Blogs

A Simple Straightforward Route to a Bone Biopsy - Right Iliac Bone TB
May 26, 2020
This 36-years old had fever and right pelvic pain. Her MRI showed a focal lesion in the right iliac bone. She was sent for a biopsy. The CT scan shows a well-defined osteolytic lesion with a sequestrum. The best route is through the posterior iliac crest, not from the sides. Going through bone minimises soft tissue trauma and allows a direct path into the lesion.I used an 18G coaxial biopsy gun and tapped it into the lesion. This was histopath proven tuberculosis. ...
Ours is Not to Question Why...Just Do the Biopsy...Enchondroma Phalanx
May 26, 2020
This is a 65-years old lady who had a swelling over the middle phalanx of her finger for many years. It started paining a month prior following an injury.The radiographs and CT scan show a clear fracture through a lesion that is characteristic of an enchondroma, even though a chondroid matrix is not seen on the CT scan. The patient and surgeon insisted on a biopsy to prove that this is a benign chondroid lesion. Like the renal tumor earlier, sometimes, it is best not to argu...
CT Contrast Guided Biopsy - Liver Neuroendocrine Tumor
May 26, 2020
This is a 49-years old lady who was found to have multiple lesions in the liver. FDG PET did not show the lesions well.The mutiphasic CT scan had shown arterially enhancing lesions with rapid wash-out, highly suggestive of neuroendocrine tumors. The plain scan did not show the lesion well. So I did a multiphasic scan again at the time of biopsy. After choosing the lesion in segment 7 that I eventually biopsied, I again gave contrast during the procedure and placed the needle...
Metastatic Lung Adenocarcinoma - Biopsy for Mutation Studies & Entry Pneumothorax
May 26, 2020
This is a 77-years old man who presented with Stage IV metastatic lung cancer. The PET CT scan showed a mass in the apico-posterior segment of the left upper lobe with extensive lung metastases.I did the biopsy in the right lateral decubitus position with a 20G coaxial biopsy gun. There was an entry pneumothorax, which I aspirated and continued with the procedure. The pneumothorax remained stable during the procedure and after as well. Since this was already metastatic, we h...
Nodes, Bones and Lungs - Lymphoma vs Metastatic Adenoca from Lung & Then Prostate
May 26, 2020
This is a 78-years old man who presented with large lymph nodes in the mediastinum, the retroperitoneum and pelvis. He was for a CT guided biopsy, but since he had lung lesions suggestive of lymphangitis or lymphomatous involvement, we had a PET/CT done. The PET/CT shows mild uptake in the nodes, but one focus of marked uptake in the left iliac bone. The working diagnosis was lymphoma. While a biopsy from the retroperitoneal node is simple and straightforward, the dictum is ...
The Trouble with Chondrosarcomas and Other Necrotic or Myxoid Tumors
May 26, 2020
This 66-years old man presented with right iliac bone pain. The radiograph shows subtle lucency but it is tough to evaluate. The MRI shows a T2 bright, septate lesion, consistent with a cartilage lesion with a large soft tissue component. The contrast images showed solid component only in the posterior iliac region. The PET/CT shows uptake of around 6 only in the posterior aspect, the rest of the lesion showing mild uptake of around 2 to 2.5. The biopsy had to be planned to ...
Small 2 cm Solid Renal Lesion - Renal Cell Ca
May 26, 2020
This is a 65 years old lady with hematuria. The CT scan showed a classic arterially enhancing 2.0 cm nodule in the lateral cortex of the lower pole of the right kidney. This is characteristic of a renal cell carcinoma, but the urologist and the patient wanted confirmation before planning partial resection. The biopsy was simple, in the prone position, using a 20G coaxial biopsy gun. The diagnosis was, as expected, renal cell carcinoma. ...
Unexpected Pneumothorax During a Mediastinal Node Biopsy - Recurrent NHL
May 26, 2020
This is a 33 years old lady diagnosed to have non-Hodgkin’s lymphoma (NHL) in Aug 2019. She responded but a recent PET showed new lesions. I did a biopsy of the left sided nodal masses using a parasternal approach with an 18G coaxial biopsy gun. She had pain halfway through the procedure and when I did a check scan, she had developed a pneumothorax. I had not gone through lung, so the only explanation was that there was sliver of pleura (which I could not appreciate even ret...
Subcarinal Node with the CT Black Pearl Sign with Extrapleural Nodal Biopsy - Sarcoidosis
May 26, 2020
This 54-years old lady presented with breathlessness. A well done CT scan showed enlarged non-necrotic subcarinal and bilateral hilar nodes. The subcarinal node showed the “black pearl” sign described by Rochita V from Chennai, a sign that is highly suggestive of sarcoidosis. The lung images also show fissural nodules.The diagnosis still had to be confirmed and I did a subcarinal node biopsy with saline hydro-dissection of the pleura from the vertebral body using an extra-pl...
Simple Extrapleural Approach - Posterior Mediastinal Squamous Cell Carcinoma
May 26, 2020
This 65-years old male smoker presented with dyspnea and dysphagia. He had a large necrotic mass in the retro-tracheal mediastinum. I don’t now remember the esophagoscopy findings, but either the lumen was not passable or it was normal. But it didn’t seem to be of esophageal origin.In the prone position, it was easy to find an extra-pleural route from the right, after injection a combination of saline and lignocaine and then using a 20G coaxial biopsy gun. The diagnosis was ...
