Transperitoneal Percutaneous Retroperitoneal Lymph Node Aspiration Biopsy 1
Diagnostic Radiology
Jesus Zornoza, M.D., Sidney Wallace, M.D., Harvey M. Goldstein, M.D. John M. Lukeman, M.D., and Bao-shan Jing, M.D. Percutaneous aspiration biopsies of opacified retroperitoneal lymph nodes, and retroperitoneal, intraperitoneal and paraspinal masses were successfully accomplished in 14 of 17 patients. A 23-gauge needle was utilized for the procedure which is performed under fluoroscopic guidance. Metastatic carcinoma, sarcoma and melanoma were readily identified by aspiration biopsy while the diagnosis of lymphoma, especially as to type, was more difficult. No significant complications have resulted from the passage of the needle through the peritoneal cavity. INDEX TERMS: Biopsies, technique. Lymph nodes, neoplasms. Lymphoma. Neoplasms, diagnosis. Retroperitoneal space, neoplasms. (Retroperitoneum, biopsy technique, 8[7].126) Radiology 122:111-115, January 1977
•
have been successfully employed in establishing the diagnosis of disease processes in the lung, bone, liver, kidney and more recently, the pancreas (6, 7). Percutaneous lymph node biopsies have also been accomplished by Nordenstrorn in the mediastinum (8, 9), Ruttimann in the pelvis (12) and Wallace et al. in the retroperitoneum (14). The availability of the 23-gauge needle has increased the opportunities by decreasing the complications from this percutaneous approach. This communication presents our initial experience with the use of needle aspiration for the cytologic diagnosis of iliac and lumbar lymph nodes, paraspinal, intraperitoneal and retroperitoneal masses in 17 patients.
a 0.7mm outer diameter, 0.5mm inner diameter and a 30-degree bevel angle is utilized (10). The needles are available in 15- and 20-cm lenqths.f Biopsy technique: Demonstration of the pathologic process in pelvic and lumbar lymph nodes is usually accomplished by bilateral pedal lymphangiography. When the mass or nodes are sufficiently large, ultrasonography is helpful for further localization, particularly as to depth. The actual biopsy is performed utilizing television-monitored fluoroscopy of the opacified node for guidance. With the patient in the supine position, the opacified lymph node to be biopsied is localized by fluoroscopy and the overlying percutaneous puncture site is marked on the skin of the abdomen. The skin and subcutaneous tissues down to the peritoneum are locally anesthetized with 2 % Xylocaine and a small incision is made in the skin. The needle is directed through the abdominal wall into the desired lymph node. In patients with a thick or muscular
ERCUTANEOUS BIOPSY TECHNIQUES
P
TECHNIQUE
Needle:
A thin-walled flexible 23-gauge needle with
Fig. 1. CASE I. Metastatic carcinoma from the prostate. A. Aspiration biopsy of an external iliac node containing metastatic carcinoma was accomplished utilizing a 23-gauge needle. The site of biopsy is just above the crescentic configuration of the residual functioning portion of the lymph node (AP view). B. The oblique view demonstrates the relationship of the needle to the node, confirming the exact site of puncture. C. Cytologic specimen (X200), pap stain reveals metastatic adenocarcinoma compatible with the primary carcinoma of the prostate. 1 From the Departments of Diagnostic Radiology (J.Z., S.W., H.M.G., B.S.J.) and Pathology (J.M.L.), The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas. Accepted for publication in July 1976. 2 Available from Cook, lnc., Bloomington, Indiana and from Bukoda Co., Tokyo, Japan. shan
111
112
JESUS ZORNOZA AND OTHERS
Table I: Patient
Age/Sex
L.R.
56 M
Primary Diagnosis
G.M.
64 M
S.H.
64 M
Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma Ca. bladder
E.M.
43 F
Ca. cervix
M.K. C.C. T.H. J.C.
43 38 72 61 72
Ca. Ca. Ca. Ca. Ca.
56 M
J.B. J.C.
F F F M M
74 M 74 M 32 F
cervix cervix cervix prostate prostate
Ca. urethra Ca. urethra Melanoma
Lymph Nodes Cytologic Diagnosis
Biopsy Site Para-aortic (L 3 ) Iliac-external (rebiopsy)
Para-aortic (L 3 ) II iac -externa I (rebiopsy) II iac-external Iliac-external II iac -externa I Para-aortic (L z ) II iac -externa [ Iliac-external (rebiopsy) II iac -external
Para-aortic (La) ltiac -externa I
anterior abdominal wall, a thin-walled 18-gauge needle is first inserted into the peritoneum through which the 23gauge needle is passed. Once the needle is at or in the lymph nodes, the patient may be rotated into each oblique position to determine the relative relationship. When the node is punctured, synchronous movement of the needle and the lymph node under fluoroscopic control indicates accurate placement. Continuous suction is applied with a 12-ml plastic syringe while the needle is moved up and down with approximately a 1-cm excursion. After the release of suction, the needle is withdrawn. The procedure is repeated two or three times to ensure sufficient cytologic material. The presence of oil droplets in the aspirate confirms that the node previously opacified during lymphangiography has been punctured. The specimen is fixed in 95 % ethyl alcohol or Cornoy's solution depending upon the amount of blood present in the specimen. The tissue is analyzed in the form of a smear and/or a cell block by the cytologist. This same technique is utilized in the biopsy of paraspinal, intraperitoneal, and retroperitoneal masses where localization is similarly accomplished by palpation, fluoroscopy, and/or ultrasound. The two paraspinal masses
Table II: Primary Diagnosis
Patient
Age/Sex
G.B.
