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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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History
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▶ Positron Emission Tomography Scan Performed in the Workup of Newly Diagnosed Breast Cancer
Biopsy of this solitary positron emission tomography (PET) positive lesion was requested.
Figure 10.1
Case 10
Figure 10.2
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Case 10 Positron Emission Tomography–Guided Biopsy
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Figure 10.3 Figure 10.4
Figure 10.5
Findings
▶ Afocus of uorodeoxyglucose (FDG) activity is seen in the posterior le iliac bone (Fig. 10.4) that does not
have a correlate on the computed tomography (CT) from the same level (Fig. 10.3).
▶ Using positron emission tomography (PET) guidance, a core biopsy needle is show within the PET avid le
iliac bone lesion (Fig. 10.5). Pathology conrmed the presence of a metastasis from the patient’s known breast
cancer.
Teaching Points
▶ PET imaging is useful to target lesions that are FDG avid, but without imaging correlate on other cross-
sectional imaging modalities more typically used for biopsy. Another use for PET-guided biopsy is to target
the FDG avid regions of a lesion with heterogeneous activity.
▶ In this case, previous biopsy performed using landmarks was nondiagnostic. Bone marrow lesions are usually
quite visible on magnetic resonance (MR), and this lesion could have more easily been sampled under MR
guidance. However, this patient had a brain aneurysm coil precluding MR.
▶ When molecular diagnostics (e.g., EGFR, KRAS, BRAF) are required, biopsy of so tissue rather than bone is
preferred because the process of decalcication is usually performed with strong inorganic acids that results in
signicant degradation of both DNA and RNA in the sample.
▶ Misregistration of the PET and CT images is common in the upper abdomen due to respiratory motion. In
some cases, long breath holds facilitated by intubation to maximize coregistration may be used. is is not
usually an issue for lesions in the pelvis.
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Management
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▶ For PET-guided biopsy, the radiotracer should be administered intravenously at least 45 minutes prior to
obtaining images. Acquisition time varies widely; if breath hold is required, images can be obtained in under
2minutes.
▶ e dose required for biopsy guidance is less than that of a diagnostic PET. At our institution we use a dose of
4–6 mCi, and acquisition time ranges from <2 minutes when breath hold is required to 20 minutes for more
diagnostic quality images.
▶ e radiation emitted from the patient is extremely low, and pregnant sta do not need to take any specic
precaution except to avoid contact with the patient’s urine.
Further Reading
Ryan ER, Sofocleous CT, Schöder H, etal. Split-dose technique for FDG PET/CT-guided percutaneous ablation:a method to
facilitate lesion targeting and to provide immediate assessment of treatment eectiveness. Radiology. 2013; 268(1):288–295.
Venkatesan AM, Kadoury S, Abi-Jaoudeh N, etal. Real-time FDG PET guidance during biopsies and radiofrequency ablation
using multimodality fusion with electromagnetic navigation. Radiology. 2011; 260(3):848–856.
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Case 11
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History
▶ Two Dierent Patients with Lung Cancer Status post Contralateral Lung Resection Presented for Biopsy of
Adrenal Masses
How would you minimize the risk of pneumothorax in the remaining solitary lung?
Figure 11.1
Figure 11.2
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Case 11 Adrenal Biopsy
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Figure 11.3
Figure 11.4
Figure 11.5
Findings
▶ Contrast-enhanced computed tomography (CT) images in two dierent patients demonstrate hypervascular
lesions (Figs. 11.3 and 11.5) with areas of central necrosis in the le and right adrenal gland, respectively.
▶ In the rst patient, le-side-down decubitous position (Fig. 11.4) was used to perform core biopsy. In this
position, the needle has been advanced into the le adrenal gland avoiding aerated lung. Note that the
nondependent right lung is seen at the same level.
▶ Atranshepatic approach to adrenal biopsy was successfully performed in the patient with the right adrenal
mass (Fig. 11.6).
Teaching Points
▶ If adrenal adenoma, which occurs in 2%–8% based on autopsy studies, is considered in the dierential of an
adrenal lesion, dedicated adrenal imaging with multiphase CT or magnetic resonance (MR) may clinch the
diagnosis without the need for biopsy.
▶ Prior to biopsy of adrenal mass, consideration should be given to the possiblity of a catecholamine-producing
pheochromocytoma. Pheochromocytoma follow the “rule of 10”:10% malignant, 10% bilateral, 10%
extraadrenal, and 10% hereditary.
