Percutaneous Fine-Needle Aspiration Biopsy during Endoscopic Retrograde C holangio-pancreatography TH. IHRE, E. PYK, T. RAASCHOU-NIELSEN & U. SELIGSON Depts. of Surgery, Radiology and Pathology, Sodersjukhuset, Stockholm, Sweden Ihre, Th., Pyk, E., Raaschou-Nielsen, T. & Seligson. U. Percutaneous fine-needle aspiration biopsy during endoscopic retrograde cholangio-pancreatography. Scand. J.
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Gasrroent. 1978, 13, 657-662..
In 12 non-icteric patients, changes in the pancreatic duct indicative of carcinoma were found during endoscopic retrograde cholangio-pancreatography(ERCP.). Percutaneous fine-needle biopsy was positive for cancer in six cases. Nine of the 12 patients were later proved to have carcinoma of the pancreas. There was one falsely negative biopsy but no false positives. In two cases no pancreatic cells were found in the smear. It seems that percutaneous fine-needle aspiration biopsy during ERCP is a feasible procedure and can be recommended in ductal changes indicative of carcinoma. Key-words: Biopsy, fine-needle aspiration; carcinoma, pancreatic, localization body or
tail; cytology; ERCP T. Ihre, Dept. of Surgery, Sodersjukhuset. 10064 Stockholm 38, Sweden
In patients with tumour of the pancreas, the result of treatment is dependent on a number of factors, of which the most important are the size of the tumour, its invasiveness, and its biological activity. The size of the tumour is dependent on how early the cancer is detected, which again is dependent on how early the tumour gives clinical signs and symptoms. Cancers in the head of the pancreas often lead to jaundice at an early stage, but in cancers of the body or tail, the symptoms are vague and the diagnosis is often made when the tumour has grown to a considerable size. The size of the tumour will affect its resectability :the smaller the tumour, the greater the chaiices are for radical surgery. Different radiological methods, such as angiography, intravenous cholangiography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio-pancreatography (ERCP), CT-scanning and ultrasonic investigations, have made it possible to investigate and to diagnose even small tumours. The radiological diagnosis must, however, be confirmed histologically at laparotomy and/or by other routes of obtaining cells for cytology. Collection of pure juice from the pancreatic duct for cytology is possible by cannulat-
ing the papilla of Vater (5, 6). Endoscopic retrograde brush cytology (ERBC) has also been reported as a useful supplement to other methods (8). Fine-needle aspiration biopsy of the pancreas during operation ( I ) , during endoscopy (3), percutaneous aspiration biopsy in combination with CTscanning (4) and under ultrasonic guidance (9) as well as in combination with angiography (10) have been reported as useful methods for obtaining cytological samples from lesions in the pancreas. Fineneedle aspiration biopsy in conjunction with PTC has been used as a routine procedure in patients with stenosis or strictures of the bile ducts. The biopsy can b e taken under direct vision and under fluoroscopic guidance ( 1 1). For 2 years we have combined ERCP with percutaneous aspiration biopsy in patients with ductal changes suspected of being cancer, in order to achieve a more precise diagnosis before surgery. We have not used any other method for obtaining cells for cytology preoperatively. METHOD ERCP was performed in the usual manner with an Olympus J F B 2 sideviewing duodenoscope and
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
658
Th. Ihre, E. Pyk, T. Raaschou-Nielsen & U.Seligson
Fig. 1. Instrument used for percutaneous fine-needle aspiration biopsy. Two needles, 140 x 0.60 mm,Franzen model (Stille 2R2) and handle to facilitate aspiration. One of the needles has been bent to show its flexibility. with the patient in the prone position. Before the investigation was started the patient was given 0.5 mg atropine, 10 mg diazepam (Valium@) and 40 mg N-butylscopolammonium bromide (Buscopan@). After cannulation of the pancreatic duct, contrast (Urografin 60%) was injected and ductfilling was checked fluoroscopically. The biopsy was performed in all patients with changes suspected of being neoplastic on fluoroscopy and verified radiographically. The patients were then turned over to the supine position. In a few patients this was possible with the catheter still in position, but in most patients this manoeuvre caused the catheter to slip out of the papilla. In some cases recannulation was done in the supine position, and in some patients there was enough contrast in the pancreatic duct to localize the lesion and to perform the fine-needle biopsy. The skin area above the suspected lesion was cleaned with 0.05% chlorhexedrine, and a 140 x 0.60 mm Franzin needle (Stille 2R2) was inserted percutaneously above the suspected lesion. No anesthesia was used, since the thin needle was hardly felt when inserted. The patient was turned on
