Surg Today (2015) 45:394–396 DOI 10.1007/s00595-014-1027-9
HOW TO DO IT
Diagnostic laparoscopic biopsy for intraabdominal tumors Yasuo Sakamoto · Ryuichi Karashima · Satoshi Ida · Yu Imamura · Shiro Iwagami · Yoshifumi Baba · Yuji Miyamoto · Naoya Yoshida · Hideo Baba
Received: 19 March 2014 / Accepted: 7 May 2014 / Published online: 12 September 2014 © Springer Japan 2014
Abstract Improvements in imaging technology have resulted in an increase in the incidental detection of intraabdominal tumors. Diagnostic computed tomography (CT)- and ultrasound (US)-guided biopsy, while minimally invasive, often provides specimens that are insufficient for histological evaluation. Moreover, it can be difficult to perform because the location and size of the tumor. In such cases, laparoscopic biopsy is useful because it is less invasive than laparotomy, but more reliable than imagingguided biopsy, to obtain a sufficient specimen, regardless of the location and size of the tumor. We report a series of seven patients who underwent laparoscopic biopsy of intraabdominal tumors of unknown origin. There were no cases of conversion to laparotomy and all patients were able to resume oral intake on postoperative day 1. There were no intraoperative or postoperative complications. Thus, laparoscopic biopsy for a tumor of unknown origin is useful and minimally invasive.
Using a CT- or US-guided approach to obtain a biopsy specimen for diagnosis is minimally invasive [1, 2]. However, the specimen obtained is often insufficient for histological evaluation, or the biopsy is difficult to perform due to the location or size of the tumor; for example, when the tumor is adjacent to important structures such as major blood vessels, the intestines or other viscera. Moreover, CT- or US-guided biopsy of intraabdominal tumors may lead to peritoneal dissemination or implantation, necessitating laparotomy to obtain a specimen for the diagnosis. However, laparotomy is invasive and the postoperative pain and scarring impacts quality of life (QOL). Recent improvements in laparoscopic techniques have allowed us to procure an adequate specimen without tumor cell dissemination or implantation. We conducted this study to evaluate the usefulness of laparoscopic biopsy for intraabdominal tumors.
Keywords Laparoscopic biopsy · Intraabdominal tumor
Procedure and results
Introduction Advances in imaging technologies, such as computed tomography (CT), ultrasonography (US), and positron emission tomography, have resulted in an increasing frequency of incidentally detected intraabdominal tumors.
Y. Sakamoto · R. Karashima · S. Ida · Y. Imamura · S. Iwagami · Y. Baba · Y. Miyamoto · N. Yoshida · H. Baba (*) Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1‑1‑1 Honjo, Chuo‑Ku, Kumamoto 860‑8556, Japan e-mail: hdobaba@kumamoto‑u.ac.jp
13
Under general anesthesia, the patient was placed in the supine or lithotomy position and the first 12-mm trocar was placed using a standard umbilical cut-down technique. Carbon dioxide (CO2) insufflation was used to establish pneumoperitoneum in the operating field, with intraabdominal pressure maintained at 10 mmHg. Under the guidance of a laparoscope, two 5-mm trocars were inserted in positions depending on the location of the tumor. To visualize the tumor, the patients were placed in the Trendelenburg or semi-Fowler’s position, depending on the tumor location, and the small bowel mesentery was retracted out of the surgical field. After identifying the tumor, the peritoneum overlying the tumor was carefully incised, and the tumor was isolated circumferentially from the surrounding tissues
Surg Today (2015) 45:394–396
395
Fig. 1 A retroperitoneal tumor was located between the right internal and external iliac arteries near the ureter (case 6). a The tumor was visualized by retracting the rectum and ureter. b The tumor was iso-
lated circumferentially from the surrounding tissues by using a laparoscopic coagulating device
Table 1 Characteristics and diagnoses of the patients who underwent laparoscopic biopsy Case
Age
Gender
Preoperative diagnosis
Location
Diameter (mm)
