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St. Anna Hospital Ferrara, Italy
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From January 2003 to June 2006, we performed 32 biopsies of suspicious renal masses (mean diameter, 4.5 cm; range, 2.5–11 cm) with inconclusive imaging findings. Twenty lesions were solid with colliquative or necrotic areas; 12 were partially or predominantly cystic. Low-mechanical-index contrast-enhanced sonography was used to identify viable tissue and to guide the placement of an 18-gauge cutting needle into viable portions of the lesions. One needle pass was performed in 24 cases, and two needle passes were performed in eight. All patients underwent control sonography 6 hours after the biopsy was performed.
One (3.1%) biopsy result was nondiagnostic, 22 biopsies (68.8%) were positive for malignancy (12 renal cell carcinomas [RCCs], four lymphomas, three metastases, and three undefined carcinomas), and nine (28.1%) revealed benign lesions (two pyelonephritis, two abscesses, two hemorrhagic cysts, one infarct, one tuberculosis, and one cystic dysplasia). No immediate or delayed complications were observed. The patient with the nondiagnostic biopsy underwent nephrectomy, and surgical pathology revealed a widely necrotic RCC. All diagnoses of benign and malignant lesions were confirmed by surgery or clinical and imaging follow-up (median, 18 months; range, 8–40 months). Biopsy findings avoided unnecessary nephrectomy in 14 patients (43.8%).
Our results are quite similar to those of Maturen et al. [1], but in our series fewer needle passes were needed to obtain diagnostic specimens. Contrast-enhanced sonographic guidance is likely to have played a key role in this regard. Contrast-enhanced sonography allows real-time imaging of microcirculation, enabling differentiation of viable from necrotic tissue and detection of residual viable foci of hepatocellular carcinomas after radiofrequency ablation [2]. Such an ability to identify viable tissue can also be useful in reducing the rate of nondiagnostic biopsies of predominantly necrotic or cystic lesions. Some years ago we successfully exploited this ability to guide transthoracic biopsy of a widely necrotic lung neoplasm after conventional sonography-guided biopsy failed to yield an adequate diagnostic sample [3].
The number of needle passes is considered a risk factor affecting the frequency of complications of liver biopsy [4], and it has also been reported to represent a risk factor in percutaneous renal biopsy [5]. Although there may have been some bias because our series was small, our results suggest that contrast-enhanced sonography can enable the achievement of a high rate of diagnostic specimens with a low number of needle passes. In our opinion, contrast-enhanced sonography should be regarded as the method of choice to guide percutaneous biopsy of renal masses, particularly when they are predominantly necrotic or cystic, whenever an adequate acoustic window can be identified.
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