About Biopsies written and compiled by doctordee

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Introduction Necessary Biopsies Fine Needle Biopsies Core Needle Biopsies Open Biopsies Seeding Local Tumors by Track Implantation Seeding of Metastases Annotated References

Introduction

A biopsy is the removal of some tissue from a body, for examination in order to diagnose a condition. Biopsies may be surgical removal of the tumor, in part or completely, or completely with wide margins. Biopsies can also be done with needles, either a core needle biopsy or a fine needle aspiration [FNA]. Cells have to undergo several mutations before they become cancer cells. Besides reproducing uncontrollably, they also must lose the 'stickiness' and orderliness of normal tissue, and be able to invade and get loose and travel and set up colonies outside the primary site. Because of the loss of cohesion, and the willingness of these cells to emigrate and colonize, it is sometimes very easy to dislodge cancer cells from a tumor during biopsy or surgical procedures. Every cell in your body has a capillary, a very small blood vessel, near it. The Capillary comes from the smaller and smaller branching of arteries, and joins with other capillaries to form veins...to take the blood back to the heart. Every cell in your body is bathed in 'interstitial' fluid. This is the fluid that surrounds all the cells, and drains into the lymphatic system, goes through the lymph channels and past the lymph nodes, up to the upper left chest, where the major lymphatic channel drains directly into a blood vessel. Tumor cells also have capillaries nearby, and are also bathed in interstitial fluid that goes to the lymphatic system. If you stick a needle into a tumor, you run the risk of dislodging a tumor cell into either a blood vessel or into the interstitial fluid. Different tissues will have different cell-to-cell stickiness. Tumors that metastasize must have decreased cell-to-cell stickiness. Tumor cells will be easier to dislodge and more likely to travel. Tumor cells that land in blood vessels will travel to distant sites. Tumor cells that are pushed into the interstitial fluid will go to local lymph nodes. And then travel up the chain of lymph nodes. Stick needles into LMS tumors at your own risk. But KNOW the risk before you do it. Excision of the tumor with wide margins is the way to go, if it is possible. If it is not possible, then fine needle or core biopsies might be necessary. Think clearly and carefully about this, and ask questions. So, in summary, during biopsies or other procedures, one can dislodge some cancer cells, either into the interstitial fluid where they are carried away to lymph nodes, or possibly into the veins draining the tissue where they enter the vascular tree and travel to the lungs. It is also possible to drag some cells along the needle track or along the surgical incision. So it is possible to increase the incidence of lymphatic and hematogenous spread of the cancer, as well as local implantation along the surgical route or needle tracks. [see reference 9, below] Some cancers are more notorious for seeding by track implantation than others; some are more likely to metastasize if biopsied before complete removal. LMS usually spreads hematogenously, but can also spread by lymph nodes, and has been noted to implant along an instrument tract. Whether the larger needle of a core needle biopsy causes more disruption in the tumor and more likelihood of track implantation or metastasis than a fine bore needle, or whether an open biopsy is even more likely to cause metastatic travel.... Is simply not known at this time. It is very likely that the 'interference' with an LMS tumor for a biopsy will increase the risk of metastasis, and possibly local recurrence as well. Which biopsy technique is the least likely to cause metastatic/recurrent problems is simply not known. The needle biopsy methods are more cost effective and less invasive than open biopsy. Core needle biopsy, because of the larger needle diameter, requires fewer passes than does the fine needle, and provides more adequate information. It is unknown whether there is a greater risk of tumor disruption and spread with the larger needle versus repeated passes with the smaller needle. Letter to the LMS List from Roger Sent: Tuesday, July 02, 2002 11:33 AM Subject: Needles, biopsies and lymph nodes I noticed some recent mentions of lymph nodes and lymphatic spread of LMS. As one of the few people with lymphatic mets I would like to put my experience in. I was talking to my first surgeon, at his annual check on my scars a couple of months ago. He is convinced that the reason my first tumor metastasized to the regional lymph node was the fact that it had been interfered with during the investigative period before he was involved. And he very privately agrees with my opinion that the FNA biopsy done on the second tumor, in the lymph glands, was the cause of the third one, especially as the second tumor was excised fully encapsulated. He has now operated on four more sarcomas after me (he tends to get the difficult extremity ones because primarily he is a reconstructive surgeon). Two of these were head/neck, one of them LMS (I have met her - she is the only other LMS patient I have knowingly met!!). In both cases their tumors had already been interfered with, one for biopsy and the other as a suspected cyst. After consulting the regional sarcoma specialist unit he dissected regional lymph nodes for both patients as well as doing wide excision of tumor sites. As a reconstructive surgeon he does free flap as well as skin grafts. In both cases the patient is doing well - one is past the year, the other (LMS) about six months ago. I feel there is a warning message about interfering with tumours. I would be strongly against sticking needles into them, even though the doctors reassure anyone when they want to do a needle biopsy. Roger Hi-grade LMS left leg dx Feb 99. Lymphatic mets dx'd Jan (surgery) and Apr 2000 (inoperable). Ifosfamide - May to Sept 2000. Disease now stable for 21 months. ANOTHER LETTER: Date: Tue, 2 Jul 2002 19:36:14 +0100 From: sheila Subject: Needles and LMS One of the reasons that we were given by the liver surgeon as to why RFA was inappropriate for treating John's multiple liver mets, was the risk of dragging cancer cells out of each met with the probe, causing seeding and further mets. What was interesting was that he regarded this as an established possibility, which was in contrast to the reassurances we had been given by the oncologist when discussing biopsies! [NB usually RFA probes are heated on the way out, so that they cauterize the tract to avoid tumor cell implantation. doctordee] Sheila Wife of John (England) retroperitoneal LMS 10/2000 A THIRD LETTER: Date: Fri, 5 Jul 2002 13:30:38 -0400 From: Lisa Subject: Re: LMS needles, probes, and biopsies Kendra, Get another surgeon. Speak with the Sarc onc on that and insist. Insist firmly without raising your voice. Insist repeatedly. Continue to insist until someone listens. If you don't have time to find the research on seeding from needle biopsy, insist that the surgeon inform you of the research that says it is safe **for LMS**. Meanwhile, here are a few references (they are all for different types of cancer, since I could find nothing on LMS [no surprise]): http://www.karlloren.com/biopsy/p31.htm http://www.ikp.unibe.ch/lab2/Seeding.html http://www.irus.rri.on.ca/~ddowney/cases/Case1.htm this one has an obscure sentence about seeding along biopsy line: http://www.vh.org/Providers/Textbooks/LungTumors/ClinicalPresentation/Text/TissueDiagnosis.html Grace and Peace, Strength and Courage, Lisa (Steve's wife)

