Presentation
Weight loss. Suspicion of malignancy. CT conglomerate para-aortic lymphadenopathy. No superficial site for biopsy.
Patient Data
Extensive conglomerate para-aortic low attenuation lymph node mass. Bulk dimensions 8 x 7cm.
The solid organs are unremarkable.
No small or large bowel abnormality.
Minor upper abdominal ascites.
Small left sided pleural effusion.
Comment: Extensive para-aortic lymphadenopathy. Differential is lymphoma, metastatic and less likely TB.
CT chest advised and clinical review of neck to established if any superficial site for tissue biopsy.
If not, CT guided para-aortic nodal biopsy is feasible
No alternative site for Bx identified
The left para-aortic lymph node mass close to the medial aspect of the kidney is the site of targeted biopsy.
Approach via the para-renal space below the level of the thoracic cage.
3cm depth of pathological tissue at this site to accommodate 2cm biopsy throw.
The histopathology of the biopsy identified an anaplastic carcinoma - clinical examination, laboratory tests, imaging investigations and the immunohistochemical staining from the biopsy was unable to location the primary.
FINAL DIAGNOSIS; Carcinoma of unknown origin.
Eventually a gastric cancer was identified at endoscopy.
Case Discussion
Deeper parts of the body, particularly para-vertebral or para-aortic may only be accessed with CT for image guided biopsy.
In this case tissue was required from a para-aortic lymph node mass.
Key aspects with a biopsy of this nature
1. Ensure pathological tissue is not accessible from a more superficial or 'safer' site.
2. Plan the access in advance with emphasis on minimizing chance of injury to adjacent structures
3. Have the right needle - this was 10cm in depth to reach so don't do all the hard work and find out your co-axial needle is only 9cm long.
4. Don't worry about too many needle position checks. Safety is more important than radiation in this case.
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