biopsy. Radiology 130:345-346 5. Holm HH. Pedersen JF. K r i s t e n s e n JK. et al. ~1975) Ultrasonica]ly-guided p e r c u t a n e o u s puncture. Radiol Clin Nortl" Am 13:493-51/3 6. Haaga JR. Alfidi RJ fl976) Precise localization by computed tomography. Radiology 118:603-607 7. G r a h a m D. Sanderse RC ~1982) Ultrasound-directed transvaginal aspiration biopsy of pelvic m a s s e s . J Ultrasound Med 1:279-280