54 F
Ca. bladder
P.C.
58 F
Ca. endometrium
A.G.
65 F
Vaginal melanoma
G.B.
50 M
Melanoma
J.H.
21 M
Osteosarcoma
B.D.
13 M
Rhabdomyosarcoma
A.M.
22 M
Ca. testes
January 1977
Pathologic Diagnosis
Insufficient for i nterpretat i on Insufficient for interpretation Malignant lymphoma Abnormal Iymphocytes, probably lymphoma Insufficient for interpretation Squamous Ca. Squamous Ca. Squamous Ca. Adenocarcinoma Normal lymph node tissue Inflammation Inflammation Fat replacement
Confirmed
Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma
Surgery
Inflammation Inflammation Fat replacement
Autopsy Autopsy Surgery
Surgery Surgery Surgery
were blopsled through a posterior approach with the patient in a prone position. These examinations are usually performed on outpatients who are observed for three to four hours after biopsy before release. No postbiopsy radiographs are routinely taken. Relative contraindications include bowel dilatation and abnormal bleeding parameters. CLINICAL MATERIAL AND RESULTS
The 17 patients in this preliminary series were evaluated at M. D. Anderson Hospital and Tumor Institute for the staging and treatment of various malignant diseases. The clinical diagnoses, biopsy sites and pathologic diagnoses are summarized in TABLES I and II. Twenty biopsy procedures were performed in 17 patients, 7 women and 10 men, ranging in age from 13 to 74 years. Lymph nodes previously visualized by lymphangiography were biopsied in 10 cases, while retroperitoneal masses were biopsied in 4, paraspinal in 2, and intraperitoneal in one. Of the 17 patients examined by percutaneous aspiration biopsies, interpretable biopsy material was obtained in 14. Confirmation of these findings was obtained by surgery and/or autopsy in 8 patients.
Retroperitoneal Masses
Biopsy Site
Cytologic Diagnosis
Pathologic Diagnosis
Confirmed
Retroperitoneal (La) Retroperitoneal (La) Intraperitoneal (mid-pelvis) Paraspinal (T 11) Paraspinal (T 11) Retroperitonea I (RUQ) Retroperitoneal (RLQ)
Transitional cell carcinoma Adenocarcinoma
Sarcoma
Rhabdomyosarcoma
Surgery
Blood
Postoperative hematoma
Surgery
Atypical cells Melanoma Osteosarcoma
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The lymph node biopsies were performed to verify Iymphangiographic findings. External iliac lymph nodes were biopsied on 9 occasions and para-aortic in 4. Two patients were biopsied in both the external iliac and para-aortic regions and, in 1 patient the same external iliac node was biopsied twice. In 2 of the 3 patients with lymphoma, biopsies were performed to determine the status of the disease after previous therapy. The masses, other than the opacified lymph nodes, were located as high as the T 11 level. The 2 neoplastic masses of epithelial origin, at the L3 level, were metastatic carcinoma from the bladder and endometrium and were probably within lymph nodes which were not examined by lymphangiography. Six of the 7 patients with metastases originating from carcinomas of the pelvic viscera were successfully diagnosed by aspiration biopsy. Biopsies obtained from only 1 of the 3 patients with lymphoma yielded definitive diagnosis of histiocytic lymphoma. In another patient with both histiocytic lymphoma and bladder carcinoma, the aspirated tissue was considered to have abnormal lymphocytes, most probably lymphoma. A definitive diagnosis as to the specific type of lymphoma, a histiocytic lymphoma, was established by surgical exploration. In the third patient with lymphoma, no tissue was obtained from attempted biopsies of the external and para-aortic nodes. Of 2 patients with melanoma, metastases were established in one by the biopsy of a paraspinal mass. The aspirated cells from a pelvic mass in the second patient with melanoma were considered as atypical. Both sarcomas (a paraspinal osteosarcoma metastasis and a retroperitoneal rhabdomyosarcoma) were diagnosed by percutaneous aspiration biopsy. The diagnosis of inflammatory nodes was made by aspiration biopsy of the same external iliac node on 2 occasions and was confirmed at autopsy. Fatty replacement was found on aspiration of an external iliac node and later confirmed at node dissection in a patient with melanoma. The biopsy of a para-aortic node considered normal by lymphangiography in a patient with carcinoma of the prostate revealed normal lymphoid tissue. And finally, the aspiration of blood from a mass in the right lower quadrant proved to be from a postoperative hematoma following an orchidectomy and resection of the cord for a carcinoma of the right testicle. None of the 17 patients experienced significant discomfort or complications from the procedure. The 7 patients who subsequently underwent surgery and the 1 patient who was autopsied did not show any evidence of hollow organ perforation or vascular damage.
