The initial CT chest, abdomen and pelvis revealed bilateral para-aortic lymphadenopathy.   No primary source was detected.  No supra-diaphragmatic lymphadenopathy.

CT guided biopsy with a 18G co-axial needle performed with the patient in the prone position.

This offered the safest, most assessible route for the least invasion way to make a definitive diagnosis.   

With the co-axial needle tip 'parked' just before the chosen lymph node, with a 2cm throw, the renal vessels draped over the anterior aspect of the lymph node are not in danger.

Histopathological analysis confirmed a anaplastic lymphoma.