Gutzeit, Andreas

Jacob, Augustinus

Kos, Sebastian

Menter, Thomas

Schubert, Tilman

Takes, Martin

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LETTER TO THE EDITORCT-Guided Percutaneous Biopsy of a Mass Lesion in the UpperPresacral Space: A Sacral Transneuroforaminal ApproachTilman Schubert • Augustinus L. Jacob •Martin Takes • Thomas Menter • Andreas Gutzeit •Sebastian KosPublished online: 26 July 2011 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011To the EditorsThe presacral region has unique anatomic and oncologicproperties. It is occupied by loose connective tissue,nerves, blood, and lymphatic vessels [6]. Syed et al. [6]analyzed the histological diagnosis of 91 cases with sacral/presacral mass lesions after biopsy. Lesions were pre-dominantly neoplastic (70%) with metastases and second-ary tumors (77%, plasma cell tumor, colorectal carcinoma,lymphoma, breast carcinoma, to name the most common)outbalancing primary neoplasms (23%). The nonneoplasticlesions were preferentially inflammatory. The variety ofmass lesions in the presacral space underlines that a his-tological analysis is essential to make the adequate therapydecision.Minimally invasive biopsy of presacral mass lesions canbe performed along different trajectories. The most com-mon approaches are anterior or lateral transabdominal,transgluteal through the greater sciatic foramen, andanterolateral extraperitoneal [1, 2]; however, alternativeapproaches, such as transosseous (transsacral or transiliac)[2, 3], precoccygeal [7], and endoscopically perineal [5],have been described. Nevertheless, lesions in the upperpresacral space especially close to the os sacrum can bechallenging to acquire histologic samples. In this context,we describe a sacral, transneuroforaminal approach. To ourknowledge, this is the first report of obtaining a biopsysample of a presacral lesion through this access. To mini-mize the risk of complications, we applied a computedtomography-based navigation system for procedureguidance.Case ReportA 62-year-old woman was referred to our department witha 5-year history of malignant melanoma of the upper back.Annual positron-emission tomography/computed tomog-raphy (PET–CT) control using a combined PET–CTscanner (GE Medical Systems, General Electric Company,Fairfield, CT, US) revealed a fluor-deoxy-glucose (FDG)-positive mass lesion in the upper presacral space. In light ofthe patient history, biopsy was immediately performed.Vulnerable structures, such as the sciatic nerve, the internaliliac artery, and the sigmoid colon along a caudocranialneedle path, precluded a transgluteal approach through thegreater sciatic foramen. Because the suspicious mass lesionwas located immediately ventral to the right S1-neurofo-ramen, a transforaminal approach was chosen.Percutaneous CT-guided intervention was performed ina 64-slice CT-scanner (Somatom Sensation 64, SiemensMedical Solutions, Erlangen, Germany) using a navigationsystem for percutaneous interventions (ActiViews, Haifa,Israel). The patient was positioned prone with arms fixedabove his head. Conscious sedation (Midazolam/Dormi-cum and Alfentanil/Rapifen) was administered intrave-nously, and vital parameters were continuously monitored.For procedure planning, noncontrast CT of the pelvis wasperformed. By means of an X-ray-absorbing grid on theskin, the cutaneous entry point was chosen. A single-useT. Schubert (&)  A. L. Jacob  M. Takes  S. KosDepartment of Radiology and Nuclear Medicine, UniversityHospital Basel, Basel, Switzerlande-mail: TSchubert@uhbs.chT. MenterDepartment of Pathology, University Hospital Basel, Basel,SwitzerlandA. GutzeitDepartment of Radiology, Cantonal Hospital Winterthur,Winterthur, Switzerland123Cardiovasc Intervent Radiol (2012) 35:1255–1257DOI 10.1007/s00270-011-0232-9reference pad with CT-visible fiducial markers wasattached to the patient’s skin. A navigation CT scanwithout contrast media was then performed and data weretransferred to the navigation system, where the needletrajectory was planned. The cutis was locally anesthetizedwith 9 ml of mepivacaine 1.5% diluted with 1 ml ofnatrium bicarbonate 8.4%. Along the prior planned tra-jectory and according to its lengths, a 17G 14.3 cm coaxialintroducer needle (Medical Device Technologies Inc.,Gainesville, FL) was chosen. A miniature, single-use videocamera was then attached to the needle (Fig. 1). Duringnavigation, the mapping of the camera and the probe aredetermined relative to the fiducial markers. The combina-tion of the above mapping enables determination of theneedle position relative to the actual target. The needle wasthen advanced in a single step to the dorsal ostium of theS1 neuroforamen (Fig. 2A). Before entering the S1 neu-roforamen, the periosteum was locally anesthetized; how-ever, only 2 ml of bupivacaine 0.25% was administered toavoid nerve root block. After a low-dose CT control (slicethickness 3 mm), the needle was slowly advanced throughthe neuroforamen without needing to correct the trajectory.During this procedure, the patient negated any radicularpain sensation. A