either side in order to position the needle optimally. A disposable syringe with a handle was used (Fig. 1). Multiple aspirations were performed from the suspected and from two or three adjacent areas. A new needle was used for each aspiration. The aspirates were usually sufficient for six to eight smears. Care was taken not to traverse the colon or to damage the duodenoscope with the needle. There have been no complications in obtaining the aspiration biopsy. The patient usually had a dull feeling of pain as the tip of the needle passed into the deeper tissues. This pain was not severe and disappeared as the needle was withdrawn. In some of the patients with cancer it was possible to feel resistance as the needle passed into the carcinoma. In 11 patients the puncture was performed through the anterior abdominal wall and in one via the lumbar route. In four patients the ERCP and fine-needle aspiration biopsy were carried out as outpatient procedures, and the patient left the hospital 2 h after the investigation. MATERIAL Fine-needle aspiration biopsy was performed in 12
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
Fine-Needle Aspiration Biopsy during ERCP
659
ticed pain in the left hypochondrium. Radiology of the gastrointestinal tract and i.v. cholangiography showed normal results. Laboratory tests were normal except for an ESR of 5 1m m h and a moderately raised alkaline phosphatase. ERCP (Fig. 2a). The pancreatic duct was normal in the head and body, but in the tail a stricture was visualized, which was suspected of being due to cancer. Percutaneous aspiration biopsy was performed through the abdominal wall (Fig. 2b). Seven smears were obtained, two of which contained malignant cells. Laparotomy. Inoperable cancer of the tail of the pancreas with liver metastases. Case 2. A 62-year-old man with no previous history of biliary or pancreatic disease. His sympCASE REPORTS toms had been vague-some pain and loss of appeCase I . A 5 8-year-old man without any previous tite. Barium meal showed normal results. Laborahistory of pancreatic or biliary disease, who prior to tory tests were normal. the admission had lost weight (6 kg) and had noERCP (Fig. 3a). There was filling of the pancreatic duct in the head and body, but a complete obstruction was found in the distal part of the duct. Percutaneous aspiration biopsy was performed through the anterior abdominal wall (Fig. 3b). Six smears were obtained. Cytology showed cancer cells. Operation was performed with a resection of 3/4 of the pancreas. The tumour was 1 cm in diameter, but there was spread of the tumour to the adjacent lymph nodes. Case 3. A 68-year-old man referred to the outpatient clinic for suspected cancer in the left breast. Biopsy from the suspected area showed only fibroadenomatous tissue. The patient complained of dyspepsia and had 12 years previously been operated on with ‘some kind of biliary operation’. An intravenous cholangiography was performed, on which a filling defect in the distal part of the common bile duct was seen. ERCP was therefore carried out. ERCP (Fig. 4a). The patient had been operated on with a choledochoduodenostomy owing to stones in the common bile duct. This explained the filling defect in the distal part of the bile duct. On the ERCP the ducts were filled from the papilla. The biliary tract was normal apart from the cholodoFig. 2. Case 1. hKP: Obstruction of normal pancreatic duct in :he tail of the gland (upper). Needle inserted in the choduodenostmy, but in the distal end of the panregion of the obstruction (lower). Cytology: cancer. creatic duct there was a stenosis and at least two
patients, all having lesions indicative of cancer on ERCP. In all patients the lesion was located either to the body or the tail of the gland. None of the patients had jaundice. In patients with jaundice we prefer PTC . Eight of the patients had weight loss and abdominal pain as the most aominant symptoms. In four of the patients, pain and elevated serum isoamylase concentrations motivated the ERCP. Ten of the patients had elevated alkaline phosphatase. The following three cases represent different findings on ERCP and fine-needle biopsy, and we should therefore like to present them as examples of the usefulness and limitations of the method.
