A variant application of the renal Quick-Core needle in 3 patients with cavo-atrial tumors is reported. In all 3 patients either a transjugular or transfemoral venous biopsy approach with this device yielded sufficient tissue for histological diagnosis at the first attempt. Bioptic diagnoses were confirmed either by surgery or radiological and clinical response to a specific chemotherapy. There were no procedure-related complication

Hechelhammer, Lukas

Kurrer, Michael O.

Marincek, Borut

Pfammatter, Thomas

Schertler, Thomas

Seebach, Jörg D.

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TECHNICAL NOTESTransvenous Biopsy of Cavo-Atrial Tumors with the Quick-CoreNeedleLukas Hechelhammer,1 Thomas Schertler,1 Jo¨rg D. Seebach,2 Michael O. Kurrer,3 Borut Marincek,1Thomas Pfammatter11Institute of Diagnostic Radiology, University Hospital, Zu¨rich, Switzerland2Department of Internal Medicine, University Hospital, Zu¨rich, Switzerland3Institute of Diagnostic Pathology, University Hospital, Zu¨rich, SwitzerlandAbstractA variant application of the renal Quick-Core needle in 3 patientswith cavo-atrial tumors is reported. In all 3 patients either a tran-sjugular or transfemoral venous biopsy approach with this deviceyielded sufficient tissue for histological diagnosis at the first at-tempt. Bioptic diagnoses were confirmed either by surgery orradiological and clinical response to a specific chemotherapy. Therewere no procedure-related complications.Key words: Cavo-atrial tumor—Transvenous biopsy—Quick-CoreneedleThe differential diagnosis of masses extending from the superior orinferior vena cava to the right atrium or vice versa includes benignconditions such as thrombus or myxoma as well as primary orsecondary malignant neoplasms of the vena cava or the heart [1].Although CT- or MR-imaging and echocardiography provide ac-curate assessment of the size, location and point of attachment ofthese tumors, tissue characterization is not possible [2, 3]. There-fore, a variety of transluminal techniques such as forceps biopsy [4,5], brushing [6], aspiration [7, 8] or scoop biopsy [9] have beenutilized to obtain tissue for histological or cytological examinationof cavo-atrial tumors. However, there are several known causes oferroneous or non-diagnostic samplings associated with some ofthese techniques including superficial apposition clots, low cellu-larity of the lesion or crushing artefacts.A high diagnostic yield combined with a low complication ratehas been repeatedly reported for transjugular liver or kidney biop-sies using a specifically designed automated tru-cut needle (Quick-Core Liver or Kidney Access and Biopsy Set, Cook Europe,Bjaeverskov, Denmark) [10–13].Biopsy with this device achieved a high diagnostic yield due tobetter tissue penetration and an excellent specimen quality. Accord-ingly, we used the same transvenous Quick-Core needle to establisha diagnosis in 3 patients with cavo-atrial tumors. Bioptic diagnoseswere confirmed by surgery in 2 patients and by the response to aspecific chemotherapy in the third patient.Case 1A 76-year-old woman with a history of an intraocular B-cell-lymphomapresented with a 2-month history of night sweat, loss of appetite andweakness. The chest CT showed a mass within the superior vena cava andthe right atrial cavity (Fig. 1). To exclude a secondary neoplasm, a biopsywas performed. After local anesthesia, the right internal jugular vein waspunctured and a 9-French sheath was introduced. A superior cavogram wasobtained with a pigtail catheter in two planes to guide fluoroscopy-guidedbiopsy using soft tissue and bony landmarks. The next steps of the proce-dure were the same for all patients. The diagnostic pigtail catheter wasremoved over a 0.035” stiff guidewire (Amplatz stiff wire guide). Then, theangled 14-gauge metallic guiding cannula was assembled with the 7-Frenchouter protection sheath of the biopsy set