CASE REPORTS CASE I. (T.H.). A 61-year-old man was referred for evaluation and treatment of carcinoma of the prostate. Lymphangiography revealed metastasis to a right external iliac lymph node. However, a tissue diagnosis was desired prior to initiating therapy. A biopsy was obtained from the right external iliac node (Fig. 1, A and B). The cytologic diagnosis was metastatic adenocarcinoma presumably from a primary carcinoma of the prostate (Fig. 1, C).
Diagnostic Radiology
Fig. 2. CASE II. Histiocytic lymphoma. A. Needle aspiration biopsy of an external iliac node in a patient with a concomitant carcinoma of the bladder (AP view). B. Oblique view. Note the relationship of the needle to the opacified node.
CASE II. (S.H). A 65-year-old man was referred for staging and treatment of a transitional cell carcinoma of the bladder. A bilateral Iymphangiogram revealed no evidence of metastatic disease. However, the nodes were abnormal and a diagnosis of lymphoma was considered (Fig. 2). Aspiration biopsy revealed multiple abnormal lymphocytes consistent with the diagnosis of lymphoma. A surgical biopsy was performed and the histiologic diagnosis of histiocytic lymphoma was established. CASE III. (G.M.). A 65-year-old man was first examined in 1973 because of an abdominal mass. A Iymphangiogram was obtained demonstrating nodal involvement compatible with lymphoma (Fig. 3, A). A surgical biopsy revealed histiocytic lymphoma. The patient received several courses of chemotherapy and was clinically improved. Repeat lymphangiography in 1975 revealed that the previously noted mass was smaller but still abnormal (Fig. 3, B). In an attempt to differentiate residual active disease from the remains of previously tr,eated lymph nodes, biopsy was suggested. The aspiration biopsy was performed at the para-aortic region (Fig. 3, C). The cytologic diagnosis was malignant lymphoma. CASE IV. (P.C.). A 58-year-old woman had undergone a hysterectomy four years previously for carcinoma of the endometrium. Because of a palpable mass in the abdomen, an inferior venacavogram was performed demonstrating an obstruction with extensive collateral circulation (Fig. 4, A and B). Ultrasound also localized the palpable mass to be 6 cm below the skin surface. The mass was biopsied and the cytologic diagnosis was metastatic adenocarcinoma (Fig. 4, C).
DISCUSSION
Selective lymphadenectomy in conjunction with lymphangiography for staging prior to therapy has found increasing application (5, 11). At present at M. D. Anderson Hospital and Tumor Institute, staging laparotomy with lymph node biopsy is performed in the management of patients with Hodgkin's disease and carcinoma of the cervix. Lymphangiography is also important in the evaluation of the extent of involvement and therefore in treatment planning for patients with carcinomas of the testicle, bladder, prostate and ovary.
Fig. 3. CASE III. Histiocytic lymphoma. A. The large retroperitoneal nodal mass displaced the proximal ureter and kidney. Only the inferior aspect of the neoplasm was opacified by lymphangiography in 1973. B. Repeat lymphangiography in 1975 demonstrates reduction in the size of the mass. C. Needle aspiration established the presence of residual histiocytic lymphoma.
Fig. 4. CASE IV. Metastatic adenocarcinoma from the endometrium. A. Inferior venacavagram reveals obstruction by a retroperitoneal mass. There is opacification of collateral veins (AP view). B. Oblique view confirms the involvement of the inferior vena cava. C. Cytologic specimen (X200). Pap smear established the diagnosis of metastatic adenocarcinoma presumably originating from the patient's previously treated endometrial carcinoma.
