Research Article: Risk of needle tract seeding after coaxial ultrasound-guided percutaneous biopsy for primary and metastatic tumors of the liver: report of a single institution

Date Published: July 5, 2019

Publisher: Springer US

Author(s): Dagmar Schaffler-Schaden, Theresa Birsak, Ramona Zintl, Barbara Lorber, Gottfried Schaffler.


The objective of this study was to determine the incidence of needle track seeding after ultrasound-guided percutaneous biopsy of indeterminate liver lesions with a coaxial biopsy system without any other additional intervention or ablation therapy.

We identified 172 patients in a retrospective cohort study who underwent ultrasound-guided biopsy due to a liver mass in our institution between 2007 and 2016. The same coaxial biopsy system was used in all patients, no consecutive ablation was performed.

None of the finally included 131 patients developed neoplastic seeding. There was one major complication (0.76%), the rest of the complications were minor (3.8%) and did not require further intervention.

Needle track seeding is a rare delayed complication after percutaneous liver biopsy. Coaxial liver biopsy is a safe method to obtain multiple samples with a single punch in patients with primary or metastatic liver lesions.

Partial Text

There is increasing demand for pathologic specimens in modern medicine that is partly being driven by personalized medicine. Ultrasound-guided percutaneous needle biopsy is still the method of choice for the assessment of focal liver lesions with suspected malignancy due to several advantages as lack of radiation exposure, low cost, and direct visualization of the needle position in real time [1]. Complications of percutaneous liver biopsy are uncommon, but may encompass bleeding, hematoma, infection, pneumothorax, or perforation [2]. A safe ultrasound-guided biopsy requires a normal coagulation status, an accessible target, and a cooperative patient [3]. One rare, but serious complication after percutaneous liver biopsy is needle tract seeding, which is a concern particularly in liver transplant recipients. The insertion of the needle and biopsy of a malignant lesion can cause spreading of tumor cells along the needle track. Usually, seeding after liver biopsy is defined as nodular neoplastic tissue along the needle tract outside the liver capsule appearing in the peritoneal cavity, the subcutaneous tissue, the abdominal muscles, or the skin. The reported incidence of seeding after ultrasound-guided liver biopsy shows wide variation depending on the technique used, the study population, and the duration and quality of surveillance of the follow-up. Seeding rates after liver biopsy have been reported within a range from 0% up to 19% [4, 5]. Presumed risk factors for needle track seeding are aggressiveness and location of the tumor, patients’ immunosuppression, the size of the needle, and the number of needle passes. While most studies report needle tract seeding after biopsy of hepatocellular carcinoma (HCC), information about biopsies of metastatic lesions of the liver is very scarce [5, 6]. Several authors suggested an increased risk of neoplastic seeding in HCC when ablation techniques were combined with biopsy and recommended to avoid biopsy whenever possible. Increased risk of seeding was also reported when Radiofrequency ablation (RFA) followed biopsy, even when track ablation has been performed [7–9]. The time interval between the biopsy and the discovery of the neoplastic seeding also varies greatly due to the quality and duration of patient follow-up. Treatment of choice for needle track seeding is radical surgical excision, local radiotherapy, or high-intensity-focused ultrasound [8].

Data of 172 patients, who underwent an ultrasound-guided biopsy of the liver with a coaxial needle system in the years 2007–2016 in the department of radiology of the St. John of God Hospital in Salzburg, were evaluated. Only patients with malignant lesions were included, patients with benign lesions, RFA, or other ablation techniques were excluded. Characteristics of liver lesions as size and distribution were recorded as well as complications. Lesions were subdivided into unifocal, multifocal, and diffuse. Diameter of lesions was assessed by measuring the largest in multifocal and diffuse lesions (Fig. 1).Fig. 1Biopsy with coaxial technique in a 77-year-old female patient with multifocal lesions

The final study group encompassed 131 persons. 11 persons were excluded due to incomplete data, 30 persons had a follow-up ≤ 30 days and were excluded from the final analysis. Characteristics of the study group and liver lesions are available in Table 1. The main complication reported was bleeding (4.6%). There was one case of death among all patients following severe hemorrhage. This woman had multiple liver metastases due to lung cancer and refused blood transfusion and further intensive care treatment. The remaining 5 patients with bleeding were treated with compression only, there was no major complication requiring therapeutic intervention (e.g., blood transfusion, embolization, drainage, or surgery).Table 1Demographic data of patients and types of lesionsCharacteristicsDataSex (m)67 (51%)Age Range31–91 Median69 Mean ± SD68.1 ± 10.8BMI (kg/m2) (n = 116) < 18.55 (4%) 18.5–24.944 (38%) ≥ 2567 (58%)Follow-up (days) Range31-3437 Median315 Mean ± SD648 ± 784No. of punches (n = 130) 137 (28%) 261 (47%) 327 (21%) 45 (4%)Pain24 (18%)Bleeding6 (5%)Primary (HCC + CC)n = 44Metastaticn = 87Mean size overall (n = 120)2.1 cmMultifocal80/127Diffuse13/127 This study summarizes the results of 131 patients with primary or metastatic malignant liver lesions, who underwent a coaxial needle biopsy in a single department without additional ablation therapy. Age, BMI, sex, underlying disease, and number of cores were not associated with post-biopsy complications. None of these patients developed needle track seeding. Although the rate of minor bleedings requiring no additional intervention in our cohort seems rather high (3.8%), we believe that this is attributed to consistent post-biopsy monitoring in our institution, because these patients were clinically inconspicuous and would not have been detected otherwise. One earlier study including 101 patients with HCC reported zero needle tract seeding with the coaxial biopsy technique as well, although 34 of these had consecutive RFA. Bleeding complications were slightly higher and more severe compared to our results (6.25%, 5 patients requiring transfusion and three of these underwent angiographic embolization) [4]. In a large sample of 1060 patients undergoing renal and hepatic biopsies, the coaxial and non-coaxial techniques were considered equivalent in terms of complications. The incidence of needle seeding was not reported in this study [13]. On the contrary, two RCTs comparing the coaxial and non-coaxial method in perineal prostate biopsy and biopsy of renal parenchyma confirmed a lower complication rate for the coaxial biopsy system [14, 15]. The study confirms the relevance and safety of ultrasound-directed coaxial biopsy technique in focal liver lesions. Ultrasound-guided liver biopsy with a coaxial needle system is a technique with a low complication rate in experienced hands and the risk of needle seeding after liver biopsy can be reduced to a minimum. However, adequate length and quality of follow-up is required to identify delayed needle tract seeding.   Source:


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