Andrew Constance

J.

Fisher, MD M. Simmons,

#{149} Erik

K. Paulson,
#{149}

RN

Rendon

MD #{149} Douglas C. Nelson, MD

H. Sheafor,

MD

Small Lymph Nodes and Retroperitoneum: of Sonographically

PURPOSE: To evaluate the usefulness of sonographically guided percutaneous biopsy of small lymph nodes in the abdomen, retroperitoneum, and pelvis. MATERIALS AND METHODS: From May 1995 through January 1997, 35 sonographically guided lymph node biopsies were performed in 34 patients. All biopsies were performed with a 20- (n 18) or 22-gauge (n = 10) self-aspirating needle alone or in combination (n 7). To determine the amount of compression achieved with the transducer, the skin-to-lesion distance on reference computed tomographic (CT) scans was cornpared with that on sonograms. A biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist. RESULTS: Of 35 sonographically guided biopsies, 30 (86%) were successful. Diagnoses included 26 (74%) cases of carcinoma, three (9%) cases of benign reactive lymphocytosis confirmed at open biopsy, and one (3%) case of a lymph node with a positive acid-fast bacilli stain. The average lymph node diameter was 2.1 cm (range, 0.9-4.3 cm). With sonography, a mean of 2.5 needle passes (range, 1-5) were made per biopsy. Transducer compression reduced the skin-to-lesion distance from an average of 8.8 cm (at CT) to 4.5 cm. CONCLUSION: Sonographic guidance seems to provide a reasonable alternative to CT in biopsy of small abdominal, pelvic, and retroperitoneal lymph nodes.

of the Abdomen, Usefulness Guided Biopsy

percutaneous biopsy procedures are a critical component of the diagnosis, staging, and follow-up of suspected or known malignancies. Although European and Asian physicians have routinely used
MAGING-GUIDED

Pelvis,

the needle and lesion, particularly when lesions are small or there is overlying bowel gas. In addition, intervening tissues can be difficult to delineate, especially with cornpression. Many radiologists decline to
visualizing

sonographic guidance (1-8), radiologists trained

for

biopsies in the United

attempt

biopsy

of such

lesions

or per-

States have relied largely on computed tomography (CT) as the modality of choice for biopsy guidance, particularly when targeting lymph nodes in the abdomen and pelvis. Sonography and CT have proved successful and are associated with unique benefits and disadvantages. Compared with CT, sonographic guidance is less familiar to most
American-trained radiologists but has

potential advantages oven CT guidance. Sonognaphic guidance with a needle guide is readily mastered and
shortens procedure time, facilitates

needle tip visualization throughout the entire process, and enables biopsy to be performed during a single breath hold. This technique also ensures that sampling is limited to the lesion. Most, if not all, equipment manufacturens provide needle guides that attach easily to transducers, inside or outside the protective condom, and provide a computer-generated path to the lesion, ensuring accurate needle placement. Other advantages of sonography are mobility of the equipment and no emission of ionizing radiation. The limitations of sonographic guidance center on the difficulty in

form biopsy with CT guidance. As a result, in some institutions sonography is used primarily for biopsy of large or superficial lesions, as an aid for renal biopsy or panacentesis on thoracentesis, and for biopsy of besions within the liver. As experience is gained, nadiologists are starting to use sonographic guidance not only for percutaneous biopsy of large or superficial lesions but also for small lesions located deeply on positioned precariously (9). These small lesions include lymph nodes within the abdomen, pelvis, and retropenitoneum. The purpose of this study was to evaluate the usefulness of sonographically guided biopsy of small lymph nodes of the abdomen, pelvis, and retropenitoneum.

