Ct Biopsy Question

[ash0479]

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Had a patient today that had a 16mm nodule in the abdomen area, no igns of attenuation, no fluid build up, nothing...just a 16mm mass...

We decided to provide with a CT Guided needle biopsy, well this little bugger did not really let me get at it, everytime we tried to get a poke at it it would move, almost seemed like a rubber ball...I was able to get one nice shot into it according to the photo's but lostly blood...I doubt they would be able to diagnos this in Pathology..

I felt so bad for the patient, however, this mass has not grown in the last 3-4 months, no signs of inflammation, nothing seems to be spreading...I was thinking maybe Sarcoma but this little guy was hard, so my comment to the patient was this was lost likely a mesentric cyst do to it's behavior, but ordered follow up CT in 3 months to check for stability...

Thoughts?

 

[colbgw02]

was there something else going on with the patient that prompted you to biopsy something that hadn't grown in 4 months?

 

[ash0479]

I do not believe so other than the patient having extreme anxiety and stress, made an emergency room visit a week prior to the biopsy complaining of abdominal pain...Everything else on the CT Scan was clean...I think he just wanted to see if this has grown due to the fact they put him on the 3 month watch and wait after his first CT Scan in July..

After reviewing the films, there was no change in size, attenuation, no fluids, does not seem to be aggressive and it bounced around like a rubber ball...characteristics of a cyst was my first thoughts...

 

[f_w]

Was that a FNA or a core ?

 

[ash0479]

We tried a heavier gauge needle without avail, we then tried using it as the guide and tried to get at it with a 22 gauge needle, was able to partially penetrate but not entirely...this thing was behaving like a rubber ball, I was completely frustrated...Especially when I had to tell the patient I don't think we got enough...Path report says acelluar but I am not sure this was a good diagnostic test...

 

[f_w]

If you use one of the core devices that can be fired sequentially you can use the momentum of the device and the inertia of the lesion to spear it, shoot another image and then actuate the sleeve. Works well on breast lesions.

 

[ash0479]

Any thoughts on what this can be, did not present itself like any tumor that I know of, that was my biggest bother, not knowing what to thell the patient in my report...I hate days like that...

 

[f_w]

Location, location, location !

(so far al I know is 'abdomen' as a general territory)

Where ?
Density ?
Enhancement ?

 

[ash0479]

you ask and you shall recieve my Friend...

16mm soft tissue density nodule, location is adjacent to the ascending colon (not attached)...there are no aggressive characteristics suggesting this is probably benign....there is no change in attenuation when comparing early and delayed post contrast imaging...no free fluid identified...

Now as mentioned this baby was very mobile when trying to get at it with a needle, almost seemed like a rubber ball...my thoughts initially may have been Sarcoma of some type, but I just do not think it would be so difficult to get into a soft tissue tumor like Sarcoma...

My thoughts would be a omental or mesentric soft tissue mass, cyst or desmoid tumor...

 

[ash0479]

Another reason I feel that this is not Sarcoma is that it is not invading surrounding tissue, as mentioned my thoughts would be a cyst or some type of desmoid tumor or lipoma...I feel as though if this was Sarcoma it would not be as mobile because it would be invading the surrounding tissue...

I must admit to you all that I almost feel as though I failed the patient by not getting a good sample, I want to call the doctor and have this patient come back for a second chance at this..I know I can get this done...

Any thoughts on what this can be though...I cannot believe this is actually bothering me so much...

 

[f_w]

I cannot believe this is actually bothering me so much...

It's not the breast, unless this thing starts growing I wouldn't loose much sleep about it. (I am not in the habit of chasing every nodule, hanging out in the mesentery).

 

[ash0479]

I am relatively new at this, do you often see nodules like this in the mesentary that are benign and just growths or cysts, this is the first time I could not actually get at something doing a biopsy, almost stunned me and I felt horrible because the patient is so anxious...

I thought this was a rare case, but you sound like you have seen this before...with the characteristics would you agree that this is potentially a benign growth like a cyst or desmoid...thanks again...Should the patient wait a few months and rescan??

 

[Whisker Barrel Cortex]

Ok man, you're throwing out some pretty contradictory stuff here.

Its hard to tell what this is just based on description. Lipoma is not going to be soft tissue density, its gonna be fat density. A random cyst in the abdomen adjacent to colon is odd and should also not be soft tissue density (unless its proteinaceous or has bled in the past). Desmoid without surrounding infliltration is also unusual. Sure, this could theoretically be a sarcoma, but you documented stability and lack of aggressive features.

In my experience, lymph nodes (whether benign or malignant) can have the rubbery consistency you mention when biopsy is attempted, so this may be possibility. Another possibility (if the enhancement is appropriate) is an unusual location for an accesory splenule.

All of this is theoretical and really adds not a whole lot to the actual management. You attempted a biopsy of what sounds like a low risk lesion, and were unsuccessful. Practically, your options are to follow this up again by CT, reattempt a biopsy (which has a high likelihood of being unsuccesful again), or to refer to a surgeon for excision. Its up to you to decide based on how worrisome this lesion was by imaging characteristics.

 

[ash0479]

You are correct my friend, I do not think this would be lymphoma, Scans do not show any lymph node involvement...

I have mentioned to the patient that the best thing we can do at this point is to come back and scan in no more than 3 months to show stability...which it seems like we have for now, first scan in July 16mm, and now the recent scan is about the same 17mm x 15mm...just kinda hanging out in the mesentary...still no signs of being aggressive or invading nearby tissue...

Here is how I summed this up in the report..

There is a 16mm soft tissue density nodular focus in the mesentric adjacent to the ascending colon without change in attenuation when comparing early and delayed postcontrast imaging, Differential considerations include omental or mesentric soft tissue mass. There are no aggressive characteristics suggesting this is probably benign, however malignant mass cannot be excluded. I suggect a follow up Ct Scan in no longer than 3 months time to check for stability of the nodue...

f_w....I would really like to know your thoughts on something like this in the mesentary, you made it sound like you have seen this before...

 

[f_w]

Most of the time, you are looking at a mesenteric lymph-node. God knows why it is there. I am not aware of a major public health hazard from: 'stuff in the mesentery that suddenly explodes and kills the patient'.

So, I think your recommendation for a follow-up study is sound (your wording of 'however malignant mass cannot be excluded' is such 'radiology-speak'. You already said that it is probably benign, you think it is benign, no need to put that phrase there. This is not mammo, you are trying to be useful)

 

[ash0479]

Thanks a bunch, my first thought was lymph node as well, however it is still less than 2cm which is a good sign and no signs of growth, as well as no signs of other lymph involvement in the abdominal/pelvic area, might just be from a previous infection...I believe the patient also had a chest scan which was clean so this is just kinda hanging out there by itself..

 

[ash0479]

Patient dropped off films from the initial CT Scan done at a different location to the physician today, I was able to take a look, Physician is located in the same hospital...The mass was in the same location and size back in July...Nothing has changed as far as denisty, size, allocation, agression, etc...I think now we are dealing with something that is most probably benign...will continue to recommend a follow up scan in 3 months time...

f_w should this be accurate? Thanks again for your assistance....