Percutaneous Fine Needle Aspiration Biopsy of the Pancreas Following Endoscopic Retrograde Cholangiopancreatography 1

Diagnostic Radiology

Chia-Sing Ho, M.B., B.S., F.R.C.P.(C), Michael J. McLoughlin, M.B., B.S., F.R.C.P.(C), James D. McHattie, M.D., F.R.C.P.(C), and Liang-Che Tao, M.D., F.R.C.P.(C) Fine needle aspiration biopsies were performed in 9 patients with suspected pancreatic malignancies demonstrated and localized by endoscopic retrograde cholangiopancreatography (ERCP). The biopsies were positive in 7 of 8 patients with pancreatic carc inoma and there were no complications. ERCP is an accurate method lor diagnosing pancreatic cancer which may be confirmed safely and easily by line needle aspiration biopsy. INDEX TERMS: Biopsies, technique. Cholangiopancreatography, 7 [7] .1227 • (Pancreas, biopsy, 77 [ 1-3].126) • (Pancreas, carcinoma , 77 [1-3] .321) • Pancreas, neoplasms Radiology 125:351-353, November 1977

With the patient supine on the fluoroscopic table the skin is prepared and the exact site of entry located under fluoroscopy. This point is marked with the tip of a Kocher forceps to avoid exposing the operator's hands. Local anesthetic is infiltrated and a small incision made with the point of a scapel blade. A fine gauge needle and stylet, e.g., a Chiba biopsy needle (22 gauge, 0.0. 0.7 mm) is inserted as perpendicular to the table top as possible under intermittent fluoroscopic control. During fluoroscopy the needle is held in the vertical position by Kocher forceps to avoid exposing the operator 's hands. Resistance is usually felt when the needle tip touches normal retroperitoneal structures or the tumor itself which often feels hard and gritty. This may cause some discomfort and a small amount of local anesthetic may be injected. The needle without the stylet is then advanced. It is rotated a few times and moved

ERCUTANEOUS fine needle aspiration biopsy is a safe

P

method of obtaining tissue diagnosis in patients with carcinoma of the pancreas without operation (2, 4-8). The techn ique is simple but the major problem is to localize the lesion. Previous workers have used angiography (6, 8), echography (5, 7) and computed tomography (4) for this purpose. We wish to report our early experience combining biopsy with endoscopic retrograde cholangiopancreatography (ERCP). METHOD

During ERCP a supine anteroposterior radiograph demonstrating the pancreatic ducts is obtained. If there is a lesion suggesting the presence of pancreatic carc inoma this is chosen as the site for biopsy (Fig. 1).

Fig. 1. A. CASE I. A supine anteroposterior film taken during ERCP shows complete occlusion 01 the main pancreatic duct by carcinoma. The arrow shows the biopsy site, i.e., to the left 01 the first lumbar vertebral body just lateral to the lelt twelfth rib . B. CASE II. A supine anteroposterior film taken during ERCP shows complete occlusion 01 the common bile and main pancreatic ducts by carcinoma of the pancreas (double duct sign). The arrow shows the biopsy site, i.e., over the right lateral hall of the L l - 2 disk space . 1 From the Departments 01 Radiology (C.S.H., M.J.M.), Medicine (J.M.), and Pathology (L.C.T.), Toronto General Hospital, Toronto, Ontario, Canada. Accepted for publication in May 1977. shan

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C. S.Ho AND OTHERS

TABLE PATIENT

I II III

IV V VI VII VIII

IX

I:

AGE/SEX

ERCP

80F 68F 60M 50M 61M 68F 70F 67F 54M

Obstructed duct tail of pancreas (Fig. 1,A) Double duct sign (Fig. 1,B) Double duct sign Obstructed duct head of pancreas Obstructed duct tail of pancreas Double duct sign Obstructed duct body of pancreas Double duct sign Localized stenosis body of pancreas

November 1977

PATIENT SUMMARY BIOPSY

COMMENT

Adenocarcinoma, necrotic Proven at surgery Adenocarcinoma, moderately differentiated Proven at surgery Adenocarcinoma, well differentiated Surgery averted Highly suggestive of adenocarcinoma' Adenocarcinoma at surgery Adenocarcinoma, papillary type Proven at surgery Adenocarcinoma, mucin secreting Proven at surgery Adenocarcinoma, well differentiated Proven at surgery Adenocarcinoma, well differentiated Proven at surgery Pancreatitis Proven at surgery

• The material on the slide showing the suspicious cells was too thick for clear observation.

short distances backwards and forwards to loosen material in the needle from surrounding tissue. Firm suction is applied with a well-fitting large glass syringe and the needle is withdrawn. Material is removed from the needle onto glass slides by blowing air through it with the syringe or introducing the stylet. Any material aspirated into the syringe is also placed on slides. Several punctures angling the needle in different directions around the area of suspicion are made and up to 12 or more slides prepared. Thin smears are made and fixed immediately (before drying) in 95 % ethyl alcohol for thirty minutes before staining by the Papanicolaou method. RESULTS