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LYMPH NODE ASPIRATION BIOPSY
The percutaneous approach to the retroperitoneal and pelvic lymph nodes with a small-caliber needle represents a simple technique to confirm the presence of neoplasm, thereby obviating in selected cases the need for exploratory laparotomy. The histologic verification of inoperable or recurrent retroperitoneal and paraspinal masses can also be readily established by this technique. In view of the relatively anterior position of the paraaortic and pelvic lymph nodes in relation to the great vessels, an anterior transperitoneal approach seems most suitable. This has also proved to be successful in the biopsy of the pancreas which is also relatively anterior in position. Paraspinal masses are lateral and at times posterior to the great vessels and are readily biopsied with the patient in the prone position. This same approach has been employed for the biopsy of the kidneys and adrenals (7). The site of biopsy in an opacified lymph node will differ depending upon the histologic type of neoplastic process. The most common lymphangiographic finding seen in metastatic carcinoma is a defect in a node not traversed by lymphatics. The residual normal functioning portion of the node frequently will have a crescentic configuration representing a node partially replaced by neoplasm. Consequently, the greatest yield would be a biopsy of the node just above the crescentic area. Lymphoma is usually a more diffuse involvement of a lymph node and the site of biopsy is not as critical. Aspiration biopsy of a lymph node containing metastatic carcinoma is more successful than that with lymphoma (15). Epithelial metastases, especially those originating in pelvic viscera, are frequently highly cellular, poorly vascularized, and readily distinguishable from the normal cells of a lymph node (1). In lymphomas, the diagnosis by fine needle aspiration is more difficult and sometimes impossible to classify, especially as to the type. However, in Hodgkin's disease, a definite diagnosis is reported to be possible in 70 % of the cases (2). Percutaneous transperitoneal lymph node biopsy involves the passage of a 23-gauge needle into the peritoneal cavity and through hollow and solid viscera. In our series there were no complications. The potential complications, such as intra-abdominal bleeding, pancreatitis and bowel perforation with peritonitis, were not encountered. Our experience with transperitoneal biopsy of the pancreas has been similar. This confirms on a small scale the findings presented by Forsgren and Orell (4), Hancke et a/. (6) and Holm et at. (7). In the most recent report by Holm et a/. (7) there was only one clinically significant complication in 1,200 ultrasonically guided percutaneous punctures. A 200-ml hematoma was found at surgery two months after aspiration of a pancreatic pseudocyst. The possibility of disseminating neoplasm by aspiration biopsy does not seem to present a significant problem as con-
Diagnostic Radiology
eluded by laboratory investigation and clinical experience with percutaneous biopsies of lymph nodes and kidney neoplasms using even larger caliber needles. (3, 13). ADDENDUM Since submission of the manuscript, 25 more biopsies have been performed. Lymph nodes were biopsled in 15 cases and retroperitoneal masses in 10. Of the 15 lymph node biopsies, 12 were successfully diagnosed by aspiration biopsy. In each of the 10 retroperitoneal masses a positive diagnosis was obtained. No complications were found in any of the patients.
Jesus Zornoza, M.D. Department of Diagnostic Radiology University of Texas M. D. Anderson Hospital and Tumor Institute Houston, Texas 77030
REFERENCES 1. Berg JW: The aspiration biopsy smear. [In] Koss LG, Durfee GR, eds: Diagnostic Cytology and Its Histopathologic Bases. Philadelphia, Lippincott Co., 1961, pp 311-321 2. Drose M. Zajicek J: Unpublished data 3. Engzell U, Esposti PL, Rubio C, et al: Investigation on tumour spread in connection with aspiration biopsy. Acta Radiol [Ther] 10: 385-398, Aug 1971 4. Forsgren L, OreII S: Aspiration cytology in carcinoma of the pancreas. Surgery 73:38-42, Jan 1973 5. Glatstein E, Guernsey JM, Rosenberg SA, et al: The value of laparotomy and splenectomy in the staging of Hodgkin's disease. Cancer 24:709-718, Oct 1969 6. Hancke S, Holm HH, Koch F: Ultrasonically guided percutaneous fine needle biopsy of the pancreas. Surg Gynecol Obstet 140: 361-364, Mar 1975 7. Holm HH, Pederson JF, Kristensen JK, et al: Ultrasonically guided percutaneous puncture. Radiol Clin N Am 13:493-503, 1975 8. Nordenstrbm B: Transjugular approach to the mediastinum for mediastinography and mediastinal needle biopsy: a preliminary report. Invest RadioI2:134-140, Mar-Apr 1967 9. Nordenstrbm B: Paraxiphoid approach to the mediastinum for mediastinography and mediastinal needle biopsy: a preliminary report. Invest Radiol 2:141-146, Mar-Apr 1967 10. Okuda K, Tanikawa K, Emura T, et al: Nonsurgical, percutaneous transhepatlc cholangiography-diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36, Jan 1974 11. Piver MS, Barlow JJ: Para-aortic lymphadenectomy in staging patients with advanced local cervical cancer. Obstet Gynecol 43: 544-548, Apr 1974 12. Ruttimann A: Iliac lymph node aspiration biopsy through paravascular approach: preliminary report. Radiology 90: 150-151, Jan 1968 13. Von Schreeb T, Arner 0, Skovsted G, et al: Renal carcinoma: is there a risk of spreading tumor cells in diagnostic puncture? Scand J Urol Nephrol 1:270-276, 1967 14. Wallace S, Schwartz PE, Anderson JH, et al: A feasibility study for percutaneous retroperitoneal lymph node biopsy. Am J Roentgenol 125:234-239, Sep 1975 15. Zajicek J: Aspiration biopsy cytology, part I: cytology of supradiaphragmatic organs. [In] WiOO GL, 00: Monographs in Clinical Cytology. Basel, Switzerland, S. Karger, 1974, pp 90-124