MATERIALS
Between May

AND
1995 and

METHODS
January 1997, we

performed

a total of 35 sonographically guided lymph node biopsies in 34 patients. The average age of the 13 men and 21 women was 59 years (range, 24-88 years). Of these patients, 23 (68%) had a known
malignancy, three (9%) had positive results

for human immuntodeficiency virus, and the remaining eight (24%) had no history of malignancy or condition predisposing

Index terms: comparative

tive studies,

Biopsies,

technology,

studies,
998.12985,

998.1261
998.12989,

#{149}

998.1261, 998.12985, 998.12989 Computed tomography (CT), Lymphatic system, biopsy, 998.1261 #{149} Ultrasound (US), compara998.12911 #{149} Ultrasound (US), guidance, 998.12985,998.12989

Radiology

1997; 205:185-190

I From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Durham, NC 27710. Received April 24, 1997; revision requested May 23; revision received accepted June 25. Address reprint requests to E.K.P.

Rd. June

20;

RSNA,

1997

185

toward lymphadenopathy. Primary tumors in the 23 patients with known malignancy included lymphoma in seven (30%) patients; colon cancer in five (22%); melanoma in two (9%), breast cancer in two (9%), ovarian cancer in two (9%), cervical cancer in two (9%); and pancreatic cancer,
ovarian cancer, or cholangiocarcinoma in

one patient each (4%). Twenty-two patients were outpatients and 12 were inpatients.
Biopsy results were reviewed retrospectively. The 35 lymph nodes in which biopsy
was performed varied widely in location.

Eight (23%) were in the ponta hepatis or portacaval region, seven (20%) were in an aortocaval or paracaval distribution (six of these seven were inferior to the bevel of the

a.
Figure 1. Images obtained in a 23-year-old

b.
woman in whom non-Hodgkin lymphoma was

left renal vein), six (17%) were paraaortic (five of these six lymph nodes were infenor to the left renal vein), four (11%) were
in the pelvic area, mesentenic region,
liac, and three (9%)

four (11%) were three (9%) were

were adjacent

in the paraceto the

suspected. (a) CT scan shows an enlarged night external iliac lymph node (arrow). (b) Sonogram shows the echogenic tip of a 20-gauge needle within the lymph node (arrow). Real-time visualization of the needle tip during the biopsy ensures that the specimen will be obtained exclusively from the lymph node without contamination from adjacent normal tissues or transgnession of the adjacent external iliac vein. Non-Hodgkin lymphoma was proved pathologi-

cabby in this specimen.

superior mesentenic artery. The mean diameter of the lymph

was 2.1 cm. Measurement was based

nodes
on an

Summary

of Lymph

Node

Biopsies

according

to Site
Mean Size Mean

average
nor

of the transverse
(range,
an Of the average

and anteroposte0.9-4.3)
35 lymph diameter

diameters

measured
nodes, less Retroperitoneal

Location
(n (n (n
= = =

Success*

(cm)t

Needle

No. of Passest

sonographically. 18 (51%) had

13)
5 (83) 1.8 (1.5-2.7) 2.3 (1-4)

than 2 cm. All patients before biopsy.

Paraaortic underwent CT scans diagnostic CT were displayed in

Aortocaval

6) (n
=

the interventional radiology suite during the biopsy procedure and were reviewed
to choose the optimal site and route biopsy. A full diagnostic abdominal
vic sonogram was not obtained

Porta hepatis Pelvic (n = 4)

Mesentenic (n
=

7) and portacavab
=

6 (86)
8) 6 (75) 3 (75) 4 (100)

2.1 (0.9-2.8)
2.2 (1.5-4.0) 2.9 (1.9-4.3) 2.4 (1.5-3.5) 1.2 (1.2-1.3) 1.6 (1.1-2.4) 2.1

2.4 (1-5)
2.5 (1-5) 3.0(2-4) 3.25 (2-4) 2.3 (1-3) 1.7(1-2) 2.5

4)

Adjacent
(n

to the superior
3) (n (n
= =

mesenteric

artery
3 (100) 3 (100) 30 (86)

for on peb-

Paracebiac
Total
* t

3) 35) are percentages. are a range.

at biopsy;

acquisition of preliminary sonognams was limited to identification of an appropriate path to the lymph node in question. Only seven (20%) of the 35 CT scans were obtained at other institutions. After written informed consent was obtained from each patient, the selected
lymph cally node and was identified path was sonographichosen. To a biopsy

