Radiology: Rad role may evolve as image-guided biopsies trend up
CT, ultrasound and MRI have helped shift biopsy techniques away from more invasive approaches toward image-guided percutaneous techniques, according to a study published in the September issue of Radiology.

The trend toward less-invasive approaches translates into enhanced safety and efficiency and could lead to more interaction between patients and radiologists.

Researchers sought to assess national levels and trends in utilization of biopsy procedures between 1997 and 2008 and investigate the relative role of biopsy approaches (open, endoscopic and percutaneous) and physician specialties, explained lead author Sharon W. Kwan, MD, of the department of radiology and biomedical imaging at University of California, San Francisco, and colleagues.

Previous studies on the topic were limited in scope; they often excluded procedures performed by non-radiologists, covered a short time span or focused on one organ system. Kwan and colleagues aimed to fill the gap and determine if percutaneous needle biopsy (PNB) largely replaced open biopsies in organs for which it is an option and if image-guided percutaneous biopsies (IGPB) replaced non-IGPBs. The researchers also sought to define the role of radiologists and non-radiologists in performing the procedures.

The study adopted a broad perspective and encompassed 10 anatomic sites and relative provider roles over a decade to provide “insight into the long-term effect of new imaging technologies on the performance of a variety of biopsy procedures within and outside the field of radiology,” wrote Kwan.

Researchers used the Centers for Medicare & Medicaid Services Physician/Supplier Procedure Master files from 1997 to 2008 as the primary data source and selected 10 anatomic regions: abdomen and retroperitoneum, bone, breast , chest, kidney, liver, musculoskeletal soft tissue, pancreas, superficial lymph node and thyroid.

During the study period, PNBs as a percentage of all approaches increased for six regions: breast, chest, liver, lymph node, pancreas and musculoskeletal soft tissue; and PNBs increased from 59 percent to 67 percent of all biopsies, reported Kwan.

Researchers found discrepancies by anatomic region. PNBs were the dominant approach for biopsies of the kidney and liver, representing 96 percent and 90 percent, respectively, noted Kwan. In contrast, PNBs accounted for 46 percent of lymph node biopsies and 30 percent of musculoskeletal soft tissue biopsies. However, the latter represent superficial tissues with palpable areas of concern, translating into low morbidity from open biopsies.

Growth in total biopsy procedures was “modest,” wrote Kwan, increasing from 1,380 biopsies per 100,000 Medicare enrollees in 1997 to 1,945 biopsies per 100,000 enrollees in 2008 for a compound annual growth rate of 3 percent.  PNBs rose from 953 to 1,645 biopsies per 100,000 enrollees during the study period for a compound annual growth rate of 5 percent, wrote Kwan.

During the study period, radiology, general surgery and pulmonology were the top three specialties performing biopsies and performed 75 percent of procedures with radiologists’ share increasing from 35 percent in 1997 to 56 percent in 2008. Radiologists’ share of PNBs increased from 48 to 66 percent between 1997 and 2008, reported Kwan.

“Practice patterns are still in evolution,” wrote Kwan, who attributed the continued evolution to the relatively recent proliferation of advanced imaging technologies, whereas PNB techniques were established more than 50 years ago. “[M]ore lesions can be efficiently and safely targeted with a percutaneously inserted needle now that imaging guidance is more readily available,” wrote Kwan.

However, overall growth in biopsy procedures was not rampant, wrote Kwan, despite the increased role of image guidance.

Ultimately, the trend could impact the role of radiologists in patient care. If image-guided biopsies continue to replace nonimaging-guided biopsies, radiologists will be increasingly involved in this aspect of patient management, opined Kwan.

 “Our responsibility probably won’t end at calling a suspicious lesion on a chest CT and sending out a report. We will likely see the patient again to perform the biopsy on that lesion. This could be a great opportunity for radiology as a field. In the past decade, we have shown that our services are invaluable for patient diagnosis and management; however, radiologists themselves have remained faceless to the patients. This could be a chance for us to meet our patients face-to-face and to provide some education [during the diagnostic process],” explained Kwan in an interview.