Received: 2 December 2002Accepted: 2 January 2003Published online: 8 May 2003© Springer-Verlag 2003

Sir,Large tumours often contain necroticareas, and biopsies from these re-gions will, of course, be non-diag-nostic. Such areas should be avoidedbut are sometimes difficult to detectand define whether the biopsy isguided by ultrasound or computedtomography. New ultrasound con-trast agents with more stable con-trast bubbles combined with low-mechanical-index scanning tech-niques make it possible to performcontrast-enhanced real-time scan-ning with little or no bubble destruc-tion. This is well documented inmany applications such as liver tu-mour detection and characterisation[1, 2]. Biopsy during the arterialphase of such an ultrasound contrastinjection may help define necroticareas from viable tissue resulting in

a better diagnostic yield [3]. Such apractice may reduce the number offailed biopsies in largely necrotic tu-mours.

We were recently asked to per-form a biopsy on a 60-year-oldwoman in whom a contrast-enhancedCT scan had revealed a partly con-trast enhancing, 10-cm-large lesionin the right upper thorax, highly suspicious of a malignancy. Twocore biopsies (1.2-mm needle) hadalready been performed, one underCT and one under ultrasound guid-ance. The histology on both attempts,however, showed only necrotic material.

Before our second ultrasound-guided biopsy attempt, the tumourwas examined with a parasternal, intercostal approach and 2.4 ml ofcontrast agent (Sonovue, Bracco,

Eur Radiol (2003) 13:L239–L240DOI 10.1007/s00330-003-1823-x L E T T E R T O T H E E D I T O R

Anders NilssonJohan Krause

Targeted tumour biopsy under contrast-enhanced ultrasound guidance

A. Nilsson (✉) · J. KrauseDepartment of Diagnostic Radiology,Ultrasound Unit, Academic Hospital,751 85 Uppsala, Swedene-mail: anders.nilsson@rtg.uas.lul.seTel.: +46-18-6114740Fax: +46-18-6113720

Fig. 1 After contrast, the areas of the tumour that are not necrotic show up as hyperechoicand the needle guidelines are positioned over such an area

Milan, Italy), i.e. half the content ofone package was injected as a bolusintravenously through a 20-G ven-flon in the left arm. Ultrasound scan-ning with contrast-specific softwareand a vector transducer at 3 MHz(Sequoia, Acuson, Mountainview,Calif.) showed patchy hyperechoiccontrast enhancement in little morethan half the mass but none in the remaining parts which showed up as anechoic. All the preparations forthe biopsy were then made and wheneverything was ready the remainingportion of the contrast was injected,also as a bolus, and the biopsy wasperformed under real-time scanningduring the actual contrast enhance-

ment (Fig. 1). Solid grey-white material was obtained the histologyof which showed a malignant lym-phoma.

Repeating a biopsy is costly, bothin monetary terms and in terms ofdelay and discomfort for the patient,and should therefore obviously beavoided. New and more stable con-trast agents enable us to perform thebiopsies real time during the con-trast enhancement after a bolusinjection rather than memorising

enhancing areas at a pre-biopsy scanor set up infusions to extend the survival time of the contrast bub-bles. This provides an easy methodfor guiding the biopsies towards theviable parts of the tumour especiallyin cases where necrotic areas maybe suspected based on tumour loca-tion, size or B-mode appearance, or when a previous biopsy attempthas failed.

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References

1. Solbiati L, Tonolini M, Cova L, Goldberg (2001) The role of contrast enhanced ultrasound in the detection of focal liver lesions. Eur Radiol 11(Suppl 3):E15–E26

2. Leen E (2001) The role of contrast enhanced ultrasound in the characterisa-tion of focal liver lesions. Eur Radiol 11(Suppl 3):E27–E34

3. Bang N, Bachman Nielsen M, Vejborg Iet al. (2000) Clinical report; contrast enhanced ultrasound of tumour perfu-sion as a guidance for biopsy. Eur J Ultrasound 12:159–161