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660
Th. Ihre, E. Pyk, T. Raaschou-Nielsen & U.S 'eligson
Fig. 3. Case 2. ERCP: Biliary ducts normal. Obstruction of the pancreatic duct in the body of the gland (left). Fine needle inserted in the gland (right). Cytology: cancer.
pancreatic pseudocysts-cancer of the tail of the pancreas ? A percutaneous aspiration biopsy was performed through the anterior abdominal wall (Fig. 4b). Eight smears were obtained, none of which showed malignant cells. It was revealed that the patient was an alcoholic, and the changes in the pancreas were thought to be due to pancreatitis. Four months later the patient died. Autopsy revealed a disseminated carcinoma of the pancreas. RESULTS Percutaneous fine-needle aspiration biopsy in conjunction with ERCP has been performed in 12 patients, all having lesions radiologically indicative of cancer in the body or tail of the pancreas. Smears were obtained from all patients and showed cancer cells in six, benign cells in four, and only blood cells
in two. Laparotomy was performed in nine of the 12 patients and showed carcinoma of the pancreas in eight, verifying the cytology finding in the six positive samples. In the remaining two patients with carcinoma at laparotomy, no cells had been obtained for cytology. In one of these patients the lumbar route was used. At laparotomy one patient had a benign pancreatic cyst which was drained to the stomach. Three patients showing benign cells at biopsy did not go to surgery. One patient (case 3) died 4 months after the investigation. Autopsy revealed a widespread carcinoma of the pancreas. The other two patients had had elevated isoamylase levels prior to the ERCP and clinical signs and symptoms of chronic pancreatitis. Both patients have recovered clinically with normal isoamylase levels and are doing well 9 and 12 months, respectively, after the investigation.
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Fine-Needle Aspiration Biopsy during ERCP
66 1
of the gland, cytology from pure juice collections gives lower accuracy than with tumours of the head (2). None of our patients had tumours of the head, and in one patient the tumour was located in the tail, positive at fine-needle biopsy and at operation found to be 1 cm in diameter. Nevertheless, this patient (case 2) was at operation found to have metastasis to adjacent lymph nodes. Percutaneous biopsy from tumours in various organs has been used routinely during the past few years. Its value in connection with percutaneous transhepatic cholangiography is undoubted, and it is now used in the investigation of tumours of the head of the pancreas as well as in tumours of the biliary tract. This method has given 90% accuracy in diagnosing malignancy in the periampullary region, with no serious complications (1 1). Percutaneous biopsy in conjunction with angiography is also employed as a routine method, as is percutaneous aspiration biopsy under ultrasonic guidance. without reports of serious complications. In our series 1 1 of the punctures were performed through the anterior abdominal wall. With an anterior approach there might be a risk ofcontamination if the needle traverses the colon. This risk, however, is very small, since the transverse colon in most cases lies more caudally than the pancreas. Even if the needle should traverse the large bowel. a leakage of bowel content is unlikely to occur as the diameter of the needle is very small. With a posterior approach the patient does not need to be turned before the puncture, but if the tumour is located just above the spine, it might be difficult to obtain a specimen from the suspected area. In the patient in whom we Fig. 4.Case 3. ERP: Almost complete obstruction in the used the lumbar route, the smears only contained middle of the duct and cysts in the distal part of the blood cells. We therefore think that the best appancreas (upper). Fine needle inserted in the lesion (lower). Cytology: N o malignant cells obtained (falsely proach to a pancreatic