0:00

so let's look at

0:02

real-world cases demonstrating diagnostic reasoning

0:05

and some potential complications that you may

0:08

arise in the setting of image guided bone biopsies.

0:11

So we have 49 year old woman with a history of cervical cancer

0:14

Complicated by complex fistula. And now she's

0:17

presenting with pelvic pain foul smelling vaginal discharge

0:20

and fevers.

0:21

Survivals are as follows a little bit of a low soft

0:24

blood pressure 90 over 62.

0:27

High temperature 102.1 degree firing

0:30

Aid and little respiratory rate that some would

0:33

elevated at 22 breaths per minute.

0:35

So she status post chemotherapy. She had some Breaky therapy

0:38

that was performed and she has a descending Loop

0:41

coloscoping. She had a partial suspectomy and

0:44

they saw pingal loophorectomy. So the patient sent

0:47

to us for a CT scan of the abdomen and

0:50

pelvis.

0:51

So in the reading room, what do we see?

0:54

axial CT

0:56

formed evaluating the patient see if

0:59

anything catches your eye.

1:06

So what was noted is the quadrai

1:09

there was some bilateral Hydro you

1:12

read her in the frosis. We had the ureters draining

1:15

into the right low quadroneleal conduit. We

1:18

had some fat stranding around the left kidney which

1:21

is suspicious for pylo and then there was some post-surgical

1:24

changes that were setting of partial suspectomy and

1:27

left local orange and colostomy, but

1:30

we saw as a little thick wall collection deep

1:33

fried pelvis pockets of air consistent

1:36

with abscess.

1:38

So let's take a look here. So what do we want to do? So the patient

1:41

started on an appropion antibiotic regimen undergo surgical

1:44

drainage arabcess?

1:46

So she becomes a febrile and hemodynamically stable.

1:50

Given the concern for her cervical cancer occurrence. She

1:53

is referred for pet scan by

1:56

her gynecologic oncologic surgeon.

2:00

So in the reading room

2:02

Let's review her pet scan.

2:09

So let's take a look and see if we were drawn to

2:12

the same thing here.

2:13

So there was a known abscess in the right pelvis.

2:16

And what was thought is that there was peripheral

2:19

intense hyper metabolic uptake. Okay

2:22

that likely involves the adjacent musculature.

2:25

So the cranial portion was thought the potentially

2:28

invade the S1 vertebral body where a

2:31

loosened Focus seem to potentially represent

2:34

either malignancy or osteomyelitis.

2:38

So what next?

2:41

The next step is to perform tissue sampling.

2:43

So I would say that the sacral region

2:46

is one of the harder regions to biopsy.

2:49

The reason being is because in this particular site.

2:53

The lamina are a little different in the

2:56

sacral region than the laminar are in the lumbar region

2:59

or the thoracic region.

3:01

There are the sacral foramen.

3:03

Which we see here these little ovoid areas.

3:07

And that's with the nerves or exiting. So we

3:10

need to go precisely through.

3:12

The region between the sake

3:15

of ramen in order to go to get to

3:18

that site in question, which is pre-sacral in

3:21

nature. Okay, she recycle and location.

3:23

So the patient was comes to IR with requests

3:26

for this biopsy of the sacrum in order to

3:29

distinguish between osteomyelitis and malignancy with question of potentially

3:32

sort of accessing this site. That's pretty

3:35

sacral in nature in order to assess for whether

3:38

it may be osteomyelitis and malignancy

3:41

or osteomyelitis versus malignancy.

3:46

So the procedure is performed by a transpendicular route

3:49

using an 11 gauge biopsy needle when

3:52

the iron question performs this

3:55

foul smelling pus

3:57

and blood are aspirated along with

4:00

them bony fragments. So what do we do with this?

4:03

We return the patient to the floor ensure that

4:06

she's stable.

4:07

Follow up with the guy on team.

4:10

So the question for you is which of

4:13

the following lab tests should actually be ordered in this patient.

4:17

Should be send that person blood and fragmented bone

4:20

tissue for surgical pathology analysis.

4:23

Should we send it for anaerobic culture and sensitivity

4:26

should be sent for fungal culture and

4:29

sensitivity or should be selling for all of the above.

4:33

Well, we would send it for all of the above. And why do you ask? Well, I

4:36

mean this patient may have super infected

4:39

recurrence of a cervical cancer several cancers,

4:42

one of those malignancies that I can really tear

4:45

across anatomic planes, but because of the

4:48

nature of the locations that are involved in the fistulas that

4:51

could be created between bowel and the reproductive organs

4:54

there could be super infection in

4:57

that region as well. So absolutely surgical

5:00

pathology should be sent along with

5:03

wide-ranging tasks for underlying organisms. And that's

5:06

why the fungal would be submitted and so we're looking for

5:09

anaerobic as well as an aerobic bacteria.

5:12

In addition to fungi capable of causing osteomyelitis. So

5:16

again surgical pathology as well as

5:19

microbiology analysis.

5:21

So what did the lab report reveal? Well, the

5:24

microbiology specimen was positive for gram-negative rods

5:27

as well as gram positive coxane impairs

5:30

suggesting the patient certainly did

5:33

have super infection.

5:35

So what about the circle pathology the tissue that we submitted in sight

5:38

to fluid for psychology analysis

5:41

or the fluid that was submitted informal and

5:44

surgical pathology analysis. Well that came back

5:47

as metastatic squamous cell carcinoma consistent with

5:50

the patient's primary cervical cancer. So imagine if the

5:53

Radiologists had just sent this particular foul

5:56

smelling fluid for an infectious workout.

5:59

Just the microbiology. We would have missed the fact that

6:02

this patient had an infection in addition to metastatic

6:05

scream a cell carcinoma consistent with

6:08

a primary cervical cancer. So we always want

6:11

to be mindful that we are leaving

6:14

a patient based on what we

6:17

suspect.

6:18

infection versus cancer and

6:21

or both

6:24

so in conclusion

6:25

the guy in team

6:27

concludes that the patient's abscess is actually due to a complex visualization

6:30

that occurred in the setting of her current cancer.

6:34

She started on Ivy broad spectrum antibiotics with

6:37

anaerobic coverage specifically for the bugs and question.

6:41

And the patient was ultimately transition to all antibiotics and

6:44

then discharge plan was for heard

6:47

of delayed pelvic exaggeration surgery in

6:50

order to allow for improvement in inflammation

6:53

secondary to the underlying localize

6:56

infection.