Image-guided Core-needle Biopsy in Gynecological Oncology | Article | GLOWM

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This chapter should be cited as follows:
Fischerova D, Facchetti E, et al., Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.419773

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 10

Ultrasound in gynecology

Volume Editors: Professor Antonia Testa, Agostino Gemelli University Hospital, Rome, Italy
Professor Simona Maria Fragomeni, Agostino Gemelli University Hospital, Rome, Italy

Chapter

Image-guided Core-needle Biopsy in Gynecological Oncology

First published: September 2025

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INTRODUCTION

Image-guided core-needle biopsy (CNB) is a minimally invasive, patient-centered technique integral to the management of gynecological malignancies. It aims to provide sufficient tissue from suspected pathological lesions for histopathology, immunohistochemistry and comprehensive genomic analysis, while avoiding the morbidity, delay, cost and resource use associated with unnecessary diagnostic laparoscopy or laparotomy. CNB yields tissue suitable for assessing tumor architecture and the tumor–stroma relationship, making it preferable to fine-needle aspiration, which often provides only limited cytological material.

To obtain representative tissue from viable tumor areas while minimizing complications, CNB should be performed under real-time imaging guidance. The broad availability of ultrasound in gynecology enables immediate, single-visit procedures. Appropriate training in gynecologic ultrasound and interventional techniques is essential to select the optimal access route and perform the biopsy safely. Operators should also prioritize patient comfort, consider prophylactic analgesia when appropriate, and ensure a calm environment to reduce anxiety. When undertaken in dedicated centers by trained operators, real-time ultrasound guidance achieves high diagnostic yield, low complication rates and a favorable patient experience, allowing outpatient management in most cases.

Close communication within the multidisciplinary team is essential, not only to obtain fit-for-purpose samples for pathological analyses but also to interpret biopsy results in the context of clinical and imaging findings, thereby minimizing the risk of false-negative results.

In the era of targeted and immune-based therapies, timely acquisition of high-quality tissue is critical for individualized treatment planning and potential clinical trial enrollment. For detailed procedural guidance, technical considerations, safety data and extended evidence, readers are referred to the recently published ISUOG/ESGO Consensus Statement on ultrasound-guided biopsy in gynecological oncology.1

INDICATIONS AND CONTRAINDICATIONS

Patient selection and a clear clinical indication are essential before performing CNB. In gynecological oncology, most CNBs are performed transvaginally and are generally considered low-risk for major bleeding complications. Procedures with a higher risk of bleeding include percutaneous biopsy of abdominal visceral organs (e.g. liver, kidneys) and sampling of hypervascular lesions (with color score 4).

In addition to procedure-related risk, patient-specific bleeding risk should be evaluated. Patients at elevated risk include those with known bleeding disorders, a history of prior bleeding complications, or those receiving anticoagulation or antiplatelet therapy.

For low-bleeding-risk procedures in patients with no or minimal bleeding risk factors, a preprocedure screening coagulation panel is not required. These procedures can be safely performed by adequately trained sonographers (minimum Level-II competence2).

For high-bleeding-risk procedures and/or patients with elevated baseline bleeding risk, a routine preprocedure coagulation panel is recommended, including hemoglobin, platelet count, prothrombin time (PT) and/or international normalized ratio (INR), and activated partial thromboplastin time (aPTT). Periprocedural management should be adjusted accordingly, and biopsies should be performed by the most experienced operators (Level-III competence2). Use of a thin core needle (18 G) may be considered to minimize tissue trauma.

Most contraindications for CNB are relative and require an individualized risk–benefit assessment, ensuring that the potential benefits of diagnosis outweigh the risks. Absolute contraindications common to all interventional procedures are listed in the last two rows of Table 1.

1

Indications and contraindications for core-needle biopsy in gynecology/gynecological oncology.

