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So let's look at a video of an actual IR performing

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an image guided bone biopsy.

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So this is a 64 year old female with past

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medical history of chronic severe anemia malnutrition and

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no prior cancer screening who not presents with about one month

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of increasing fatigue and intermittent bright red blood in the

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stool with Associated diarrhea. So this week the patient

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notice Rapidan said growth on her left clavicle.

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She went to a primary care physician where she was found out the

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hemoglobin of 2.9 and then she was

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referred to the emergency room. Here. We see the patient.

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in an image to the right

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Here we see an initial in the region of

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her Delta vectoral groove on the left by the

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operator ensuring that the site was marked. And

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this was one of the important things that are noted during

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the timeout that site is marked.

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As noted by The Operators initials

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to the left. And then what we see here is also the

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region where this individual

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has a little bit of a protuberance in their

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left clavicle.

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The vital signs for the person is stable.

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They have a little shoddy cervical and vaginopathy.

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They have a 5 by 5 centimeter firm non-modalamas

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hemoglobinous 3.1.

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And what we notice is there's a little bit of a low ferritin.

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So the patient was given one unit of packed red blood cells

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as a result.

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As far as Imaging is concerned and non-contin CT of

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the chess abdomen pelvis was then requested.

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So what do we see in?

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the reading room

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Here we see a coronal CT of the chest.

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So what catches your eye?

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So what do we see here on this axial?

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CT of the chassis lucency with

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a bit of moth eating the parents in the region of the

1:55

left clavicular head. We see some Regional

1:58

swelling which corresponds to the silent

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question on clinical examination.

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And so what is our impression is erosion of the left clavicular

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head with Associated super sternal soft tissue,

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Mass.

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And that can be seen here as well in this

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particular region.

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And so as we move through there are

2:20

also scattered hypodensities throughout the liver that were

2:23

incompletely characterized.

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But metastatic disease is not excluded.

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So what are the next steps that we want to take So the

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patient's case is discussing the interdepartmental conference

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and it's agree that our clavicular Mass may

2:38

actually represent metastasis, which is a little concerning. But

2:41

this also thought that perhaps this could be a workout node

2:44

in that region a supercovicular node.

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That's enlarge possibly from a primary GI

2:50

cancer. She's then schedule for CD got it

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biopsy of the lesion.

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So now that we're in the room, what are our procedural steps?

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So the radiologist places the radio pick grid with the radio

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pick markers oriented in

3:04

a cranial card at Direction. The Radiologists achieves

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a scout of the area. Then

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three separate numbers that

3:13

are in particularly important for us to triangulate the needle approach then

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documented.

3:18

So what do we see?

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So this is our initial Scout. We

3:22

have our radio pick grid. We

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see our little markers in question. We then

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select our route specifically from

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that third marker from a

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medial approach.

3:35

To that clavicular head and then

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once that lateral grid position closest to

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the patient's lesion is made.

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We then make note of the depth how many

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centimeters in question from the skin marker to the

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actual lesion in question.

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And then once we move back into the room, we want to

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identify the exact City slice where that

3:59

lesion is best visualize that corresponds to that

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particular location that we selected.

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So this is that location radio pick marker.

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Now we want to actually use a skin marker to

4:11

identify that site. So what we have

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we have the lesion documented we have the actual marker

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on the grid third medial marker.

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And then we have the city slice level three very

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important pieces of information that allow

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us to correlate the image to the anatomic Landmark

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to allow us to then begin our biopsy.

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Here we're performing a line.

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drawing on the patient's skin

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to ensure that we know exactly where we want

4:43

to biopsy from.

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So what comes next?

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So the side of the entry is sterilized with chlorhexidine and

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antiseptic.

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And so what?

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The proceduralist is doing is cross hatching motion

4:56

using the chlorhexidine swab.

5:01

The radiologist then performs eight

5:04

four tall Border in order to

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localize and canvas the Aryan

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question.

