Presentation
Right middle lobe endobronchial mass - confirmed adenocarcinoma. Past history of TB. Left upper lobe subpleural lesion. Cardiothoracic surgeon queries nature of second lesion.
Patient Data
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The skin surface markers have been placed over the anterior left chest - the only viable potential route for biopsy given the high location of the lesion.
The scapula is obstructive posteriorly and the subclavian vessels and ribs laterally.
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The CT fluroscopy data is present in one cycle from the procedure - acquired using 'i-spiral' technique.
The initial infiltration needle, co-axial needle siting, subsequent advancement before biopsy acquisition and post biopsy check for pneumothorax are shown.
A pneumothorax is evident on a CXR performed the following morning - the most common complication of a lung biopsy.
Initial conservative management.
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24 hours later the pneumothoarax was significantly larger.
A pleural drain was inserted.
Case Discussion
Modern CT machines with a 32 slice and above capability offer CT fluroscopic functions for use in CT guided procedures.
This has several advantages:
a. More control to operating radiologist
b. Speedier procedure
c. Lower dose procedure
Initial systems allowed for a single slice to be shown - this had its limitations. However, one can now acquire 3 images (head, center, feet) given much more confidence on the exact needle position.
The process of biopsy remains otherwise the same, with a flawless biopsy ( no repositioning due to angulation of patient movement ) having 5 steps.
A. Image aqusition with markers to plan approach.
B. Check of maintained position and angulation planning with infiltration needle.
C. Co-axial insertion - check correct route prior to pleural breech.
D. Advancement of co-axial needle to lesion and biopsy aqusition.
E. Post biopsy pneumothorax check.