Indications

Contraindications

Primary inoperable/non-resectable genital tumor (e.g. advanced tubo-ovarian carcinoma)

Uncorrectable coagulopathy

Cancer of unknown primary, including metastasis to genital organs

Significant thrombocytopenia*

Uterine mesenchymal tumor with atypical appearance on ultrasound or MRI

Antiplatelet or anticoagulation therapy†

Suspicious cervical (or, rarely, endometrial, vaginal and perineal) lesion‡

Lack of safe needle pathway (including technically inaccessible lesion)

Suspicion of recurrence of a genital tumor

High risk of tumor spillage

Predictive genomic testing during cancer journey, including research biopsies for translational studies and clinical trial enrollment

Absence of qualified operator or inadequate technical equipment§

Staging purposes – inconclusive imaging findings

Unstable clinical condition and/or patient refusal or inability to cooperate§

*Thrombocytopenia thresholds: low-risk procedures generally require platelet count (PLT) >30 × 109/L; high-risk procedures (visceral or hypervascular targets) require PLT >50 × 109/L.

†Antiplatelet therapy: if possible, interrupt 5 days prior. Single antiplatelet therapy may be continued for low-risk procedures; dual therapy requires specialist input. Anticoagulation therapy: vitamin K antagonists (INR <2.0 for low-risk, <1.5 for high-risk) and direct oral anticoagulants require periprocedural management.

‡CNB can provide better-quality tissue than punch biopsy in cervical, vaginal and perineal lesions, and is useful in endometrial cancer when biopsy is not feasible due to cervical os synechiae.

§Absolute contraindications. If a patient refuses the procedure, underlying concerns should be explored and addressed.

INR, international normalized ratio; MRI, magnetic resonance imaging.

The indications for CNB are demonstrated in different clinical cases in descending order of frequency in Figure 1 and Videoclip 1.

1

Indications for core-needle biopsy (CNB) in gynecology/gynecological oncology. On the left are representative cases for each indication documented on ultrasound; on the right are the corresponding histological images of the CNB specimens (hematoxylin and eosin [H&E] staining). (a,b) Primary non-resectable genital tumor. Gray-scale transvaginal ultrasound image showing visceral carcinomatosis appearing hyperechogenic and deeply infiltrating the wall of the sigmoid colon, including the mucosa, in a 61-year-old patient referred after detection of bulky tumor on colonoscopy; transvaginal CNB confirmed low-grade serous carcinoma. (c,d) Cancer of unknown primary. Gray-scale transvaginal ultrasound image showing solid right ovarian tumor with multiple hypoechoic nodules in an 80-year-old patient with prior lung cancer; transvaginal CNB confirmed metastatic lung carcinoma. (e,f) Uterine mesenchymal tumor with atypical appearance. Gray-scale transvaginal ultrasound image showing an abnormal mesenchymal tumor in the posterior uterine wall of a young asymptomatic woman desiring fertility preservation. The endometrial cavity is also visualized and indicated by a dotted circle. A transcervical CNB confirmed a typical leiomyoma. (g,h) Suspicious perineal lesion. Gray-scale transvaginal ultrasound image showing an incidental perineal hypoechoic solid lesion with lobulated margins adjacent to the superficial transverse perineal muscle in a 60-year-old asymptomatic woman. Transvaginal CNB revealed perineal angiofibroma. (i,j) Suspicion of recurrence of genital tumor. Gray-scale transvaginal ultrasound image showing hypoechogenic visceral carcinomatosis infiltrating anterior rectal wall in a 46-year-old woman post chemoradiotherapy for locally advanced cervical cancer (squamous cell carcinoma); transrectal CNB confirmed recurrence of the cervix. (k,l) Research biopsy. Gray-scale transvaginal ultrasound image showing hyperechoic visceral carcinomatosis in the bowel of a 40-year-old patient with prior serous borderline ovarian tumor; transvaginal CNB confirmed low-grade serous carcinoma, enabling molecular testing. (m,n) Biopsy for staging ambiguity. Volume contrast imaging (VCI) transvaginal ultrasound image showing two independent sigmoid colon lesions, a suspected tumor and an inactive deep endometriosis nodule in a 72-year-old patient with an incidentally detected appendiceal neoplasm. Transvaginal CNB of the suspicious lesion confirmed distant metastasis of a mixed neuroendocrine/non-neuroendocrine tumor of the appendix, contributing to upstaging. All clinical cases are demonstrated in Video 1.

1

Indications for core-needle biopsy in gynecology.