Diagnostic Radiology
Jesus Zornoza, M.D., Sidney Wallace, M.D., Harvey M. Goldstein, M.D. John M. Lukeman, M.D., and Bao-shan Jing, M.D. Percutaneous aspiration biopsies of opacified retroperitoneal lymph nodes, and retroperitoneal, intraperitoneal and paraspinal masses were successfully accomplished in 14 of 17 patients. A 23-gauge needle was utilized for the procedure which is performed under fluoroscopic guidance. Metastatic carcinoma, sarcoma and melanoma were readily identified by aspiration biopsy while the diagnosis of lymphoma, especially as to type, was more difficult. No significant complications have resulted from the passage of the needle through the peritoneal cavity. INDEX TERMS: Biopsies, technique. Lymph nodes, neoplasms. Lymphoma. Neoplasms, diagnosis. Retroperitoneal space, neoplasms. (Retroperitoneum, biopsy technique, 8[7].126) Radiology 122:111-115, January 1977
•
have been successfully employed in establishing the diagnosis of disease processes in the lung, bone, liver, kidney and more recently, the pancreas (6, 7). Percutaneous lymph node biopsies have also been accomplished by Nordenstrorn in the mediastinum (8, 9), Ruttimann in the pelvis (12) and Wallace et al. in the retroperitoneum (14). The availability of the 23-gauge needle has increased the opportunities by decreasing the complications from this percutaneous approach. This communication presents our initial experience with the use of needle aspiration for the cytologic diagnosis of iliac and lumbar lymph nodes, paraspinal, intraperitoneal and retroperitoneal masses in 17 patients.
a 0.7mm outer diameter, 0.5mm inner diameter and a 30-degree bevel angle is utilized (10). The needles are available in 15- and 20-cm lenqths.f Biopsy technique: Demonstration of the pathologic process in pelvic and lumbar lymph nodes is usually accomplished by bilateral pedal lymphangiography. When the mass or nodes are sufficiently large, ultrasonography is helpful for further localization, particularly as to depth. The actual biopsy is performed utilizing television-monitored fluoroscopy of the opacified node for guidance. With the patient in the supine position, the opacified lymph node to be biopsied is localized by fluoroscopy and the overlying percutaneous puncture site is marked on the skin of the abdomen. The skin and subcutaneous tissues down to the peritoneum are locally anesthetized with 2 % Xylocaine and a small incision is made in the skin. The needle is directed through the abdominal wall into the desired lymph node. In patients with a thick or muscular
ERCUTANEOUS BIOPSY TECHNIQUES
P
TECHNIQUE
Needle:
A thin-walled flexible 23-gauge needle with
Fig. 1. CASE I. Metastatic carcinoma from the prostate. A. Aspiration biopsy of an external iliac node containing metastatic carcinoma was accomplished utilizing a 23-gauge needle. The site of biopsy is just above the crescentic configuration of the residual functioning portion of the lymph node (AP view). B. The oblique view demonstrates the relationship of the needle to the node, confirming the exact site of puncture. C. Cytologic specimen (X200), pap stain reveals metastatic adenocarcinoma compatible with the primary carcinoma of the prostate. 1 From the Departments of Diagnostic Radiology (J.Z., S.W., H.M.G., B.S.J.) and Pathology (J.M.L.), The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas. Accepted for publication in July 1976. 2 Available from Cook, lnc., Bloomington, Indiana and from Bukoda Co., Tokyo, Japan. shan
111
112
JESUS ZORNOZA AND OTHERS
Table I: Patient
Age/Sex
L.R.
56 M
Primary Diagnosis
G.M.
64 M
S.H.
64 M
Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma Ca. bladder
E.M.
43 F
Ca. cervix
M.K. C.C. T.H. J.C.
43 38 72 61 72
Ca. Ca. Ca. Ca. Ca.
56 M
J.B. J.C.
F F F M M
74 M 74 M 32 F
cervix cervix cervix prostate prostate
Ca. urethra Ca. urethra Melanoma
Lymph Nodes Cytologic Diagnosis
Biopsy Site Para-aortic (L 3 ) Iliac-external (rebiopsy)
Para-aortic (L 3 ) II iac -externa I (rebiopsy) II iac-external Iliac-external II iac -externa I Para-aortic (L z ) II iac -externa [ Iliac-external (rebiopsy) II iac -external
Para-aortic (La) ltiac -externa I
anterior abdominal wall, a thin-walled 18-gauge needle is first inserted into the peritoneum through which the 23gauge needle is passed. Once the needle is at or in the lymph nodes, the patient may be rotated into each oblique position to determine the relative relationship. When the node is punctured, synchronous movement of the needle and the lymph node under fluoroscopic control indicates accurate placement. Continuous suction is applied with a 12-ml plastic syringe while the needle is moved up and down with approximately a 1-cm excursion. After the release of suction, the needle is withdrawn. The procedure is repeated two or three times to ensure sufficient cytologic material. The presence of oil droplets in the aspirate confirms that the node previously opacified during lymphangiography has been punctured. The specimen is fixed in 95 % ethyl alcohol or Cornoy's solution depending upon the amount of blood present in the specimen. The tissue is analyzed in the form of a smear and/or a cell block by the cytologist. This same technique is utilized in the biopsy of paraspinal, intraperitoneal, and retroperitoneal masses where localization is similarly accomplished by palpation, fluoroscopy, and/or ultrasound. The two paraspinal masses
Table II: Primary Diagnosis
Patient
Age/Sex
G.B.