Numbers Numbers

in parentheses in parentheses

After the skin with bactericidal

was thoroughly soap, the skin

washed site and

and
with

out of the lymph

slight rotation.

node
Operators

five

to 10 times,
paid careful

improve visualization of the lymph node, the overlying abdominal wall was cornpressed with the transducer to displace or minimize intervening bowel loops and fatty tissues. The needle path was interrogated routinely with color Doppler sonography to detect and avoid intervening blood vessels. The route chosen was the
shortest possible but also free of interven-

anterior
with with achieved 5-10

abdominal
mL of 1%

wall Astra,
needle.

were

infiltrated
hydrochbo-

lidocaine Sedation

ride (Xybocaine;
a 25-gauge with

Westbonough,

Mass)
was

attention to the needle tip, attempting to avoid sampling adjacent normal structures or blood vessels (Fig 1). The needle was removed (without the stylet), and the pa-

intravenous

administration

tient was instructed

to breathe

normally.

of diazepam (Valium; Elkins-Sinn, Hill, NJ) and/or fentanyl citrate

limaze; formed gauge Akorn, with Decatur, Ill)

Cherry (Subperon 22-

as necessary.

In all lymph

nodes,
a 20-gauge

biopsy
(ii

was
18)

ing critical structures such on bile ducts. No particular

made to avoid intervening

as large attempt
bowel;

vessels was
in fact,

Biopsies were performed or supervised directly by one of a group of eight attending abdominal radiologists (E.K.P., RC.N.). A cytopathobogist was present during all procedures to determine if adequate tissue
was obtained interpretation. and to provide The procedure a preliminary was consid-

needle
Scientific,

(n = 10) self-aspirating Crown without suction (Medi-tech/Boston

Watertown, Mass) alone or in

with
sible

compression
to differentiate

it typically
compressed

was

not pos-

from mesentenic fatty tissue. solid organs was avoided except in cases in which there was no alternative (eg, porta hepatis and portacaval lymph nodes).
All biopsies were performed with a

bowel A path through

combination

(n

was also performed gauge automated

7). In six cases, biopsy with an 18- on 20spring-loaded cutting Scientific).

ered completed once the pathologist determined an adequate sample had been obtamed. recovery
opsy assess

Patients were area for 4-6

monitored hours after

All

in a the biand

needle

(Medi-tech/Boston

model 128 sonognaphic unit (Acuson, Mountain View, Calif) except for a single biopsy performed with a Logic 700 unit (GE Medical Systems, Milwaukee, Wis). A 3.25- or 2.5-MHz sector transducer equipped with an attachable needle guide
was used. This needle guide directs the

The needle pass technique lows: One physician (A.J.F., or R.C.N.) held the transducer
ond manipulated the needle.

was
E.K.P.,

as folD.H.S.,

procedure to monitor for complications.

vital signs outpatients

while
Initially,

a secthe

were contacted by a nurse 1 or 2 days after the biopsy procedure to determine complications such as persistent pain, fever, or

needle
the patient

pierced
suspended

the skin
fatty

and
tissue.

advanced
While the path

into
the of

bleeding

subcutaneous

respiration,

the needle
lymph node into it. The without

guide
and stylet

was

aligned

with

the

site. The inpatients were monitored by their clinical team, and the medical records were reviewed for the development of peritonitis,
unexplained scess, or blood fever or abdominal pain, abtransfusion requirement.

at the puncture

needle at a 15#{176} or 30#{176} angle with respect to the orientation of the transducer.

the needle was then the needle

was advanced removed, and, was passed in

suction,

Final

pathology

reports

were

reviewed.

isa;

#{149}

R1inlnv

October

1997

with hand-held calipers. This distance was measured on the CT scans and sonograms.
Sonograms and CT scans were available in only 25 cases. The reason for this is that many of the CT scans were from other institutions and had been returned.