Necessary Biopsies

My personal bias is for surgical excision with wide margins of any questionable mass. However, this is not always possible. If a lesion is inoperable, it is sometimes necessary to biopsy in order to find out what it is. A diagnosis is absolutely necessary before starting treatment. How else would you know what to treat the tumor with? Remember that 7.5% of LMS patients will develop a second primary cancer. A new lump in an LMS patient is not always an LMS metastasis. When a biopsy is required, it should be carried out after a complete imaging work-up [which sometimes allows a correct prebiopsy diagnosis] to indicate the biopsy modality, approach and site. Complete imaging is also mandatory to stage the tumor, plan the surgical approach and technique, and show fine details of any occult tumor spread. [1, 15, 16] Most importantly, to accurately diagnose and classify most sarcomas, an expert sarcoma pathologist (or cytopathologist in the case of FNA) to examine the specimen is paramount. This is particularly true of FNA where the sample of tissue provided to establish a diagnosis is quite limited. If the tumor cannot be removed completely with wide margins, if a biopsy is inevitable, the biopsy should be planned and done by doctors expert in the site of the tumor, and be the least invasive possible. However, a core needle biopsy might give better results with fewer passes than a fine needle biopsy, and be less invasive than an open biopsy. Discuss with your doctor, as well as his personal record of complications with the proposed procedure. Needle biopsies should be taken seriously as they can indeed cause seeding along the path of the needle, and might be responsible for metastatic spread as well. The best course of action would be to surgically remove the tunnel the needle had followed in the next surgery. If the clinical and Xray information favors a diagnosis of malignant or aggressive bone tumor, the patient should be referred to an experienced orthopedic oncologist without any additional tests or biopsies. If a soft tissue mass is 5cm or larger, and especially if it is deep, the patient should also be referred to an orthopedic oncologist, because of the relatively high probability that the mass is malignant. [14] The risk of implantation metastases induced by fine-needle biopsy warrants consideration in patients with abdominal malignancies since it may compromise the outcome of radical surgery. It should only be performed when the result of the procedure has a direct impact on the choice of therapy. [30]

Fine Needle Biopsies

Fine needle aspiration (aka "FNA") utilizes a smaller needle to aspirate cells (as opposed to a core of tissue) from the tumor. This is processed for cytology (as opposed to pathology in the case of core biopsy) to determine sarcoma subtype and sometimes grade. The sample aspirated with this technique consists of scattered cells that do not usually maintain the typical "architecture" of the tumor. This makes establishing a diagnosis more challenging. Despite these challenges, FNA is a safe and reasonably accurate biopsy technique in experienced hands. Fine needle biopsies have advantages to surgery in that they can be done quickly, with only sedation and local anesthetic. If they are positive for malignancy, they are useful, but a negative result is not reliable because it is possible to miss the malignant sector of a nonhomogeneous tumor. In about 20% of cases it is not possible to make a diagnosis from the material. [2, 3, 5, 13] The problems with fine needle biopsies: 1. they may not give enough tissue for a diagnosis 2. they may miss the cancerous part of the tumor 3. they may loosen cancer cells to float through the bloodstream and set up secondary tumors at other sites [distant metastases] 4. they may loosen cancer cells to float through the lymph system and set up secondary tumors at other sites [lymphatic metastases] 5. they may drag cancer cells with them along the tract of their path and set up secondary tumors at other sites [tract or track implantation] 6. the tumor is still there Insertion of a needle into an LMS tumor might liberate LMS cells into the lymphatic or blood circulation, or possibly seed cells along the needle track. For this reason, I personally feel that biopsies should be kept to a minimum, and used only when situations are inoperable, and a diagnosis is imperative. If lesions are operable, an excisional biopsy with wide margins would remove the suspicious lesion, treat it, give a diagnosis, and also provide tissue for chemoresistance and other testing. Fine needle biopsies can miss the malignant part of the lesion, can remove too little tissue for adequate diagnosis, and do not remove enough tissue for chemosensitivity testing.] Most importantly, to accurately diagnose and classify most sarcomas, an expert cytopathologist to examine the specimen is paramount. Needle biopsies should be taken seriously as they can indeed cause seeding along the path of the needle. The best course of action would be to surgically remove the tunnel the needle had followed in the next surgery. Fine needle aspiration may also shed breast cells into peripheral blood [28]. For rebuttal of this argument against fine needle biopsies: Medscape Article Search Pubmed on needle biopsies and seeding Search Pubmed on needle biopsies and diagnosis

Core Needle Biopsies

Core needle biopsies, sometimes called tru-cut biopsies, use a larger bore needle than fine needle biopsies. A larger sample of tissue is obtained than with FNA (fine needle aspiration). A larger sample is removed, with fewer passes, more often allowing a specific cell type to be diagnosed. [12, 13] Most importantly, to accurately diagnose and classify most sarcomas, an expert sarcoma pathologist to examine the specimen is paramount. Needle biopsies should be taken seriously as they can indeed cause seeding along the path of the needle. [26] The best course of action would be to surgically remove the tunnel the needle had followed in the next surgery. Furthermore, tumor cell displacement was observed in 32% of patients who had undergone large-gauge needle core biopsy of the breast. [27] Search Pubmed on needle biopsies and seeding