GUIDANCE METHODS AND APPROACHES

Real-time imaging guidance is essential to maximize tissue yield and minimize complications. Ultrasound is the preferred modality in most cases, offering:

  • Continuous intraprocedural visualization of the needle and target.
  • Dynamic multiplanar access to lesions in almost any anatomical plane.
  • High soft-tissue resolution, particularly when the endocavitary probe is placed in the vagina (endovaginal) or rectum (endorectal).
  • Integration of color or power Doppler to identify safe access routes and target viable, vascularized tumor areas.

A variety of transducers (endocavitary, convex, linear, sector) can be used, enabling different approaches depending on lesion location, patient anatomy and operator expertise to ensure the safest path to the target and optimal visualization (Figure 2):

  • Transvaginal. Preferred for pelvic lesions, including adnexal, parametrial and peritoneal, and subperitoneal targets (e.g. lymph nodes), because of its close proximity to gynecological tumors. Image quality is unaffected by obesity or ascites.
  • Transrectal. Shares the similar advantages of short distance to the target and comparable visualization as well as similar indications and limitations to the transvaginal route. It is indicated when transvaginal access is not feasible (e.g. vaginal stenosis, virgin patient, vaginismus or anatomic distortion). Less comfortable for patients and, if transperitoneal passage occurs, carries a risk of bacterial contamination.
  • Transcervical. Typically indicated for uterine mesenchymal lesions not accessible by other approaches without breaching the uterine serosa and risking tumor spillage (e.g. fundal mesenchymal tumors). To ensure an in-organ biopsy, the needle is inserted through the endocervical canal and advanced within the uterine cavity to the target, guided in real time by an ultrasound probe placed in the rectum or on the abdomen, the rectal approach providing higher resolution.
  • Percutaneous. Used for abdominal wall, peritoneal (including omental), hepatic or nodal targets. Typically guided by ultrasound or, when access is difficult or image quality is poor, by computed tomography (CT). Limitations of ultrasound guidance include reduced image quality in obese patients, large-volume ascites, acoustic shadowing from intestinal gas or dense structures (e.g. bone, calcifications) and, in some cases, limited experience with abdominal scanning among gynecologists performing the procedure.

Ultrasound is favored for its real-time feedback, absence of ionizing radiation and ability to assess vascularity. CT guidance may be used for deep or poorly visualized targets, but it has major limitations, including low soft-tissue contrast, the need for patient fasting, radiation exposure, and the risk of contrast-agent-related toxicity. Magnetic resonance imaging (MRI) guidance provides excellent soft-tissue resolution and avoids radiation exposure, yet it is still rarely used as it requires specialized non-magnetic equipment and operator expertise. Positron emission tomography (PET) combined with CT or MRI has also been proposed for biopsy guidance, though it is uncommon in gynecological practice. The use of CT, MRI or PET-CT/PET-MRI can be challenging when lesion position changes with breathing, bowel motion or patient movement, scenarios in which real-time ultrasound offers a clear advantage in a co-operative patient and should be considered the first-choice guidance method. Detailed procedural techniques are described in the ISUOG/ESGO consensus1 and demonstrated in Videoclip 2.

2

Core-needle biopsy approaches. (a,b) Transvaginal/transrectal: the biopsy needle is inserted through a needle guide attached to the endocavitary probe (a). Example of biopsy from an infiltrated pelvic parietal (iliac) lymph node (arrow indicates needle tip) (b). (c,d) Percutaneous: needle introduced using a guided or free-hand technique, along the longitudinal axis of the probe, just below the ultrasound beam (c). Example of biopsy from an infiltrated abdominal wall lesion (Sister Mary Joseph’s nodule; arrow indicates needle tip) (d). (e,f) Transcervical: biopsy guided by a transabdominal or, alternatively, a transrectal ultrasound probe (both shown here for illustrative purposes) (e). Example of biopsy targeting a uterine fundal lesion, guided by a convex array probe placed on the lower abdomen (f). The dotted line delineates the endocervical canal, into which a plastic catheter was inserted to facilitate smooth needle passage into the uterine cavity. The needle was then advanced transcavitary into the lesion for an in-organ biopsy (arrow indicates needle tip). ECC, endocervical canal; LN, lymph node. All approaches are demonstrated in Video 2.