RESULTS Sonographically guided biopsy was successful in 30 (86%) of 35 biopsies. These biopsies yielded new or recurrent metastatic carcinoma in 26 (74%) patients, benign reactive lymphocytes confirmed at subsequent open surgical biopsy in three (9%) patients, and positive findings in a lymph node from acid-fast bacilli stain consistent with Mycobacterium tuberculosis in one
(3%) patient (Table). The five unsuccessful biopsies yielded nonspecific

Figure 2. aontocavab

Carcinoma lymph node

of the cervix in a 32-year-old (arrow). The anteroposterior

woman. distance

(a) CT scan shows an enlarged from the skin to the beading

edge

of the lymph

node

is 9 cm. (b) Sonogram

shows visualization

that with

gradual
3 cm.

compression
Displacement

produced
and

with tip

the transducer,
sion ofbowel (arrowhead).

the skin-to-lesion
and fatty tissue A = aorta.

distance
improve

is reduced

to

only

compres-

of the lymph

node

(arrow)

and

needle

15

15

inflammation, fibrous evidence of malignancy.

purposes, these cases

tissue, or no For analysis

were considered

FE
.lO
I)

.I
.b0
Ic

unsuccessful, histopathobogic
lesions was (range,

although proof
determined.

no subsequent of malignant

I.

{n

0 CT a.
Figure 3. (a, that measured cases in which seven cases in

0 US b. b)
Graphs show comparison of the skin-to-lesion distance measured at CT with

CT

US

diameter was though these lymph nodes were small, an avenage of 2.5 needle passes (range, 1-5) were made. Eight procedures were completed successfully in a single
2.1 cm 0.9-4.3). Even pass. A mean of three passes were

The mean

lymph

node

made
sies.

in the five unsuccessful

biop-

at sonognaphically guided biopsy. (a) The lines connect the measurements CT scans and sonograms were available (n = 25). (b) The measurements which liver transgression was necessary were excluded.

in all
in the

The final pathologic diagnosis was based on examination of the cytopathobogic

specimen in all cases and of the cytopatho-

area.
time

tion

Procedure time was from commencement through preliminary

Differences

defined as the of skin preparacytopathobogic

in the amount

logic specimen and histopathobogic specimen in six cases. A biopsy was considered
successful if a specific malignant diagnosis

interpretation.

Part of the success of sonographic guidance rebated to the ability to reduce the needle path distance with application of transducer pressure (Fig 2). Under CT guidance, the lymph nodes sampled for biopsy had an average skin-to-lesion distance of
8.8 cm (range, sonographically 2.5-13.0 guided cm). During biopsy, this

of room
lymph

time
node

necessary
biopsies

for all CT-guided (n = 23) performed

was made

or a benign

diagnosis

was made

oven a 1-year

period

were

determined

with

and confirmed subsequently at open surgical biopsy. A biopsy was considered unsuccessful if the pathology report revealed nonspecific findings such as reactive tis-

sue, suspicious cells, fibrous or fatty tissue, or acute or chronic inflammation. In addition, a specific benign diagnosis not confirmed at open biopsy was deemed unsuccessful even though these biopsy procedures may have resulted in true-negative specimens. time (n = 35) and proce25) were recorded. Early in our experience, procedure time was not recorded, accounting for the difference in sample size. Room time was defined as the period during which the patient was in the
dare time (n
=

a two-tailed Student t test. For CT-guided biopsies, acquisition of scans was limited to biopsy planning, and a full diagnostic abdominal on pelvic study was not performed. Therefore, although diagnostic
scans were available guided during biopsies, parameters. CTroom on sonotime for graphically

average distance path) was only 4.5 reduction of 49% cases in which the are excluded, the marked. In these
skin-to-lesion

(shortest cm (range, (Fig 3). If liven was difference biopsies,

was

measurable 1.5-11.5), the seven transgressed is more average

9.5 cm on

distance

CT-and
encompassed Images

sonognaphically
similar

guided

biopsies

CT scans; this distance was cm with transducer pressure,

tion of 58%.

only 4.0 a reduc-

The total

room

agnostic viewed

(A.J.F.,
retrospective

from the procedure and the diCT scans, if available, were neretrospectively by two radiologists E.K.P.) in consensus. As this was a review, a standard imaging

Results from the the five unsuccessful biopsies were not substantially
different from results cessfub biopsies. Four sies yielded primary from the sucof the five biopmalignancy. The

format

was

not followed

for each

case.