lesion by the percutaneous negative). method is from the anterior abdominal wall. The diagnosis in our series was accurate in six out DISCUSSION of nine patients with cancer in the body or tail and in The value of radiological methods in diagnosing three patients with benign lesions. It was falsely carcinoma of the pancreas will be limited as long as negative in one patient, and no samples were obthey are not combined with a method of obtaining tained in two patients with cancer. There were no definite diagnosis by histology or cytology. The falsely positive diagnoses. The results of treatment in carcinomas of the most commonly used cytological technique is pure juice cytology after stimulation with secretin. Posi- body and tail of the pancreas are discouraging. It tive findings are reported with pure juice cytology in might therefore be that this method, as well as other 50-75% (2. 3, 6). With tumours in the distal parts cytological methods, has its greatest value in
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
662
Th. Ihre. E. Pyk, T. Raaschou-Nielsen & I/. Seligson
determining when not to operate on a patient. In increase the chances of a correct diagnosis in cases many patients with clinical evidence of metastatic where tumours of the body or tail of the pancreas are growth, a histological or cytological confirmation in suspected. combination with other investigations such as It appears that percutaneous fine-needle aspiraangiography can prevent an unnecessary operation tion biopsy in conjunction with ERCP is a feasible and thereby give the patient a better quality of life procedure which can be recommended as a suppleduring his remaining time. ment to other methods in cases where it is difficult to Peroperative biopsies with wedge excisions or by differentiate between cancer and benign lesions in the Vilm-Silverman punch technique have been re- the pancreas. ported to give up to 20% complications in the form of haemorrhages or fistulas (7). There is a much lower incidence of complications with a peropera- REFERENCES 1. Amesjo, B., Stormby, N. & Akerman, M. Acra Chir. tive fine-needle aspiration biopsy (1). However, at Scand. 1972. I38, 363-369 an operation where a pancreatic mass is found, it can 2 . Cotton, P. B. Gut 1977, 18. 316-341 be difficult to obtain representative material. By 3. Endo, Y., Morii, T., Tamura, H; & Okuda, S . Gasboenterologv 1974, 6 7, 944-95 1 combining ERCP with a percutaneous fine-needle 4. Ferruchi, J. Localization by computerized axial tomaspiration biopsy, it is possible to direct the needle, ograph and direct needle biopsy. Paper read at 63rd under fluoroscopic guidance, towards the suspected Annual Congress of the American College of Surgeons, Dallas, 1977 lesion, thereby increasing the chances of obtaining a 5. Haffield, A. R. W., Whittaker, R. & Gibbs, D. D. Gut representative cytological material. 1974.15, 305-307 6. Haffield, A. R. W., Smithies, A., Wilkins, R. & Levi, If the patient is to be operated on, it is of great A. J. Gut 1976, 17, 14-21 value for the surgeon to have the diagnosis con7. Lund, F. Acta Chir. Scand. 1969, 135, 515-517 firmed preoperatively. Also, some patients will have 8. Osnes, M., Serck-Hansen,A. & Myren, J. Scand. J. Gastroent. 1975, I0 (S), 829-831 had a laparotomy without any biopsy taken from a pancreatic mass. In these cases a percutaneous fine- 9. Smith, E. H., Bartrum, R. J., Jr, Chang,Y. C., D’Orsi, C. J., Lokich, J., Abbruzzese, A. & Dantono, J. New needle aspiration biopsy can give the lacking histoEngl. J. Med. 1975, 292, 825-828 10. Tylin, U., Amesjo, B., Lindberg, L. G . , Lundequist, logical evidence. A. & Akerman, M. Surg. Gynec. Obsret. 1976,142. We do not think that percutaneous aspiration 73 7-739 biopsy in coniunction with ERCP excludes any of 1 1 . Wiechel, K.-L. Ann. Swed. Med. Coll. Surg. 1974, the other cytological methods, but it will perhaps 16, 87 Received 8 March 1978 Accepted 4 April 1978
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
Gasrroent. 1978, 13, 657-662..