Postoperative diagnosis
1 2 3 4 5 6
84 64 58 64 55 74
M M M F M F
Malignant lymphoma Malignant lymphoma GIST Malignant lymphoma Malignant lymphoma Malignant lymphoma
Rt. iliac A Rt. external iliac A Paraaorta Small bowel mesentery Para-common hepatic A Lt. internal iliac A
10 15 26 20 16 20
LN metastasis of prostate cancer Malignant lymphoma Pheochromocytoma Malignant lymphoma Non-specific inflammatory changes Tuberculosis
7
66
M
Unknown
Sigmoid colon mesentery
25
LN metastasis of pancreatic cancer
Rt. right, Lt. left, A artery, LN lymph node, GIST gastrointestinal stromal tumor
using laparoscopic coagulating devices (Fig. 1a, b). After retrieving the tumor, the abdomen was irrigated, and hemostasis was verified. Specimens were sent for frozen and permanent sectioning by a pathologist. After confirming that an appropriate tissue specimen had been obtained, the operation was finished. Between January 2012 and December 2013, seven patients underwent laparoscopic biopsy to obtain a specimen for pathological diagnosis. Table 1 summarizes the patients’ clinical characteristics and pre- and postoperative diagnoses. There were five men and two women, ranging in age from 55 to 84 years. Preoperative diagnoses included malignant lymphoma, gastrointestinal stromal tumor (GIST), and unknown tumors. The mean operative time was 174 min (range 55–215 min) and the mean blood loss was 10 ml (range 0–40 ml). All patients were able to resume oral intake on postoperative day (POD) 1. The postoperative diagnoses were malignant lymphoma, pheochromocytoma, tuberculosis, non-specific inflammatory changes, and lymph node metastasis of another cancer. There were no intraoperative or postoperative complications and all patients were discharged within 6 days (mean 4.5 days).
Discussion Laparoscopic biopsy is less invasive than biopsy via laparotomy and more reliable than CT- or US-guided biopsy in terms of obtaining a sufficient specimen. Originally, laparoscopic biopsy was performed to diagnose intraabdominal lymphoma [3–6]. However, recently, the indications have widened to include tumors of unknown origin [7]. Moreover, laparoscopic retroperitoneal lymph node dissection has been reported as an effective procedure for germ-cell tumors [8, 9]. Although CT- or US-guided biopsy does not always allow us to obtain a sufficient specimen for chromosomal analysis of malignant lymphoma, laparoscopic excisional biopsy can always provide a sufficient specimen. It is difficult to puncture a very small intraabdominal tumor, but laparoscopic biopsy allows us to procure the specimen, regardless of the size of the tumor. In fact, intraabdominal tumors ranging from 10 to 26 mm in diameter were resected laparoscopically in this series. Asoglu et al. [6] reported that conversion to laparotomy was necessary in 17 % of their patients because of inadequate exposure and insufficient tissue. Diulus et al. [10] reported a conversion rate of 13 %, but a low complication
13
396
rate for laparoscopic lymph node biopsy. In our small series, there were no cases of conversion and no complications, even when the tumor was located near major vessels. Moreover, the laparoscopic approach is superior to laparotomy in terms of impact on QOL [11, 12]. Similarly, laparoscopic biopsy may be superior to laparotomy, especially in regard to the postoperative pain and cosmetic result. Indeed, three patients with lymph nodes in the small bowel mesentery underwent an open biopsy via a small incision during the same period. Nevertheless, a tendency toward a long postoperative hospitalization period was noted (mean 8.0 days), with a significantly higher need for painkillers (mean 7.5 times) than after laparoscopic biopsy (mean 4.5 days and 4.0 times). However, a randomized trial is needed to prove the lower impact on QOL. In conclusion, when it is difficult to obtain a specimen for a diagnosis using CT- or US-guided biopsy, laparoscopic biopsy is an effective and minimally invasive diagnostic procedure. Conflict of interest Yasuo Sakamoto and his co-authors have no conflicts of interest to declare in association with this study.