Open Biopsies

Open, or Incisional, biopsy utilizes a surgical procedure to open the tumor to obtain a large sample of the tissue for analysis. This technique is rarely required for satisfactory diagnosis, and is overly invasive and riskier than the less invasive needle biopsy techniques described above. Incisional biopsy carries all the risks of surgery and anesthesia including infection, bleeding, and incorrect choice of incision. As a biopsy technique, it should be utilized only when fine needle and/or core biopsy (performed in an experienced center) cannot accurately diagnose a soft tissue tumor.] To accurately diagnose and classify most sarcomas, an expert sarcoma pathologist to examine the specimen is paramount. Many patients suffer poor outcomes as a direct result of open biopsy (eg, local recurrences, extensive unnecessary reconstructions, and amputations in cases that were potentially amenable to limb-salvage resection). Admittedly, better surgical biopsy planning and technique could have prevented some of these adverse events; however, virtually all may have been avoided by the use of fine needle or core needle biopsy instead of open biopsy. [11] However, to obtain an adequate amount of tissue if testing of the tumor for various treatment markers, chemoresistance, or DNA or RNA microarray is desired, only complete excision or open biopsy can provide the amount of tissue needed for testing. [17]

Seeding Local Tumors by Track Implantation

Instances in which sarcomas were seeded along needle biopsy tracks are easier to document as iatrogenic [doctor-caused] because the tumors are obviously growing in an artificial path. Viable tumour spread in FNA biopsy tracks has been histologically confirmed. Although this complication is not common and is of unknown clinical significance, it is one that all clinicians who undertake FNA of malignant neoplasms should be aware of. [24] There are documented instances in which sarcomas were seeded along needle biopsy tracks. [4, 6, 7] At least one cancer so frequently implants along the needle track that fine needle biopsies of its suspected lesions are no longer routinely recommended. [8] It is also possible to track and implant tumor deposits with other devices than needles, including gastrostomy tubes, stereotactic cannulas, and postoperative drains. [10, 17, 18, 22, 23] Implantation also can occur after percutaneous ethanol injection into the tumors [25] and thoracoscopic or laparoscopic or other surgical intervention. [29] "The incidence of implantation metastases after fine-needle procedures is probably underestimated. There is a slight but definite risk that the procedure may render an otherwise curative resection palliative. Implantation metastases cause local complaints of varying severity and seem to have a tendency to recur locally. We recommend that fine-needle biopsy should be restricted to patients who will truly benefit from a more accurate preoperative diagnosis." [20] "Two cases are reported in which percutaneous biopsy of resectable liver tumours was performed unnecessarily and resulted in needle track seeding. In both instances patients who underwent potentially curative liver resection were rendered incurable because of biopsy track recurrence. The common practice of performing percutaneous ultrasound or CT guided biopsy of potentially resectable lesions in the liver is generally neither necessary nor desirable." [21] The risk of implantation metastases induced by fine-needle biopsy warrants consideration in patients with abdominal malignancies since it may compromise the outcome of radical surgery. It should only be performed when the result of the procedure has a direct impact on the choice of therapy. [30] Search Pubmed on needle biopsies and seeding Search Pubmed on needle biopsies, track seeding, and SARCOMAS

Seeding of Metastases

Tumors that are biopsied or otherwise 'interfered with' have a higher incidence of metastasis than tumors that were removed in an untouched block with wide margins and good tumor hygiene. In a study reported in The American Journal of Surgical Pathology, the clinical features of 42 LEIOMYOSARCOMAS were analyzed. " In a univariate analysis age >62 years, size >4 cm, extensive necrosis, modified updated French Federation of Cancer Centers (FFCC) grade, and whether the tumor had been "disrupted" by a previous incisional biopsy or incomplete excision were significantly correlated with metastasis.... Disruption was the only significant risk factor for metastasis in a multivariate analysis (relative risk 2.70; p = 0.0001) but was strongly correlated with large size and deep location ." [9] The study concluded, "The risk of metastasis can be calculated from a model incorporating age, FFCC grade, and disruption. Because disruption correlates with size and depth, it could represent a surrogate as opposed to causal marker for metastasis. Nevertheless, in view of their vascular origin, the possibility that tumor disruption may facilitate or promote access to the bloodstream merits further study."[9] Tumor cell displacement was observed in 32% of patients who had undergone large-gauge needle core biopsy of the breast. [27] Fine needle aspiration may shed breast cells into peripheral blood [28]. In addition, in people on the LMS list, three of the people with regional lymph node metastasis either had multiple FNA biopsies of the primary lesion (2) or major manipulations to get the primary tumor removed (1). Search Pubmed on biopsies, cancer, seeding and metastases. biopsy, cancer, seeding, displacement biopsy, cancer, seeding, metastasis

