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"Hemorrhage" as a friend in CT guided core needle biopsy
of sub-centimeter pulmonary nodules.
Poster No.: C-1614
Congress: ECR 2013
Type: Scientific Exhibit
Authors: B. Jankharia
1
, N. Burute
2
;
1
Mumbai/IN,
2
Toronto, ON/CA
Keywords: Hemorrhage, Technical aspects, Biopsy, CT, Lung, Interventional
non-vascular
DOI: 10.1594/ecr2013/C-1614
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Purpose
Subcentimeter lung nodules are often difficult to evaluate, especially in the setting of a
known primary elsewhere. They do not show uptake on FDG-PET/CT due to their small
size and apart from a biopsy or on follow-up, there is no other way to get a diagnosis.
The biopsy of small lung nodules can be difficult, especially if they "slip" underneath the
needle/canula tip and then become difficult to pierece.
We would like to report a successful biopsy technique for such sub-centimeter metastatic
pulmonary nodules.
Methods and Materials
A standard lung metastases protocol (1 mm sections at 0.5 mm intervals) on a 64-slice
CT scanner (Somatom 64, Siemens, Erlangen), read using an 8 mm maximum intensity
projection (MIP) protocol identified five nodules, measuring 7.5mm, 8.2mm, 8.5mm,
8.8mm and 9.2mm in maximum diameters respectively, suspicious to be metastatic in
origin.
These were biopsied under CT fluoroscopy guidance using the same CT scanner
(Somatom 64, Siemens, Erlangen, Germany).
In all patients, the coagulation profile was evaluated and a biopsy was performed only if
the parameters were normal. The patient was counselled and trained to perform shallow,
regular breathing.
In all nodules, after the needle was localized on the CT scanner, a 20G coaxial needle
(Quickcore, Cook, Inc) (Figure 1) was introduced into the nodule. If the nodule slipped,
then the gun was fired next to the nodule to induce hemorrhage (3/5) (Figure 2).
Perilesional hemorrhage helped fix the mobile subcentimeter nodule. This facilitated
biopsy by the gun-canula method. A minimum of six cores per nodule were obtained.
Images for this section:
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Fig. 2: Successive images during a typical biopsy of a small nodule (A). (B) shows
the nodule slipping. It is then repositioned (C) and then the gun is fired (D) causing
perilesional hemorrhage (E), which fixes the nodule allowing it to be pierced and biopsied
(E). (F) shows hemorrhage along the needle track after completion of the biopsy.
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Results
Mild perilesional hemorrhage occurred in all five nodules. A small pneumothorax,
measuring 1.0 cm in maximum axial thickness was seen in one patient. It stabilized within
5 minutes and no further treatment was required. None of the patients has hemoptysis.
Adequate diagnostic samples were achieved in all five nodules. All the nodules were
confirmed histopathologically to be metastatic in origin.
Images for this section:
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Fig. 3: Perilesional hemorrhage and pneumothorax: Prone axial CT sections of the
lower thorax post-biopsy; an area of perilesional hemorrhage (red arrow) and a small
pneumothorax (blue arrow) are seen.
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Conclusion
The diagnosis of subcentimeter lung nodules, especially if solitary can be a problem in
the presence of a known primary.
CT-guided biopsy helps to understand the nature of the nodule. However, it can get quite
difficult to pierce these nodules during the procedure.
The induction of perilesional "hemorrhage" allows the nodule to be fixed, especially
with small, slippery nodules. Careful technique with CT fluoroscopy and a gun-canula
technique allows easy biopsy of such nodules.
References
1. Libby DM, Smith JP, Altorki NK, Pasmantier MW, Yankelevitz D, Henschke CI.
Managing the small pulmonary nodule discovered by CT. Chest 2004;125(4)1522-9
2. M Gould, Fletcher J, Lannettoni M, Lynch W, Midthum D, Naidich D, Ost D.
Evaluation of Patients with Pulmonary Nodules: When Is It Lung Cancer? Chest
2007;132(3)108S-130S
3. Wallace M, Krishnamurthy S, Broemeling L, Gupta S, Ahrar K, Morello F, Hicks M. CT-
guided Percutaneous Fine Needle Aspiration Biopsy of small (<1cm) pulmonary lesions.
Radiology 2002;225(3)822-8
4. Ng Y, Patsios D, Roberts H, Walsham A, Paul N, Chung T, Herman S, Weisbrod G.
CT guided percutaneous fine needle biopsy of pulmonary nodules measuring 10mm or
less. Clin Radiol 2008;63(3)272-287
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