References 1. vanSonnenberg E, Wittenberg J, Ferrucci JT Jr, et al. Triangulation method for percutaneous needle guidance: the angled approach to upper abdominal masses. AJR Am J Roentgenol. 1981;137:757–61. 2. Peter S, Eltoum I, Eloubeidi MA. EUS-guided FNA of peritoneal carcinomatosis in patients with unknown primary malignancy. Gastrointest Endosc. 2009;70:1266–70.
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Surg Today (2015) 45:394–396 3. Silecchia G, Fantini A, Raparelli L, et al. Management of abdominal lymphoproliferative diseases in the era of laparoscopy. Am J Surg. 1999;177:325–30. 4. Cowles RA, Yahanda AM. Laparoscopic biopsy of abdominal retroperitoneal lymphadenopathy for the diagnosis of lymphoma. J Am Coll Surg. 2000;191:108–13. 5. Silecchia G, Raparelli L, Perrotta N, et al. Accuracy of laparoscopy in the diagnosis and staging of lymphoproliferative diseases. World J Surg. 2003;27:653–8. 6. Asoglu O, Porter L, Donohue JH, Cha SS. Laparoscopy for the definitive diagnosis of intra-abdominal lymphoma. Mayo Clin Proc. 2005;80:625–31. 7. Hara I, Tanaka K, Yamada Y, et al. Usefulness of laparo- or retroperitoneoscopic biopsy for retroperitoneal lymph node swelling of unknown origin. Int J Urol. 2007;14:466–9. 8. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol. 2005;2:330–5. 9. Finelli A. Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: long-term oncologic outcomes. Curr Opin Urol. 2008;18:180–4. 10. Diulus L, Chalikonda S, Pitt T, Rosenblatt S. Efficacy of laparoscopic mesenteric/retroperitoneal lymph node biopsy. Surg Endosc. 2009;23:389–93. 11. Kornblith AB, Huang HQ, Walker JL, et al. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009;27:5337–42. 12. Janda M, Gebski V, Brand A, et al. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncol. 2010;11:772–80.
HOW TO DO IT
Diagnostic laparoscopic biopsy for intraabdominal tumors Yasuo Sakamoto · Ryuichi Karashima · Satoshi Ida · Yu Imamura · Shiro Iwagami · Yoshifumi Baba · Yuji Miyamoto · Naoya Yoshida · Hideo Baba
Received: 19 March 2014 / Accepted: 7 May 2014 / Published online: 12 September 2014 © Springer Japan 2014
Abstract Improvements in imaging technology have resulted in an increase in the incidental detection of intraabdominal tumors. Diagnostic computed tomography (CT)- and ultrasound (US)-guided biopsy, while minimally invasive, often provides specimens that are insufficient for histological evaluation. Moreover, it can be difficult to perform because the location and size of the tumor. In such cases, laparoscopic biopsy is useful because it is less invasive than laparotomy, but more reliable than imagingguided biopsy, to obtain a sufficient specimen, regardless of the location and size of the tumor. We report a series of seven patients who underwent laparoscopic biopsy of intraabdominal tumors of unknown origin. There were no cases of conversion to laparotomy and all patients were able to resume oral intake on postoperative day 1. There were no intraoperative or postoperative complications. Thus, laparoscopic biopsy for a tumor of unknown origin is useful and minimally invasive.
Using a CT- or US-guided approach to obtain a biopsy specimen for diagnosis is minimally invasive [1, 2]. However, the specimen obtained is often insufficient for histological evaluation, or the biopsy is difficult to perform due to the location or size of the tumor; for example, when the tumor is adjacent to important structures such as major blood vessels, the intestines or other viscera. Moreover, CT- or US-guided biopsy of intraabdominal tumors may lead to peritoneal dissemination or implantation, necessitating laparotomy to obtain a specimen for the diagnosis. However, laparotomy is invasive and the postoperative pain and scarring impacts quality of life (QOL). Recent improvements in laparoscopic techniques have allowed us to procure an adequate specimen without tumor cell dissemination or implantation. We conducted this study to evaluate the usefulness of laparoscopic biopsy for intraabdominal tumors.