Annotated References

1. Eur J Radiol 1998 May;27 Suppl 1:S116-22 The value of imaging in the diagnosis and treatment of bone tumors. Campanacci M, Mercuri M, Gasbarrini A, Campanacci L. I Orthopedics Clinic, Rizzoli Orthopedics Institute, Bologna, Italy. "... When a biopsy is required, it should be carried out after a complete imaging work-up, which sometimes allows a correct prebiopsy diagnosis, indicates the biopsy modality, approach and site, and is also mandatory to stage the tumor, plan the surgical approach and technique, and show in the finest details the occult tumor spread. ...". Fetch PMID: 9652511 2. Diagn. Cytopathol. 2002;27:354-361. (c) 2002 Wiley-Liss, Inc. Reliability of fine-needle aspiration biopsy in the initial diagnosis of soft-tissue lesions Keiko Nagira, M.D. 1, Tetsuji Yamamoto, M.D. 1 *, Toshihiro Akisue, M.D. 1, et.al. Kobe University Graduate School of Medicine, Kobe, Japan "...We retrospectively reviewed fine-needle aspiration biopsy (FNAB) specimens of 301 soft tissue lesions of the extremities and trunk. ... Of the 301 FNAB samples, 279 (93%) were adequate for cytologic diagnosis. ... Specific FNAB diagnoses were correct in 151 of 279 cases (54%) in combination with clinical and radiologic findings. FNAB is a valuable technique for the primary diagnosis of soft-tissue lesions." Fetch Abstract 3.Diagn. Cytopathol. 2002;27:350-353. (c) 2002 Wiley-Liss, Inc. Utility of fine-needle aspiration in the diagnosis of primary osteosarcoma Leslie G. Dodd, M.D. 1 *, Sean P. Scully, M.D., Ph.D. 2, R. Lee Cothran, M.D. 3, John M. Harrelson, M.D. 4 1Department of Pathology, Duke University Medical Center, Durham, North Carolina 2Department of Surgery, Mayo Clinic, Rochester, Minnesota 3Department of Radiology, Duke University Medical Center, Durham, North Carolina 4Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina email: Leslie G. Dodd (leslie.dodd@duke.edu) *Correspondence to Leslie G. Dodd, Box 3712, Department of Pathology, Duke University Medical Center, Durham, NC, 27710-3712 "... We reviewed our experience with the use of FNA as a diagnostic technique over the past 8 yr at our institution. Diagnosis was conclusive in 26 (65%) of 40 patients, 18 of whom went to neoadjuvant therapy and/or resection based solely on the FNA interpretation of either high grade sarcoma or osteosarcoma. Of the remaining 14 (25%) patients, 12 had inconclusive diagnosis and two (5%) were false-negatives. An inconclusive diagnosis was most likely to be an inadequate or paucicellular aspirate, seen in six (15%) patients. An additional six patients had variants of osteosarcoma (four chondroid, one giant cell rich, one parosteal) that made definitive diagnosis impossible. The two that were incorrectly classified were diagnosed as fracture callus and plasmacytoma. FNA is an accurate and cost-effective tool for the initial diagnosis of primary osteosarcoma with a sensitivity of 65% and accuracy of 95%. Inconclusive diagnoses are likely to be due to insufficient sample cellularity or the presence of OGS variant. In our experience, FNA is sufficient to provide the diagnosis of OGS prior to definitive treatment when interpreted in conjunction with imaging studies and clinical findings. In those cases where FNA fails to yield a diagnostic sample, a traditional biopsy can be performed." 4: Eur Urol 1983;9(6):368-9 Needle tract seeding following puncture of retroperitoneal liposarcoma. Hidai H, Sakuramoto T, Miura T, Nakahashi M, Kikyo S. 9 case of needle tract seeding following percutaneous puncture of an avascular mass, which proved to be a retroperitoneal liposarcoma, is presented. Fetch PMID: 6653630 5: Arch Pathol Lab Med 2001 Nov;125(11):1463-8 Fine-needle aspiration biopsy of vertebral and intervertebral disc lesions: specimen adequacy, diagnostic utility, and pitfalls. Phadke DM, Lucas DR, Madan S. Department of Pathology, Wayne State University/Detroit Medical Center, Detroit, MI 48201, USA. "Fine-needle aspiration biopsy (FNAB) is used extensively in the clinical workup of radiologically detected bony lesions. The aims of this study were to evaluate the diagnostic utility of FNAB of such radiologically detected vertebral and intervertebral disc lesions in patients with and without a known primary malignancy, to establish criteria for specimen adequacy, and to evaluate the diagnostic pitfalls...Thirty-five cases (45%) were positive for malignancy, 1 case (1.3%) was suspicious for malignancy, 9 (11.5%) consisted of normal cellular elements with no evidence of malignancy, 21 (27%) were unsatisfactory/inadequate for diagnosis, and 12 (15.2%) were benign nonneoplastic lesions. ... ... Through assessment of the specimen adequacy, correct interpretation of the cytologic material available, and correlating with the clinical and radiologic findings, a definitive diagnosis can be made in most cases." Fetch PMID: 11698003 6: Nihon Kyobu Shikkan Gakkai Zasshi 1992 Jul;30(7):1333-7 [A case of pulmonary metastasis from carcinosarcoma of uterus with subcutaneous implantation of tumor cells along the needle tract after percutaneous needle biopsy of lung]. [Article in Japanese] Takahashi T, Mori K, Suga Y, Saito Y, Tominaga K, Yokoi K, Miyazawa N, Shimamura K. Division of Thoracic Disease, Tochigi Cancer Center, Japan. "A 68-year-old female who had undergone total hysterectomy for carcinosarcoma five months previously was noted to have a solitary nodular shadow in the right lung on chest X-ray. Percutaneous needle biopsy of the lung was performed via the right anterior chest wall, and the histologic findings showed metastasis from carcinosarcoma of uterus. Two months after needle biopsy, a chest wall mass appeared of the site of puncture of the lung needle biopsy. The mass was resected to relieve the chest wall pain and the specimen showed carcinosarcoma of uterus histologically. We consider that tumor cells were implanted to the chest wall along the needle tract after percutaneous needle biopsy of the lung. The postoperative chest computed tomogram showed the route of tumor implantation from the metastasis of right lung into the right chest wall. ..." Fetch PMID: 1405112 7. Hidai H, Sakuramoto T, Miura T, Nakahashi M, Kikyo S. Needle tract seeding following puncture of retroperitoneal liposarcoma. Eur Urol. 1983;9(6):368-9. Fetch PMID: 6653630 8: Schweiz Med Wochenschr 2000 Jun 10;130(23):871-7 [Risks and consequences of tumor seeding after percutaneous fine needle biopsy four diagnosis of hepatocellular carcinoma]. [Article in French] Pelloni A, Gertsch P. Service de chirurgie, Ospedale San Giovanni, Bellinzona. "A review of the literature shows that tumour seeding after fine-needle biopsy of a hepatocellular carcinoma is observed in 0.6 to 5.1% of cases. This