Nevertheless, for each case the sonographic images documented the targeted lymph

mean as
(2.2

interventional

radiology

suite,

including

node

and the anticipated

needle

path

all preparation (consent, placement of intravenous catheter, patient transfers, etc) and postprocedural monitoring (initial vitab signs, hemostasis assessment for pain,

prescribed by the needle guide. To assess the amount of compression of the abdominab wall achieved by applying downward transducer pressure, we measured the
shortest distance from the abdominal wall

lymph node size was similar cm). An average of 3.0 passes were performed compared with 2.4 for successful biopsies. The sonographic depth was comparable (5.0 cm for unsuccessful biopsies vs 4.5 cm for
successful biopsies). Clinical on imag-

dressing of the puncture site, etc) before the patient was transferred to a recovery Volume 205
#{149}

to the leading

edge

of the lymph

node

ing follow-up

was

performed Radiology

at our
#{149} 187

Number

Figure 4. Images obtained (arrow). Note the proximity

with needle guidance shows

in a 32-year-old of this lymph

a safe route

man with human node to the hepatic

to the lymph node

immunodeficiency artery, portal vein,

(arrow), free

virus. (a) CT scan shows an enlarged portocaval and common bile duct (not shown). (b) Sonogram with
critical structures. M tuberculosis. (c) Sonogram shows

of intervening

lymph node obtained the needle tip

(arrow)

within

the lymph

node,

which

stained

positive

for acid-fast

bacilli

consistent

institution cases, and

in only the CT

one of these five findings showed

results

confirm

the

recent

study

by

We

found

that

sonographic

guidlymph guide,

Memel

et al (9), which

included

26

ance
pelvic, nodes.

is useful
and With

in biopsy

of abdominal,
the

stable disease at 8 months. There was a single bleeding complication. In this case, injury to the infenor epigastnic artery occurred during needle placement; transcatheter antenab embolization was necessary to
obtain hemostasis. All remaining pa-

tients none
pain,

tolerated the procedure well; of the outpatients reported fever,

or admission to other hospitals

patients with abdominal, pelvic, and retropenitoneal bymphadenopathy and yielded tissue adequate for diagnosis in 21 (91%) of 23 sonographically guided procedures. Nagano et al (4) reported a successful procedure in 13 (81%) of 16 pelvic and 21 (81%) of 26 paraaortic lymph node biopsies. Similarly, Al-

retroperitoneab use of a needle

needle

can be passed

accurately

into

the lesion during real-time visualization and the procedure may be penformed during one or two patient breath holds. Most, if not all, equip-

ment

manufacturers

provide

needle

Mofleh

(10) obtained

diagnoses

in

when

contacted

by our

nurse

(C.M.S.).

None of the inpatients peritonitis, unexplained

developed abdominal

75% of 37 sonographically guided biopsies. Tikkakoski et al (7) obtained correct results in 31 (91%) of 34 abdominal and retropenitoneab lymph

pain, or abscess or required a blood transfusion after the biopsy procedune. One inpatient had a temperature of 40#{176}C 3 days after biopsy. The patient had no abdominal pain or tenderness, and the fever was attributed

node biopsies. Part of the success in European studies probably relates to the increased availability of sonography compared dition, European
may have

with that of CT. cytopathobogists

In ad-

guides, which usually attach to the transducer and provide a computergenerated path to the lesion, ensuring accurate needle placement. Experienced operators may favor the freehand technique, although we have found the needle guide helpful in efficient and direct placement of the needle into lesions. One drawback of the

needle

guide

is that

in some

cases

it is

to lymphoma.
spiratory failure autopsy showed scess, or injury

The

patient

died

of reand an ab-

needle

more aspiration

familiarity techniques

with fineand

2 weeks later, no hematoma, to bowel.

