J Islamabad Med Dental Coll 2022 158
Open Access
Outcome of Ultrasound Guided Trucut Biopsy of Adnexal
Masses with Suspected Malignancy
Syeda Zakia Shah1, Sara Shahid2, Syed Murtaza Hussain3, Hadia Hina4, Hyder Wajid Abbasi5, Haseeb Noor6.
1Assistant Professor, Radiology Department, PIMS, Islamabad.
2Medical Officer, Radiology Department, PIMS, Islamabad.
3Medical Officer, CDA Hospital, Islamabad.
4Assistant Professor, Gynaecology Department, PIMS, Islamabad.
5Medical Officer, Department of Gastroenterology, PIMS, Islamabad.
6Medical Officer, Polyclinic Hospital, Islamabad.
A B S T R A C T
Background: Ultrasound guided sampling techniques are frequently used in the tissue diagnosis of various tumours.
Female patients commonly present with adnexal masses and require tissue diagnosis by trucut biopsy for initiation of
the treatment. This study was done to determine the outcome of ultrasound guided trucut biopsy in patients presenting
with suspected adnexal malignancy.
Methodology: This cross sectional study was done at the Department of Radiology, MCH Centre, PIMS hospital,
Islamabad from October 2018 to September 2020. In this study, all female patients aged 18 years and above with
suspected adnexal malignancy were included. Trucut biopsy was performed under ultrasound guidance, sample sent
for histopathology and various histopathological outcomes were assessed. Patients were kept under observation for 2
hours following biopsy. The data was entered and assessed by using SPSS version 24.0. Frequencies and percentages
were calculated for nominal data and mean and standard deviation for numerical data.
Results: Mean age of the subjects was 50.24±10.52 years and mean duration of symptoms was 2.97±1.23 months.
Definitive diagnosis made in 59 (95.1%) out of 62 cases and only 3 (0.04%) cases were inconclusive; among which two
showed inadequate sample and one showed normal tubo-ovarian tissue. 90% histopathological findings were conclusive
and no complication was reported.
Conclusion: Trucut biopsy has high diagnostic yield with no complications and most common malignancy detected was
serous cystadenocarcinoma followed by mucinous carcinoma.
Key words: Biopsy, Malignancy, Ultrasound
Authors’ Contribution:
1,2Conception; Literature research;
manuscript design and drafting; 2,3 Critical
analysis and manuscript review; 5,6 Data
analysis; Manuscript Editing.
Correspondence:
Syeda Zakia Shah
Email: sphoolsh@gmail.com
Article info:
Received: July 10, 2021
Accepted: September 20, 2022
Cite this article. Shah Z S, Shahid S, Hussain M S, Hina H, Abbasi W H, Noor H. Outcome of
Ultrasound Guided Trucut Biopsy of Adnexal Masses with Suspected Malignancy.J Islamabad
Med Dental Coll. 2022; 11(3): 158-163
DOI: https://doi.org/10.35787/jimdc.v11i3.742
Funding Source: Nil
Conflict of interest: Nil
I n t r o d u c t i o n
Adnexal mass etiology accounts for a substantial
number of gynaecologic diseases and approximately
10% of females undergo surgery for adnexal masses
during their life. 1-2 Despite great evolution in cancer
control and healthcare, mortality from ovarian
cancer is still rising high due to late stage diagnosis
of the disease thus significantly affecting the 5-year
survival rate of only 47.4%, whilst only 14.9% of
ovarian cancers are diagnosed when localized with a
remarkable survival rate of 92.3%.3
O R I G I N A L A R T I C L E
J Islamabad Med Dental Coll 2022 159
The most common associated risk factors are higher
age, postmenopausal status, radiation exposure,
smoking and family history of malignancies.
Abdominal pain, distension, weight loss and
bleeding are the cardinal manifestations of these
lesions and early and prompt diagnosis is the key to
success.4-5 Apart from the detailed history and
clinical examination, ultrasonography (USG) and
contrast enhanced computed tomography (CT) are
the investigations of choice. The cardinal features
leading towards malignant etiology include complex
solid cum cystic mass, multiloculated mass with
irregular walls, vascularity on colour Doppler,
presence of ascites and the increasing biomarker
production like CA125.6
With advent of neoadjuvant chemotherapy, biopsy
is desired investigation for pathologic diagnosis to
initiate therapy. In addition, metastatic
gastrointestinal tumours such as colon, gastric, and
pancreatic adenocarcinomas and even breast cancer
can mimic ovarian cancer therefore tissue diagnosis
is ultimately needed to reach a definitive diagnosis
and to target management therapy.7
It can be done either through needle biopsy under
image guidance or open or laparoscopic surgical
biopsies where latter are invasive and require
general anaesthesia. Belinga et al reported 6.77%
complication rate in gynaecological laparoscopic
procedures. 8
Trucut biopsy is an easy and cheap method with
relatively lesser risk associated to reach a definitive
diagnosis. Addition of immunohistochemistry
staining can also increase the probability of
diagnosis. Biopsy sample can be obtained through
various imaging modalities like ultrasound,
fluoroscopy, CT and MRI. CT and fluoroscopy cause
exposure to considerable amount of ionizing
radiation. Leng et al. found that the mean
DLPbody (dose length product) of CT-guided
interventional procedure was 909 mGy cm thus
resulting in significant exposure to patient as well as
to the staff.9
MR guided biopsy also becomes tough with hefty
price and requiring all instruments to be MR
compatible. Therefore, ultrasound is the most
convenient option with no radiation exposure, ease
of portability, real time imaging and being cost
effective. 10
Perfection in imaging of adnexal mass
characterization can lead to appropriate triage,
resulting in better treatment outcomes. 11So far very
few studies have been reported on the outcome of
ultrasound guided biopsy. Image guided biopsy
plays an important role in providing quick and fast
definitive histological diagnosis, making invasive
debulking surgeries ineffectual and unnecessary for
initiation of neoadjuvant chemotherapy. The
current study was conducted to acknowledge the
efficacy of the procedure by confirming it with the
histopathological report as well as recognizing
various tumour subtypes in adnexal lesions
histologically.