complication may be detected between one and 72 months after needle biopsy, and the lapse of time between biopsy and diagnosis of recurrence is influenced neither by the tumour grading nor by the diametre of the needle and number of puncture. In most cases, needle biopsy is not necessary to establish the surgical indication and may compromise the result of surgery; it should therefore be restricted to exceptional cases. Because needle-tract seeding may be the sole tumour recurrence, close follow-up of patients who have undergone pre-operative needle biopsy is important for early detection and possible cure." Publication Types: Review Fetch PMID: 10897488 9. THE AMERICAN JOURNAL OF SURGICAL PATHOLOGY 2002;26:14-24 Leiomyosarcomas of the somatic soft tissues (SST) are rare compared with their retroperitoneal and cutaneous counterparts and, therefore, have not been extensively studied. We have analyzed the clinicopathologic features of 42 SST leiomyosarcomas referred in consultation to determine what factors affect outcome. Cutaneous, visceral, retroperitoneal, uterine, gastrointestinal, and major vessel leiomyosarcomas were excluded. By definition all lesions possessed at least focal cytologic atypia and mitotic activity, although the latter varied from <1/10 high power fields to 66/10 high power fields. The patients (21 females and 21 males) ranged in age from 26 to 86 years (mean 60 years); tumors developed in the lower (n = 28) or upper extremity (n = 11) and trunk (n = 3). Most arose in deep (n = 27) as opposed to superficial (n = 15) soft tissue; 39 arose from a small vein. During the follow-up period (mean 47 months, range 9-162 months), 3 of 38 (8%) patients developed local recurrence and 17 of 38 metastasized (45%) mostly to the lungs. In a univariate analysis age >62 years, size >4 cm, extensive necrosis, modified updated French Federation of Cancer Centers (FFCC) grade, and whether the tumor had been "disrupted" by a previous incisional biopsy or incomplete excision were significantly correlated with metastasis. AJCC stage also approached significance (p = 0.096) but could not be reliably tested because of the sparseness of the data. In multivariate analyses the logistic regression model that best predicted metastasis at 36 months incorporated the effects of age, FFCC grade, and disruption and had a sensitivity of 94.1% and a specificity of 95.2%. Disruption was the only significant risk factor for metastasis in a multivariate analysis (relative risk 2.70; p = 0.0001) but was strongly correlated with large size and deep location. Other parameters did not improve the predictive power of the model significantly. We concluded that the majority of SST leiomyosarcomas are actually of vascular origin, an observation that has clinical and possibly biologic ramifications. Our histologic definition of leiomyosarcoma to include atypia and any level of mitotic activity appears warranted by the biologic outcome in our cases. The risk of metastasis can be calculated from a model incorporating age, FFCC grade, and disruption. Because disruption correlates with size and depth, it could represent a surrogate as opposed to causal marker for metastasis. Nevertheless, in view of their vascular origin, the possibility that tumor disruption may facilitate or promote access to the bloodstream merits further study. 10: Head Neck 2000 Dec;22(8):826-30 Metastasis to a percutaneous gastrostomy site from head and neck cancer: radiobiologic considerations. Douglas JG, Koh W, Laramore GE. Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington USA. .. The use of percutaneously placed feeding tubes has increased in recent years in an effort to maintain adequate caloric balance in patients receiving combined therapy for head and neck cancers, ... We report a case of a metastasis to a percutaneous endoscopic gastrostomy site occurring in a patient ... and review the published literature regarding this subject. ... ... Six cases of percutaneous endoscopic site metastases occurring in patients with head and neck primary tumors have been reported in the literature. The interval from performance of the procedure to development of the metastases ranged from 3 to 16 months. Tumor kinetics suggest that a significant tumor burden (10(5)-10(6) cells) would need to be present at the site to manifest a metastatic lesion in such a short time interval. .. The development of metastases at percutaneous endoscopic gastrostomy sites is a relatively uncommon occurrence. Direct tumor implantation by means of instrumentation at the time of the procedure is most likely explanation for such metastases, although hematogenous seeding cannot be completely discounted. Techniques should be used so as not to disrupt the tumor bed, particularly when gross residual disease is present. Fetch PMID: 11084645 11. Is Fine-Needle Aspiration Biopsy a Practical Alternative to Open Biopsy for the Primary Diagnosis of Sarcoma? Scott E. Kilpatrick, MD,[1] James O. Cappellari, MD,[2] Gary D. Bos, MD,[3] Stuart H. Gold, MD,[4] and William G. Ward, MD[5] [Am J of Clin Pathology 115(1):59-68, 2001. (c) 2001 ASCP, Inc.] "We reviewed the clinicopathologic features of 145 consecutive fine-needle aspiration biopsy (FNAB) specimens." "Discussion For the diagnosis and management of malignant neoplasms, FNAB has several advantages over traditional open incisional biopsy, including little to no risk of tumor cell contamination of the biopsy tract, significantly less risk of morbidity and mortality, and ease of learning and performance by most physicians... An added advantage (over core needle and traditional open biopsy) is the ability, especially in pediatric sarcoma, to determine an immediate interpretation, allowing for obtainment of ancillary studies and planning of surgical intervention and/or neoadjuvant therapy at the initial presenting clinic visit." "Given the emphasis in the current medical environment on cost-containment, FNAB also represents a cost-effective alternative to open incisional biopsy. ...Ward and Kilpatrick[11] reviewed the estimated charges for establishing a diagnosis among 26 consecutive cases of osteosarcoma (some of which are included in the present report). Seven patients were diagnosed using traditional open biopsy; 19 patients underwent FNAB, of which 15 FNABs were diagnostic and 4 required subsequent open biopsy. The elapsed time between the initial clinic visit and diagnostic confirmation averaged 5 days for 11 patients requiring open biopsy and less than 1 hour for 15 patients whose clinic FNAB was diagnostic...The total estimated charge for FNAB for a typical distal femoral osteosarcoma was $1,060.00 compared with $4,312.25 for open biopsy. When the charges for the open biopsy of the 4 nondiagnostic FNABs were added to the total charges (generating the true cost of the intent to diagnose by FNAB), the average total charge for FNAB was $1,968.64, a figure still well below the cost for an open biopsy... " "An argument against the use of FNAB has been the availability of cells or tissues for necessary ancillary studies.