In 12 non-icteric patients, changes in the pancreatic duct indicative of carcinoma were found during endoscopic retrograde cholangio-pancreatography(ERCP.). Percutaneous fine-needle biopsy was positive for cancer in six cases. Nine of the 12 patients were later proved to have carcinoma of the pancreas. There was one falsely negative biopsy but no false positives. In two cases no pancreatic cells were found in the smear. It seems that percutaneous fine-needle aspiration biopsy during ERCP is a feasible procedure and can be recommended in ductal changes indicative of carcinoma. Key-words: Biopsy, fine-needle aspiration; carcinoma, pancreatic, localization body or
tail; cytology; ERCP T. Ihre, Dept. of Surgery, Sodersjukhuset. 10064 Stockholm 38, Sweden
In patients with tumour of the pancreas, the result of treatment is dependent on a number of factors, of which the most important are the size of the tumour, its invasiveness, and its biological activity. The size of the tumour is dependent on how early the cancer is detected, which again is dependent on how early the tumour gives clinical signs and symptoms. Cancers in the head of the pancreas often lead to jaundice at an early stage, but in cancers of the body or tail, the symptoms are vague and the diagnosis is often made when the tumour has grown to a considerable size. The size of the tumour will affect its resectability :the smaller the tumour, the greater the chaiices are for radical surgery. Different radiological methods, such as angiography, intravenous cholangiography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio-pancreatography (ERCP), CT-scanning and ultrasonic investigations, have made it possible to investigate and to diagnose even small tumours. The radiological diagnosis must, however, be confirmed histologically at laparotomy and/or by other routes of obtaining cells for cytology. Collection of pure juice from the pancreatic duct for cytology is possible by cannulat-
ing the papilla of Vater (5, 6). Endoscopic retrograde brush cytology (ERBC) has also been reported as a useful supplement to other methods (8). Fine-needle aspiration biopsy of the pancreas during operation ( I ) , during endoscopy (3), percutaneous aspiration biopsy in combination with CTscanning (4) and under ultrasonic guidance (9) as well as in combination with angiography (10) have been reported as useful methods for obtaining cytological samples from lesions in the pancreas. Fineneedle aspiration biopsy in conjunction with PTC has been used as a routine procedure in patients with stenosis or strictures of the bile ducts. The biopsy can b e taken under direct vision and under fluoroscopic guidance ( 1 1). For 2 years we have combined ERCP with percutaneous aspiration biopsy in patients with ductal changes suspected of being cancer, in order to achieve a more precise diagnosis before surgery. We have not used any other method for obtaining cells for cytology preoperatively. METHOD ERCP was performed in the usual manner with an Olympus J F B 2 sideviewing duodenoscope and
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
658
Th. Ihre, E. Pyk, T. Raaschou-Nielsen & U.Seligson
Fig. 1. Instrument used for percutaneous fine-needle aspiration biopsy. Two needles, 140 x 0.60 mm,Franzen model (Stille 2R2) and handle to facilitate aspiration. One of the needles has been bent to show its flexibility. with the patient in the prone position. Before the investigation was started the patient was given 0.5 mg atropine, 10 mg diazepam (Valium@) and 40 mg N-butylscopolammonium bromide (Buscopan@). After cannulation of the pancreatic duct, contrast (Urografin 60%) was injected and ductfilling was checked fluoroscopically. The biopsy was performed in all patients with changes suspected of being neoplastic on fluoroscopy and verified radiographically. The patients were then turned over to the supine position. In a few patients this was possible with the catheter still in position, but in most patients this manoeuvre caused the catheter to slip out of the papilla. In some cases recannulation was done in the supine position, and in some patients there was enough contrast in the pancreatic duct to localize the lesion and to perform the fine-needle biopsy. The skin area above the suspected lesion was cleaned with 0.05% chlorhexedrine, and a 140 x 0.60 mm Franzin needle (Stille 2R2) was inserted percutaneously above the suspected lesion. No anesthesia was used, since the thin needle was hardly felt when inserted. The patient was turned on
