Useless and dangerous—fine needle aspiration of hepatic colorectal metastases
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《英国医生杂志》
1 University of Adelaide Department of Surgery, Queen Elizabeth Hospital, Woodville, SA 5011, Australia
Correspondence to: G J Maddern guy.maddern@adelaide.edu.au
Introduction
Of the seven previous reports of fine needle aspiration cytology of hepatic colorectal metastases causing needle tract metastases, six involve only one or two cases each and provide no indication of the rate at which the complication occurs.7-12 The most recent report found that for FNAC of all hepatic malignancy there was a 3% risk of needle tract metastasis, a rate consistent with that found in other recently reported studies.13 For colorectal metastases specifically, the rate was 10% (5/51 cases); four of these five patients died as a direct result of this complication, despite radical excision of the deposits, as in this case.
The sensitivity of FNAC for detecting hepatic malignancy has been reported as 90-93%,6 7 similar to the diagnostic accuracy obtainable with radiological investigations of up to 91% sensitivity.14
Clearly it is desirable to avoid a situation where major surgery is done—only to discover that the suspected malignant tumour in the liver is benign. The rate at which this happens for suspected colorectal metastases has been reported to be only two of 159 cases, or 1.9%.15
In view of the rate of needle tract metastases (10%), the appreciable rate of false negative FNAC results (7-10%), and the low rate (< 2%) of benign resection for suspected malignancy, the authors agree with the conclusions drawn in prior reports: that FNAC should be avoided when hepatic colorectal metastasis are suspected.
In view of the case presented, the authors strongly recommend that hepatic colorectal metastases be diagnosed and treated without FNAC at all. The investigations of an undiagnosed liver lesion should not include the procedure, but rather should be directed to detect the primary lesion. If these are all negative, then further investigation of the liver lesion by positron emission spectroscopy or laparoscopic biopsy may confirm the diagnosis without further disseminating disease.16 17 The abdominal wall is protected from direct contact with tumour cells by the ports used for laparoscopy, so laparoscopic biopsy is less likely to result in abdominal wall metastases than percutaneous biopsy. Positron emission spectroscopy may differentiate between benign and malignant lesions as malignant cells take up a radiolabelled marker more avidly than most normal tissues and so tend to "light up" on scanning.
If a hepatic lesion is discovered at the same time or after a primary colorectal malignancy is diagnosed, and if it appears to be malignant either on imaging or on appearances at laparotomy, then it should be treated as such, without biopsy. If the appearances are of a benign lesion, or are equivocal, then repeat evaluation with further imaging after an interval of three months or with positron emission spectroscopy17 may clarify the situation. If the disease progression is so rapid that it appeared resectable when first detected but becomes unresectable within three months, then the prognosis after resection would be very poor in any event,18 so little is lost by the delay.
Conclusion
Fornari F, Civardi G, Cavanna L, Di Stasi M, Rossi S, Sbolli G, et al. Complications of ultrasonically guided fine-needle abdominal biopsy. Results of a multicenter Italian study and review of the literature. The Cooperative Italian Study Group. Scand J Gastroenterol 1989;24: 949-55.
Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991;178: 253-8.
Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000;6: 67-72.
Chapoutot C, Perney P, Fabre D, Taourel P, Bruel JM, Larrey D, et al. Needle-tract seeding after ultrasound-guided puncture of hepatocellular carcinoma. A study of 150 patients. Gastroenterol Clin Biol 1999;23: 552-6. (In French.)
Kim SH, Lim HK, Lee WJ, Cho JM, Jang HJ. Needle-tract implantation hepatocellular carcinoma: frequency and CT findings after biopsy with a 19.5-gauge automated biopsy gun. Abdom Imaging 2000;25: 246-50.
Durand F, Regimbeau JM, Belghiti J, Sauvanet A, Vilgrain V, Terris B, et al. Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma. J Hepatol 2001;35: 254-8.
Herszenyi L, Farinati F, Cecchetto A, Marafin C, de Maria N, Cardin R, et al. Fine-needle biopsy in focal liver lesions: the usefulness of a screening programme and the role of cytology and microhistology. Ital J Gastroenterol 1995;27: 473-8.
