This 50-years old lady had infectious spondylitis at C6/7, with marrow edema and epidural soft tissue, and a pattern that is typical of bacterial, non TB infectious spondylitis. The CT showed end-plate irregularity. The plan was to enter the disc and scrape the end-plates. Tried first with a right anterolateral approach with an 18G coaxial biopsy gun, but got no material. Because her neck was short, I couldn’t manipulate more, so then decided to use a left trans-thyroid appr...

This 62-years old lady was found to have a focal lesion in the anterior segment of the right upper lobe towards the apex on a CT scan done for COVID-19 screening. Though the uptake on PET was low, it showed spiculated margins. Morphology often trumps uptake in such lesions. The challenge like in the last case was to get in without injury to the vessels and bronchi. In her case, the lateral decubitus approached seemed more apt, and using a 20G coaxial biopsy gun, I was able t...

This 76-years old man had one episode of hemoptysis. CT scan shows an irregular lesion in the anterior segment of the right upper lobe, partly encasing the segmental bronchi and the vessels at the periphery. The challenge in such cases is to be able to get into the lesion with minimal injury to the vessels and bronchi. It is also very important that the patient co-operates with a good shallow breathing rhythm and does not move. This particular patient was extremely co-operat...

A 70-years old man treated for carcinoma tongue came with a rib mass. The PET/CT also showed a right adrenal nodule and he came for biopsies of both lesions. The right adrenal nodule measured 14 x 9 mm in diameter. Since the lung and pleura would be in the way, in the prone position, the ipsilateral decubitus position was chosen, which splints the diaphragm and allows good access as well. As seen here, it was easy to find a path along the para-vertebral region, just superior...

This is a 53-years old man who had an incidentally discovered prevascular space mass. PET/CT showed no other lesion. He came for a biopsy. The only approach was through the lung, so I chose a trans-sternal approach directed along the long axis of the lesion through the lung using a 20G coaxial biopsy gun. A trans-sternal approach is safe and this can be done without sedation, by just infiltrating the periosteum of the anterior cortex. The bone is thin enough that a light tap...

This is a 67-years old lady who was operated for a sarcomatoid thymic carcinoma. The repeat PET/CT shows recurrence of disease, with spread to the lungs, pleura and the liver. A biopsy was needed to reconfirm recurrence. In her case, an oblique left para-sternal approach using an 18G coaxial biopsy gun allowed a safe biopsy, with the needle tip directed away from the vessels. She had recurrence of disease. ...

This is a 66-years old lady operated for thymoma. A routine follow-up PET/CT showed an active right pleural/extrapleural nodule in the lower hemithorax with another smaller nodule in the subcutaneous fat. She had non-active right pleural thickening and another subpulmonic non-active nodule (arrowhead on the PET image). This may have been due to seeding along an ICD track, but I couldn’t find comparative images with an ICD. The biopsy using an 18G coaxial gun was straightforw...

This is a 52-years old lady operated for thymoma. She presented with left sided chest pain and a PET/CT showed subpulmonic nodules on the left. Dry pleural metastases are known with thymomas and a biopsy was performed using a 20G coaxial biopsy gun in the right lateral decubitus position. The decubitus position helps with breath-control and in this case also allowed easier and simpler access to the lesion. The diagnosis was recurrence of thymoma. ...

This 30-years old lady presented with fever and a large right paratracheal node. The working diagnosis was lymphoma, given its homogeneous appearance and size. While the nodal mass is easy to biopsy, I did not want to go through the lung. In the prone position, I first inserted a 20G spinal needle obliquely into the space between the pleura and the vertebral body and then injected a combination of saline and local anesthetic. There was adequate separation. Then using an 18G ...

This 81 years old lady presented with a hydropneumothorax. A CT scan showed a possible mass in the atelectatic right upper lobe. A PET/CT confirmed a mass with uptake. She came with a chest tube for a CT guided biopsy, which made the biopsy very simple and straightforward. The biopsy, using an 18G coaxial biopsy gun was uneventful. Enough material could be obtained for all the mutation studies, which included EGFR, ALK, ROS1, PDL1. Apart from hemorrhage, the only other compl...