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So the four towel sterile board is placed around the sterilized area

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with the site marked.

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So let's look at our table. We have our lidocaine needle

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the biopsy needles the sample container with

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our sterile saline in which we're going to place our sample

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in after it's been harvested.

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We have Betadine in order to clean

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the needle in question after if it's been

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placed in formalin, for example

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So the biopsy needle is then prepared and loaded.

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And what we see here is the introducer.

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We see the biopsy needle we say the sharp style

5:54

at then attached to the introducer.

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So let's look here. The next step for us is to now

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take that depth that intended depth and

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then Mark that on our introducer so we

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know exactly the depth to which we are then entering.

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So that appropriate biopsy depth is marked on the needle Pride

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insertion.

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So now we take our procedural steps a bit further. So

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what we want to do now is to anesthetize the skin

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with 1% or 2% lidocaine. We

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then want to advance that needle to the

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area of concern perhaps as I mentioned before to

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the periosteum and then from there we want to leave the

6:34

needle in place.

6:37

So here the operator has hit

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bone.

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It stopped and then leaves the needle in place.

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That needle in place is then identified to

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be in plain.

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And then once it's left in place this acts

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as a guide for the placement of the biopsy needle which

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then is placed almost juxtapose to

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the site where the lidocaine needle was placed.

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And then once that's inappropriate position

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lidocaine needle is then removed.

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So what happens next?

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so the lidocaine needle

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as we saw was removed the introducing needle

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for the biopsy needle is Advanced using the CT lays

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indicate as a guide here. We see the laser pointer

7:21

directly on the needle shows that it's in plane so

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that you'll be able to see the needle the entire time as it's being advanced.

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So what do we do next Once the

7:30

biopsy needle has actually been stabilized.

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We then Advanced the biopsy needle through the Hub

7:37

to the Aryan question.

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And then perform the biopsy.

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Once we remove the sample,

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we evaluate it in the tree in

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order to ensure that we actually have a sample of

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note inspect. It sure that it's grossly adequate

7:53

that's then placed into the sample medium

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and then given to our nurse or

7:59

outsideopathologists if they're on site.

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Once the exposed biops you need let's place in the

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fluid in this particular case. The needle is

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being placed into formalin and this

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formulin is non-sterile.

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So in a case where the needle is

8:16

being made to be in contact with something, that's not sterile.

8:20

What would need to happen is that needle would then need to be disinfected

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perhaps with Betadine, which is also in addition

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to being an antiseptic drying agent.

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The fluid of course that we're choosing could be formalin.

8:34

Could be a cytofluid which would be sent to

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cytology. It could be rpmi if we suspect lymphoma or

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it could be saline in each case. We may suspect

8:43

infection.

8:44

Here is an example of the operator rinsing

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the needle tip in Betadine to sterilize

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the needle then reintroduce for another biopsy pass.

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So here we have the fluid which is

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aspirated from the side for additional analysis in which

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case this is microbiology cultures.

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This is a little bit of an agitation Motion in order

9:08

to get a sample. That would be appropriate to be

9:11

placed in Saline now.

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Not formalin to be submitted for microbiology

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analysis.

9:18

So once the entry site is revealed after

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the introducer has been removed from the body and adhesive

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bandages then placed over the site. No hematoma

9:27

formation. No losing from the site the

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patient is then okay to then transport to the

9:33

recovery room.

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So in conclusion the path analysis actually for the patient's biopsy

9:39

demonstrated chronic inflammatory changes, there wasn't

9:42

any evidence of malignancy.

9:44

The culture results were actually negative as well.

9:47

And the patient was discharged without any other additional issues

9:50

in order to ensure that this was

9:53

not a GI cancer and that was not missed the patient

9:56

had outpatient workup with their GI doctor

9:59

and as recommended by their oncology

10:02

physician the patient also had

10:05

evidence of severe iron deficiency. Anemia

10:08

That Was Then ultimately managed as well.