McGrath FP, Gibney RG, Rowley VA, Scudamore CH. Cutaneous seeding following fine needle biopsy of colonic liver metastases. Clin Radiol 1991;43: 130-1.
Jourdan JL, Stubbs RS. Percutaneous biopsy of operable liver lesions: is it necessary or advisable? N Z Med J 1996;109: 469-70.
Scheele J, Altendorf-Hofmann A. Tumour implantation from needle biopsy of hepatic metastases. Hepatogastroenterology 1990;37: 335-7.
Goletti O, Chiarugi M, Buccianti P, Macchiarini P. Subcutaneous implantation of liver metastasis after fine needle biopsy. Eur J Surg Oncol 1992;18: 636-7.
Vergara V, Garripoli A, Marucci MM, Bonino F, Capussotti L. Colon cancer seeding after percutaneous fine needle aspiration of liver metastasis. J Hepatol 1993;18: 276-8.
Ohlsson B, Nilsson J, Stenram U, Akerman M, Tranberg KG. Percutaneous fine-needle aspiration cytology in the diagnosis and management of liver tumours. Br J Surg 2002;89: 757-62.
Kinkel K, Lu Y, Both M, Warren RS, Thoeni RF. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology 2002;224: 748-56.
Clayton RAE, Clarke DL, Currie EJ, Madhaven KK, Parks RW, Garden OJ. Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy. The Surgeon 2003;1: 32-8.
Luketich JD, Schauer P, Urso K, Townsend DW, Belani CP, Cidis Meltzer C, et al. Minimally invasive surgical biopsy confirms PET findings in esophageal cancer. Surg Endosc 1997;11: 1213-5.
Strasberg SM, Dehdashti F, Siegel BA, Drebin JA, Linehan D. Survival of patients evaluated by FDG-PET before hepatic resection for metastatic colorectal carcinoma: a prospective database study. Ann Surg 2001;233: 293-9.
Fong Y, Cohen AM, Fortner JG, Enker WE, Turnbull AD, Coit DG, et al. Liver resection for colorectal metastases. J Clin Oncol 1997;15: 938-46.(M S Metcalfe, visiting su)
Correspondence to: G J Maddern guy.maddern@adelaide.edu.au
Introduction
Of the seven previous reports of fine needle aspiration cytology of hepatic colorectal metastases causing needle tract metastases, six involve only one or two cases each and provide no indication of the rate at which the complication occurs.7-12 The most recent report found that for FNAC of all hepatic malignancy there was a 3% risk of needle tract metastasis, a rate consistent with that found in other recently reported studies.13 For colorectal metastases specifically, the rate was 10% (5/51 cases); four of these five patients died as a direct result of this complication, despite radical excision of the deposits, as in this case.
The sensitivity of FNAC for detecting hepatic malignancy has been reported as 90-93%,6 7 similar to the diagnostic accuracy obtainable with radiological investigations of up to 91% sensitivity.14
Clearly it is desirable to avoid a situation where major surgery is done—only to discover that the suspected malignant tumour in the liver is benign. The rate at which this happens for suspected colorectal metastases has been reported to be only two of 159 cases, or 1.9%.15
In view of the rate of needle tract metastases (10%), the appreciable rate of false negative FNAC results (7-10%), and the low rate (< 2%) of benign resection for suspected malignancy, the authors agree with the conclusions drawn in prior reports: that FNAC should be avoided when hepatic colorectal metastasis are suspected.
In view of the case presented, the authors strongly recommend that hepatic colorectal metastases be diagnosed and treated without FNAC at all. The investigations of an undiagnosed liver lesion should not include the procedure, but rather should be directed to detect the primary lesion. If these are all negative, then further investigation of the liver lesion by positron emission spectroscopy or laparoscopic biopsy may confirm the diagnosis without further disseminating disease.16 17 The abdominal wall is protected from direct contact with tumour cells by the ports used for laparoscopy, so laparoscopic biopsy is less likely to result in abdominal wall metastases than percutaneous biopsy. Positron emission spectroscopy may differentiate between benign and malignant lesions as malignant cells take up a radiolabelled marker more avidly than most normal tissues and so tend to "light up" on scanning.