Keywords Laparoscopic biopsy · Intraabdominal tumor
Procedure and results
Introduction Advances in imaging technologies, such as computed tomography (CT), ultrasonography (US), and positron emission tomography, have resulted in an increasing frequency of incidentally detected intraabdominal tumors.
Y. Sakamoto · R. Karashima · S. Ida · Y. Imamura · S. Iwagami · Y. Baba · Y. Miyamoto · N. Yoshida · H. Baba (*) Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1‑1‑1 Honjo, Chuo‑Ku, Kumamoto 860‑8556, Japan e-mail: hdobaba@kumamoto‑u.ac.jp
13
Under general anesthesia, the patient was placed in the supine or lithotomy position and the first 12-mm trocar was placed using a standard umbilical cut-down technique. Carbon dioxide (CO2) insufflation was used to establish pneumoperitoneum in the operating field, with intraabdominal pressure maintained at 10 mmHg. Under the guidance of a laparoscope, two 5-mm trocars were inserted in positions depending on the location of the tumor. To visualize the tumor, the patients were placed in the Trendelenburg or semi-Fowler’s position, depending on the tumor location, and the small bowel mesentery was retracted out of the surgical field. After identifying the tumor, the peritoneum overlying the tumor was carefully incised, and the tumor was isolated circumferentially from the surrounding tissues
Surg Today (2015) 45:394–396
395
Fig. 1 A retroperitoneal tumor was located between the right internal and external iliac arteries near the ureter (case 6). a The tumor was visualized by retracting the rectum and ureter. b The tumor was iso-
lated circumferentially from the surrounding tissues by using a laparoscopic coagulating device
Table 1 Characteristics and diagnoses of the patients who underwent laparoscopic biopsy Case
Age
Gender
Preoperative diagnosis
Location
Diameter (mm)
Postoperative diagnosis
1 2 3 4 5 6
84 64 58 64 55 74
M M M F M F
Malignant lymphoma Malignant lymphoma GIST Malignant lymphoma Malignant lymphoma Malignant lymphoma
Rt. iliac A Rt. external iliac A Paraaorta Small bowel mesentery Para-common hepatic A Lt. internal iliac A
10 15 26 20 16 20
LN metastasis of prostate cancer Malignant lymphoma Pheochromocytoma Malignant lymphoma Non-specific inflammatory changes Tuberculosis
7
66
M
Unknown
Sigmoid colon mesentery
25
LN metastasis of pancreatic cancer
Rt. right, Lt. left, A artery, LN lymph node, GIST gastrointestinal stromal tumor
using laparoscopic coagulating devices (Fig. 1a, b). After retrieving the tumor, the abdomen was irrigated, and hemostasis was verified. Specimens were sent for frozen and permanent sectioning by a pathologist. After confirming that an appropriate tissue specimen had been obtained, the operation was finished. Between January 2012 and December 2013, seven patients underwent laparoscopic biopsy to obtain a specimen for pathological diagnosis. Table 1 summarizes the patients’ clinical characteristics and pre- and postoperative diagnoses. There were five men and two women, ranging in age from 55 to 84 years. Preoperative diagnoses included malignant lymphoma, gastrointestinal stromal tumor (GIST), and unknown tumors. The mean operative time was 174 min (range 55–215 min) and the mean blood loss was 10 ml (range 0–40 ml). All patients were able to resume oral intake on postoperative day (POD) 1. The postoperative diagnoses were malignant lymphoma, pheochromocytoma, tuberculosis, non-specific inflammatory changes, and lymph node metastasis of another cancer. There were no intraoperative or postoperative complications and all patients were discharged within 6 days (mean 4.5 days).