Although
was 81 minutes

the average
for

room 45-135

time mmwas

sonographicalby procedure time 10-85 minutes).

analysis than their counterparts in the United States. Proponents for the use of CT for lymph node biopsy argue that CT provides superior anatomic visualization

not possible to follow the prescribed path of the needle due to intervening vital structures. In these cases the hand technique is necessary.

free-

Real-time
also helps

needle
ensure

tip visualization
that sampling will are with

guided

biopsies
average (range,

(range,

and
and and

detailed
adjacent osseous

delineation
structures. structures

of the lesion
Bowel gas that hinder

be limited to the lesion; samples far less likely to be contaminated

utes), the 35 minutes

extraneous
may be easier

tissue

or blood

and
by the

thus
pa-

to interpret

The
utes sies

average

room

time

was

95 minnode biopThe dif-

for CT-guided (range, 50-157

lymph minutes).

sonographic problem diobogists

localization pose no such at CT. In addition, many raprefer the broad field of

ference

in procedure time between and CT-guided lymph node biopsies was not statistically significant (P > .19).
sonographically

view provided by CT and the relative ease of needle visualization. However, there are several drawbacks to CT guidance. CT precludes real-time visualization during needle placement
and biopsy; in the case of small lymph nodes, lack of visualization during the procedure may result in sampling of adjacent normal tissue. More time is typically necessary to perform a biopsy with CT rather than with sonography. Use of CT in biopsy procedures occupies valuable time on busy CT schedules, which are often already overburdened.

thobogist. With real-time visualization it is also possible to ensure that the needle excursions are short of adjacent critical structures such as blood yessels or the common bile duct. With sonographic guidance, the length of

time

that

the needle

is actually

in the

DISCUSSION Our results show

and

that
safe

sonography
guidance tech-

is an accurate

nique for biopsy and retropenitoneal

of abdominal, pelvic, lymph nodes. Our

par with with rere-

patient is often limited to less than 30 seconds. Another advantage of sonography is its multiplanan capability. The operator can angle and rotate the transducer to avoid adjacent vessels and organs (Fig 4). This type of transducer

movement
for biopsy

is particularly
of portal, pelvic,

important
and Biopsies retroper-

success rate of 86% is on sults from other institutions,

penitoneal
adjacent

nodes,
to large

which
vessels.

are frequently

ported 188
#{149}

success Radiology

rates

of 75%-91%.

Our

October

1997

formed outside the axial plane are far more complex when CT is used. Use of sonognaphy for biopsy of lymph nodes may seem paradoxical because this modality, unlike CT, is not particularly sensitive in the depiction of lymph nodes. Lymph nodes may be difficult to visualize with sonography because of deep location and overlying bowel. Accordingly, it has become our routine always to display previously obtained diagnostic CT scans or magnetic resonance images in the interventional radiology suite to
serve as a guide for lymph node iden-

(0.2%

morbidity)

with

a mortality

rate
needle

of 0.028%
aspiration

in a study
biopsies

of 3,500
between

fine-

tification. We also found that lymph node visualization is improved markedly by applying firm pressure with the transducer to compress and displace overlying fatty tissue and bowel loops, decreasing the necessary depth of sound penetration and the length of needle excursion. Compared with the
skin-to-lesion distance on the refer-

1969 and 1987. Two cases of portal lymph node biopsies were compbicated by bile leaks. Other questionname studies with large numbers of patients have yielded mortality rates of 0.006%-0.031% (14-16). Although careful attention to cnitical structures may limit complication rates, superficial vessels such as the inferior epigastric artery affected in our one case with complications, or the internal mammary vessels as reported by others (17), can be a source of serious bleeding. Caneful attention to superficial vasculature during biopsy planning with color Doppler sonography should limit these cases. It has been suggested that biopsy of
netroperitoneal lymph nodes is pen-

ated by attachment of a syringe to the biopsy needle. However, we and others have found that samples obtained with the capillary technique have adequate number of cell clusters and less contamination from blood than samples obtained with the suction technique (19-21). Although our success rate is high,
technical developments in imaging

guidance may lead to even higher success and lower complication rates. A number of new techniques and equipment options have already had an effect on sonographic guidance and will most likely improve success and reduce complication rates (22-26). Sonography is a diagnostically accurate and safe guidance technique for biopsy of abdominal, pelvic, and retroperitoneab lymph nodes. Benefits include continuous needle tip visualization, adjacent vessel identification,