If a hepatic lesion is discovered at the same time or after a primary colorectal malignancy is diagnosed, and if it appears to be malignant either on imaging or on appearances at laparotomy, then it should be treated as such, without biopsy. If the appearances are of a benign lesion, or are equivocal, then repeat evaluation with further imaging after an interval of three months or with positron emission spectroscopy17 may clarify the situation. If the disease progression is so rapid that it appeared resectable when first detected but becomes unresectable within three months, then the prognosis after resection would be very poor in any event,18 so little is lost by the delay.
Conclusion
Fornari F, Civardi G, Cavanna L, Di Stasi M, Rossi S, Sbolli G, et al. Complications of ultrasonically guided fine-needle abdominal biopsy. Results of a multicenter Italian study and review of the literature. The Cooperative Italian Study Group. Scand J Gastroenterol 1989;24: 949-55.
Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991;178: 253-8.
Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000;6: 67-72.
Chapoutot C, Perney P, Fabre D, Taourel P, Bruel JM, Larrey D, et al. Needle-tract seeding after ultrasound-guided puncture of hepatocellular carcinoma. A study of 150 patients. Gastroenterol Clin Biol 1999;23: 552-6. (In French.)
Kim SH, Lim HK, Lee WJ, Cho JM, Jang HJ. Needle-tract implantation hepatocellular carcinoma: frequency and CT findings after biopsy with a 19.5-gauge automated biopsy gun. Abdom Imaging 2000;25: 246-50.
Durand F, Regimbeau JM, Belghiti J, Sauvanet A, Vilgrain V, Terris B, et al. Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma. J Hepatol 2001;35: 254-8.
Herszenyi L, Farinati F, Cecchetto A, Marafin C, de Maria N, Cardin R, et al. Fine-needle biopsy in focal liver lesions: the usefulness of a screening programme and the role of cytology and microhistology. Ital J Gastroenterol 1995;27: 473-8.
McGrath FP, Gibney RG, Rowley VA, Scudamore CH. Cutaneous seeding following fine needle biopsy of colonic liver metastases. Clin Radiol 1991;43: 130-1.
Jourdan JL, Stubbs RS. Percutaneous biopsy of operable liver lesions: is it necessary or advisable? N Z Med J 1996;109: 469-70.
Scheele J, Altendorf-Hofmann A. Tumour implantation from needle biopsy of hepatic metastases. Hepatogastroenterology 1990;37: 335-7.
Goletti O, Chiarugi M, Buccianti P, Macchiarini P. Subcutaneous implantation of liver metastasis after fine needle biopsy. Eur J Surg Oncol 1992;18: 636-7.
Vergara V, Garripoli A, Marucci MM, Bonino F, Capussotti L. Colon cancer seeding after percutaneous fine needle aspiration of liver metastasis. J Hepatol 1993;18: 276-8.
Ohlsson B, Nilsson J, Stenram U, Akerman M, Tranberg KG. Percutaneous fine-needle aspiration cytology in the diagnosis and management of liver tumours. Br J Surg 2002;89: 757-62.
Kinkel K, Lu Y, Both M, Warren RS, Thoeni RF. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology 2002;224: 748-56.
Clayton RAE, Clarke DL, Currie EJ, Madhaven KK, Parks RW, Garden OJ. Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy. The Surgeon 2003;1: 32-8.
Luketich JD, Schauer P, Urso K, Townsend DW, Belani CP, Cidis Meltzer C, et al. Minimally invasive surgical biopsy confirms PET findings in esophageal cancer. Surg Endosc 1997;11: 1213-5.
Strasberg SM, Dehdashti F, Siegel BA, Drebin JA, Linehan D. Survival of patients evaluated by FDG-PET before hepatic resection for metastatic colorectal carcinoma: a prospective database study. Ann Surg 2001;233: 293-9.
Fong Y, Cohen AM, Fortner JG, Enker WE, Turnbull AD, Coit DG, et al. Liver resection for colorectal metastases. J Clin Oncol 1997;15: 938-46.(M S Metcalfe, visiting su)