Blogs

Proving Lymphoma
March 31, 2020
This 50-years old man was diagnosed to have T-cell rich “B” cell non-Hodgkin’s lymphoma from a right axillary node biopsy in 2016. He was treated and came back a year later with a lung mass and skeletal disease as seen on the PET scans. The question was; is this recurrence of lymphoma or is this a new lung carcinoma with metastatic disease. A CT guided biopsy done in the lateral decubitus position showed that this was lymphoma recurrence. #CTbiopsy #nonHodgkinlymphoma #lymph...
The Power of Reconstructions
March 31, 2020
This is a 40 years old lady who had mild chest pain and a radiograph shows a right mid and lower zone mass. She was referred for a CT guided biopsy of a right middle lobe mass.The CT scan shows a mass, either in the lateral segment of the right middle lobe or the superior segment of the right lower lobe on the axial images. The coronal image shows that it is bounded superiorly by a tissue. But it is the sagittal images that show that the mass lies in the major fissure. This ...
The Costovertebral Approach to Dorsal Vertebral Body Lesions
March 31, 2020
This 38 years old lady known to have carcinoma breast presented with metastatic disease. She had a D9 body lesion that needed a biopsy for ER, PR, HER2 estimation. Transpedicular biopsies are usually the simplest to do with a very low complication rate if any. In the dorsal spine, one can go through the costovertebral joint and then through the pedicle to reach the vertebral body lesion. As seen in these images, the needle was placed in the costovertebral joint and with gent...
The Lateral Decubitus Approach to Lung Biopsies
March 31, 2020
The is a 64-years old lady with a mass in the left lower lobe of the lung on this PET/CT image, who presented for a CT guided biopsy. Both supine and prone positions are acceptable approaches, but if we want to go through the least amount of lung and use the straightest approach to the lesion, then that would be the lateral decubitus approach in this case, the right lateral decubitus position.If this is combined with an immediate roll-over into the left lateral decubitus pos...
Distal Tibia GCT with ABC Transformation
March 31, 2020
This is a 16-years old girl with a mature skeleton who had an osteolytic lesion in the distal tibia with a narrow zone of transition extending up to the articular surface. The MRI shows fluid-fluid levels, suggesting an aneurysmal bone cyst (ABC) component, but the plain radiograph appearance is typical of a giant cell tumor (GCT). The CT scan shows an expansile lesion without abnormal trabeculation, again a finding in favor of GCT. A CT guided biopsy was done and histopatho...
Trans-Sternal Biopsy - To get an answer come what may
March 31, 2020
This is a 70-years old man who presented with fever. He had retrosternal and prevascular space nodes and lung lesions. Bronchoscopy was not possible. A CT guided biopsy was done through the sternum - this is an easy procedure - the sternum can be pierced using a standard 18G Cook needle with a light hammer tap without sedation, except for periosteal infiltration of local anesthesia.The patient had PCR positive MTB and was put on anti-tuberculosis treatment. 9 months later, h...
Pre-sacral TB
March 31, 2020
This is a 24-years girl with an MRI and CT scan that is typical of tuberculosis, showing an infectious spondylitis of L5/S1 extending inferiorly. A biopsy in any case is mandatory to confirm the diagnosis and check for culture, sensitivity. In this case, an easy approach was to go through the sacral ala and then obtain material. Going through bone is always an easy way to get to a lesion, as we shall see in tomorrow’s case as well.#ctbiopsy #tuberculosis #tbspine ...
Unforeseen Circumstances
January 28, 2020
This is a 42-years old woman who had a CT myelogram done for CSF leak. The leak was found and repaired.Three months later she had gradually progressive back pain at the site of the lumbar puncture. MRI revealed an infectious discitis at this level. The CT done at the time of the biopsy also shows typical findings.While tuberculosis was always on the top of the list of differential diagnosis, the chance of this being non-tuberculous was much higher.A CT guided biopsy was done...
Fate’s Triple Whammy
January 24, 2020
This is an alert 86-years old man who has been treated successfully earlier for carcinoma colon and prostate. He had weight loss and a repeat PET shows liver lesions and a lesion in the left iliac bone. The question was which tumor spread did these lesions represent, colon (most likely) or prostate (less likely) or both.A CT guided biopsy of the left iliac lesion was done, which to everyone’s surprise showed that this was a metastatic lesion from a liver primary, essentially...
