Feedback on splenic lesion biopsy Solved on SIR Connect
By Avinash Medsinge, MD, Jackson Bennett, MD, Mithil B. Pandhi, DO, and Sudhen B. Desai, MD, FSIR
Original post, lightly edited for flow
bit.ly/3KNUDyF
The patient is an 81-year-old female with underlying dementia who presented with recurrent fever, chills, cough and generalized weakness. Clinical labs and imaging cannot narrow the differential of splenic lesions. An IR consult was requested for biopsy. Would you biopsy these lesions? Any input is appreciated about fine needle aspiration versus core and needle gauge size.
Author name and contact information
Avinash Medsinge, MD
Avinash.medsinge@
chp.edu
Author background and current practice preferences for splenic lesion biopsy? I am an assistant professor and core faculty of interventional radiology at University of Pittsburgh Medical Center and have been in practice for almost 10 years.
Consults for splenic lesion biopsy are less common than other viscera in the body. Most of the splenic biopsies I have done so far have been for discrete, large splenic masses. I still consider splenic biopsy as a high bleeding risk procedure and a last-ditch effort when I cannot get tissue elsewhere in the body. I usually perform them as an outpatient procedure with conscious sedation. I order pre-procedure coagulation labs along with CBC and am very particular about INR<1.5 and platelets >50K.
Please elaborate on the specific patient background and presentation in this case. An 81-year-old female with a history of dementia, hypertension, diabetes, and recently treated pneumonia presented for evaluation of recurrent fever, chills, cough and generalized weakness after completing antibiotic treatment. CT of the abdomen/pelvis showed multiple small, hypoenhancing non-specific splenic lesions. Contrast enhanced MRI did not narrow the differential. The impression on the MR study was: the splenic lesions are nonspecific and unlikely to represent lymphoma (expected to have T2 isointensity), sarcoid (expected to have T2 hypointensity) and metastases (which should remain visible as discrete lesions following contrast). Multiple hemangiomas and micro abscesses cannot be excluded. Hence IR was consulted for biopsy.
Which specific methods or techniques do you find useful in performing a splenic lesion biopsy? Most of the time I use ultrasound guidance unless the patient’s body habitus limits visualization of the lesion. I position the patient in supine/right lateral decubitus position (though literature suggests doing in left lateral decubitus position to reduce left lung expansion).
I use a coaxial technique with 17 G trocar and 18 G needle. After achieving local anesthesia up to a splenic capsule, I introduce the trocar. I prefer an 18 G full core biopsy needle (Biopince) over side cutting device. Typically, I get one to three cores. The biopsy throw length depends on the lesion dimension and morphology. After obtaining cores, I usually embolize the tract using a thick Gelfoam slurry.
What would be your preferred biopsy approach, and what prompted you to reach out regarding this topic? I chose a subcostal approach after scanning the patient. Due to the broad differential and diffuse, nonspecific lesions throughout the spleen, I needed multiple random focal versus non-focal tissue cores and the longest throw possible without compromising safety. I used a trocar to reduce multiple punctures of the splenic capsule.
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