and introduced over the guidewire.After bringing the sheated cannula into the desired position, the guidewirewas withdrawn. The final location was fluoroscopically confirmed by con-trast injection through the cannula. Finally, the transjugular renal Quick-Core needle (Cook Europe, Bjaeverskov, Denmark), which is a 19-gauge,blunt-tipped tru-cut needle with a 2 cm throw length, was advanced throughthe cannula. In this case, two passes were performed, obtaining 3 tissuecores with a maximal length of 11 mm. The histology confirmed a relapseof the non-Hodgkin’s lymphoma. Chemotherapy with cyclophosphamid,vincristin, doxorubicin and prednison was started, leading to rapid clinicaland radiological improvement.Case 2A 51-year-old woman with a history of a breast carcinoma and left nephrec-tomy for trauma presented with retrosternal pressure lasting for one year.After cardiac causes were ruled out, a chest CT was performed to excludepulmonary embolism. Surprisingly, a mass expanding from the hepatic venacava segment to the right atrium was found but no evidence of pulmonaryemboli. Gadolinium-enhanced magnetic resonance imaging showed a lob-ular tumor which seemed to either infiltrate locally or originate from thedorsal caval wall at the level of the uncinate processus of the pancreas. Toplan further treatment, a transvenous biopsy was performed.Right transfemoral venous access was chosen, as we felt the attachmentpoint was next to the pancreas, in order to reduce tumor manipulation andavoid biopsy of a possible apposition clot. After local anesthesia, a 9-Frenchsheath was introduced, a 5-French pigtail catheter was advanced into theinferior vena cava and a digital subtraction cavography was performed in 2planes. Attention was paid to obtain also the intravenous digital subtractionCorrespondence to: T. Pfammatter, M.D.CardioVascularand InterventionalRadiology© Springer-Verlag New York, LLC. 2004 Cardiovasc Intervent Radiol (2004) 27:251–253Published Online: 4 May 2004 DOI: 10.1007/s00270-003-0142-6arteriogram for renal artery localization in order to avoid inadvertent renalarterial puncture (Fig. 2). The cavogram showed filling defects beginning atthe level of the right renal vein reaching into the right atrium. Underfluoroscopic guidance the renal Quick-Core needle was easily steered trans-femorally to the tumor, using bony landmarks and contrast. Three passeswere performed, yielding tissue cores with a maximal length of 8 mm.Histological examination of the biopsy revealed a highly differentiatedleiomyosarcoma. A diagnosis which was confirmed histologically afterresection of the tumor.Case 3A 75-year-old woman presented with a 8-month history of dyspnea andsigns of a superior vena cava syndrome. CT scanning demonstrated onocclusive tumor in the superior vena cava in continuity with a right atrialintracavitary mass and evidence of acute pulmonary embolism. The echo-cardiographical findings were atypical for an atrial myxoma leading tosuperior caval thrombosis, therefore a preoperative biopsy was requested.As both innominate veins were occluded, a transfemoral route wasselected. The right atriogram showed a lobular spherical mass attached tothe mouth of the superior vena cava. Visualization of the mass underfluoroscopy was facilitated by the pooling of the contrast agent in thecorrugated tumor surface (Fig. 3). Using a hepatic 18-gauge Quick Coreneedle, two passes were performed. After removal the Quick Core Needlewas replaced by an endomyocardial biopsy forceps (5.5 Fr), Cordis, Miami,FL, USA) and 2 additional biopsy specimens were obtained. The Quick-Core-specimen had a maximal length of 12 mm whereas the forcepsspecimen was only 3 mm in the biggest dimension. In contrast to the forcepsspecimen showing fibrin with a few dispersed cells of an adenocarcinoma,Fig. 1. Case 1. Sagittal reconstruction of thecardiac multidetector-row CT showing massprotruding