M e t h o d o l o g y
This descriptive cross-sectional study was
performed in PIMS hospital, Islamabad from
October 2018 to September 2020. The study
included patients with suspected malignancy who
were being referred on OPD basis to the Radiology
department for establishing definite diagnosis
through ultrasound guided trucut biopsy.
In this study, all female patients with age ranging
from 18 years and above, presenting with abdominal
pain with or without distension and with history of
weight loss were recruited. They were assessed with
ultrasound for adnexal mass with or without ascites.
The inclusion criteria had specification for the mass
that was solid/ complex cystic lesion containing thick
septa or solid component with in it. The size of the
mass not more than 2cm was considered for the
study. Large cystic lesions without thick internal
septation or solid component, patients having gut
loops anterior to the adnexal lesion and patients
J Islamabad Med Dental Coll 2022 160
having bleeding diathesis were excluded from this
study.
The sample size calculated was 62 using Epitools
sample size calculator, by keeping the confidence
interval as 95%, estimated proportion of 95.8% and
desired precision of 0.05.12
The data was entered and assessed by using SPSS
version 24.0. Frequencies and percentages were
calculated for nominal data and mean and standard
deviation for numerical data.
Ethical certificate was obtained prior to commencing
the study from Hospital’s Ethical Committee.
(Reference number F.1-1/2015/ERB/SZAMBU/759).
For ultrasound-guided trucut biopsy, coagulation
profile of the patient was done initially. If normal,
then written consent from the patients/ patients’
attendants was taken. Site of biopsy needle insertion
was marked with ultrasound guidance. Under strict
aseptic measures, local anaesthetic was
administered (10 ml of 1% xylocaine) for trans
abdominal biopsy.
A trucut monopty needle of 18 gauge was used for
the procedure. The tip of the biopsy needle was
carefully visualized on monitor of ultrasound
machine (Aplio500) avoiding injury to gut loops,
major vessels and areas with high vascularity with in
the lesion. Biopsy sample was taken from solid
component or thick internal septation avoiding
cystic/ necrotic areas, preserved in formalin, and
sent for histopathology and immunohistochemistry.
Figure 1. Needle tracking under ultrasound
guidance with aided Colour Doppler to avoid areas
with high vascularity with in the lesion.
If either a benign or malignant tumor was
acknowledged on biopsy report, the procedure was
labelled as accurately performed. In patients with
inconclusive results on gross and microscopic
histopathology report, immunohistochemistry
staining was done to reach a definitive diagnosis and
when that also failed to give result, report was
considered inconclusive. The final outcome was
recorded.
R e s u l t s
In this study, 62 cases with suspected adnexal
malignancy were included. Mean age of the subjects
was 50.24±10.52 years and mean duration of
symptoms was 2.97±1.23 months as shown in table
I.
Table I: Demographics of study subjects
(n= 62)
Mean Range
Age (years) 50.24±10.52 18-62
BMI (kg/m2) 23.25±2.36 20-27
Duration of
symptoms
(months)
2.97±1.23 1-6
J Islamabad Med Dental Coll 2022 161
On trucut biopsy, definitive diagnosis was made in
59 (95.1%) out of 62 cases and only 3 (0.04%) cases
were inconclusive; among which two showed
inadequate sample and one showed normal tubo-
ovarian tissue.
On further analysis, ovarian serous
cystadenocarcinoma was the most commonly
detected lesion seen in 29 (46.77%) of the cases
followed by mucinous CA seen in 13 (20.96%) of the
cases. One of the samples also showed extensive
necrotic material which on repeated biopsy yielded
small fragments of adenocarcinoma with extensive
necrosis that raised the possibility of metastatic
disease with colorectal primary.
