How to Request A
Guided Biopsy or Aspiration for Cytology

Radiology performs biopsies and drainage of fluid collections under the guidance of ultrasound, CT, and fluoroscopy. These are done by many of our faculty, using different techniques and protocols, and incurring different risks. It is often logistically confusing to arrange for such procedures. The following questions and answers should help smooth the process. For convenience, the term "biopsy" will apply to drainage procedures, biopsies, and aspirations for cytology: 

Q: What kinds of biopsies does Radiology perform?

We are prepared to perform biopsies of the liver, pancreas, adrenal, retroperitoneal, mediastinal or other adenopathy, soft tissue masses and fluid collections (including the kidneys, lungs, and breasts), bone, thyroid, and lung masses. We also drain abscesses and other fluid collections. While many of these biopsies are also performed by other services, we are often consulted when imaging guidance is needed.

Q: Will Radiology do thoracenteses and paracenteses?

We usually provide guidance for these procedures, and mark the best locations for entry. The patient is then returned to their room. If the clinical service can perform the procedure, it avoids the addition of a Radiology procedure charge. However, in special circumstances, we will perform the procedure itself with fine-gauge needles, or permit the procedure to be performed by the clinical team in the ultrasound laboratory, timed as our workload permits. Such a request should be handled as other biopsy requests.

Q: Will Radiology do percutaneous tumor ablation?

Yes. We have experience both with arterial embolization (done in our Vascular and Interventional section) and percutaneous ethanol ablation of hepatocellular carcinoma (done under ultrasound guidance). For more information about intraarterial procedures, contact Dr. Saddekni or another member of the V&I section at 5-4850, and for percutaneous ablation, contact Dr. Robbin or Dr. Berland at 4-7978 (or UAB paging), or another member of the Abdominal Imaging section.

Q: Where are the biopsies done?

Most of our procedures are done at University Hospital because they require close monitoring and observation of the patients during and after the procedure, and may require sedation or other specialized assistance. However, thyroid aspiration procedures and breast biopsies may be performed on outpatients at The Kirklin Clinic. These are performed with fine-gauge needles with no substantial risk or need for subsequent observation.

Q: When are biopsies done?

Procedures may require the coordinated actions and prolonged attention of several radiologists and both radiology and pathology technologists. Staffing at off-hours (evenings and weekends) is designed only to manage emergencies. Also, the Pathology Department may not be prepared to accept or analyze the specimen. Therefore, we prefer to perform biopsies only during weekday hours. Due to our light staffing, we have had to consider stopping a biopsy in progress to perform a medically emergent study. Drainage of infected fluid collections are performed on an emergency basis when appropriate.

Procedures will usually be scheduled for the next day which is convenient for the patient. At times, we may be able to perform the procedure the same day.

Q: Who do I call to arrange or request a consultation about a biopsy?

The appropriate radiologist should be consulted directly when requesting biopsies. We understand that it may not always be clear who is the appropriate person or even which is the appropriate Radiology section. The following guidelines should help: Biopsies of the chest (lung mass, mediastinum or drainage of fluid/air collections) should be referred to Drs. Nath or Sanders (934-5345). Biopsies of bone masses or fluid collections which require traversing intact bone, and catheter drainage of abscesses and other extrathoracic fluid collections will usually be performed by V&I (Dr. Saddekni or an associate (975-4850)). The remaining abdominal, and soft tissue masses or fluid collections will be performed by Abdominal Imaging. Thyroid aspirations may be scheduled by calling The Kirklin Clinic radiology scheduling at 731-9380.

To determine the appropriate individual to speak to in Abdominal Imaging, call University Hospital ultrasound at 4-1383, or the Abdominal Imaging office at 934-7978, and ask to speak either to the attending radiologist that day, or the attending radiologist scheduled for the day you prefer the biopsy. The radiologist you speak to can contact the appropriate individual if they will be unable to perform the procedure. Plans for procedures are often left indefinite after an initial consultation because of complex clinical circumstances. Please be certain to call the radiologist and submit a computer request for the procedure as soon as you are certain that you want it.

Q: What information do I need to request this procedure?

In addition to the basic information including the patient's medical record number and location, please be aware of any prior radiolographic studies which are relevant. If these are UAB studies, and not checked out to you, we can call for them and review them. If they are outside studies in your possession, the radiologist may want to review them to confirm that your request is the most appropriate procedure as well as to use them to help design the approach. We frequently find that we modify the outside interpretation, and therefore propose another course of action. It is embarrassing, inconvenient and expensive to admit the patient, only to find that a biopsy is not indicated.

Q: Do outpatients need to be admitted to the hospital for a biopsy?

For major procedures with the risk of hemorrhage or other complications or the need for conscious sedation, we now often perform these procedures after admitting the patient to same-day care. If admitted in the morning, they will be able to leave the hospital from two to four hours after completing the procedure. However, many thoracic biopsies often do not require same day admission. Please consult the appropriate radiology service for instructions.

Q: What kind of lab tests and preps do the patients need?

In most cases, we will need a PT, PTT and platelet count, and should know if the patient is taking aspirin. No other special preparation is usually required, except for the patient being NPO, depending on the procedure. If so, you should be so informed. The patient should come to Radiology only after the procedure and the reasons for it are explained. A consent form must be signed by the patient or responsible guardian. Therefore, if the patient is not competent to sign because of age or mental condition, the appropriate individual must consent before the patient is sent to Radiology. If you do not feel comfortable explaining the nature and risks of the procedure, we will be happy to obtain the consent.

Q: Does Radiology sedate patients for biopsies?

Usually not. We generally perform local anaesthesia only. If sedation or anaesthesia will be required, this should be considered in planning, before the patient arrives for the procedure.

Q: What techniques and needles are used for biopsies?

The devices used will be at the discretion of the radiologist. It is our priority to obtain the most satisfactory specimen possible, taking patient risk into consideration. If there are special needs for specimen volume or type, please let us know in advance.

Q: How are biopsy specimens handled?

Cytology specimens are collected by a cytology technologist who prepares the specimen on site. Inspection occurs in their lab and a final diagnosis is usually rendered the following day. Core specimens are usually placed in formalin and taken to the lab by our personnel. Specimens for stain and culture are collected appropriately and taken to the lab, also by our personnel. If any special handling or tests are required, please let us know in advance.

Q: If the results of a biopsy are inconclusive, what should we do next?

The yield from a procedure varies considerably from one situation to another. Too often, it is assumed that if a procedure fails to acquire a diagnostic specimen at the first procedure, that an alternative procedure will be required. Depending on the clinical situation, however, it may be most reasonable to repeat the biopsy to obtain additional samples, rather than subject the patient to a more invasive or expensive procedure. Please consult the radiologist.

 If you have further questions, please call Dr. Lincoln L. Berland at 934-7978, write to NHB 623B, or ask a radiologist in the appropriate clinical service. We will respond to your written questions, or, if of general interest, will include a follow-up in the next issue of Visions. Please submit suggestions or questions for future articles.