into the right atrial cavity(arrowheads) (A). Corresponding venogramwith a pigtail catheter in the superior venacava (B). Transjugular biopsy guiding cannuladirected anteriorly towards the mass (C).Histology revealed non-Hodgkin’s lymphoma.Fig. 2. Case 2. Digital subtraction cavogramdemonstrates expansile filling defect in thesuprarenal segment (A). In the late phase theaorta and right renal artery (arrowhead) areopacified. The left kidney had been removedyears before because of trauma (B).Transfemorally inserted 14-gauge angulatedstiffening cannula providing directionalcontrol. The coaxially passed Quick-Coreneedle is not seen (C). Histology revealedhighly differentiated leiomyosarcoma.Fig. 3. Case 3. Transversal CT scan at theaortic root showing an occlusion of thesuperior vena cava (A). The homogeneousnonenhancing mass extends into the rightatrium (B). Cine-spot-image after atriographywith intracavitary floating mass (arrowheads)and tip of transfemorally inserted biopsycannula at the attachment of the mass (arrow)(C). Histology revealed adenocarcinoma.252 L. Hechelhammer et al.: Biopsy Cavo-Atrial Tumors with Quick-Core Needlein the tru-cut biopsy specimen cardial myocytes with bands of loose con-nective tissue were also visible by light microscopy. A day after theprocedure the patient complained of right shoulder pain and paresis of theright arm and a destructive process in the fifth cervical vertebral body withcompression of the medulla was demonstrated by a CT of the neck. Asurgical resection of the cavo-atrial tumor and the cervical metastasis wasperformed, and, the operative specimen confirmed the diagnosis of anadenocarcinoma.The patient died 3 weeks later, and postmortem examination revealed a0.4 cm pancreatic adenocarcinoma which most likely represented the originof the metastatic disease.The coagulation parameters for all 3 patients were within normal limits.There were no biopsy-related complications immediately after the proce-dure and during the following time of hospital stay. The InstitutionalReview Board did not require approval for the procedure.DiscussionHigh diagnostic yield, ease of the procedure, cost-effectiveness andsafety are important determinants of any biopsy technique. Al-though cavo-atrial tumors are rare, a variety of biopsy techniquesranging from percutaneous CT-guided fine needle aspiration tomore complex procedures such as transesophageal echocardio-graphically-guided transfemoral forceps biopsy have been de-scribed [8, 14]. As the pertinent literature consists mostly of casereports, no conclusion can be drawn regarding the technique thatshould be chosen for cavo-atrial tumors. Moreover, as these tumorsare often coated with appositional clots, a false-positive diagnosisof thrombus may mask an underlying malignant tumor [6, 9, 15, 16].To our knowledge, transcaval biopsy of an inferior vena cavaltumor was first reported in 1972 using a gastroscopic biopsy for-ceps [4]. A complication rate of 6% and a mortality rate of 0.3% hasbeen reported for transvenous right ventricular endomyocardialforceps biopsy in a large series of patients with cardiomyopathy[17]. Myocardiac perforation resulting in tamponade was the causeof biopsy-related death in 2 cases. Therefore, procedures yieldingeven larger samples such as the Quick-Core needle require goodsteerability to minimize complications due to unintentional perfo-ration of the vena cava or the right atrium. Successful transjugularQuick-Core biopsy of an inferior vena caval tumor has been de-scribed in a single case [18]. In our experience the Quick-Coreneedle could be directed equally well from a jugular or femoralvenous access towards the desired cavo-atrial biopsy site. Theangulation of the tru-cut needle can be modified by bending orstraightening the metallic guiding cannula. The modifications madeby the manufacturer to adapt the liver system for renal biopsies(19-gauge, blunt-tip) may