[3] Nevertheless, FNAB passes may be performed for immunocytochemistry (cell block), conventional cytogenetic analysis, flow cytometry, and image analysis, and even for research purposes, with informed consent of the patient. In our experience, each ancillary study generally requires 1 additional (separate) FNAB pass ... " "In our series, morphologic heterogeneity was not a significant problem in the overwhelming majority of cases..." "We do not believe that FNAB reliably can distinguish inadvertently sampled subcutaneous fat, lipoma, or well-differentiated lipoma-like liposarcoma, as all of these lesions may contain areas of relatively normal-appearing adipose tissue. ..., deeply seated soft tissue lesions that, by current imaging modalities, appear predominantly fatty are probably best evaluated by incisional or excisional biopsy. ..." "The vast majority of FNAB specimens from bone and soft tissue sarcomas are recognized easily as sarcoma. Histologic subtyping seems more accurate in bone sarcomas than in soft tissue sarcomas and in pediatric sarcomas than in adult sarcomas. Although histologic subclassification of adult soft tissue sarcomas is often not possible, no influence on initial therapy, as used at our institutions, usually was observed... " "The internal heterogeneity of some sarcomas that may result in sampling errors seems limited generally to dedifferentiated sarcomas, but is otherwise not a substantial problem if a multidisciplinary approach is undertaken. With appropriate clinicoradiologic correlation and in experienced hands, false-negative (eg, malignant tumor diagnosed as benign) and false-positive diagnoses (eg, benign tumor diagnosed as malignant) are exceedingly rare, occurring in far less than 1% of cases. In our experience, complications and local recurrences from needle tract seeding from FNAB of bone and soft tissue sarcomas have not occurred. As a matter of daily practice, we treat many patients who have suffered poor outcomes as a direct result of open biopsy (eg, local recurrences, extensive unnecessary reconstructions, and amputations in cases that were potentially amenable to limb-salvage resection). Admittedly, some of these adverse events could have been prevented by better surgical biopsy planning and technique; however, virtually all may have been avoided by the use of FNAB instead of open biopsy. Given the advantages and minimal risks of FNAB for patients with suspected sarcoma, FNAB represents a viable alternative to open biopsy for the primary diagnosis of sarcoma." [The above quotes were selected from the article's nine pages. Ed.] Copyright (c) 1994-2001 by Medscape Inc. All rights reserved. This website also contains material copyrighted by 3rd parties. Fetch PMID: 11190808 12. J Ultrasound Med 2000 Dec;19(12):849-55 Diagnostic sensitivity of ultrasound-guided needle biopsy in soft tissue masses about superficial bone lesions. Yeow KM, Tan CF, Chen JS, Hsueh C. Department of Diagnostic Radiology, Chang Gung University, Chang Gung Memorial Hospital, Taiwan. We evaluated the value of ultrasound-guided needle biopsy in 20 soft tissues masses about superficial bone lesions in 20 oncology patients. Sonographically guided needle biopsies were performed without an on-site pathologist. A diagnostic sensitivity of 95% and specificity of 100% in separating a benign or a malignant lesion was obtained. Fine needle aspiration cytology allowed the specific cell type of malignancy to be diagnosed in 80% of cases, while core needle biopsy allowed it in 91%. Real-time ultrasonographic guidance permits precise needle placement into the targets, avoidance of hypervascular areas, and flexibility of patient positioning so that needle biopsy can be performed quickly and safely on soft tissue masses about superficial bone lesions. Fetch PMID: 11127010 13. Can Assoc Radiol J 1999 Apr;50(2):121-5 Percutaneous biopsy of the musculoskeletal system: a review of 77 cases. Hodge JC. Royal Victoria Hospital, Montreal, Que. jchodge@rad.mgh.mcgill.ca " To analyze the accuracy of percutaneous bone and soft-tissue biopsies. ..There were 44 true-positive, 17 true-negative, 8 false-negative and no false-positive results. The correct diagnosis was obtained in 57 of 68 cases (83.8%). For bone biopsies, the accurate diagnosis was obtained in 47 of 55 cases (85.5%). For soft-tissue biopsies, the correct diagnosis was obtained in 10 of the 13 cases (76.9%). ...Accuracy also varied with lesion site and needle type. Cytology and pathology specimens were almost equally useful in contributing to the correct diagnosis...: The accuracy of percutaneous biopsy achieved in this series is similar to that found in other series. Fetch PMID: 10226638 14. J Bone Joint Surg Am 1993 Apr;75(4):622-31 Diagnostic strategy for bone and soft-tissue tumors. Simon MA, Finn HA. Department of Surgery, University of Chicago Medical Center, Illinois 60637. The diagnostic strategy to be used for a bone tumor depends on the ability of the clinician to make an accurate differential diagnosis on the basis of clinical information and plain radiographs. The clinician must be able to classify the patient as having a non-progressive or a progressive primary benign bone tumor, a primary malignant bone tumor, or a metastatic bone tumor. Only after assignment to one of these four categories can an effective diagnostic strategy ensue. If the clinical and radiographic information favors a diagnosis of malignant or aggressive benign bone tumor, the clinician should refer the patient to an experienced orthopaedic oncologist without performing additional diagnostic tests or a biopsy. If a soft-tissue mass is five centimeters in diameter or larger on physical examination, and especially if it is deep to the fascia, the patient should also be referred to an orthopaedic oncologist, without additional evaluation or biopsy, because of the relatively high probability that the mass is malignant. Fetch PMID: 8478392 15: Acta Radiol 1997 Sep;38(5):890-5 Assessment of suspected bone metastases. CT with and without clinical information compared to CT-guided bone biopsy. Ciray I, Astrom G, Sundstrom C, Hagberg H, Ahlstrom H. Department of Diagnostic Radiology, Uppsala University Hospital, Sweden. " In most cases, CT in combination with clinical information gives enough information about the nature-malignant or benign-of a skeletal lesion. In uncertain