further CT control showed correctplacement of the needle tip at the target lesion. Afterremoval of the inner stylet, an 18G 20-cm Menghini-typesemiautomatic biopsy device (Biomol, H.S. Hospital Ser-vice, Rome, Italy) was inserted for biopsy. Five biopsyspecimens were taken from different portions of the lesionby a slight movement of the coaxial needle tip in left–rightand cranio–caudal directions (Fig. 2B, C). The solidspecimens were deposited in a fixating solution and sent forhistopathological analysis. The procedure lasted 53 minfrom the initial CT planning to the postinterventionalcontrol. The follow-up CT showed no signs of complica-tions. The patient tolerated the procedure well and wasmonitored for an additional 6 h after the procedure withoutevidence of S1-palsy, paresthesia, or other complications.The combined morphologic and immunohistochemicaldiagnosis was that of a soft-tissue metastasis of the previ-ously diagnosed malignant melanoma.DiscussionThe cytological and histological assessment of suspiciousmass lesions is mandatory to allow potential tumor stagingand therapy planning. Small lesions in the upper presacralspace can be challenging for needle biopsy, because theyare difficult to impossible to reach via a caudal or lateralapproach. In those cases, and if in the effective direction, atransneuroforaminal approach is an alternative. The sacraltransneuroforaminal approach is a common technique forelectrical nerve stimulation for bladder dysfunction orFig. 1 Setup of the applied, CT-based navigation system. Thefiducial markers on the reference pad on the patient’s skin arecaptured by the miniature camera attached to the needleFig. 2 A CT control after carefully advancing the needle through theS1- neuroforamen after application of a minimal amount of localanesthesia at the dorsal ostium to avoid nerve root block. To obtainthe biopsy specimen, the needle tip was slightly moved in lateral andcranio-caudal directions (B, C)1256 T. Schubert et al.: CT-Guided Percutaneous Biopsy123chronic pain management [4]; however, needle diameter issignificantly less than that necessary to obtain biopsyspecimen. The utilized 17-gauge (1.4 mm) coaxial needleis still small compared with the S1 neuroforamen. Wemeasured 8.5 mm as the minimal diameter of the ventralostium where the S1-nerve root leaves and 5.8 mm for thedorsal ostium, where only minor sensory skin branchesleave. A navigation system for CT-guided biopsies ensuresthat the needle exactly follows the planned trajectory,especially in off-axial approaches. Therefore, the use of anavigation system minimizes the risk of injuring the nerveroot due to intraforaminal correction of the needle path orreposition of the needle. To avoid nerve root injury whilepassing intraforaminally, we administered only a smallamount of local anesthetic at the dorsal ostium of theneuroforamen to anesthetize the periosteum and still havepatient feedback regarding pain or sensomotory sensations.The costs of the applied system are $75,000 USD, whichincludes training, service, and disposables for a year.Subsequent disposables amount to $300 per procedure.Acknowledgement This work was supported through an educa-tional grant from Bracco Imaging S.p.A., Milano, Italy.Conflict of interest The authors declare that there is no actual orpotential conflict of interest in relation to this article.References1. Butch RJ, Wittenberg J, Mueller PR, Simeone JF, Meyer JE,Ferrucci JT Jr (1985) Presacral masses after abdominoperinealresection for colorectal carcinoma: the need for needle biopsy.AJR Am J Roentgenol 144:309–3122. Gupta S, Nguyen HL, Morello FA Jr, Ahrar K, Wallace MJ,Madoff DC, Murthy R, Hicks ME (2004) Various approaches forCT-guided percutaneous biopsy of deep pelvic lesions: anatomicand technical considerations. Radiographics 24:175–1893. Iguchi T, Asami S, Kubo S, Kin H, Katusi K, Sakurai J, Hiraki T,Kanazawa S (2007) CT-guided placement of a drainage catheterwithin a pelvic abscess using a transsacral approach. CardiovascIntervent Radiol 30:1277–12794. Jezernik S, Craggs M, Grill WM, Creasey G, Rijkhoff NJ (2002)Electrical stimulation for the treatment of bladder dysfunction:current status and future possibilities. Neurol Res 24:413–4305. Nieuwenhuis DH, Gagner M, Consten EC (2009) The endoscopicperineal approach to the presacral space: an excision biopsy.J Laparoendosc Adv Surg Tech A 19:799–8016. Syed R, Bishop JA, Ali SZ (2010) Sacral and presacral lesions:cytopathologic analysis and clinical correlates. Diagn Cytopatholdoi:10.1002/dc.214807. Trambert JJ (1999) Percutaneous interventions in the presacralspace: CT-guided precoccygeal approach–early experience. Radi-ology 213:901–904T. Schubert et al.: CT-Guided Percutaneous Biopsy 1257123

CT-Guided Percutaneous Biopsy of a Mass Lesion in the Upper Presacral Space: A Sacral Transneuroforaminal Approach

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CT-Guided Percutaneous Biopsy of a Mass Lesion in the Upper Presacral Space: A Sacral Transneuroforaminal Approach

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