Trucut biopsy in splenic lesions

Mohammad Yaqoob Wani; Naseer Choh; Suhail Rafiq; Tariq Ahmad Gojwari; Musaib Ahmad Dar

doi:10.4103/jcrsm.jcrsm_27_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 6 | Issue : 2 | Page : 145-151

Trucut biopsy in splenic lesions

Mohammad Yaqoob Wani¹, Naseer Choh², Suhail Rafiq³, Tariq Ahmad Gojwari², Musaib Ahmad Dar³
¹ Department of Radiodiagnosis and Imaging, Sarawathi Hospital, Hapur, Uttar Pradesh, India
² Department of Radiodiagnosis and Imaging, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
³ Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission	22-Apr-2020
Date of Decision	01-May-2020
Date of Acceptance	18-May-2020
Date of Web Publication	21-Dec-2020

Correspondence Address:
Suhail Rafiq
Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcrsm.jcrsm_27_20

Abstract

Background: There are currently six techniques for the acquisition of splenic tissue specimens for pathologic evaluation. Less invasive percutaneous techniques, performed by an interventional radiologist using ultrasonography guidance or computed tomography are fine-needle aspiration biopsy and tissue core biopsy. These are associated with lesser complications and high accuracy.
Materials and Methods: The study was prospective in nature done in SKIMS, Soura, from August 2016 to August 2018.
Aims and Objectives: (1) The aim is to determine the diagnostic accuracy of percutaneous image-guided tru-cut biopsy of the spleen. (2) To determine the complication rate of percutaneous image-guided tru-cut biopsy of the spleen using coaxial biopsy needle system.
Results: A total of 18 patients underwent percutaneous tru-cut biopsy of the spleen. All patients underwent a single time biopsy. In this study, 17 (94.4%) patients had splenic lesions, and 1 patient (5.6%) had splenomegaly under evaluation. Our study had a sensitivity of 93.7%, the specificity of 100%, positive predictive value of 100%, negative predictive valve of 50%, accuracy of 94.1% and diagnostic yield = 94.4%.
Conclusion: Percutaneous image-guided tru-cut biopsy of the spleen with an 18G core biopsy needle has high diagnostic accuracy and minimal complications. We conclude that percutaneous image-guided tru-cut biopsy of the spleen is an effective alternative procedure to splenectomy in patients with splenic lesions.

Keywords: Spleen, Splenectomy, trucut biopsy

How to cite this article:
Wani MY, Choh N, Rafiq S, Gojwari TA, Dar MA. Trucut biopsy in splenic lesions. J Curr Res Sci Med 2020;6:145-51

How to cite this URL:
Wani MY, Choh N, Rafiq S, Gojwari TA, Dar MA. Trucut biopsy in splenic lesions. J Curr Res Sci Med [serial online] 2020 [cited 2023 May 30];6:145-51. Available from: https://www.jcrsmed.org/text.asp?2020/6/2/145/304201

Introduction

The spleen is a large, vascular lymphatic organ lying in the upper part of the abdominal cavity on the left side, between the stomach and diaphragm, composed of white and red pulp; the white pulp consists of lymphoid nodules and diffuse lymphoid tissue, and the red pulp consists of venous sinusoids between which are splenic cords. The stroma of both red and white pulp is composed of reticular fibers and cells.^[1] The spleen is well known to be the largest lymphoid organ in the body. Unlike the lymph nodes, however, the spleen does not receive drainage from the lymphatic system but is rather connected to the systemic circulation. Spleen is not commonly affected by disease; however, those that do affect the spleen are extensive, including malignancy (lymphoma, metastatic), infection (tuberculosis, fungal), and infiltrative processes such as sarcoidosis.^[2],[3] As advances in medical therapy in the oncology setting are leading to longer patient survival, there is a corresponding increased need for biopsy. Additional factors that have expanded the indications for splenic biopsy include the regular use of immune-suppressive drugs in therapy and improved imaging techniques. Diseases that commonly affect the spleen can pose a diagnostic challenge to the clinician, radiologist, and pathologist. Because imaging has not been demonstrated to be accurate for diagnosis, tissue samples from the spleen may be required to stage or diagnose malignancy or to assess for possible infection.^[4],[5] The reported diagnostic accuracy of splenic biopsy varies, ranging between 84% and 90%.^{[6],[7],[8],[9],[10],[11],[12],[13]} The nature of the splenic lesions is of primary diagnostic importance and often defines the course of treatment in these patients.^{[14],[15],[16]}

