Blogs

Low Grade Myxofibrosarcoma - a Story of Solid Components & Fascial Tails
July 31, 2020
This is a 38-years old runner who felt a swelling in the popliteal fossa following a run. The assumption was he had injured a muscle or tendon and he came for an MRI. The MRI shows a mixed cystic, solid tumor in the posterior compartment of the proximal leg (T2 sagittal, post contrast axial and sagittal) with a fascial tail that suggested a more aggressive sarcoma with a likely myxoid element. A PET/CT was performed to see if there were any other lesions in the body. The les...
Pigmented Nodular Synovitis of the Knee - Typical Appearance - Radiology & Pathology
July 31, 2020
This 53-years old man presented with left knee pain. His MRI showed a T2 intermediate and dark lesion posterior to the ACL and PCL, with homogeneous enhancement. The findings were suggestive of nodular synovitis, perhaps pigmented. The surgeon wanted pre-treatment confirmation, so a biopsy was performed from the posterior aspect using an 18G coaxial biopsy gun. The diagnosis was “tenosynovial giant cell tumor” (localized type), which is basically nodular synovitis (histopath...
Co-Axial Biopsy Gun for Sclerotic Bone Lesions as Well - Spinal Metastasis from Ca Prostate
July 31, 2020
This is a 61-years old man treated for carcinoma prostate, who presented with backache. His MRI showed a focal L4 lesion. There was no disease anywhere else (FDG PET done) and so he was sent for a CT guided biopsy.   The lesion is mixed osteolytic / sclerotic, but predominantly sclerotic.   Under intravenous sedation, I first inserted an 11G diamond-tipped bone biopsy needle in with a combination of a screwing motion and the use of a mallet. Once inside the vertebral body us...
The Shrinking Lung - Progressive Dysplasia & Volume Loss due to Adenoid Cystic Carcinoma
July 22, 2020
This is a 33-years old man who presented with cough for over 3 years. The 3 radiographs from 2015 to 2018 show gradually progressive reduction in the right lung volume. Finally a CT scan was done, which showed a large active mass occluding the right main bronchus. However, the segmental bronchi were visible likely due to collateral air flow. The lung was dysplastic with cystic areas and basically non-functional. The biopsy was simple from a posterior approach using an 18-G c...
Unilateral Sacroilitis - Infective Arthritis - Tuberculosis
July 22, 2020
This 53-years old lady presented with left sided backache with tenderness over the SI joint. Her radiograph showed a possible erosion. The MRI showed extensive marrow edema with large articular margin erosions (STIR and T1W axial). The CT scan done at the time of biopsy showed a sequestrum anteriorly with large erosions. This is definite sacroilitis, but it is unilateral. All mono-articular arthropathies should be assumed to be infective unless proven otherwise. The biopsy w...
When There is No Choice But to Biopsy a Likely Liver Hemangioma - Patient with Low Grade Endometrial Stromal Sarcoma
July 22, 2020
This is a 43-years old woman operated for a low grade endometrial sarcoma. In 2014, she had an MRI that showed two lesions in the liver, likely hemangiomas, in segments 3 and 7 respectively, as shown. She had a PET/CT in 2018, which showed that while the segment 7 lesion was more or less the same, the segment 3 lesion had significantly increased in size, without any uptake and with a contrast CT picture of puddling that was quite typical of a hemangioma. So here is the conun...
When the Only Person Who Does Not Think a Biopsy is Need is You...Enchondroma Humerus
July 22, 2020
This is a 53-years old woman with pain in the right shoulder. An MRI (PD fat sag axial and sagittal and STIR coronal) was performed, which showed a T2 bright lesion in the right humeral head without cortical break or marrow edema, findings absolutely characteristic of enchondroma and likely completely unrelated to her pain. However, she had a couple of doctors in her family, who believed that the only truth is histology. They consulted an orthopedic oncologist who advised a ...
Axillary MPNST Recurrence - Simply Biopsy and Rules Followed
July 22, 2020
This is a 34-years old man known to have a malignant peripheral nerve sheath tumor (MPNST) in the left axilla. He had recurrent swelling. The MRI shows a T2 bright, heterogeneous mass involving the short head of the biceps - the first two images are T2W sag and STIR coronal, followed by post-contrast axial images showing heterogeneous enhancement. The neurovascular bundle does not seem involved. He came for a repeat biopsy. The biopsy was simple, but we needed to make sure o...
TB TB TB - It's The Biggest Chronic Scourge....Tuberculosis Lateral Mass C1
July 22, 2020
This is a 32-years old man with neck pain. The MRI showed a focal lesion involving the lateral mass of C1 on the left (STIR coronal, T2 axial and T1 axial). Prior to the biopsy, I did a whole spine CT on table, to see if there was any other lesion elsewhere in the spine (often there is and it’s easier to biopsy dorsal and lumbar spine lesions). In this case, there wasn’t. The CT scan showed the destruction well. I then gave IV contrast to see the position of the vertebral ar...
Another Infectious Spondylitis - Not TB - MSSA
July 22, 2020
This is a 42-years old man with backache. MRI shows an L3/4 lesion with anterior soft tissue. The findings are unusual for TB and more suggestive of an infective bacterial disciitis, but without a biopsy and microbiological proof, it is not possible to differentiate tuberculosis from non-tuberculous etiologies. Rule: Every infectious spondylitis has to be biopsied. The biopsy was simple using an 18G coaxial biopsy gun introduced into the anterior soft tissue. The etiology wa...