Nine patients underwent ERCP following biopsy. The diagnosis at ERCP was carcinoma in 8 ("double duct" sign in 4; occlusion of the pancreatic duct in 4) and the biopsies were positive in 7 of these. In the eighth patient one slide contained two overlapping clumps of highly suspicious cells. Unfortunately this slide was bloody and the smear was too thick for the cells to be clearly visible. This could have been avoided by more careful preparation. Carcinoma of the pancreas was confirmed at surgery in 7 of the 8 patients. Surgery was considered unnecessary as a result of the positive biopsy in one patient. In the ninth patient a pancreatic mass thought to be carcinoma had been found at previous laparotomy, but operative biopsies were negative. A nonspecific stricture of the pancreatic duct was present at ERCP in one patient. A diagnosis of carcinoma of the pancreas was made at angiography, based on encasement of the superior mesenteric and hepatic arteries and occlusion of the splenic vein. The percutaneous fine needle biopsy was negative. A diagnosis of chronic pancreatitis was finally made after a second operation at which the pancreas was completely mobilized. The subsequent clinical course of this patient indicates benign disease. DISCUSSION

A review of the previous literature (2, 4-8) reveals 68 patients with malignant lesions of the pancreas who underwent percutaneous fine needle aspiration biopsy. The biopsies were positive in 55 (81 % ) and no complications were reported.

The procedure causes mild discomfort only and, although a variety of structures, e.g., liver, stomach, bowel, and blood vessels, may be needled, this appears to be of little consequence. An objection to the technique which is sometimes raised is the risk of spreading tumor cells. A few cases of tumor seeding in the needle tract following biopsy with wide-bore needles and instruments, e.g., the Vim Silverman biopsy needle (12 gauge, 0.0. 2.6 mm) are reported, most commonly following transperineal biopsy of the prostate (1). On the other hand, we have been unable to find a single documented case of tumor recurrence attributed to fine needle (greater than 20 gauge, 0.0. 0.9 mm) aspiration biopsy, although many thousands of biopsies have been performed on a variety of malignancies over the past two decades. At the Toronto General Hospital over 1500 fine needle aspiration biopsies of lung, thyroid and breast have been performed, mainly for malignant disease without evidence of seeding. Thus it is clear that fine needle aspiration biopsy of the pancreas is a procedure with a high diagnostic yield in malignant disease with minimal risk to the patient. Like others (3) we have found ERCP to be highly accurate in the diagnosis of carcinoma of the pancreas. We have also used it as an easy and accurate way to local ize the lesions for biopsy. In this way a highly probable radiographic diagnosis can be confirmed with a tissue diagnosis in a high proportion of patients. A positive biopsy may eliminate the need for surgery. This will occur with patients who are unfit for radical resection, whose lesions have been shown to be unresectable, e.g., by angiography, or who have been shown to have liver metastases and who do not need a palliative operation. In patients requiring surgery, a positive biopsy will enable the surgeon to procede confidently with palliative or radical treatment, and the added risk of operative biopsy and delay in awaiting results of frozen sections will be avoided. Surgery was averted in only one of our patients, but it is anticipated that this will occur more frequently in the future with increasing confidence in the results of aspiration biopsy. This method of biopsy is quick, relatively painless, and requires no elaborate apparatus. It may be performed immediately following ERCP on outpatients allowing a tissue diagnosis without hospitalization or at a later time

Vol. 125

PERCUTANEOUS FINE NEEDLE ASPIRATION BIOPSY OF THE PANCREAS

provided an anteroposterior supine radiograph is obtained for localization.

ADDENDUM Since submittingthis article for publication, Goldstein et al. (Radiology

123: 319-322, May 1977) have published a report which includes the results of percutaneous fine needle aspiration biopsy in 18 patients with pancreatic masses. Fourteen patients had carcinoma and the biopsies were unequivocally positive in 8, highly suspicious in 2 and negative in 4. There were no complications. ACKNOWLEDGMENTS: We are most grateful to Miss Susan Harris, Mrs. Eileen Lunny and Miss Ingrid Breitenauer for secretarial assistance.

1. Desai SG, Woodruff LM: Carcinoma of the prostate. Local extension following perineal needle biopsy. Urology 3:87-88, Jan 2. Dodd GO,Goldstein HM: Newer radiological techniques in the diagnosis of gastrointestinal cancer. Clin Gastroenterol 5:597-624, Sep 1976

Diagnostic Radiology

3. Freeny PC, Bilbao MK, Katon RM: "Blind" evaluation of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic carcinoma: the "double duct" and other signs. Radiology 119:271-274, May 1976 4. Haaga RJ, Alfidi RJ: Precise biopsy localization by computed tomography. Radiology 118:603-607, Mar 1967 5. Hancke S, Holm HH, Kock F: Ultrasonically guided percutaneous fine needle biopsy of the pancreas. Surg Gynecol Obstet 140:361-364, Mar 1975 6. Oscarson J, Stormby N, Sundgren R: Selective angiography in fine needle aspiration cytodiagnosis of gastric and pancreatic tumours. Acta Radiol [Diag] 12:737-749, Nov 1972 7. Smith EH, Bartrum RJ,ChangVC, et al: Percutaneous aspiration biopsy of the pancreas under ultrasonic guidance. N Engl J Med 292:825-828, 17 Apr 1975 8. Tyh3n V, Arnesjb B, Lindberg LG, et al: Percutaneous biopsy of carcinoma of the pancreas guided by angiography. Surg Gynecol Obstet 142:737-739, May 1976

REFERENCES

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C. S. Ho, M.B., B.S. Department of Radiology Toronto General Hospital Toronto, Ontario, Canada

Percutaneous fine needle aspiration biopsy of the pancreas following endoscopic retrograde cholangiopancreatography.

Percutaneous Fine Needle Aspiration Biopsy of the Pancreas Following Endoscopic Retrograde Cholangiopancreatography 1 Diagnostic Radiology Chia-Sing...
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