There are currently six techniques for the acquisition of splenic tissue specimens for pathologic evaluation. Surgical techniques include open biopsy, open splenectomy, and laparoscopic splenectomy, and laparoscopic biopsy. Splenectomy carries a relatively high reported morbidity (8.6%–37%) and mortality (0%–2.9%) rate, primarily because of infection.^{[17],[18],[19]} Currently, however, the surgical trend is toward the preservation of the spleen whenever possible. Asplenia has been known to predispose one to infection. A particularly significant and specific infectious complication of splenectomy is overwhelming postsplenectomy infection. This is caused by encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenzae type B. This condition, which occurs at an annual frequency rate of 0.5% in patients postsplenectomy, is associated with 50% mortality. Thrombosis, especially portal vein thrombosis, is a well-recognized complication of splenectomy. Increases in accuracy and frequency of imaging studies have led to an increase in the detection of portal vein thrombosis.

Less invasive percutaneous techniques, performed by an interventional radiologist using ultrasonography (US) guidance or computed tomography (CT), are fine-needle aspiration biopsy (FNAB) and tissue core biopsy. US-guided core biopsy of the spleen is a relatively new procedure for sampling target lesions, which leaves the architectural relationships and stromal elements intact for histopathologic evaluation.

The use of ultrasound or CT guidance for percutaneous biopsies of solid intra-abdominal organs, such as the kidney, pancreas, and liver, is a well-established practice because of its diagnostic accuracy and relative safety.^[20] Historically, image-guided percutaneous biopsy of the spleen has been approached with fear and apprehension because of concerns regarding accessibility and risk of hemorrhage.^[7] This reluctance was related to the fact that spleen being the highly vascular organ and that early reports of a high major complication rate (13%) for percutaneous biopsy of the spleen performed with a 14-gauge needle.^[15] Early investigations into the use of image-guided core needle biopsy (CNB) of the spleen showed promising diagnostic efficacy but an unacceptably high rate of major hemorrhage.^[15] Subsequently, a biopsy of the spleen was rarely undertaken because of fears about the risk of major bleeding and the perceived technical challenges of the procedure.^[21] However, there were several studies and more recent publications reporting much lower complication rates with smaller needle diameters (18 gauge or smaller).^[6],[8]

Materials and Methods

This study was conducted in the Department of Radiodiagnosis and Imaging Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar in collaboration with Department of Medical and Surgical Oncology, General Surgery, Pathology and Haematology from August 2016 to August 2018. Patients with an indication for splenic biopsy were referred to our department. A total of 18 patients underwent biopsy of the spleen during the period of 2 years, which included 10 male and 8 female patients [Table 1] and [Table 2].

Table 1: Age distribution

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Table 2: Gender distribution

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Study design

The present study of diagnostic accuracy and complication rate of tru-cut biopsy in splenic lesions was prospective in design.

Inclusion criteria

Radiologically indeterminate splenic lesions
Splenomegaly of unknown etiology.

Exclusion criteria

Uncorrectable coagulopathy
Hemodynamic instability
Lack of a safe biopsy pathway, and
Uncooperative patient.

Aims and objectives

To determine the diagnostic accuracy of percutaneous image-guided tru-cut biopsy of the spleen
To determine the complication rate of percutaneous image-guided tru-cut biopsy of the spleen using a coaxial biopsy needle system.

The biopsies were carried under image guidance (ultrasonography, CT) whichever was appropriate. The biopsy was done using a coaxial biopsy system of 18 gauge with a 1–2 cm throw of cutting needle. Biopsies were performed using Bard® Mission® Disposable Core Biopsy Instrument 18G 16 cm [Figure 1]. US-guided procedures were performed using GE Logic P5 or Sonosite M-Turbo. CT-guided procedures were performed using Siemens SOMATOM Sensation 64 slice.

Figure 1: From left to right, BARD MISSION Disposable Core Biopsy Instrument, Compatible coaxial needle with trocar tip stylet within the coaxial needle, Blunt tip stylet, 10mm Adapter (upper right) and Depth stop (lower right)

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The procedure was mostly performed using a subcostal or intercostal approach. The shortest possible pathway was attempted to minimize the trauma to the parenchyma. The patient would then perform the instructed breath-hold technique to bring the lesion into the field of view and the biopsy trajectory. The coaxial needle with trocar tip stylet was advanced into the lesion, trocar tip stylet was removed, and Bard Mission core biopsy instrument introduced through coaxial needle. Adequate sample was retrieved and put in the biopsy vial and sent for histopathological examination. The core biopsy instrument was withdrawn. In each case, 2-4 mL of the paste of gelatin sponge was administered through the coaxial needle, along the path of the biopsy, from the target site to the organ capsule, a procedure that was also guided by imaging.

