Spot Diagnosis

Cervical vertebra biopsy

This 24-yeras old student had neck pain. An MRI revealed a C4 vertebral lesion. A contrast-enhanced CT scan prior to the biopsy showed an expansile osteolytic lesion involving the body and pedicle (Figs. 1, 2) with abnormal soft tissue. Under CT guidance, a core biopsy was performed, both of the soft tissue as well as from within the lesion (Figs. 3, 4).

Adequate tissue was obtained, which was reported to be tuberculosis.

Scapular focal lesion - biopsy

This 26-years old lady had a compression fracture of the C5 vertebral body. She came for a biopsy, but there was no access route. A bone scan was advised, which revealed a lesion in the scapula. This was biopsied (Figs. 1, 2), by introducing a bone cannula inside, through which an 18G Quick-Core gun was used. It revealed metastatic squamous cel carcinoma.

A CT scan of the chest subsequently revealed a mass in the right lower lobe.

Renal biopsies in the adult

Renal biopsies have always been a bit controversial and in the adult patient, have rarely been required in the presence of an enhancing renal mass, which is always assumed to be a renal cell carcinoma, unless proved otherwise. The only time we have gone ahead with biopsies, has been when there is a high possibility of infection, especially in younger individuals.

A new article by Silverman SG et al in the July issue of Radiology talks about this issue in detail. It divides the indications for renal biopsy into established and emerging.

Established

1. When there is an extra-renal primary and a renal mass
2. When the mass seems non-operable
3. When there are significant co-morbid conditions preventing surgery (Fig. 3)
4. When there is a high risk of infection

Emerging

1. Small lesions less than or equal to 3cms, homogeneous and hyperattenuating. The chance that such lesions may be benign increases with reducing size, being almost 44% in those less than 1cm.
2. Before RF ablation
3. In Bosniak type III indeterminate cystic renal masses (Figs. 1, 2)

Transpedicular biopsy for central body tuberculosis

This 21 years old man had backache. The MRI showed a focal lesion involving the L3 vertebral body. The clinico-radiologic profile was suggestive of tuberculosis, but the orthopedic surgeon wanted to be sure.

The lesion (Fig. 1 arrow) was biopsied using a transpedicular approach. An 11G needle was introduced through the pedicle into the body (Figs. 2-4) and through it, an 18G gun was passed to obtain the biopsies (Figs. 5,6).

The diagnosis of tuberculosis was confirmed on the biopsy.

Biopsy of a vertebral lesion - tuberculosis

This 36-years old man had back pain. His MRI had shown a lesion in the L2 vertebral body. The assumption was of tuberculosis, but the findings were not pathognomic. A CT guided biopsy was advised. The CT scan shows an osteolytic lesion with sclerosis with minimal adjacent soft tissue. Instead of biopsying the soft tissue, it was felt that the best thing would be to go through the sclerotic bone into the osteolytic lesion - this was done and the biopsy material obtained was proven to be tuberculosis.

Multiple osteolytic lesions - metastases from signet cell carcinoma - stomach

This 56-years old man, with mild bone pain, but otherwise well-preserved and asymptomatic, was found to have extensive osteolytic lesions on MRI and plain radiographs. A biopsy was attempted at another hospital, but was inconclusive.

Using a Cook 18G co-axial gun canula system, biopsies were obtained from two sesions, one in the sacrum and one in the ilium. There was clear fluid obtained from both lesions, so the walls of both lesions were biopsied.

The eventual diagnosis was of metastases from signet cell carcinoma, probably from the stomach - a gastric mass was found on endoscopy.

Mediastinal mass biopsy - transcostal approach

This is a 20-years old lady who presented with a mediastinal mass, predominantly in the aorto-pulmonary window. A CT-guided biopsy was suggested.

On the contrast-scan, it was possible to delineate the aorta and pulmonary arteries separate from the mass with a 1cm wide window between the two (Figs. 1, 2). Using a transcostal approach (Fig. 3), the cannula was slowly advanced (Fig. 4), until it lay within the centre of the mass, away from the vessels and bronchus. A biopsy was then performed (Fig. 5). This turned out to be lymphoma.

Tranpedicular biopsy of a pedicle lesion - metastasis

This 62-years old man with local pain and tenderness was shown to have a focal L3 pedicular and body lesion on MRI. A biopsy was suggested. The lesion was well seen on the CT (Fig. 1). A COOK bone biopsy cannula was advanced into the pedicle (Fig. 2). Once in place, through the cannula, using an 18G COOK biopsy gun, multiple cores were obtained.

The patient had metastasis from adenocarcinoma, which eventually turned out to be a small lung lesion.

7mm solitary pulmonary (lung) nodule (SPN) biopsy

This 42 years old non-smoker had a small nodule on the chest radiograph. The CT showed a small 7mm nodule in the right apex, with a small central cavity. There was mild enhancement, which made the nodule indeterminate (Figs. 1, 2) and a CT-guided biopsy was offerred to the patient. The patient was extremely co-operative with his breath-holds, allowing accurate needle placement (Figs. 2, 3). Post-biopsy, there was mild peri-nodule hemorrhage (Fig. 4), with hemorrhage along the needle tract upto the pleura, which prevents the occurrence of a pneumothorax.

The report was of a necrotizing granuloma, most likely to be of tuberculous etiology, though acid-fast bacilli (AFB) were not found.