either side in order to position the needle optimally. A disposable syringe with a handle was used (Fig. 1). Multiple aspirations were performed from the suspected and from two or three adjacent areas. A new needle was used for each aspiration. The aspirates were usually sufficient for six to eight smears. Care was taken not to traverse the colon or to damage the duodenoscope with the needle. There have been no complications in obtaining the aspiration biopsy. The patient usually had a dull feeling of pain as the tip of the needle passed into the deeper tissues. This pain was not severe and disappeared as the needle was withdrawn. In some of the patients with cancer it was possible to feel resistance as the needle passed into the carcinoma. In 11 patients the puncture was performed through the anterior abdominal wall and in one via the lumbar route. In four patients the ERCP and fine-needle aspiration biopsy were carried out as outpatient procedures, and the patient left the hospital 2 h after the investigation. MATERIAL Fine-needle aspiration biopsy was performed in 12
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
Fine-Needle Aspiration Biopsy during ERCP
659
ticed pain in the left hypochondrium. Radiology of the gastrointestinal tract and i.v. cholangiography showed normal results. Laboratory tests were normal except for an ESR of 5 1m m h and a moderately raised alkaline phosphatase. ERCP (Fig. 2a). The pancreatic duct was normal in the head and body, but in the tail a stricture was visualized, which was suspected of being due to cancer. Percutaneous aspiration biopsy was performed through the abdominal wall (Fig. 2b). Seven smears were obtained, two of which contained malignant cells. Laparotomy. Inoperable cancer of the tail of the pancreas with liver metastases. Case 2. A 62-year-old man with no previous history of biliary or pancreatic disease. His sympCASE REPORTS toms had been vague-some pain and loss of appeCase I . A 5 8-year-old man without any previous tite. Barium meal showed normal results. Laborahistory of pancreatic or biliary disease, who prior to tory tests were normal. the admission had lost weight (6 kg) and had noERCP (Fig. 3a). There was filling of the pancreatic duct in the head and body, but a complete obstruction was found in the distal part of the duct. Percutaneous aspiration biopsy was performed through the anterior abdominal wall (Fig. 3b). Six smears were obtained. Cytology showed cancer cells. Operation was performed with a resection of 3/4 of the pancreas. The tumour was 1 cm in diameter, but there was spread of the tumour to the adjacent lymph nodes. Case 3. A 68-year-old man referred to the outpatient clinic for suspected cancer in the left breast. Biopsy from the suspected area showed only fibroadenomatous tissue. The patient complained of dyspepsia and had 12 years previously been operated on with ‘some kind of biliary operation’. An intravenous cholangiography was performed, on which a filling defect in the distal part of the common bile duct was seen. ERCP was therefore carried out. ERCP (Fig. 4a). The patient had been operated on with a choledochoduodenostomy owing to stones in the common bile duct. This explained the filling defect in the distal part of the bile duct. On the ERCP the ducts were filled from the papilla. The biliary tract was normal apart from the cholodoFig. 2. Case 1. hKP: Obstruction of normal pancreatic duct in :he tail of the gland (upper). Needle inserted in the choduodenostmy, but in the distal end of the panregion of the obstruction (lower). Cytology: cancer. creatic duct there was a stenosis and at least two
patients, all having lesions indicative of cancer on ERCP. In all patients the lesion was located either to the body or the tail of the gland. None of the patients had jaundice. In patients with jaundice we prefer PTC . Eight of the patients had weight loss and abdominal pain as the most aominant symptoms. In four of the patients, pain and elevated serum isoamylase concentrations motivated the ERCP. Ten of the patients had elevated alkaline phosphatase. The following three cases represent different findings on ERCP and fine-needle biopsy, and we should therefore like to present them as examples of the usefulness and limitations of the method.
