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 approach. Aspirated blood from the disc and end-plates. The culture was E.coli.

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 to get 3 cores, before I stopped, fearing that the gun tip would go through one of the adjacent vessels.

The diagnosis was adenocarcinoma.

The patient was very co-operative and that helped. The decubitus position also helps with better breath-control. The procedure was done in free breathing.

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 to get 3 cores, before I stopped, fearing that the gun tip would go through one of the adjacent vessels.

The diagnosis was adenocarcinoma.

The patient was very co-operative and that helped. The decubitus position also helps with better breath-control. The procedure was done in free breathing.

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-operative and it was possible to maneuver the needle into the lesion without bleeding or pneumothorax using a 20G coaxial biopsy gun. The diagnosis was adenocarcinoma.

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 to the upper pole of the kidney using a 20G coaxial biopsy gun.

The diagnosis was metastasis, consistent with a squamous cell tongue primary.

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 of the mallet is sufficient to push the needle through. The only disadvantage is the inability to maneuver the needle if needed.

The diagnosis was thymoma WHO B type. There was no complication.

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 straightforward and showed recurrent squamous carcinoma of thymus.

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 coaxial biopsy gun, I went in straight and again injected a little more saline to complete the separation and managed to get into the node using an extra pleural approach.

The diagnosis was non-caseating granulomatous disease and in view of the lung lesion, she was treated for tuberculosis.

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 complication to worry about is a pneumothorax. When it is already present and the patient has a chest tube, then even that is no longer an issue and we can go through the pneumothorax or as in this case, the hydronpneumothorax and safely biopsy the lung lesion.