54 F
Ca. bladder
P.C.
58 F
Ca. endometrium
A.G.
65 F
Vaginal melanoma
G.B.
50 M
Melanoma
J.H.
21 M
Osteosarcoma
B.D.
13 M
Rhabdomyosarcoma
A.M.
22 M
Ca. testes
January 1977
Pathologic Diagnosis
Insufficient for i nterpretat i on Insufficient for interpretation Malignant lymphoma Abnormal Iymphocytes, probably lymphoma Insufficient for interpretation Squamous Ca. Squamous Ca. Squamous Ca. Adenocarcinoma Normal lymph node tissue Inflammation Inflammation Fat replacement
Confirmed
Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma Histiocytic lymphoma
Surgery
Inflammation Inflammation Fat replacement
Autopsy Autopsy Surgery
Surgery Surgery Surgery
were blopsled through a posterior approach with the patient in a prone position. These examinations are usually performed on outpatients who are observed for three to four hours after biopsy before release. No postbiopsy radiographs are routinely taken. Relative contraindications include bowel dilatation and abnormal bleeding parameters. CLINICAL MATERIAL AND RESULTS
The 17 patients in this preliminary series were evaluated at M. D. Anderson Hospital and Tumor Institute for the staging and treatment of various malignant diseases. The clinical diagnoses, biopsy sites and pathologic diagnoses are summarized in TABLES I and II. Twenty biopsy procedures were performed in 17 patients, 7 women and 10 men, ranging in age from 13 to 74 years. Lymph nodes previously visualized by lymphangiography were biopsied in 10 cases, while retroperitoneal masses were biopsied in 4, paraspinal in 2, and intraperitoneal in one. Of the 17 patients examined by percutaneous aspiration biopsies, interpretable biopsy material was obtained in 14. Confirmation of these findings was obtained by surgery and/or autopsy in 8 patients.
Retroperitoneal Masses
Biopsy Site
Cytologic Diagnosis
Pathologic Diagnosis
Confirmed
Retroperitoneal (La) Retroperitoneal (La) Intraperitoneal (mid-pelvis) Paraspinal (T 11) Paraspinal (T 11) Retroperitonea I (RUQ) Retroperitoneal (RLQ)
Transitional cell carcinoma Adenocarcinoma
Sarcoma
Rhabdomyosarcoma
Surgery
Blood
Postoperative hematoma
Surgery
Atypical cells Melanoma Osteosarcoma
113
LYMPH NODE ASPIRATION BIOPSY
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The lymph node biopsies were performed to verify Iymphangiographic findings. External iliac lymph nodes were biopsied on 9 occasions and para-aortic in 4. Two patients were biopsied in both the external iliac and para-aortic regions and, in 1 patient the same external iliac node was biopsied twice. In 2 of the 3 patients with lymphoma, biopsies were performed to determine the status of the disease after previous therapy. The masses, other than the opacified lymph nodes, were located as high as the T 11 level. The 2 neoplastic masses of epithelial origin, at the L3 level, were metastatic carcinoma from the bladder and endometrium and were probably within lymph nodes which were not examined by lymphangiography. Six of the 7 patients with metastases originating from carcinomas of the pelvic viscera were successfully diagnosed by aspiration biopsy. Biopsies obtained from only 1 of the 3 patients with lymphoma yielded definitive diagnosis of histiocytic lymphoma. In another patient with both histiocytic lymphoma and bladder carcinoma, the aspirated tissue was considered to have abnormal lymphocytes, most probably lymphoma. A definitive diagnosis as to the specific type of lymphoma, a histiocytic lymphoma, was established by surgical exploration. In the third patient with lymphoma, no tissue was obtained from attempted biopsies of the external and para-aortic nodes. Of 2 patients with melanoma, metastases were established in one by the biopsy of a paraspinal mass. The aspirated cells from a pelvic mass in the second patient with melanoma were considered as atypical. Both sarcomas (a paraspinal osteosarcoma metastasis and a retroperitoneal rhabdomyosarcoma) were diagnosed by percutaneous aspiration biopsy. The diagnosis of inflammatory nodes was made by aspiration biopsy of the same external iliac node on 2 occasions and was confirmed at autopsy. Fatty replacement was found on aspiration of an external iliac node and later confirmed at node dissection in a patient with melanoma. The biopsy of a para-aortic node considered normal by lymphangiography in a patient with carcinoma of the prostate revealed normal lymphoid tissue. And finally, the aspiration of blood from a mass in the right lower quadrant proved to be from a postoperative hematoma following an orchidectomy and resection of the cord for a carcinoma of the right testicle. None of the 17 patients experienced significant discomfort or complications from the procedure. The 7 patients who subsequently underwent surgery and the 1 patient who was autopsied did not show any evidence of hollow organ perforation or vascular damage.