cases, diagnostic accuracy can be improved by means of CT-guided bone biopsy. " Fetch PMID: 9332251 16: Nippon Igaku Hoshasen Gakkai Zasshi 1996 Mar;56(4):178-82 [Percutaneous CT guided bone biopsy in patients with suspected bone neoplasm] [Article in Japanese] Yasui K, Kanazawa S, Tanaka A, Hiraki Y. Department of Radiology, Okayama University. Bone biopsy is necessary for the diagnosis of ambiguous skeletal lesions. ... CT-guided bone biopsy ... was performed in 19 consecutive patients. ... All biopsies but one were diagnostic. Malignancy was proved in 11 lesions. ... CT-guided bone biopsy is useful to evaluate the presence of malignancy and the effect of therapy for it, and to determine the primary site. Fetch PMID: 8992453 17: Hematol Oncol Clin North Am 1995 Jun;9(3):541-4 The importance of the open surgical biopsy in the diagnosis and treatment of bone and soft-tissue tumors. Huvos AG. Memorial Sloan-Kettering Cancer Center, New York, New York, USA. To obtain the maximal diagnostic benefit from a pretreatment biopsy, an adequate amount of tissue should be removed. An open surgical biopsy eminently qualifies for such a diagnostic technique because a careful histologic examination of the bone or soft-tissue tumor is of particular importance for proper treatment. An open biopsy yields the exact diagnosis in most instances. Publication Types: Review Fetch PMID: 7649941 18. Surg Neurol 2001 Jan;55(1):41-5 Secondary tumor formation after stereotactic biopsy for intracerebral metastatic disease. Marx T, Rainov NG, Heidecke V, Burkert W. Martin-Luther-University Halle-Wittenberg, Department of Neurosurgery, Faculty of Medicine, Magdeburger Str. 16, D-06097 Halle, Germany. .. There are only a few published cases of iatrogenic tumor seeding and distant neoplastic growth along the path of the cannula after stereotactic biopsy... We report the case of a female patient with a solitary lung cancer metastasis in the left parietal brain lobe. The tumor was stereotactically biopsied and treated by radiosurgery. One month after the initial biopsy, a smaller de novo tumor mass located along the track of the stereotactic cannula was detected by contrast-enhanced MRI. The spatial location of this neoplastic nodule and the short time before development of a macroscopic lesion seemed to confirm iatrogenic tumor cell spread due to the stereotactic procedure. CONCLUSION: Our findings and the reviewed literature suggest that this complication is rare. Nevertheless, neurosurgeons should be aware of the potential risk and, if necessary, should be able to modify the technical procedure and the adjuvant treatment. Fetch PMID: 11248312 19. Implantation metastasis following external biliary drainage in biliary tract cancers--cause for concern! Srivastava S, Sikora SS. Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014 India. Three patients with periampullary cancer developed tumor seedings along the T-tube choledochostomy tract, thus precluding curative resection in two patients and an early recurrence at the choledochostomy exit site in the third patient. External biliary drainage and intraoperative bile spill should be avoided in patients with curable biliary tract neoplasms. Fetch PMID: 11148996 20. 37: Eur J Surg 1996 Jul;162(7):551-4 Implantation metastases from gastrointestinal cancer after percutaneous puncture or biliary drainage. Andersson R, Andren-Sandberg A, Lundstedt C, Tranberg KG. Department of Surgery, Lund University Hospital, Sweden. .. Evaluation of incidence and outcome of implantation metastases after percutaneous fine-needle biopsy or biliary drainage. ... Retrospective study. ... University hospital, Sweden. ....Eight patients with implantation metastases from gastrointestinal cancers after percutaneous fine-needle biopsy (n = 7) or biliary drainage (n = 1). ... Incidence of implantation metastases, treatment and influence on outcome and survival. ..In two out of three patients who had had otherwise radical operations, the implantation metastases meant that the operations were palliative rather than curative. Patients who had had palliative resections of the implantation metastases developed major local complications. One patient is alive with no signs of disease after 106 months, while one is alive with disease 30 months after the diagnosis of the implantation metastases. The remaining patients have died after 6 to 23 months. CONCLUSION: The incidence of implantation metastases after fine-needle procedures is probably underestimated. There is a slight but definite risk that the procedure may render an otherwise curative resection palliative. Implantation metastases cause local complaints of varying severity and seems to have a tendency to recur locally. We recommend that fine-needle biopsy should be restricted to patients who will truly benefit from a more accurate preoperative diagnosis. Fetch PMID: 8874162 21. 34: N Z Med J 1996 Dec 13;109(1035):469-70 Percutaneous biopsy of operable liver lesions: is it necessary or advisable? Jourdan JL, Stubbs RS. Wakefield Clinic for Gastrointestinal Diseases, Wellington. AIM: The necessity and desirability of performing percutaneous biopsy of potentially resectable liver tumours is called into question. METHODS: Two cases are reported in which percutaneous biopsy of resectable liver tumours was performed unnecessarily and resulted in needle track seeding. RESULTS: In both instances patients who underwent potentially curative liver resection were rendered incurable because of biopsy track recurrence. CONCLUSION: The common practice of performing percutaneous ultrasound or CT guided biopsy of potentially resectable lesions in the liver is generally neither necessary nor desirable. Fetch PMID: 9006629 22. Med Pediatr Oncol 1997 Mar;28(3):223-7 Implantation metastasis of primary malignant rhabdoid tumor of the brain in an adult (one case report). Ashraf R, Bentley RC, Awan AN, McLendon RE, Ragozzino MW. Department of Medicine, New Hanover Regional Medical Center, Wilmington, North Carolina, USA. Fetch PMID: 9024522 23: J Neurooncol 1998 Feb;36(3):243-6 Iatrogenic seeding of anaplastic astrocytoma following stereotactic biopsy. Perrin RG, Bernstein M. Division of Neurosurgery, The Toronto Hospital and University of Toronto, Ontario, Canada. Fetch PMID: 9524102 24: J Clin Pathol 1998 Mar;51(3):241-3 Histological identification of carcinoma in 21 gauge needle tracks after fine needle aspiration biopsy of head and neck carcinoma. Mighell AJ, High AS. Diagnostic Services, Leeds Dental Institute, UK. Six cancer resection specimens were thoroughly sectioned and microscopically examined at areas known to have been around 21 gauge fine needle aspiration (FNA) biopsy sites, in an attempt to identify needle tracks. All