D i s c u s s i o n
Adnexal pathology has various etiological factors
depending on congenital, inflammatory and
neoplastic processes and are prevalent in women of
all age groups.13 Ultrasound is primary imaging
modality for evaluation and management of adnexal
pathology having significant correlation with
histological features but some of the benign lesions
also have similar appearance as malignancy
requiring additional work-up. 14-15. In approximately
70% cases, ovarian malignancy does not become
clinically overt until it has metastasized therefore
effective detection approaches are the need of the
hour.16-17
Our results show that USG-guided trucut biopsy of
adnexal masses is high yielding with definitive
diagnosis in 59 (95.1%) out of 62 cases and only 3
(0.04%) cases were inconclusive. These results are
fairly comparable to the findings of the studies done
in the past confirming high reliability and safety of
this minimally invasive procedure. According to a
study done by Vlasak et al, ultrasound guided biopsy
confirmed malignancy in 96.2% patients and the
sample obtained was insufficient in three patients
for complete identification of the tumor. 12
Another study done by Oge T et al to assess the
utility of USG guided trucut biopsy revealed a
definitive diagnosis in 96.4% of the cases while in
3.6% of the cases, the tissue material was
inadequate to reach a definitive diagnosis, and
among various lesions detected primary ovarian CA
was seen in 65.4% of the cases with its serous type
most common 58.2%.18 This is also similar to the
present study where serous cystadenocarcinoma
was the most commonly detected lesion seen in 29
(46.77%) of the cases followed by mucinous CA seen
in 13 (20.96%) of the cases. Accurate diagnosis
depends on the adequacy of the technique and an
Table: II Type of lesion detected on trucut biopsy
Biopsy outcome N (%)
Ovarian serous cystadenocarcinoma 29 (46.77%)
Ovarian mucinous cystadenocarcinoma 13 (20.96%)
Spindle cell CA 3(4.83%)
Adenocarcinoma 3(4.83%)
Inconclusive (scanty tissue/normal tissue) 3(4.83%)
Smooth muscle neoplasm 2(3.22%)
Poorly differentiated neoplasm 2(3.22%)
Granulomatous inflammatory disease 1(1.61%)
Benign serous cystadenoma 1(1.61%)
Cystic teratoma 1(1.61%)
Dysgerminoma 1(1.61%)
Struma ovarii 1(1.61%)
Other benign lesions (fibroid/benign stromal tumors) 2(3.22%)
Total 62(100%)
J Islamabad Med Dental Coll 2022 162
experienced operator can definitely do best.
Verschuere et al. reported increasing adequacy of
the biopsy over the years likely due to the operators’
improving skills with the procedure19. It has also
been noticed that elevated CA-125 and ascites are
good predictors and increase the yield of trucut
biopsy while obesity is considered a factor hindering
the accuracy of ultrasound thereby indirectly
limiting yield of trucut biopsy as well.
Previous literatures do not signify any specific
relationship between biopsy needle gauge and
better diagnostic accuracy but Hoffmann P et al
reported 16 G or wider needle more suitable for
pelvic lesion biopsies, likely attributable to a fact
that wider bore needles allow for extraction of more
diseased tissue.20 However the use of a 18 G needle
is the most mentioned biopsy tool in literature
therefore was needle of choice in our patients as
well.
Like any other invasive procedure, ultrasound
guided biopsies can also result in various
complications like bleeding at the site of biopsy,
visceral injury, hemoperitoneum and infectious
complications reported previously in the scientific
articles.13 Post procedure, patients were again
assessed with Doppler USG in our study which was
beneficial in evaluating the target organ for any
haemorrhage. The identification of a “track” or a
haemorrhagic jet is a good indicator of post-biopsy
bleeding.21
In our study no complication was noted. On
completion of the procedure, bleeding from the
biopsy site was checked for. Patients were kept
under observation for 2 hours following the biopsy
and then discharged. Mild subjective discomfort or
momentary mild pain at the site of the biopsy was
reported, however no major complication was
reported. Thus with increasing incidence of
malignancy worldwide, this minimally invasive
procedure is an important step in patients’
management.
Fine needle aspiration cytology of ascites has been
done routinely which is easier and even less invasive
but it has a poor predictive value for organ-specific
tumor diagnosis. Furthermore, core needle biopsy
yields tissue for immunohistochemistry and
molecular profiling thus modifying the treatment
according to the tumor genotype.7
The study has limitations, which include the fact that
some patients with adnexal masses didn’t show up
on the given time for procedure even when advised
for it by the clinician. It was a small sample size and
further studies with larger sample size may better
characterize the outcomes of biopsy.
C o n c l u s i o n
Ultrasound guided trucut biopsy in adnexal masses
is a befitting modality to reach the definitive
diagnosis in adnexal masses with no major
complication. It can help the patients’ selection for
surgery, chemotherapy as well as by providing fast
definitive histological diagnosis in advanced disease
patients, makes invasive debulking surgeries
unnecessary for the initiation of neoadjuvant
chemotherapy.
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