2

Methods for performing ultrasound-guided core-needle biopsy.

DIAGNOSTIC PERFORMANCE

Diagnostic yield increases with longer cores, wider needles and more passes, but these factors also raise the risk of trauma and bleeding. Evidence suggests obtaining at least two 10-mm cores with an 18-G needle (or wider needle for epithelial tumors), which is generally adequate for diagnostic, molecular and genetic purposes. For lymphoma or sarcoma, at least three such cores are recommended (Figure 3).1

Accuracy and adequacy

  • Specimen adequacy (sufficient material for diagnosis): 84–100%.1
  • Diagnostic accuracy (concordance with final pathology): 80–100%.1
  • False negatives are uncommon and usually result from sampling necrotic/fibrotic areas, or post-treatment change.

Predictors of higher yield

  • Operator expertise and higher case volume.
  • Aiming for viable tissue i.e. that with vascularity on color/power Doppler (indicating non-necrotic tissue).
  • Presence of a solid component ≥ 10–15 mm, and a clear, short needle path (the shorter the distance between target and probe the better).
  • Multiple passes, with adequacy influenced by needle gauge and the length of the tissue core obtained (the penetration depth).
  • Immediate specimen fixation in formalin and close communication with the pathology team regarding differential diagnosis and the anticipated need for immunohistochemistry (IHC) and next-generation sequencing (NGS).

When to repeat or escalate

  • Repeat CNB (using an alternative route/target), ideally by an experienced operator, if results are non-diagnostic but clinical/imaging suspicion persists, and a safe pathway exists.
  • Consider surgical biopsy when safe access to the target is not feasible or when prior CNB is repeatedly non-diagnostic.

3

Demonstration of core-needle biopsy (CNB) samples in clinical cases. (a–d) Tubo-ovarian carcinoma: (a) Transvaginal ultrasound showing enlarged right external iliac lymph nodes (LN) adjacent to the external iliac vein (EIV) and artery (EIA) in a patient with high-grade serous tubal carcinoma. (b) CNB of the lymph node (arrow indicates needle tip). (c) Histology: hematoxylin and eosin (H&E) stain demonstrating characteristic morphology of high-grade serous carcinoma. (d) Immunohistochemistry (IHC) for PAX8 and SOX17 confirming ovarian origin. (e–i) Cervical rhabdomyosarcoma: (e) Transvaginal ultrasound of a large cervical tumor. (f) Color Doppler showing marked intratumoral vascularity. (g) CNB of the cervical mass (arrow points towards needle tip). (h) Histology: H&E, and (i) IHC for desmin confirming pleomorphic rhabdomyosarcoma. (j–m) Ovarian low-grade B-cell lymphoma with plasmacytoid differentiation: (j) Transvaginal ultrasound showing a hyperechoic nodule within a non-enlarged left ovary (dotted outline). (k) CNB of the ovarian lesion (arrow points towards needle tip). (l) Histology: H&E, and (m) IHC for CD20 confirming B-cell lymphoma. 

SAFETY AND PATIENT EXPERIENCE

Following the Classification of the Society of Interventional Radiology,3 major complications are defined as those requiring active therapy, resulting in hospital admission (for outpatient procedures), an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae or death. Minor complications result in no sequelae and require, at most, nominal therapy or a short hospital stay for observation (generally overnight).

CNB is generally safe. The largest multicenter trial prospectively followed patients undergoing this procedure for 6 weeks after biopsy and reported only minor complications (13%) without the need for therapeutic hospitalization, blood transfusions or surgical intervention.4 Overall, patient experience was favorable, with 94% scoring in the upper half of the satisfaction scale (0 indicated an extremely negative experience and 100 an extremely positive experience) and median pain scores of 20/100 (0 indicating no pain and 100 the worst pain imaginable).4 Thus, the high safety profile allows most procedures to be performed on an outpatient basis.

Safety (complication rate)

  • Major complication rate < 1.5%.1
  • Minor complication rate 13%.4

Potential early complications

  • Pain at the puncture site.
  • Hemorrhage (usually self-limiting; rarely requiring intervention).
  • Infection.
  • Organ injury.
  • Vasovagal reaction.