Discussion Laparoscopic biopsy is less invasive than biopsy via laparotomy and more reliable than CT- or US-guided biopsy in terms of obtaining a sufficient specimen. Originally, laparoscopic biopsy was performed to diagnose intraabdominal lymphoma [3–6]. However, recently, the indications have widened to include tumors of unknown origin [7]. Moreover, laparoscopic retroperitoneal lymph node dissection has been reported as an effective procedure for germ-cell tumors [8, 9]. Although CT- or US-guided biopsy does not always allow us to obtain a sufficient specimen for chromosomal analysis of malignant lymphoma, laparoscopic excisional biopsy can always provide a sufficient specimen. It is difficult to puncture a very small intraabdominal tumor, but laparoscopic biopsy allows us to procure the specimen, regardless of the size of the tumor. In fact, intraabdominal tumors ranging from 10 to 26 mm in diameter were resected laparoscopically in this series. Asoglu et al. [6] reported that conversion to laparotomy was necessary in 17 % of their patients because of inadequate exposure and insufficient tissue. Diulus et al. [10] reported a conversion rate of 13 %, but a low complication
13
396
rate for laparoscopic lymph node biopsy. In our small series, there were no cases of conversion and no complications, even when the tumor was located near major vessels. Moreover, the laparoscopic approach is superior to laparotomy in terms of impact on QOL [11, 12]. Similarly, laparoscopic biopsy may be superior to laparotomy, especially in regard to the postoperative pain and cosmetic result. Indeed, three patients with lymph nodes in the small bowel mesentery underwent an open biopsy via a small incision during the same period. Nevertheless, a tendency toward a long postoperative hospitalization period was noted (mean 8.0 days), with a significantly higher need for painkillers (mean 7.5 times) than after laparoscopic biopsy (mean 4.5 days and 4.0 times). However, a randomized trial is needed to prove the lower impact on QOL. In conclusion, when it is difficult to obtain a specimen for a diagnosis using CT- or US-guided biopsy, laparoscopic biopsy is an effective and minimally invasive diagnostic procedure. Conflict of interest Yasuo Sakamoto and his co-authors have no conflicts of interest to declare in association with this study.
References 1. vanSonnenberg E, Wittenberg J, Ferrucci JT Jr, et al. Triangulation method for percutaneous needle guidance: the angled approach to upper abdominal masses. AJR Am J Roentgenol. 1981;137:757–61. 2. Peter S, Eltoum I, Eloubeidi MA. EUS-guided FNA of peritoneal carcinomatosis in patients with unknown primary malignancy. Gastrointest Endosc. 2009;70:1266–70.
13
Surg Today (2015) 45:394–396 3. Silecchia G, Fantini A, Raparelli L, et al. Management of abdominal lymphoproliferative diseases in the era of laparoscopy. Am J Surg. 1999;177:325–30. 4. Cowles RA, Yahanda AM. Laparoscopic biopsy of abdominal retroperitoneal lymphadenopathy for the diagnosis of lymphoma. J Am Coll Surg. 2000;191:108–13. 5. Silecchia G, Raparelli L, Perrotta N, et al. Accuracy of laparoscopy in the diagnosis and staging of lymphoproliferative diseases. World J Surg. 2003;27:653–8. 6. Asoglu O, Porter L, Donohue JH, Cha SS. Laparoscopy for the definitive diagnosis of intra-abdominal lymphoma. Mayo Clin Proc. 2005;80:625–31. 7. Hara I, Tanaka K, Yamada Y, et al. Usefulness of laparo- or retroperitoneoscopic biopsy for retroperitoneal lymph node swelling of unknown origin. Int J Urol. 2007;14:466–9. 8. Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol. 2005;2:330–5. 9. Finelli A. Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: long-term oncologic outcomes. Curr Opin Urol. 2008;18:180–4. 10. Diulus L, Chalikonda S, Pitt T, Rosenblatt S. Efficacy of laparoscopic mesenteric/retroperitoneal lymph node biopsy. Surg Endosc. 2009;23:389–93. 11. Kornblith AB, Huang HQ, Walker JL, et al. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009;27:5337–42. 12. Janda M, Gebski V, Brand A, et al. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncol. 2010;11:772–80.