This is a 55-years old lady treated for carcinoma breast. A post-chemo PET/CT showed a new left internal mammary node as compared to an earlier normal PET/CT. The node was non-necrotic. In such instances, a biopsy is mandatory to differentiate metastasis from infection. There wasn’t a clear para-sternal route, so instead of mucking around, we sedated her and went through the overlying costal cartilage, with an 18G coaxial biopsy gun. The diagnosis was metastasis from carcino...

This 16-years old boy presented in 2011 with waxing and waning pain in the hips and back. The MRI at the time (top row) showed areas of marrow edema in both femoral necks and the sacral alae. Another MRI a year later showed regression with a new iliac crest lesion (not shown). He was thought to have CRMO (NBO) and treated accordingly. One more year later when his symptoms increased, the MRI (bottom row) showed classic asymmetry sacroilitis and he was diagnosed to have a juve...

This 8-years old girl presented with pain in the right hip. The radiograph showed areas of osteolysis and sclerosis in the right femoral neck and greater trochanter and in the right iliac crest. The MRI showed another lesion in the left acetabular roof. All 3 lesions were well seen on CT scan. A CT guided biopsy of the lesion involving the right trochanteric physis and subjacent bones was negative for any definitive etiology.   Based on the multiple lesions and the clinical ...

This 19-years old boy had a left clavicular swelling. CT showed dense sclerosis and cortical thickening. The MRI also showed marrow and periosteal edema. Two biopsies were negative for everything. Whole body MRI showed this to be the only lesion. Based on all this, he was labeled as CNO and responded to anti-inflammatory medication. ...

This 39-years old woman presented with manubrio-sternal pain. She had met many doctors with no respite. One surgeon thought of an osteoid osteoma and sent for an MRI., which revealed no abnormal focal enhancement. Since the MRI showed an arthropathy, I did a CT guided biopsy, which was negative for everything. Based on all this, the physician eventually labelled her as CNO and treated her. She responded well. ...

This 16-years old girl presented with sacral pain. She had an aggressive looking lesion on MRI but without significant enhancement of the soft tissue and without much uptake in the soft tissue, though there was bone uptake and marked sclerosis. She had 3 biopsies, all negative for malignancy or a specific infection. Once she was labeled as chronic non-bacterial osteitis (CNO) and put on appropriate treatment, she improved clinically. CNO encompasses the earlier terms of chro...

This 70-years old man with COVID-19 has a CT scan showing typical lung findings. He also has bilateral adrenal hemorrhage in the upper abdomen, which was unsuspected clinically. There have been a few case reports of patients with adrenal hemorrhage and insufficiency in the setting of COVID-19, likely related to a coagulation disorder. This can be life-threatening causing acute adrenal insufficiency. Unfortunately, this patient did not survive. He collapsed the next day befor...

This 60-years old man came for a CT KUB, which shows a right ureteric calculus. The lower lobe lung images that are always captured on a CT scan of the abdomen show changes of COVID-19, for which the patient is and was asymptomatic. Are these new or old or resolving or active? I guess an antibody test would tell us whether the patient has been infected in the recent past and an RT-PCR test would tell us whether the patient is current infected or not. However we have no idea ...

This 53-years old man came with a recent inferior wall infarct, for viability imaging. The top left image shows the inferior wall infarct with a thrombus (arrow). The HASTE and contrast VIBE MRI images showed wedge-shaped areas (arrows) of altered signal in the posterior segment of the left upper lobe and the superior segment of the left lower lobe of the lung. A CT scan done immediately thereafter shows typical COVID-19 lung changes (arrows) in the same segments and the dia...

This 52-years old lady also came for a follow-up PET/CT for Ca breast evaluation. She had been COVID-19 positive in the first week of August and hospitalized. Unfortunately the Augst scan is not available. The lung shows typical findings of post COVID-19 sequelae with no significant uptake on the PET. In about 8 weeks, the activity has regressed. But are these regressing residual lesions with regression of active inflammation or is this already fibrosis? It is hard to tell. ...