Try and Try Till You Succeed - A Lymphoma Story
January 24, 2020
This is a 77-years old man who presented with progressive increase in size of nodes and skeletal lesions, seen well on the PET. The left para-aortic retroperitoneal node was easy to access. The biopsy however showed only lymphoid tissue with microgranulomas, essentially non-diagnostic. This didn’t make sense, so I pushed and managed to convince the patient and his treating doctor to let me biopsy the right sacral ala lesion. The PET showed marked uptake with some rarefaction...
Adult Tetralogy of Fallot
January 14, 2020
This is a 38-years old man who presented for the first time with breathlessness. The echo showed a perimembranous ventricular septal defect (VSD) and pulmonary arterial hypertension (PH). The MRI shows the perimembranous VSD, the aorta subtending the RV & LV and infundibular hypertrophy with resultant RVoT obstruction. To find a tetralogy of Fallot morphology presenting for the first time at this age is highly unusual. #adulttcongenital #congenitalheartdisease #ToF #tetra...
DOTA-PET - How it Changes the Game
January 13, 2020
This is a 64-years old man who presented with cough. There was a mass occluding the left lower lobe bronchus with post-obstructive changes in the subjacent lower lobe. The minIP shows this well. A PET/CT done prior to the biopsy showed mild uptake with no other lesion in the body. A biopsy showed carcinoid. A DOTA-PET was then performed, which to our surprise showed extensive skeletal metastatic disease.DOTA-PET is more sensitive than FDG-PET when it comes to neuroendocrine ...
Occipital Condylar TB - One More Unusual Site
January 10, 2020
This is a 22-years old lady who presented with neck pain with painful movements. An MRI showed an osteolytic lesion involving the right occipital condyle (axial T2) and the adjacent occipito-atlantal joint (sagittal T2). She was sent for a biopsy. We did a contrast CT to understand the anatomy of the lesion and found that there was easy access with the vertebral artery inferior to the lesion and not in the path of the needle. Frank pus was aspirated that was PCR positive for...
Endobronchial TB - The Power of MinIPs
January 10, 2020
This is a 64-years old lady with chronic cough. She had an earlier CT in 2008 showing calcified mediastinal nodes. The current CT shows that the subcarinal node is calcified and causes narrowing of the intermediate bronchus. The minIP image in the coronal plane shows it the best and makes it very easy to appreciate and understand the pathology. Bronchoscopy showed endobronchial nodules, positive for active tuberculosis. #tuberculosis #endobronchialTB #minIP ...
The Lost Art of Plain Radiograph Interpretation
January 7, 2020
This 56 years old man was referred for a CT guided biopsy on the basis of an MRI report of an osteolytic lesion at D10 with abnormal soft tissue.The MRI showed a fracture extending from the anterior to the posterior elements. I then looked at the radiographs, which showed frank ankylosing spondylitis.This has never been picked up. The patient effectively had a fracture through D10, essentially a pseudarthrosis / Andersson lesion and he did not need a biopsy.  ...
Congenital Lobar Emphysema (CLE)
January 3, 2020
This 3 years old boy came with sudden breathlessness. A simulated radiograph from the CT scan images shows increased lucency of the left upper and mid-zones, which on the axial CT scan is seen a left upper lobe overinflation due to a high-grade stenosis of the left upper lobe bronchus (arrow). The minIP image shows this well (arrow). The operated overinflated lung is seen in the last panel.  ...
GIST
January 3, 2020
This 74-years old man came with a retro-gastric mass picked up on USG. He had some non-specific complaints. The CT scan shows a mass with a typical “target” appearance. The MRI shows a variegated appearance that is typical of a gastro-intestinal stromal tumor (GIST). A CT guided biopsy confirmed the diagnosis. ...
Portal Nodal Tuberculosis
January 1, 2020
This 24-years old man had fever every night starting April 2019, when a CT scan showed necrotic portal nodes. A biopsy could not be done at the time and he was not put on any treatment. He came in the 3rd week of Dec, with an increase in the size of the nodes. A trans hepatic CT guided biopsy yielded pus and the PCR (GeneXpert) on the same day was positive for TB, with rifampicin resistance. ...
Head-Cheese Sign
December 31, 2019
This has nothing to do with cheese, but represents a mish-mash of meat made from the head of a calf or pig. This variegated appearance when seen in a patient with interstitial lung disease (ILD), suggests fibrotic hypersensitivity pneumonitis as mentioned. The blue arrow points to the ground-glass, the green to the area of air-trapping and the red to a normal spared lung lobule. ...
Mounier-Kuhn disease
December 30, 2019
60-years old man with treated for asthma. CT chest shows bronchiectasis. The trachea and bronchi show diverticular disease, which is beautifully captured in the minIP images. MinIP is an excellent tool for depiction of tracheo-bronchial disorders like these. ...