ence CT scans, the distance from the anterior abdominal wall to the lymph node was reduced by approximately one-half as a result of transducer pressure. Predictably, there was less compression achieved in biopsy of lymph nodes in the ponta hepatis because the liver and subcostal region is less compressible than bowel or mesenteric fat. We made no particular attempt to avoid transgression of intervening small bowel or colon. In fact, with compression it is usually impossible to differentiate bowel from mesenteric or omental fatty tissue. None of our patients received antibiotics and none had complications related to bowel perforation; in selected cases, however, panticulanly those in which tnans-

formed best with a posterior paraspinab approach. The theoretical advantage of this approach is that should arterial bleeding occur, the result would be a contained netropenitoneab hematoma rather than an intraperitoneal hematoma. In addition, this approach may be less painful than an anterior approach. A disadvantage of
sonography compared with lymph CT, how-

scanning in nonaxial planes, and avoidance of ionizing radiation. Sonographic guidance provides a reasonable alternative to CT guidance. #{149}

References
1. Damgaard-Pedersen K, Von der Maase H.

ever,
identify

is that

it is often

impossible

to
nodes
2.

Ultrasound and ultrasound guided biopsy, CT and lymphography in the diagnosis of

retroperitoneah metastases in testicular can-

retroperitoneab

when Also,

a paraspinal window is used. biopsy of pelvic lymph nodes cannot be penformed from a posterior approach because of the osseous pelvis. An alternative approach in the pelvis would be an endorectal or endovaginab technique (18).
limitation is a retrospective

cer. Scand 144.

Dodd GD Sonography:

I Urol Nephrol

1991; 137:139DS, et a!. jewel of in-

III, Esola CC, Memel the undiscovered

terventional
3.

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RadioGraphics
US guidance Radiology of 1990; Di-

1996; 16:1271-1288. Matalon TAS, Silver B. interventiona! procedures.

174:43-47.

4.

One

of our review

study is that it of our expeni-

Nagano agnosis

T, Nakai Y, Taniguchi F, et a!. of paraaortic and pelvic lymph

node

metastasis

of gynecologic

gression of the colon is anticipated, prophylactic antibiotics may be indicated. Further, in patients with bowel distention on when a 16-18-gauge cutting needle is used, the risk of penitoneal contamination may be increased.
In dogs, Petit et al (11) showed no un-

ence. It is possible that there were patients who were referred for an imaging-guided lymph node biopsy who were not referred for sonography because it was believed that the node would be inaccessible sonographicalby. Although we are not aware of

5.

tumors by ultrasound-guided ous fine-needle aspiration 1991; 68:2571-2574. Nyman RS, Cappe!en-Smith

malignant percutaneCancer

biopsy.

a!.
guided

Yield and complications

biopsy of abdominal

J, Brismar J, et in ultrasoundlesions. Acta

Radio!
6.

1995; 36:485-490.

toward effect from transgressing bowel with needles and catheters. There was one major complication that resulted from an injury to the infenior epigastric artery and necessitated subsequent embolization, giving our small senies a complication rate of
3%. This rate is higher than the re-

such patients, inclusion of these potential cases would bias our results in favor of sonography. Alternatively, it
is possible that some were readily amenable lymph nodes

7.

ported complication rates associated with percutaneous biopsies of focal lesions within the abdomen. In an extensive review of 11,700 patients undergoing fine-needle abdominal biopsies between 1969 and 1982, Livraghi et a! (12) reported a mortality rate of 0.008% with a 0.5% serious and 0.49% minor complication rate. Nolsoe et al (13) reported seven complications Volume 205
#{149}

to sonographically guided biopsy but not amenable to CT-guided biopsy. This issue could be addressed by a prospective randomized direct comparison of CT yensus sonographic guidance. In the 26 consecutive cases reported by Memel et al (9), biopsy with sonognaphic guidance was successful in 23 (88%) cases; in only three cases was use of a CT scanner necessary. An additional potential limitation of our study is that we used a nonaspiration capillary
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