further reduce possible complications.A small risk of tumor cell seeding is inherent to any tumormanipulation including biopsies. However, as tissue specimens areencapsulated at withdrawal the probability of tissue embolizationmight even be lower using the Quick-Core needle in comparison toforceps-assisted procedures.The biopsies obtained with the Quick-Core needle reported herein 3 cases of cavo-atrial tumors contained sufficient tissue forhistological diagnosis at the first attempt. Consequently thoracot-omy, which hitherto was performed for diagnosis of cardiac non-Hodgkin’s lymphoma, could have been be avoided in case 1 [19].Further, retrospectively, thoracotomy should also have been de-ferred in the patient with metastatic adenocarcinoma of unknownorigin (Case 3) in the light of the transvenous Quick-Core biopsyresult.In conclusion, there were no biopsy-related complications in 3consecutive cases of cavo-atrial tumors of unknown origin. Thehistological results of the biopsies were essential to the establish-ment of a diagnosis and influenced treatment. Therefore, our lim-ited experience suggests that transfemoral or transjugular biopsiesusing a Quick-Core needle represent a safe, expeditious and reliablesampling procedure for cavo-atrial tumors.References1. Burke A, Virmani R (1996) Tumors of the heart and great vessels. In:Atlas of tumor pathology, 3rd series, fasc 16. Washington DC. ArmedForces Institute of Pathology 1–11, 221–2232. Grebenc ML, Rosado-de-Christenson ML, Green CE, et al. (2002)Cardiac myxoma: imaging features in 83 patients. Radiographics 22(3):673–6893. Blum U, Wildanger G, Windfuhr M, et al. (1995) Preoperative CT andMR imaging of inferior vena cava leiomyosarcoma. Eur J Radiol20(1):23–274. Robins JM, Bookstein JJ (1972) Percutaneous transcaval biopsy tech-nique in the evaluation of inferior vena cava occlusion. Radiology105(2):451–4525. Adachi K, Tanaka H, Toshima H, et al. (1988) Right atrial angiosar-coma diagnosed by cardiac biopsy. Am Heart J 115(2):482–4856. Mills SR, Doppman JL, Head GL, et al. 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Cluzel P, Martinez F, Bellin MF, et al. (2000) Transjugular versuspercutaneous renal biopsy for the diagnosis of parenchymal disease:comparison of sampling effectiveness and complications. Radiology215(3):689–69313. Sofocleous CT, Bahramipour P, Mele C, et al. (2002) Transvenoustransjugular renal core biopsy with a redesigned biopsy set including ablunt-tipped needle. Cardiovasc Intervent Radiol 25(2):155–15714. Rubin DC, Ziskind AA, Hawke MW, et al. (1994) Transesophagealechocardiographically guided percutaneous biopsy of a right atrialcardiac mass. Am Heart J 127(4 Pt 1):935–93615. Nitta R, Sakomura Y, Tanimoto K, et al. (1998) Primary cardiacangiosarcoma of the right atrium undiagnosed by transvenous endocar-dial tumor biopsy. Intern Med 37(12):1023–102616. Withers CE, Casola G, Herba MJ, et al. (1988) Intravascular tumors:transvenous biopsy. Radiology 167(3):713–71517. Deckers JW, Hare JM, Baughman KL (1992) Complications of trans-venous right ventricular endomyocardial biopsy in adult patients withcardiomyopathy: a seven-year survey of 546 consecutive diagnosticprocedures in a tertiary referral center. J Am Coll Cardiol 19(1):43–4718. D’Altorio RA, Elliott JZ, Reiser M, et al. (2001) Transjugular biopsy ofinferior vena caval tumor. J Urol 165(6 Pt 1):1988–198919. Chalabreysse L, Berger F, Loire R, et al. (2002) Primary cardiaclymphoma in immunocompetent patients: a report of three cases andreview of the literature. Virchows Arch 441(5):456–461L. Hechelhammer et al.: Biopsy Cavo-Atrial Tumors with Quick-Core Needle 253

Transvenous Biopsy of Cavo-Atrial Tumors with the Quick-Core Needle

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Transvenous Biopsy of Cavo-Atrial Tumors with the Quick-Core Needle

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