CASE REPORTS CASE I. (T.H.). A 61-year-old man was referred for evaluation and treatment of carcinoma of the prostate. Lymphangiography revealed metastasis to a right external iliac lymph node. However, a tissue diagnosis was desired prior to initiating therapy. A biopsy was obtained from the right external iliac node (Fig. 1, A and B). The cytologic diagnosis was metastatic adenocarcinoma presumably from a primary carcinoma of the prostate (Fig. 1, C).
Diagnostic Radiology
Fig. 2. CASE II. Histiocytic lymphoma. A. Needle aspiration biopsy of an external iliac node in a patient with a concomitant carcinoma of the bladder (AP view). B. Oblique view. Note the relationship of the needle to the opacified node.
CASE II. (S.H). A 65-year-old man was referred for staging and treatment of a transitional cell carcinoma of the bladder. A bilateral Iymphangiogram revealed no evidence of metastatic disease. However, the nodes were abnormal and a diagnosis of lymphoma was considered (Fig. 2). Aspiration biopsy revealed multiple abnormal lymphocytes consistent with the diagnosis of lymphoma. A surgical biopsy was performed and the histiologic diagnosis of histiocytic lymphoma was established. CASE III. (G.M.). A 65-year-old man was first examined in 1973 because of an abdominal mass. A Iymphangiogram was obtained demonstrating nodal involvement compatible with lymphoma (Fig. 3, A). A surgical biopsy revealed histiocytic lymphoma. The patient received several courses of chemotherapy and was clinically improved. Repeat lymphangiography in 1975 revealed that the previously noted mass was smaller but still abnormal (Fig. 3, B). In an attempt to differentiate residual active disease from the remains of previously tr,eated lymph nodes, biopsy was suggested. The aspiration biopsy was performed at the para-aortic region (Fig. 3, C). The cytologic diagnosis was malignant lymphoma. CASE IV. (P.C.). A 58-year-old woman had undergone a hysterectomy four years previously for carcinoma of the endometrium. Because of a palpable mass in the abdomen, an inferior venacavogram was performed demonstrating an obstruction with extensive collateral circulation (Fig. 4, A and B). Ultrasound also localized the palpable mass to be 6 cm below the skin surface. The mass was biopsied and the cytologic diagnosis was metastatic adenocarcinoma (Fig. 4, C).
DISCUSSION
Selective lymphadenectomy in conjunction with lymphangiography for staging prior to therapy has found increasing application (5, 11). At present at M. D. Anderson Hospital and Tumor Institute, staging laparotomy with lymph node biopsy is performed in the management of patients with Hodgkin's disease and carcinoma of the cervix. Lymphangiography is also important in the evaluation of the extent of involvement and therefore in treatment planning for patients with carcinomas of the testicle, bladder, prostate and ovary.
Fig. 3. CASE III. Histiocytic lymphoma. A. The large retroperitoneal nodal mass displaced the proximal ureter and kidney. Only the inferior aspect of the neoplasm was opacified by lymphangiography in 1973. B. Repeat lymphangiography in 1975 demonstrates reduction in the size of the mass. C. Needle aspiration established the presence of residual histiocytic lymphoma.
Fig. 4. CASE IV. Metastatic adenocarcinoma from the endometrium. A. Inferior venacavagram reveals obstruction by a retroperitoneal mass. There is opacification of collateral veins (AP view). B. Oblique view confirms the involvement of the inferior vena cava. C. Cytologic specimen (X200). Pap smear established the diagnosis of metastatic adenocarcinoma presumably originating from the patient's previously treated endometrial carcinoma.