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
660
Th. Ihre, E. Pyk, T. Raaschou-Nielsen & U.S 'eligson
Fig. 3. Case 2. ERCP: Biliary ducts normal. Obstruction of the pancreatic duct in the body of the gland (left). Fine needle inserted in the gland (right). Cytology: cancer.
pancreatic pseudocysts-cancer of the tail of the pancreas ? A percutaneous aspiration biopsy was performed through the anterior abdominal wall (Fig. 4b). Eight smears were obtained, none of which showed malignant cells. It was revealed that the patient was an alcoholic, and the changes in the pancreas were thought to be due to pancreatitis. Four months later the patient died. Autopsy revealed a disseminated carcinoma of the pancreas. RESULTS Percutaneous fine-needle aspiration biopsy in conjunction with ERCP has been performed in 12 patients, all having lesions radiologically indicative of cancer in the body or tail of the pancreas. Smears were obtained from all patients and showed cancer cells in six, benign cells in four, and only blood cells
in two. Laparotomy was performed in nine of the 12 patients and showed carcinoma of the pancreas in eight, verifying the cytology finding in the six positive samples. In the remaining two patients with carcinoma at laparotomy, no cells had been obtained for cytology. In one of these patients the lumbar route was used. At laparotomy one patient had a benign pancreatic cyst which was drained to the stomach. Three patients showing benign cells at biopsy did not go to surgery. One patient (case 3) died 4 months after the investigation. Autopsy revealed a widespread carcinoma of the pancreas. The other two patients had had elevated isoamylase levels prior to the ERCP and clinical signs and symptoms of chronic pancreatitis. Both patients have recovered clinically with normal isoamylase levels and are doing well 9 and 12 months, respectively, after the investigation.
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
Fine-Needle Aspiration Biopsy during ERCP
66 1
of the gland, cytology from pure juice collections gives lower accuracy than with tumours of the head (2). None of our patients had tumours of the head, and in one patient the tumour was located in the tail, positive at fine-needle biopsy and at operation found to be 1 cm in diameter. Nevertheless, this patient (case 2) was at operation found to have metastasis to adjacent lymph nodes. Percutaneous biopsy from tumours in various organs has been used routinely during the past few years. Its value in connection with percutaneous transhepatic cholangiography is undoubted, and it is now used in the investigation of tumours of the head of the pancreas as well as in tumours of the biliary tract. This method has given 90% accuracy in diagnosing malignancy in the periampullary region, with no serious complications (1 1). Percutaneous biopsy in conjunction with angiography is also employed as a routine method, as is percutaneous aspiration biopsy under ultrasonic guidance. without reports of serious complications. In our series 1 1 of the punctures were performed through the anterior abdominal wall. With an anterior approach there might be a risk ofcontamination if the needle traverses the colon. This risk, however, is very small, since the transverse colon in most cases lies more caudally than the pancreas. Even if the needle should traverse the large bowel. a leakage of bowel content is unlikely to occur as the diameter of the needle is very small. With a posterior approach the patient does not need to be turned before the puncture, but if the tumour is located just above the spine, it might be difficult to obtain a specimen from the suspected area. In the patient in whom we Fig. 4.Case 3. ERP: Almost complete obstruction in the used the lumbar route, the smears only contained middle of the duct and cysts in the distal part of the blood cells. We therefore think that the best appancreas (upper). Fine needle inserted in the lesion (lower). Cytology: N o malignant cells obtained (falsely proach to a pancreatic lesion by the percutaneous negative). method is from the anterior abdominal wall. The diagnosis in our series was accurate in six out DISCUSSION of nine patients with cancer in the body or tail and in The value of radiological methods in diagnosing three patients with benign lesions. It was falsely carcinoma of the pancreas will be limited as long as negative in one patient, and no samples were obthey are not combined with a method of obtaining tained in two patients with cancer. There were no definite diagnosis by histology or cytology. The falsely positive diagnoses. The results of treatment in carcinomas of the most commonly used cytological technique is pure juice cytology after stimulation with secretin. Posi- body and tail of the pancreas are discouraging. It tive findings are reported with pure juice cytology in might therefore be that this method, as well as other 50-75% (2. 3, 6). With tumours in the distal parts cytological methods, has its greatest value in
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/29/14 For personal use only.
