FIGURE 1.
The Standards for the Reporting of Diagnostic Accuracy studies (STARD) flow diagram for a study of 607 patients undergoing CT-guided liver biopsy.
FIGURE 2.
The decision for a biopsy of the suspicious hepatic lesion was made for the same male patient. Because of the small lesion size and isodensity in the unenhanced CT, a prior intra-arterial Lipiodol-marking (A) was performed. Directly after the intervention (B) and during the CT intervention (C) (white arrow) was well displayable, and the biopsy was successful, revealing a hepatocellular carcinoma.
FIGURE 3.
A male patient with a suspect and unclear hepatic lesion with 6 mm in segment 7. While not visible in the unenhanced CT (A), the lesion impressed arterial hypervascularized after intravenous contrast medium application (B) (white arrow).
TABLE 1.
Overview of patient characteristics. P-values based on the Chi-square test indicate only a difference in the distribution of liver cirrhosis in comparison of the three enhancement groups
| Characteristic | Overall | Unenhanced biopsy | Lipiodol-enhanced | i.v. contrast-enhanced | p-value |
|---|---|---|---|---|---|
| Age, y (SD) | 61.0 ± 12.0 | 61.9 ± 11.95 | 60.4 ± 11.12 | 59.6 ± 13.04 | 0.228 |
| Gender, n (%) | 0.134 | ||||
| Male | 358 (59.0) | 177 (55.1) | 108 (74.5) | 73 (51.8) | |
| Female | 249 (41.0) | 144 (44.9) | 37 (25.5) | 68 (48.2) | |
| Hepatic disease, n (%) | 0.354 | ||||
| HCV | 101 (16.6) | 34 (10.6) | 53 (36.6) | 14 (9.9) | |
| HBV | 28 (4.6) | 6 (1.9) | 17 (11.7) | 5 (3.5) | |
| HCV+HBV | 8 (1.3) | 3 (0.9) | 3 (2.1) | 2 (1.4) | |
| NASH | 34 (5.6) | 12 (3.7) | 17 (11.7) | 5 (3.5) | |
| Toxic damage | 48 (7.9) | 20 (6.2) | 16 (11.0) | 12 (8.5) | |
| Others | 53 (8.7) | 26 (8.1) | 19 (13.1) | 8 (5.7) | |
| No disease | 335 (55.2) | 220 (68.5) | 20 (13.8) | 95 (67.4) | |
| Cirrhosis | 188 (33.0) | 59 (19.2) | 100 (71.9) | 29 (3.6) | 0.013 |
| Intrahepatic lesions, n (%) | 0.541 | ||||
| 1 lesion | 297 (48.9) | 164 (51.1) | 68 (46.9) | 65 (46.1) | |
| 2 lesions | 116 (19.1) | 45 (14.0) | 37 (25.5) | 34 (24.1) | |
| 3 or more lesions | 194 (32.0) | 112 (34.9) | 40 (27.6) | 42 (29.8) | |
| Lesion size, mm (SD) | 29.3 ± 18.0 | 30.1 ± 18.1 | 25.9 ± 17.4 | 29.8 ± 18.7 | 0.182 |
[i] Results are presented as mean and standard deviation or number (%)
[ii] HBV = Hepatitis-B-Virus; HCV = Hepatitis-C-Virus; i.v. – intravenous; NASH – Non-alcoholic steato hepatitis; SD = Standard deviation
TABLE 2.
Biopsy characteristics overall and for the three enhancement groups. A Chi-square test was performed to test for differences between the groups. Significance is indicated in bold
| Characteristic | Overall | Unenhanced biopsy | Lipiodol-enhanced | i.v. contrast-enhanced | p-value |
|---|---|---|---|---|---|
| Biopsy access path | 0.718 | ||||
| Lateral-intercostal | 335 (55.2) | 162 (50.5) | 94 (64.8) | 79 (56.0) | |
| Anterior-subcostal | 224 (36.9) | 25 (7.8) | 9 (6.2) | 10 (7.1) | |
| Anterior-lateral | 44 (7.2) | 132 (41.1) | 42 (29.0) | 50 (35.5) | |
| Dorsal-lateral | 4 (0.7) | 2 (0.6) | 0 | 2 (1.4) | |
| Segment localization | 0.052 | ||||
| 1 | 6 (1.0) | 2 (0.6) | 2 (1.4) | 2 (1.4) | |
| 2 | 54 (8.9) | 29 (9.0) | 14 (9.7) | 11 (7.8) | |
| 3 | 41 (6.8) | 23 (7.2) | 8 (5.5) | 10 (7.1) | |
| 4 | 112 (18.5) | 66 (20.6) | 23 (15.9) | 23 (16.3) | |
| 5 | 95 (15.7) | 57 (17.8) | 21 (14.5) | 17 (12.1) | |
| 6 | 112 (18.5) | 69 (21.5) | 21 (14.5) | 22 (15.6) | |
| 7 | 82 (13.5) | 31 (9.7) | 22 (15.2) | 29 (20.6) | |
| 8 | 105 (17.3) | 44 (13.7) | 34 (23.4) | 27 (19.1) | |
| Access path length [mm] (SD) | |||||
| Cutis to lesion | 83 ±26 | 82 ±27 | 85 ±27 | 83 ±26 | 0.527 |
| Liver capsule to lesion | 43 ±26 | 44 ±21 | 41 ±21 | 43 ±21 | 0.473 |
| Obtained probes (SD) | 2.6 ±1.3 | 2.7 ±1.5 | 2.5 ±0.9 | 2.4 ±0.9 | 0.158 |
| Radiation exposure (SD) | |||||
| Whole examination [mGycm2] | 498.3 ±429.5 | 361.0 ±166.6 | 411.3 ±517.9 | 900.3 ±495.6 | 0.019 |
| Biopsy scans [mGycm2] | 80.1 ±58.0 | 79.7 ±60.0 | 88.2 ±56.3 | 72.6 ±56.4 | 0.053 |
| Intervention (i)-images [n] | 34.4 ±24.0 | 34.6 ±23.8 | 37.7 ±23.4 | 30.6 ±24.7 | 0.182 |
| Complications | 0.870 | ||||
| Sub-capsular liver bleeding | 3 (0.5) | 1 (0.3) | 1 (0.7) | 1 (0.7) | |
| Fluid edge around liver | 2 (0.3) | 1 (0.3) | 0 | 1 (0.7) | |
| Bleeding along the access path | 1 (0.2) | 0 | 1 (0.7) | 0 | |
| Circulatory problems | 1 (0.2) | 1 (0.3) | 0 | 0 | |
[i] Values are mean and standard deviation or number (%)
[ii] i.v. = – intravenous; SD = Standard deviation
FIGURE 4.
Presentation of histopathologically correlated puncture successes for the overall cohort and individual groups individually.