Patients were assessed for complications which include;

Minor complications

Pain requiring analgesia (oral or intravenous anlagesics)
Asymptomatic bleeding identified incidentally on postprocedural imaging (e.g., small subcapsular splenic or perinephric hematomas).

Major complications

Those who scored at or above grade 3, according to the National Institutes of Health's Common Terminology Criteria for Adverse Events (AEs), version 4.0.^[22] Common Terminology Criteria for AEs (CTCAEs) version 4.0 (u.S. Department of health and human services, National Institutes of Health, National Cancer Institute, USA)displays grades 1 through 5 for surgical and medical procedures.

Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated
Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental activities of daily living (ADL)
Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care ADL
Grade 4: Life-threatening consequences; urgent intervention indicated
Grade 5: Death related to AE.

Patients were followed, and their histopathological reports were obtained [Table 3] and [Figure 2], [Figure 3], [Figure 4]. Patients were followed for the treatment they received and the response to treatment. Biopsy from the alternate site if required, was done, and its histopathological report checked. Biopsy results were characterized using classification similar to used by Tam et al.^[23] with slight modification. The pathology reports of each specimen were reviewed and were grouped into one of the four following categories:

Table 3: Histopathological diagnosis

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Figure 2: Computed tomography guided biopsy of the splenic lesion. Images in upper row show the axil scan with biopsy needle in lesion. Histopathological examination in lower row reveals NHL (DLBCL) low and high power, respectively

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Figure 3: These images show ultrasonography guided biopsy of splenic lesion. Histopathological examination in lower row shows metastatic carcinoma (low and high field respectively)

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Figure 4: Ultrasonography guided biopsy of splenic lesion. Histopathological examination in lower row shows granulomatous pathology (low and high field microscopic images, respectively)

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Positive for malignancy
Suspicious for malignancy but not definitively diagnostic
Benign
Nondiagnostic.

Biopsies categorized as suspicious were regarded as positive for the purpose of statistical analysis. A biopsy was considered a true-positive if the result was corroborated histocytologically with biopsy of tissue obtained from another site such as lymph node, bone marrow biopsy, or solid-organ biopsy or splenectomy or if the clinical follow-up suggested the disease.

A biopsy was considered a true negative if the result was confirmed by splenectomy or if it resulted in a clinical decision not to treat a patient, or if ensuing imaging studies showed signs of stability or benignity (e.g., decreased fluorodeoxyglucose avidity on positron emission tomography or complete resolution of the lesion after initiation of antibiotic therapy). False-negative or false-positive biopsies were those whose results were contradicted by alternative tissue sampling or clinical or imaging follow-up or both. Nondiagnostic results (i.e., insufficient tissue for diagnosis) were not included in calculations of specificity, sensitivity, predictive value, or accuracy.

Statistical analysis

Data were entered in Excel and analyzed using SPPS v 20.0 software (SPSS South Asia (P) Ltd, Bangalore, India). Results were represented in the form of tables and graphs. Categorical data are given in number and percentage while continuous data in the form of mean + standard deviation. Diagnostic performance of percutaneous biopsy was estimated for sensitivity, specificity, positive predictive value (PPV), negative predictive value, overall accuracy, and diagnostic yield.

Results

A total of 18 patients underwent percutaneous tru-cut biopsy of the spleen. All patients underwent a single time biopsy. In our study, 17 (94.4%) patients had splenic lesions and 1 patient (5.6%) had splenomegaly under evaluation. Of the 18 biopsies, 6 were CT guided and 12 were performed using ultrasound guidance. Biopsies were performed using an 18-gauge coaxial biopsy needle system. Most of the biopsies were performed under local anesthesia (94.4%) and one biopsy was performed under conscious sedation (5.6%). There were two minor complications. One (5.6%) patient developed subcapsular hemorrhage and one developed pain requiring analgesia (5.6%). None of our patients developed a major complication. Of the diagnoses made, 11 out of 17 were (64.7%) were malignant, notably including lymphoma in (41.1%) cases. A benign diagnosis was made in 6 out of 17 (35.3%) cases [Table 4].

