0:00

So let's talk about case four.

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So where we have a 66 year old woman with history of hepatitis C

0:06

and endometrioid carcinoma status

0:09

posts tabso one year prior.

0:12

The patient reports localized pain in the right fifth rib following

0:15

a minor fall, which was worse than by breathing.

0:18

She currently is undergoing weekly radiation and

0:21

chemotherapy and follows regularly with her gynon provider.

0:24

She scheduled for reassessment of disease staging

0:27

via PET scan.

0:29

So, let's see what we see in the reading room.

0:37

So it catches our eye well, perhaps this

0:40

does.

0:42

an intensely hypermetabolic lesion in the right fifth Rib

0:45

posteriorly was noted to have our underlying letter component

0:48

by the

0:49

nuclear medicine doc

0:51

punctate hyper metabolic lesion in the right seventh rib,

0:54

in addition to there's an ill-defined hyper metabolic

0:57

activity in the left pelvic side wall.

0:59

So overall the concern is obvious lesions

1:02

consistent with metastases.

1:05

so next steps

1:07

Patients referred to Interventional Radiology for biopsy

1:10

of one of the hypermetabolic lesions and the

1:13

rib lesion was deemed to be the most appropriate one to Target.

1:17

So during biops even obvious lesion in the rib, should the cartil of

1:20

the cephalot portion of lesion be targeted.

1:23

Well, the cephalon region should be

1:26

targeted and the region being is because as we can see here.

1:30

The neurovascular actually courses

1:33

within the groove just below the ribs. So

1:36

if we go

1:37

Below the ribs. We would be perhaps at

1:40

risk of traversing the neurovascular bundle. So

1:43

we go above cephalot to avoid

1:46

these to prevent bleeding and pain and other neuropathies

1:49

that could result.

1:51

so next steps

1:53

the patient undergoese an uncomplicated CT guided

1:56

core needle biopsy.

1:57

we see the

1:59

operator traversing the skin

2:02

soft tissues and into the

2:05

fifth plus year rib lesion question

2:08

Sample is submitted in formal and incentive pathology.

2:12

So the path report.

2:14

Shows what benign fibrous tissue with woven and

2:17

Lamela bone but no evidence of malignancy seen

2:20

in spite of this evidence that perhaps the

2:23

patient has multiple metastatic Foci

2:26

seen on their nuclear medicine

2:29

Imaging scan.

2:33

So what are our next steps?

2:36

In the intervening months the patient continues to report worsening of

2:39

back pain the pain no longer control with oxycodone and

2:42

its growing to become rather diffuse. She's referred

2:45

for repeat PET scan.

2:48

So in the reading room now.

2:50

What are we seeing?

2:58

So impression here is focused on the following.

3:02

There's progression now of radio Trace uptake in

3:05

the previous observed rib lesions.

3:07

This one is the one that we targeted before so we'll

3:10

use this one for reference.

3:12

There's now a new pathologic fraction with mass in the

3:15

posterior. Right fifth. There's also a new focus of

3:18

uptake at T10.

3:20

Findings overall a consistent with progression of metastatic disease.

3:24

So what next?

3:26

so now we take

3:29

a more medial route. We target the soft tissue

3:32

focus and question within this rib that's

3:35

expanding it and we target the soft

3:38

tissue component.

3:39

Being sure that we avoid traversing a

3:42

violating the pleura that's underlying it.

3:45

And so in this repeat CT guided biopsy of the posterior

3:48

fifth rib lesion.

3:49

We actually using softer approach

3:52

and that entails using a side

3:55

cutting.

3:57

Biopsy needle that's Advanced into the soft tissue

4:00

area pretty easily in this particular case a biopsy

4:03

throw that about 10 millimeters

4:06

is Advanced ensuring that

4:09

the tip does not end up Crossing through the lesion into the plural risk

4:12

anumothorax.

4:14

What is the path report say here?

4:16

Sample that was fixed in formula and sent for pathology demonstrates

4:19

metastatic and no carcinoma consistent

4:22

with malarian origin.

4:24

This is likely metastasis from the patient's

4:27

primary endometrioid adenocarcinoma.

4:30

So what feature of this patient's initial lesion most

4:33

likely led to a negative tissue diagnosis following biopsy. Was

4:36

it patient movement during the procedure?

4:38

Was it the size of the rib lesion? Was it

4:41

the scan soft tissue component, or was it

4:44

the pathologist error?

4:46

It was a scan tissue that was soft tissue

4:49

specifically in this question. What we see

4:52

here is not really the expanse Style.

4:55

Soft issue lesion that we saw in the more recent expanded,

4:58

Mass.

5:00

This was just pretty much bone small loose and lesion and as

5:03

we know the soft tissue lesions end up being the ones that

5:06

have the higher diagnostic heel.

5:08

So we know that metastatic bone lesions May induce reactive deposition of

5:11

osteus material obscuring specimens of

5:14

diagnose utility soft. As you components are

5:17

more likely to contain identifiably malignant tissue, which

5:20

is why we had higher diagnostic

5:23

yield and the subsequent case.

5:26

In conclusion oncology team is notified of the histologic

5:29

diagnosis and response to upstaging of

5:32

the patient's primary cancer radiation and chemotherapy regimens are

5:35

escalated.