Potential late complication

  • Tumor seeding along the needle tract (rare with properly performed technique).

Risk-reduction strategies

  • Careful selection of access route and shortest safe path to the lesion.
  • Use of color Doppler to avoid vascular injury.
  • Adherence to aseptic technique (hand antisepsis, sterile needle handling, use of probe cover).
  • Application of post-procedure compression if needed.
  • Immediate post-procedure ultrasound to exclude internal bleeding.

PRACTICAL TIPS AND PITFALLS

The following measures are recommended to ensure safe, accurate and effective CNB:

  • Review indications and contraindications before the procedure.
  • Perform ultrasound prior to biopsy to determine optimal approach and access route.
  • Use the shortest safe route to the lesion.
  • Avoid traversing bowel or bladder unless unavoidable and confirmed safe.
  • Ensure continuous visualization of the needle tip on the ultrasound monitor throughout the procedure.
  • Collect sufficient cores (typically three) for histology and ancillary testing.
  • Fix specimens immediately in formalin.
  • Perform immediate ultrasound after biopsy to exclude internal bleeding.
  • Communicate with the pathology team regarding suspected diagnosis and need for molecular studies.

The following common pitfalls should be avoided:

  • Losing needle tip visibility during the procedure (‘blind firing’).
  • Targeting necrotic or cystic areas, leading to non-diagnostic samples.
  • Obtaining too few cores or cores with insufficient viable tumor tissue (posing the risk of inadequate material for histology and ancillary testing).
  • Delayed or improper specimen fixation, compromising IHC or molecular analysis.
  • Poor communication with the pathology team, resulting in diagnostic delay, misinterpretation or false-negative findings.

TRAINING AND COMPETENCE

Operators should be proficient in abdominopelvic ultrasound imaging (minimum Level-II competency2), familiar with biopsy device mechanics and trained in the prevention and management of complications. Competence should be developed through simulation or phantom-based training, supervised clinical procedures and adherence to professional society recommendations (e.g. ISUOG, ESGO and others).

Clinical training under the supervision of an experienced operator should initially involve simple CNBs using a sonographic needle guide attached to the probe. A minimum of 20 supervised CNBs is recommended before performing the procedure independently. To maintain competence, each operator should perform at least 20 CNBs annually. The different approaches to training are demonstrated in Figure 4 and Video 3.

Not only does performing CNB require expertise, but the accurate interpretation of biopsy samples also demands the involvement of competent pathologists. Pathologists reporting biopsy samples should have completed postgraduate training in pathology, in accordance with national authority regulations. Pathology laboratories should operate under national accreditation frameworks to ensure quality and reproducibility.

4

Training in ultrasound-guided core-needle biopsy (CNB). (a–d) Ex-vivo training on a phantom model. Phantom-based training performed by a gynecologist using an agar model with embedded olives (asterisk) as simulated targets. Training is demonstrated with both an endovaginal probe equipped with a needle guide (a,b), and a linear array probe using the free-hand technique, with simultaneous visualization of the real-time ultrasound image on the monitor (c). (d) Ultrasound image showing the biopsy needle targeting one of the simulated lesions (olive embedded in agar). (e,f) In-vivo training session. (e) A trainee gynecologist performs a guided biopsy under expert supervision, using an endovaginal probe with needle guide and an automated biopsy device. (f) Ultrasound image showing the biopsy needle targeting a suspicious perineal mass. Phantom-based (ex-vivo) and supervised in-vivo training are demonstrated in Video 3.

3

Phantom-based and supervised in-vivo training for core-needle biopsy.

SUMMARY – KEY POINTS

Step

Recommendation

Patient selection

Proceed when tissue biopsy is required to guide clinical management.

Imaging guidance

Use ultrasound as the first-line guidance method; employ computed tomography for targets that are inaccessible or poorly visualized with ultrasound.

Sample adequacy/
accuracy

Target viable, vascularized tissue; obtain three cores whenever possible. Place samples immediately in formalin fixative.

Safety

Avoid traversing vessels or hollow organs; maintain aseptic technique.