cases had an interval of not less than 10 days between FNA biopsy and surgery. Foci of tumour were identified histologically in needle tracks from two patients with carcinoma. This is the first instance, outside of experimental animal models, of histologically confirmed, viable tumour spread in FNA biopsy tracks. Although this complication is not common and is of unknown clinical significance, it is one that all clinicians who undertake FNA of malignant neoplasms should be aware of. Fetch PMID: 9659269 25: Hepatogastroenterology 1998 Jul-Aug;45(22):1097-9 Needle track seeding following percutaneous ethanol injection for treatment of hepatocellular carcinoma. Sammak B, Yousef B, Abd El Bagi M, Al Karawi M, Mohamed A, Gali M, Al Shahed M. Department of Radiology, Riyadh Armed Forces Hospital, Saudi Arabia. We report two cases of needle track seeding in the subcutaneous tissue and intercostal muscles following percutaneous ethanol injection for the treatment of hepatocellular carcinoma. In one patient, tumor seeding was observed 11 months after a total of 12 alcohol injections, and in the other patient, tumor seeding was observed 30 months after a total of 18 alcohol injections. The cases reported in the literature are discussed. Fetch PMID: 9756013 26: Abdom Imaging 1999 Jul-Aug;24(4):401-3 Color Doppler findings of tumor seeding after US-guided liver tumor biopsy. Konno K, Ishida H, Hamashima Y, Komatsuda T, Sato M, Furuya T, Asanuma Y, Masamune O. First Department of Internal Medicine, Akita University School of Medicine, 1-1-1 Hondo, Akita, Japan, We present two cases with tumor seeding along the needle tract occurring after a large-core needle liver tumor biopsy performed at other hospitals. Color Doppler sonography showed the hypervascular nature of the lesion and increased diagnostic confidence. Fetch PMID: 10390566 27: AJR Am J Roentgenol 1999 Nov;173(5):1303-13 Are malignant cells displaced by large-gauge needle core biopsy of the breast? Diaz LK, Wiley EL, Venta LA. Department of Pathology, Northwestern University Medical School, Chicago, IL60611, USA. The purpose of this paper is to determine the rate of tumor displacement resulting from large-gauge needle core biopsy in patients with breast carcinoma. Three hundred fifty-two cancer excisions in patients who had undergone large-gauge needle core biopsy were evaluated for evidence of tumor displacement. Three needle procedures were compared: vacuum-assisted, automated gun, and core biopsy guided by palpation. Needle track visualization, presence and amount of tumor displacement, tumor morphology, and interval between core biopsy and surgical excision were recorded for each case. RESULTS: Seventy-six cases showed tumor displacement of one or two cell clusters, and 38 cases-showed displacement of multiple tumor fragments. Tumor displacement was identified in 37% of automated gun specimens, 38% of specimens obtained with palpable guidance, and 23% of specimens obtained with a vacuum-assisted needle. Tumor displacement was seen in 42% of patients with an interval between biopsy and excision of less than 15 days, in 31% of patients with an interval of 15-28 days, and in 15% of tumors excised more than 28 days after core biopsy (p < .005). CONCLUSION: Tumor cell displacement was observed in 32% of patients who had undergone large-gauge needle core biopsy. The incidence and amount of tumor displacement was inversely related to the interval between core biopsy and excision. This relation suggests that tumor cells do not survive displacement. Fetch PMID: 10541110 28. Oncology 2000 Sep;59(3):217-22 Fine needle aspiration may shed breast cells into peripheral blood as determined by RT-PCR. Hu XC, Chow LW. Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Pokfulam, Hong Kong. "A diagnostic test ... was used to evaluate the impact of fine needle aspiration (FNA) on breast cell shedding into peripheral blood. ... For blood samples of 24 cases with benign breast diseases and 20 cases with malignant ones, 5 ml of peripheral blood was drawn before and within 10 min after puncture. ,,, For 24 benign cases, none of the pre- FNA samples was positive for CK20 and beta-hCG, and 3 cases (12.5%) were positive for CK19. As for 20 malignant cases, 1 pre-FNA sample was positive for all three markers and 2 other samples were positive for CK19. After aspiration, 3/21 benign cases and 1/17 malignant case with pre-FNA negative signals became positive for CK19, while 3/19 malignant cases with pre-FNA negative signals were converted to a positive result for CK20 and beta-hCG. Of 6 pre-FNA positive cases, all cases remained positive for the respective marker. ,,, FNA to breast tumor may cause hematogenous dissemination of breast cells." [Abstract heavily edited.] Copyright 2000 S. Karger AG, Basel Fetch PMID: 11053989 29: Ann Thorac Surg 1995 Jan;59(1):42-5 Thoracoscopic implantation of cancer with a fatal outcome. Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Department of Surgery, Evanston Hospital, Northwestern University Medical School, Illinois. A case is presented in which an indeterminate lung lesion was extracted through an accessory incision during a video-assisted thoracic surgical lung biopsy. The lesion was malignant, and a completion lobectomy was performed. An incisional recurrence developed 5 months later, and this was treated with a wide chest wall resection and reconstruction. However, there was a second massive chest wall recurrence that proved fatal. We believe that tumor seeding to the chest wall occurred at thoracoscopy. To prevent such tumor seeding, thoracoscopic biopsy specimens should be removed in some sort of receptacle when cancer is suspected. Fetch PMID: 7818356 30. Acta Radiol 1991 Nov;32(6):518-20 Tumor seeding occurring after fine-needle biopsy of abdominal malignancies. Lundstedt C, Stridbeck H, Andersson R, Tranberg KG, Andren-Sandberg A. Department of Diagnostic Radiology, University Hospital, Lund, Sweden. Percutaneous fine-needle aspiration biopsy is a commonly used diagnostic procedure with a high accuracy and a low complication rate. However, tumor seeding in the biopsy tracts has been recorded with a frequency of one in 20,000-40,000 biopsies. We report 5 cases of percutaneous tumor seeding recorded after 5,000 fine-needle biopsies of abdominal malignancies at our institution. The risk of implantation metastases induced by fine-needle biopsy warrants consideration in patients with abdominal malignancies since it may compromise the outcome of radical surgery. It should only be performed when the result of the procedure has a direct impact on the choice of therapy. Fetch PMID: 1742134 Compiled by doctordee December 2002

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