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Figure 11.6
▶ ere are several approaches to adrenal biopsy. Prone position is very common but has an increased risk of
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transpleural needle pass and resulting pneumothorax (even when there is no interposition of lung seen on the
prebiopsy, supine CT). Ipsilateral-side-down decubitus compresses the lung and in some cases can be used to
avoid pleural puncture and the risk of pneumothorax. To access right adrenal lesions, a transhepatic approach
may be considered. Alternatively, a subdiaphragmatic approach may be performed with the patient prone
using ultrasound or MR, or by tilting the CT gantry.
Management
▶ If pheochromocytoma is in the dierential, 24-hour urine catecholamines should be performed prior to
biopsy. If elevated and a biopsy is still indicated, pretreatment with alpha blockade should be considered to
avoid hypertensive crisis.
▶ Because the adrenal gland is a common site of metastatic disease, biopsy of the adrenal tumor (as opposed to
the suspected primary) has the potential to provide information for staging as well as tissue diagnosis. ere
are some data to support that the diagnostic yield from biopsy of metastatic disease may be higher than that of
the primary in lung cancer.
Further Reading
Tam AL, Kim ES, Lee JJ, etal. Feasibility of image-guided transthoracic core-needle biopsy in the BATTLE lung trial. J orac
Oncol. 2013; 8(4):436–442.
ompson GB, Young WF Jr. Adrenal incidentaloma. Curr Opin Oncol. 2003; 15(1):84–90.
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History
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▶ A62-Year-Old Female with Postprandial Pain
Figure 12.1
Case 12
Figure 12.2
Figure 12.3
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Case 12 Transcaval Pancreatic Biopsy
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Figure 12.4
Figure 12.6 Figure 12.7
Figure 12.5
Figure 12.8
Findings
▶ Asingle image from a contrast-enhanced computed tomography (CT) (Fig. 12.4) shows a 1.2cm mass in the
uncinate process of the pancreas (arrow).
▶ Endoscopic ultrasound-guided biopsy of the mass (arrows) was performed (Fig. 12.5) but yielded a
nondiagnostic specimen.
▶ Percutaneous needle biopsy using a posterior transcaval approach (Fig. 12.6) clinched the diagnosis of
pancreatic cancer.
▶ CT from a dierent patient with a cystic pancreatic head mass (Fig. 12.7) with an enhancing mural nodule
(arrow) who subsequently underwent endoscopic ultrasound-guided biopsy. Several days following biopsy
the patient complained of abdominal pain, and a second CT was performed (Fig. 12.8) demonstrating acute
pancreatitis with multiple developing pseudocysts. Biopsy conrmed a branch duct intraductal pancreatic
mucinous neoplasm.
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Teaching Points
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▶ Pancreatic biopsy may be performed using endoscopic ultrasound guidance. Compared to percutaneous
biopsy, endoscopic biopsy has higher yield for small lesions, may detect peripancreatic lymph nodes, and
minimizes the risk of tract seeding (see Case 103). However, this technique is highly operator dependent and
not all lesions are accessible.
▶ Fine-needle aspiration biopsy of uncinate and pancreatic head masses may be safely performed using a
transcaval approach. Alternatively, in some cases, an anterior transgastric approach may be possible.
▶ Complications include bleeding, tract seeding, and acute pancreatitis.
Management
▶ e need for preoperative biopsy in patients with resectable pancreatic masses is controversial. Indications
for biopsy of a resectable lesion include diagnosing a lesion that would not be treated surgically, for example,
lymphoma, focal autoimmune pancreatitis, or a pancreatic neuroendocrine tumor that potentially could be
enucleated and not require a pancreaticoduodenectomy.
▶ Identication of the right renal artery should be made prior to biopsy to avoid inadvertent puncture of this
vessel.
Further Reading
Sofocleous, CT, Schubert J, Brown KT, etal. CT-guided transvenous or transcaval needle biopsy of pancreatic and
peripancreatic lesions. J Vasc Interv Radiol. 2004; 15(10):1099–1104.
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History
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▶ Abdominal Pain and Jaundice Elevated Amylase and Lipase. What is the most likely diagnosis?
Figure 13.1
Case 13
Figure 13.2
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