Post-procedure

Most uncomplicated core-needle biopsies are outpatient procedures. Perform immediate ultrasound to exclude internal bleeding. No prolonged monitoring is needed after uncomplicated procedures. Inform patient about potential complication risks and provide written instructions on warning symptoms (e.g. heavy bleeding, fever, severe pain) and when to seek medical help. Ensure proper labeling and completion of the pathology request form.

Quality assurance

Audit of sample adequacy, complication rates, turnaround times (from biopsy to verified pathology report) and patient experience should be performed regularly as part of local quality assurance.

PRACTICE RECOMMENDATIONS

  • Core-needle biopsy (CNB) is a minimally invasive outpatient procedure that is able to provide sufficient tissue for histology, immunohistochemistry and genomic testing.
  • Indications include primary inoperable/non-resectable tumors, cancer of unknown primary, atypical mesenchymal tumors, suspicious cervical/endometrial/vaginal/perineal lesions, suspected recurrence, staging clarification and predictive genomic testing (including research biopsy).
  • Ultrasound is the preferred modality for guidance of CNB in gynecology. Most procedures are low risk and performed via the transvaginal approach. If transvaginal biopsy of a pelvic mass is not feasible, the transrectal route may be used; prophylactic antibiotics are recommended if the needle passes through the rectal wall into the peritoneal cavity. The transcervical approach (in-organ biopsy) may be used for uterine mesenchymal tumors located high in the fundus to avoid traversing the uterine serosa. The percutaneous approach is reserved for targeting masses outside the pelvis, and computed-tomographic guidance may occasionally be employed when the target is deep or poorly visualized in the abdomen.
  • Indications and contraindications, including both procedure-related and patient-specific bleeding risks, should always be reviewed. Coagulation screening is required only for high-risk procedures or in patients with elevated bleeding risk.
  • To optimize specimen adequacy, target viable, vascularized tissue and obtain three cores whenever possible. Place samples immediately in formalin and ensure complete pathology documentation.
  • CNB is safe, generally well-tolerated and usually performed on an outpatient basis.

ACKNOWLEDGMENTS

We thank Tomas Herrmann (Institute of Scientific Information, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic) for video editing. The research evidence for the recommendations reported in this chapter was supported by the Ministry of Health of the Czech Republic (NV19–03–00552 and NU21–03–00461), the Charles University in Prague (UNCE/24/MED/018), the Charles University Research program, ‘Cooperatio-Maternal and Childhood Care; Neonatology’, and the institutional grant of the General University Hospital in Prague (CZ-DRO-VFN64165).


CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

REFERENCES

1

Fischerova D, Planchamp F, Alcázar JL, Dundr P, Epstein E, Felix A, Frühauf F, Garganese G, Haldorsen IS, Jurkovic D, Kocian R, Lengyel D, Mascilini F, Stepanyan A, Stukan M, Timmerman S, Vanassche T, Ng ZY, Scovazzi U. ISUOG/ESGO Consensus Statement on ultrasound-guided biopsy in gynecological oncology. Ultrasound Obstet Gynecol. 2025;65(4):517–35. Epub 20250321. doi: 10.1002/uog.29183. PubMed PMID: 40114523; PMCID: PMC11961111.

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Minimum training recommendations for the practice of medical ultrasound. Ultraschall Med. 2006;27(1):79–105. doi: 10.1055/s-2006-933605. PubMed PMID: 16508866.

3

Khalilzadeh O, Baerlocher MO, Shyn PB, Connolly BL, Devane AM, Morris CS, Cohen AM, Midia M, Thornton RH, Gross K, Caplin DM, Aeron G, Misra S, Patel NH, Walker TG, Martinez-Salazar G, Silberzweig JE, Nikolic B. Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol. 2017;28(10):1432–7.e3. Epub 20170727. doi: 10.1016/j.jvir.2017.06.019. PubMed PMID: 28757285.

4

Timmerman S, Taliento C, Haesen J, Dababou S, Pozzati F, Quagliozzi L, Moro F, Mascilini F, Testa A, Fruhauf F, Fischerova D, Epstein E, Fruscio R, Ledger A, Van den Bosch T, Froyman W. Ultrasound-guided tru-cut biopsy in pelvic masses: a prospective multicentre study on diagnostic yield, safety and patient-reported outcomes. Ultrasound Obstet Gynecol. 2025;66(S1).

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