Unusual Site of Metastasis - Renal Cell Carcinoma with Frontal Sinus Metastasis
May 26, 2020
This is a 57-years old man with renal cell carcinoma. He had a growing swelling in the frontal bone region. A PET/CT showed a mass destroying the frontal sinus and another nodule in the subcutaneous region of the right upper back. Sometimes you wonder…this biopsy could have been done blindly by the physician / surgeon, but more and more all of these come for image-guided, I guess to ensure there is no complication whatsoever. I used an 18G coaxial biopsy gun with an oblique ...
Familial Pulmonary Fibrosis and the Risk of Malignancy - Adenocarcinoma Lung with FPF
May 26, 2020
This is a 49-years old man who was known to have a fibrosing ILD. When he came to us, he had a “probable usual interstitial pneumonia” (probable UIP) pattern, which was suggestive of idiopathic pulmonary fibrosis (IPF). He also had a focal wedge-shaped opacity with air bronchiolograms in the superior segment of the right lower lobe, which had grown from an earlier scan (not available). We found later that a cousin of his and another sister both had variable forms of pulmonar...
Subcarinal Node Biopsy Through a Pre-Existing Pneumothorax - Sarcoidosis
May 26, 2020
This is a 55 years old man with fever who had subcarinal and bilateral hilar adenopathy with septal thickening in the lungs that suggested sarcoidosis. A subcarinal node biopsy was attempted elsewhere using a trans-pulmonary route, which left him with a pneumothorax. I started with an extra-pleural approach by injecting saline and lignocaine and creating a space between the pleura and the vertebral body, but eventually had to go through the pneumothorax into the subcarinal n...
Intra-Thoracic Approach for a Rib Lesion - Squamous Metastasis from Ca Tongue
May 26, 2020
This 38-years old had carcinoma tongue and presented with left pleural effusion. A PET/CT showed erosions of the left 7th and 8th ribs with soft tissue along the endosteal surfaces.It was a toss up between going straight in from the mid / posterior axillary line (green arrow) versus cutting across the pleural effusion and targeting the soft tissue internally. I finally chose the latter approach (red arrow), with an 18G coaxial biopsy gun, just to ensure that I could get adeq...
Lymphomas are Tricky - And This Was Splenic
May 26, 2020
This was a 54-years old man who was found to have splenic lesions on USG and went in for a PET/CT, which showed multiple active splenic lesions and one large precaval node with smaller neck lesions. He had fever for the last 3 months and was on empirical anti-tuberculous treatment with no improvement.I chose the larger splenic lesions over the precaval node. but did the biopsy using a 20G coaxial biopsy gun. Ideally, a mass such as this could have easily biopsied with a larg...
Ant Mediastinal Mass - Simple Biopsy - Thymic Carcinoma
May 26, 2020
This 39-years old man presented with breathlessness and edema and puffiness of the face. The CT scan showed a large anterior mediastinal mass involving the SVC (blue arrow). There was pleural effusion on the right (green arrow) and lung nodules (red arrow) as well. The differential is aggressive thymic neoplasm, lymphoma and malignant germ cell tumor. The biopsy was simple using a right parasternal approach with an 18G coaxial biopsy gun. The diagnosis was thymic carcinoma. ...
Why Biopsy? The Triple Whammy Lung Nodule
May 26, 2020
This is a 57-years old lady, treated in the past for Ca rectum and Ca breast. A surveillance PET showed a mildly active 7.8 x 6.5 mm lung nodule in the posterior basal segment of the left lower lobe with a small nodule more anterior to it. It was new as compared to a scan done in the past.The question was; is this metastasis from breast or from rectum or something else? The biopsy was simple using a 20G coaxial biopsy gun. There was no complication. The diagnosis was adenoca...
Invasive Lung Adenocarcinoma and Lymphangitis
May 26, 2020
This is a 61-years old man with breathlessness. The CT scan showed consolidation in the right lower lobe with air bronchograms. The soft tissue window showed bubble lucencies. While this is described with infarction, it is also known to occur with invasive mucinous adenocarcinoma, lymphoma and some forms of pneumonia as well. The upper lobe shows diffuse septal thickening, suggesting of lymphangitis. This combination suggests a malignant neoplasm. I would have preferred a PE...
The Ubiquitousness of Tuberculosis - TB Chest
May 26, 2020
This is a 36-years old man with fever of unknown origin. A chest radiograph showed mediastinal widening. A CT scan of the chest showed left para-aortic nodes. Prior to a biopsy, a PET/CT was done, which along with the mediastinal nodes, showed a focal area of soft tissue thickening with uptake in the left 8th intercostal space.   This was unexpected and had been missed on the earlier CT scan. This is also easier to biopsy than the left para-aortic mediastinal nodes. I used a...
Post Biopsy Air-Fluid Level - Confirming the Diagnosis of a Thymic Cyst
May 26, 2020
This 30-years old patient was found to have a thymic lesion on a CT scan following a pre-employment chest radiograph that showed superior mediastinal widening. She had no signs or symptoms. A CT guided biopsy was done. When the 18G coaxial biopsy gun needle was introduced, jelly like fluid was aspirated. A biopsy was obtained from one of the septa. I also did a post-contrast study to reconfirm the margins of the lesion. The biopsy report was that of a benign thymic cyst. ...