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LYMPH NODE ASPIRATION BIOPSY
The percutaneous approach to the retroperitoneal and pelvic lymph nodes with a small-caliber needle represents a simple technique to confirm the presence of neoplasm, thereby obviating in selected cases the need for exploratory laparotomy. The histologic verification of inoperable or recurrent retroperitoneal and paraspinal masses can also be readily established by this technique. In view of the relatively anterior position of the paraaortic and pelvic lymph nodes in relation to the great vessels, an anterior transperitoneal approach seems most suitable. This has also proved to be successful in the biopsy of the pancreas which is also relatively anterior in position. Paraspinal masses are lateral and at times posterior to the great vessels and are readily biopsied with the patient in the prone position. This same approach has been employed for the biopsy of the kidneys and adrenals (7). The site of biopsy in an opacified lymph node will differ depending upon the histologic type of neoplastic process. The most common lymphangiographic finding seen in metastatic carcinoma is a defect in a node not traversed by lymphatics. The residual normal functioning portion of the node frequently will have a crescentic configuration representing a node partially replaced by neoplasm. Consequently, the greatest yield would be a biopsy of the node just above the crescentic area. Lymphoma is usually a more diffuse involvement of a lymph node and the site of biopsy is not as critical. Aspiration biopsy of a lymph node containing metastatic carcinoma is more successful than that with lymphoma (15). Epithelial metastases, especially those originating in pelvic viscera, are frequently highly cellular, poorly vascularized, and readily distinguishable from the normal cells of a lymph node (1). In lymphomas, the diagnosis by fine needle aspiration is more difficult and sometimes impossible to classify, especially as to the type. However, in Hodgkin's disease, a definite diagnosis is reported to be possible in 70 % of the cases (2). Percutaneous transperitoneal lymph node biopsy involves the passage of a 23-gauge needle into the peritoneal cavity and through hollow and solid viscera. In our series there were no complications. The potential complications, such as intra-abdominal bleeding, pancreatitis and bowel perforation with peritonitis, were not encountered. Our experience with transperitoneal biopsy of the pancreas has been similar. This confirms on a small scale the findings presented by Forsgren and Orell (4), Hancke et a/. (6) and Holm et at. (7). In the most recent report by Holm et a/. (7) there was only one clinically significant complication in 1,200 ultrasonically guided percutaneous punctures. A 200-ml hematoma was found at surgery two months after aspiration of a pancreatic pseudocyst. The possibility of disseminating neoplasm by aspiration biopsy does not seem to present a significant problem as con-
Diagnostic Radiology
eluded by laboratory investigation and clinical experience with percutaneous biopsies of lymph nodes and kidney neoplasms using even larger caliber needles. (3, 13). ADDENDUM Since submission of the manuscript, 25 more biopsies have been performed. Lymph nodes were biopsled in 15 cases and retroperitoneal masses in 10. Of the 15 lymph node biopsies, 12 were successfully diagnosed by aspiration biopsy. In each of the 10 retroperitoneal masses a positive diagnosis was obtained. No complications were found in any of the patients.
Jesus Zornoza, M.D. Department of Diagnostic Radiology University of Texas M. D. Anderson Hospital and Tumor Institute Houston, Texas 77030
REFERENCES 1. Berg JW: The aspiration biopsy smear. [In] Koss LG, Durfee GR, eds: Diagnostic Cytology and Its Histopathologic Bases. Philadelphia, Lippincott Co., 1961, pp 311-321 2. Drose M. Zajicek J: Unpublished data 3. Engzell U, Esposti PL, Rubio C, et al: Investigation on tumour spread in connection with aspiration biopsy. Acta Radiol [Ther] 10: 385-398, Aug 1971 4. Forsgren L, OreII S: Aspiration cytology in carcinoma of the pancreas. Surgery 73:38-42, Jan 1973 5. Glatstein E, Guernsey JM, Rosenberg SA, et al: The value of laparotomy and splenectomy in the staging of Hodgkin's disease. Cancer 24:709-718, Oct 1969 6. Hancke S, Holm HH, Koch F: Ultrasonically guided percutaneous fine needle biopsy of the pancreas. Surg Gynecol Obstet 140: 361-364, Mar 1975 7. Holm HH, Pederson JF, Kristensen JK, et al: Ultrasonically guided percutaneous puncture. Radiol Clin N Am 13:493-503, 1975 8. Nordenstrbm B: Transjugular approach to the mediastinum for mediastinography and mediastinal needle biopsy: a preliminary report. Invest RadioI2:134-140, Mar-Apr 1967 9. Nordenstrbm B: Paraxiphoid approach to the mediastinum for mediastinography and mediastinal needle biopsy: a preliminary report. Invest Radiol 2:141-146, Mar-Apr 1967 10. Okuda K, Tanikawa K, Emura T, et al: Nonsurgical, percutaneous transhepatlc cholangiography-diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36, Jan 1974 11. Piver MS, Barlow JJ: Para-aortic lymphadenectomy in staging patients with advanced local cervical cancer. Obstet Gynecol 43: 544-548, Apr 1974 12. Ruttimann A: Iliac lymph node aspiration biopsy through paravascular approach: preliminary report. Radiology 90: 150-151, Jan 1968 13. Von Schreeb T, Arner 0, Skovsted G, et al: Renal carcinoma: is there a risk of spreading tumor cells in diagnostic puncture? Scand J Urol Nephrol 1:270-276, 1967 14. Wallace S, Schwartz PE, Anderson JH, et al: A feasibility study for percutaneous retroperitoneal lymph node biopsy. Am J Roentgenol 125:234-239, Sep 1975 15. Zajicek J: Aspiration biopsy cytology, part I: cytology of supradiaphragmatic organs. [In] WiOO GL, 00: Monographs in Clinical Cytology. Basel, Switzerland, S. Karger, 1974, pp 90-124
