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So let's review a video of an eye or

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actually performing an image guided biopsy of an introdominal

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lesion.

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We have a 16 year old female with a past medical

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history of right lung adenocarcinoma with noon involvement

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of the contralateral lung.

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Now undergoes surveillance CT.

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Here to the right we have cd demonstrating the patient's known right

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lung adenocarcinoma.

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So the patient feels particularly. Wow, overall and

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really has no complaints except for nausea vomiting which

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is apparently from the chemotherapy and

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the radiation.

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So in the reading room, what do we see?

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So if you saw this kudos to

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you.

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So what did the impression read the impression read? We have a

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focal 1.1 centimeter soft tissue nodule along

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the peritoneum in the left of a quadrant no evidence

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of ascites free or fluid collection.

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So what are the next steps the patient's abdominal one

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nodule is particularly worrisome for potential metastasis of

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her primary lung cancer.

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She's ordered for a pet scan for further evaluation to assess the

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hyper metabolic nature of this little

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finding.

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So what do we see?

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well

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If you identified this little guy kudos to

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you again, so what did the impression read the

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impression read that this was a single small but enlarging peritoneal nodule

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in the left upper quadrant that was concerning for

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peritoneal metastasis. It was too small for characterization

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with pet and a biopsies is recommended and oftentimes

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eight millimeters is the order

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in which a pet can actually really truly characterize a

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lesion in question.

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So let's review our procedural steps here.

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We see the grid being placed on the

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abdomen.

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Scout performed and this is the region that our

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CT initial CT was performed from the

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cranial region to the cephalad region

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What's the next thing that we are doing?

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We review the initials topograph.

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the initial CT shows our radio

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pick markers on the skin

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we see from laterally we see the fourth marker.

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And the distance to the lesion in question.

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and then the

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three numbers that we want to take in

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mind in order to triangulate the needle approach or

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then noted and what does that entail?

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That until the lateral grid position here. We

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have the fourth marker from both medial

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and lateral.

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We have the depth of the lesion in this particular

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case. We note that depth.

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and then finally, we note the actual

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Slice on the CT in this

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case I 2 17.5

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And that allows us to triangulate exactly

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where we want to be.

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On the skin surface on the radio pick

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marker. We then line up the grid mark

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on the skin surface the laser pointer

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in order to triangulate the particular point in

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which we're going to enter the patient's skin. So now we have

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three markers. We have the lesion dap from the

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skin to the lesion in question. We have

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the CT level slice and we have to tap.

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From the skin to the lesion from

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the middle fourth Radio

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pick marker.

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So we sterilize with chlorhexidine.

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You place a four tile border?

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and we prepare to

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move forward with our sterile feel

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So once this four tall border is obtained.

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Then a drape is placed over the top of that

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region in order to complete the sterile

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feel.

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The Radiologists then draws up. It's

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a range of 1% Lidocaine with the help of the staff member.

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And then we evaluate the table to ensure that we have the appropriate equipment

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and question. We have our lidocaine

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needle check filled syringe labeled.

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We have our biopsy needle in this case a side cutting needle.

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spring loaded four core biopsy

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We have our sample container in this case a sterile

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cup with saline.

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We also have some Betadine in the event that we place our

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biopsy needle in formalin off the

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table in order to advance our

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sample in formalin for submission for

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surgical pathology analysis. We then can place our

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biopsy needle back in the beta 9 which is an antiseptic as

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well as a desiccant in order to cleanse and

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then dry our needle on a gauze

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to proceed with repeat biopsy.

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The Radiologists then of teens drug control of the CT scanner.

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And then the biopsy track is in a NASA ties and Lidocaine needle

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slept in place to guide the biopsy needle

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through the same puncture site.

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Nice Dremel wheel is obtained that the skin site.

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and then the

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lidocaine is administered more deeply along

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the intended trajectory.

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The initial trajectories confirmed the CAT scan and

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what we can see here is the laser pointer

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is lined up with the Hub of the needle as

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well as where the needle crosses at that

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particular site on the skin.

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The next step is for the initial Place lidocaine needle

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which was placed as a guide for the

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introducing needle then to be placed just adjacent to

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that site in line with the anticipated trajectory.

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of the intended biopsy

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the lidocaine needle is then removed.

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The trajectory of the introducing needles then reconfirm a

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CT again. Noting that the laser pointer

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is

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in line with the Hub of the needle the shaft of

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the needle even during respiration ensuring that

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everything is in line.

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The Stylist is then removed from the introducing needle in

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the biopsy needle is placed through the introducer Hub.

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in this particular case given that the

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anterior abdominal wall lesion is particularly superficial

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this of note is actually a short introducer when

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your order of about five centimeters. And so what

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the radiologist does is knowing that five

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centimeters is actually very short

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and this is just anchored into the anterior abdominal

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wall. There is a possibility that with the weight of

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the biopsy needle that this introducer could fall out during respiration.

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So to achieve further

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support of the introducer the radiologist

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actually supports it with the fold that Sarah towel and

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this helps to guide and support the intended

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trajectory to the side of the biopsy.

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So with the sterile towels in place.

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The radiologist confirms the final trajectory of the

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biopsy needle before firing it.

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for core needle sampling

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once it's fired.

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The biopsy needle is then removed then the stylist

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is replaced in the introducer.

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The radiologist deposits the sample in a container formulin

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for histopathologic analysis.

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note that the

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tip is gently flipped

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off the bottom of the sterile container.

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and then

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the operator takes that same needle

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in the Betadine who's in retracts

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the needle to back and forth and then dries it

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removing the Betadine off of the needle tip.

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The biopsy needle is now Place once again through the introducer the

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radiologist then turns rotates the

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needle 90 degrees which equates to about a quarter turn to sample the

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new area of the lesion.

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The cycle of CT confirmation natal firing

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in the sample deposition is then repeated.

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and so this end cutting needle

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it allows that in cutting needle with every 90 degree

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quarter turn rotation to sample a

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new site.

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So once about four

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20 gauge core biopsy samples have been obtained

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in this particular site. The introducer in stylets are

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removed manual hemostatic pressure is applied. The track

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is sealed with an adhesive bandage.

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So in conclusion, the patient's pathology actually returned.

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Several days later and reveal the final diagnosis of

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metastatic adenocarcinoma. The patients

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oncologist was notified and a new found

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peritoneal carcinitosis was identified

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causing the oncologist to

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escalate a therapeutic regimen appropriately.