CT guided lung biopsy - fluroscopic method

Case contributed by Dr Ian Bickle

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

Age: 70
Modality: CT

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.

Modality: CT

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.

Modality: X-ray

A pneumothorax is evident on a CXR performed the following morning - the most common complication of a lung biopsy.

Initial conservative management.

Modality: X-ray

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, centre, 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.

 

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Case Information

rID: 30802
Case created: 4th Sep 2014
Last edited: 9th Jan 2016
Inclusion in quiz mode: Included

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