Table 4: Classification of biopsy results

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Sensitivity = 93.7%
Specificity = 100%
PPV = 100%
Negative predictive valve = 50%
Accuracy = 94.1%
Diagnostic yield = 94.4% [Table 5].

Table 5: Sensitivity, specificity, and accuracy and diagnostic yield

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Discussion

Splenic abnormalities are uncommon and may present as solitary or multiple splenic lesions or splenomegaly. Diagnosis may be made with correlation to the patient's clinical history, laboratory findings, or other radiological examinations, but where the diagnosis remains unclear, tissue diagnosis is required. After Lindgren et al.^[15] reported a series of 32 CNBs of the spleen using a 14G needle in which four of 32 (12.5%) patients suffered major hemorrhage requiring transfusion, splenic biopsy developed a reputation as a risky procedure with potential complications. More recent series have shown lower complication rates^{[7],[8],[24],[25],[26],[27]} but have either focused primarily on FNAB of the spleen or have included a relatively small number of CNBs. Meta-analysis by McInnes et al.^[21] examined pooled complication rates for FNAB and CNB and found an overall complication rate of 4.2% with a major complication rate of 2.2%; these numbers increased to 5.8% and 3.2%, respectively, for CNB alone. Oslon et al.^[28] in their 92 biopsies had seven (7.2%) minor complications and a single (1.0%) major complication.

The study showed a diagnostic accuracy of 94.12% (95% confidence interval [CI], 71.3%^__99.85%), and diagnostic yield of 94.4%. The sensitivity was 93.7% (95% CI, 69.77%^__99.84%), and because there were no false-positive biopsies, the specificity was 100% (95%, CI 2.5%^__100%). The PPV was 100%, and the negative predictive value was 50% (95% CI, 13.04%^__86.96%). This includes one biopsy, in which the pathology specimen was reported as suspicious neoplastic lesion but not definitively diagnostic, but the subsequent lymph node biopsy confirmed lymphoma. Biopsy of the spleen yielded adequate diagnostic tissue in 17 of these 18 cases.

Gómez-Rubio et al.^[29] in their study, demonstrated that the diagnostic accuracy of CNB of spleen was 92%, and for splenic lymphomas, the CNB had 100% accuracy and Olson et al.^[28] showed the diagnostic accuracy was 94.5%. These studies support the result of our study showing the diagnostic accuracy of 94.1%. McInnes et al.^[30] in their meta-analysis had the pooled sensitivity of 87.0% (95% confidence interval [CI]: 80.7%, 91.4%) and specificity of 96.4% (95% CI: 81.4%, 99.4%). Olson et al.^[28] showed the sensitivity was 90.7%, the specificity was 100%. Our study showed 93.7% sensitivity and 100% specificity. The sensitivity and specificity results of our study are comparable to that of Olson et al. Patel et al.^[31] had a positive diagnostic yield of 90.4%. Olson et al.^[28] showed the diagnostic yield of CNB was 93.8%, these results are consistent with the diagnostic yield of 94.4% in our study.

Of the 18 spleen trucut biopsy procedures, there were two minor complications This was comparable with the study published by Patel et al.^[31] wherein the major and minor complication rates were 0% and 1.9% (1/52), respectively. This study showed the major complication rate similar to our study (0%); however, the minor complication rate was (1.9%) much lower than our study (11.11%).

However, studies including that of McInnes et al.^[30] “Percutaneous Image-guided Biopsy of the Spleen: Systematic Review and Meta-Analysis of the Complication Rate and Diagnostic Accuracy” showed a major complication rate of 1.3% (95% CI: 0.6%, 2.5%) for biopsies performed with 18 gauge needle. Olson et al.^[28] in their study had 7.2% minor complication and a 1.0% major complication rate; the overall complication rate was 8.2% (n = 8). In these studies, major complication on an average is 1.2% and one of the studies showing 7.2% minor complication. However, in our study, we had no major complications, but there were 11.11% of minor complications. The reason for such disagreement could be the small sample size of our study and the lack of standard definition for classifying a complication to be major.

Conclusion

Percutaneous image-guided tru-cut biopsy of the spleen with an 18G core biopsy needle has high diagnostic accuracy. We conclude that percutaneous image-guided tru-cut biopsy of the spleen is an effective alternative procedure to splenectomy in patients with splenic lesions. Percutaneous image-guided tru-cut biopsy of the spleen is a safe procedure with no evidence of increased risk of complications compared with biopsy of other solid abdominal organs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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