662
Th. Ihre. E. Pyk, T. Raaschou-Nielsen & I/. Seligson
determining when not to operate on a patient. In increase the chances of a correct diagnosis in cases many patients with clinical evidence of metastatic where tumours of the body or tail of the pancreas are growth, a histological or cytological confirmation in suspected. combination with other investigations such as It appears that percutaneous fine-needle aspiraangiography can prevent an unnecessary operation tion biopsy in conjunction with ERCP is a feasible and thereby give the patient a better quality of life procedure which can be recommended as a suppleduring his remaining time. ment to other methods in cases where it is difficult to Peroperative biopsies with wedge excisions or by differentiate between cancer and benign lesions in the Vilm-Silverman punch technique have been re- the pancreas. ported to give up to 20% complications in the form of haemorrhages or fistulas (7). There is a much lower incidence of complications with a peropera- REFERENCES 1. Amesjo, B., Stormby, N. & Akerman, M. Acra Chir. tive fine-needle aspiration biopsy (1). However, at Scand. 1972. I38, 363-369 an operation where a pancreatic mass is found, it can 2 . Cotton, P. B. Gut 1977, 18. 316-341 be difficult to obtain representative material. By 3. Endo, Y., Morii, T., Tamura, H; & Okuda, S . Gasboenterologv 1974, 6 7, 944-95 1 combining ERCP with a percutaneous fine-needle 4. Ferruchi, J. Localization by computerized axial tomaspiration biopsy, it is possible to direct the needle, ograph and direct needle biopsy. Paper read at 63rd under fluoroscopic guidance, towards the suspected Annual Congress of the American College of Surgeons, Dallas, 1977 lesion, thereby increasing the chances of obtaining a 5. Haffield, A. R. W., Whittaker, R. & Gibbs, D. D. Gut representative cytological material. 1974.15, 305-307 6. Haffield, A. R. W., Smithies, A., Wilkins, R. & Levi, If the patient is to be operated on, it is of great A. J. Gut 1976, 17, 14-21 value for the surgeon to have the diagnosis con7. Lund, F. Acta Chir. Scand. 1969, 135, 515-517 firmed preoperatively. Also, some patients will have 8. Osnes, M., Serck-Hansen,A. & Myren, J. Scand. J. Gastroent. 1975, I0 (S), 829-831 had a laparotomy without any biopsy taken from a pancreatic mass. In these cases a percutaneous fine- 9. Smith, E. H., Bartrum, R. J., Jr, Chang,Y. C., D’Orsi, C. J., Lokich, J., Abbruzzese, A. & Dantono, J. New needle aspiration biopsy can give the lacking histoEngl. J. Med. 1975, 292, 825-828 10. Tylin, U., Amesjo, B., Lindberg, L. G . , Lundequist, logical evidence. A. & Akerman, M. Surg. Gynec. Obsret. 1976,142. We do not think that percutaneous aspiration 73 7-739 biopsy in coniunction with ERCP excludes any of 1 1 . Wiechel, K.-L. Ann. Swed. Med. Coll. Surg. 1974, the other cytological methods, but it will perhaps 16, 87 Received 8 March 1978 Accepted 4 April 1978