Simple Transpedicular Biopsy Using a Coaxial Gun - TB Spine
July 22, 2020
This 62-years old man had backache and MRI showed classic infectious spondylitis. The CT scan shows the lesion well at L4/5, with no significant soft tissue on the MRI or CT scan. Rule: Every infectious spondylitis has to be biopsied. Since the lesions were in the bone, a transpedicular into the vertebral body lesion was simple and straightforward. Using mild intravenous sedation with an 18G coaxial biopsy gun lightly tapped through the pedicle, the biopsy showed PCR MTB +ve...
Classic Aunt Minnie - But Surgeon Not Convinced - Adrenal Myelolipoma Using Lateral Decubitus Approach
July 3, 2020
This 70-years old man came with pain in the abdomen. USG showed a right adrenal mass, so a CT scan was done, which showed an incidental classic right adrenal myelolipoma. The surgeon still wanted a biopsy. I argued, but he said he wanted to prove there was no malignancy. Unless the pleura is completely clear in the prone position, I prefer to do adrenal biopsies in the ipsilateral lateral decubitus position. So in the right lateral decubitus position, I inserted a 20G coaxia...
Neurosurgeon's Domain - Think Again - Skull Bone Osteolytic Lesion Bx - Metastasis From Ca Breast
July 3, 2020
This 59-years old lady came with a breast lump, which on biopsy turned out to be carcinoma. Her PET/CT showed a solitary osteolytic lesion in the left frontal bone. There were no nodes and no other abnormality. The surgeon wanted a biopsy of the left frontal lesion. I told him that this is normally done by a neurosurgeon. His question was…but can you do it anyway? There was no technical difficulty and so no reason not to. I placed the patient in the right lateral decubitus p...
Trans-Pulmonary Node Biopsy - When Hydro-Dissection - Salinoma Does Not Work
July 3, 2020
This 35-years old lady had mediastinal and bilateral hilar adenopathy. She came for a CT guided biopsy. I placed her prone hoping to do a standard subcarinal node biopsy, but I just could not find a safe window for an extra-pleural hydro-dissection. So I decided to biopsy the right paratracheal node. I inserted the cannula hoping to do an extra-pleural biopsy with hydro-dissection, but somehow even after injecting saline mixed with lignocaine, the pleura did not move out of ...
The Beauty and Power of Hydro-Dissection aka Salinoma - Granulomatous Right Paratracheal Mediastinal Lymphadenopathy
July 3, 2020
This 8-years old girl had progressive right paratracheal adenopathy along with neck nodes from February 2020. The neck nodes were biopsied with imaging guidance and excision on two different occasions respectively and were negative for a specific diagnosis. The physicians were left with the growing right paratracheal node. Given the problems currently with emergency admission in hospitals, the idea was to reduce the chance of any complication to a bare minimum. In the prone ...
The Problem with Ruptures and Missed Lesions - Mediastinal Dermoid
July 3, 2020
This 29-years old lady presented with fever while studying abroad in one of the Western countries. A CT scan showed necrotic right paratracheal nodes and she underwent at least two procedures, one EBUS and one that I don’t remember that were both inconclusive. Three months after the first onset of symptoms and fed-up with the system in that country, she came down to India. We repeated her CT scan and found a fat containing mass in the thoracic inlet that had somehow been ove...
The TB Problem That Just Doesn't Go Away - Tuberculosis Lung
July 3, 2020
This is a 53-years old man, alcoholic, with fever and weight loss. The CT scan showed a focal lesion with spiculated margins in the right apex anteriorly. Posteriorly there were satellite bronchocentric nodules, highly suggestive of tuberculosis. It wasn’t clear though whether these were old or active. Sputum was negative for acid-fast bacilli (AFB). Because of the “mass-like” appearance of the focal lesion, it was decided to go ahead with a CT guided biopsy rather than bron...
Using Contrast to Guide the Needle - Pancreatic Head Biopsy - Adenocarcinoma
July 3, 2020
This 56-years old lady presented with a pancreatic head mass. She was known to have Hodgkin’s lymphoma in the past, and a biopsy was needed for the exact histology. The mass encases the celiac axis and the portal vein and we can see the CBD stent that was put in to relieve the obstructive jaundice. The pancreatic duct is also dilated. There was a good window between the celiac axis and the SMA towards the right. I gave intravenous contrast to ensure that I could visualize th...
Choosing the Appropriate Biopsy Route - Iliac Nodal Metastasis from Ca Vulva
July 3, 2020
This 69-years old lady had been treated in the past for Ca vulva and presented with swelling in the left limb. The CT scan showed a mass encasing the iliac vessels. It was highly necrotic, with one apparently solid component next to the left ureter. While it is very easy to biopsy this lesion, the issue is to get into a non-necrotic component, which was a small component anteriorly (green arrow). That biopsy too is simple, but these issues need to be sorted out in advance to...
Trans-Organ Biopsies - Portal Node through Liver - Tuberculosis
July 3, 2020
Two days ago, a consultant in Gujarat got back with his first trans-sternal biopsy of a right paratracheal node. And he echoed what I keep saying, “the sternum is a friend”. But there are other organs we can safely go through as well. Here is a 59-years old lady with necrotic portal nodes. The only approach to this node is through the liver, but with no major vessels along the needle path. Many would say, “why not do EUS?”. My answer would be another question, “Why”? Using a...