Diagnostic Radiology
Fine Needle Aspiration Biopsy of Retroperitoneal Lymph Nodes and Abdominal Masses: An Updated Report 1 Jesus Zornoza, M.D.,2 Kjell Jonsson, M.D., Sidney Wallace, M.D., and John M. Lukeman, M.D. Percutaneous fine needle aspiration biopsy of retroperitoneal lymph nodes and abdominal masses was performed in 109 patients. Eighty-five per cent of the aspiration biopsies yielded sufficient cytologic material for a correct diagnosis. Indications include confirmation of Iymphangiographic findings and the establishment of a histologic diagnosis in lieu of surgery. No significant complications were encountered. INDEX TEAMS:
Biopsies, technique. Lymph nodes, neoplasms, 9[9].321
Radiology 125:87-88, October 1977
of a malignant neoplasm is essential prior to instituting therapy. Angiography, venography, lymphangiography, ultrasound, and computed tomography assist in establishing the extent of disease. Histologic verification can be accomplished by percutaneous aspiration biopsy (2, 3, 6). This report presents our updated experience with fine needle (23 gauge) aspiration biopsy of lymph nodes and retroperitoneal and abdominal masses in 109 patients.
S
TABLE
TAGING
I:
PERCUTANEOUS NEEDLE BIOPSY OF LYMPH NODES
Carcinoma Lymphoma Carcinoma Lymphoma Carcinoma Lymphoma
True positives True negatives False negatives
37
6 13 3 8
5
72
Total Correct diagnosis
TABLE
TECHNIQUE
II:
82%
PERCUTANEOUS NEEDLE BIOPSY (ABDOMINAL MASS LOCATION)
49
TOTAL
11 11 11
Retroperitoneal Liver Pelvic area Intraperitoneal Kidney Paraspinal Adrenal
The biopsy technique employed has been previously described in detail (6). The passage of the fine caliber 23 gauge needle3 through the abdominal wall was consistently accomplished. Two to 6 passes were usually required to ensure retrieval of sufficient material. The lymph nodes were visualized by lymphangiography. The masses were localized by barium studies, angiography, venography, and ultrasound.
8 4 3 1
CLINICAL MATERIAL
RESULTS
The series includes 121 consecutive proved biopsies performed upon 109 patients between September 1975 and March 1977. There were 49 male and 60 female patients aged 6 to 81 years. Lymph nodes were biopsied in 72 instances and other mass lesions in 49. In 9 patients biopsies of lymph nodes in both the external iliac and para-aortic regions were performed, while in 2 patients the same external iliac node was aspirated on two occasions. Only one patient with an abdominal mass had two biopsies performed. The majority of the biopsies were performed with the patient in the supine position, with an anterior approach. Only four biopsies of paravertebral masses were done through a posterior approach with the patient in the prone position. Confirmation of the biopsy results was obtained by clinical follow-up, surgery, and/or autopsy.
Lymph nodes: 58 biopsies were performed in patients with lymph node metastasis and 14 in patients with lymphoma. The primary neoplasms in metastatic lymph nodes and their frequency of occurrence were: carcinoma of the cervix 32, carcinoma of the prostate 11, endometrial carcinoma 3, carcinoma of the bladder 4, testicular carcinoma 2, urethral carcinoma 2, melanoma 2, ovarian carcinoma 1, and unknown primary 1. In a patient with carcinoma of the bladder, the aspirated tissue was considered to have abnormal lymphocytes, probably lymphoma. Subsequent surgical biopsy results revealed histiocytic lymphoma. A true positive diagnosis was obtained from the results of 43 biopsies; 16 yielded true negatives and 13 yielded false negatives. The overall success rate was 82 % and results tabulated according to the patients' primary tumors
1 From the Departments of Diagnostic Radiology (J. Z., K. J., S. W.) and Pathology (J.M.L.), The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, Houston, Texas 77030. Accepted for publication in May 1977. 2 Present address: Department of Diagnostic Radiology, University of Kansas Medical Center, College of Health Sciences & Hospital, Rainbow Blvd. at 39th, Kansas City, Kansas 66103. 3 Available from Cook, Inc., Bloomington, Indiana and from Johannah Medical Services, Inc., Minneapolis, Minnesota. shan
87
88
JESUS ZORNOZA AND OTHERS
are summarized in TABLE I. Biopsy results yielded correct diagnosis in 50 (86 %) patients with metastatic carcinoma while results for 8 (14 %) remained inconclusive. In patients with lymphoma, 9 (64 %) biopsy specimens revealed adequate cytologic material for a correct diagnosis while 5 (36 % ) were inadequate. External iliac lymph nodes were biopsied in 50 patients and para-aortic lymph nodes in 22. Forty-three (86 %) biopsy specimens from nodes in the external iliac region yielded successful diagnoses whi Ie 7 (14 %) yielded no interpretable material. Para-aortic lymph nodes were correctly diagnosed in 16 patients (72 %), while 6 (28 % ) yielded inconclusive results. Masses: The locations of the masses upon which biopsies were performed are summarized in TABLE II. Of the 49 biopsies performed, 35 yielded true positive diagnoses, 9 true negatives, and 5 false negatives for a success rate of 90 %. In 42 cases there was a known primary neoplasm (carcinoma 32, lymphoma 4, sarcoma 4, leukemia 2) and in 7 no primary tumor had been previously known. Cytologic material provided the definite diagnosis in 5 of the 7 patients. In the other 2, no malignant cells were found. The results of posterior surgical biopsies revealed a granuloma of the abdominal wall in 1 case and disseminated peritoneal tuberculosis in the other. The biopsy specimen of a pelvic mass in a patient with leukemia yielded a diagnosis of ovarian dysgerminoma. In the 5 cases in which biopsy results were inconclusive, surgical exploration revealed 4 as having metastatic malignant neoplasms and the other as having an exoenteric gastric leiomyoma. Complications: In none of the 109 patients did percutaneous aspiration biopsy cause significant complications. The patients who subsequently underwent surgery or autopsy did not show any evidence of perforation, vascular damage or bleeding although most patients did experience discomfort in biopsies performed in the para-aortic region. DISCUSSION
Although lymphangiography has an accuracy rate of
90-95 % when considered positive, needle aspiration biopsy of opacified pathologic lymph nodes can confirm the presence of a neoplasm (4). In patients with abdominal masses the primary purpose is to obtain histologic material, thereby obviating the need for exploratory laparotomies. A correct diagnosis was obtained from 86 % of the biopsies of the external iliac lymph nodes and 72 % of the para-aortic lymph nodes. This lower success rate at the para-aortic region may be due to the difficulty in guiding the needle, as at this level more tissue is traversed.
October 1977
The results of aspiration biopsy of lymph nodes containing metastatic carcinoma were more successful than those involving lymphoma. Eighty-six per cent of the diagnoses of patients with metastatic carcinoma and 64 % of the lymphoma patients were correct. Epithelial metastases are frequently highly cellular and readily distinguishable from the normal cells of a lymph node (1). In lymphomas a correct diagnosis is more difficult to obtain, especially as to histologic type. Histiocytic lymphoma and Hodgkin's disease are less difficult to diagnose, and in Hodgkin's disease a definite diagnosis is reported to be possible in 70 % of the cases (5). Proper handling of the cytologic material is critical to a high diagnostic yield. The aspirated material should be smeared properly onto the glass slides and quickly fixed in 95 % ethyl alcohol or a similar solution to avoid drying the cells. The smearing technique is readily accomplished by the radiologist. In several patients subjected to laparotomy after a negative aspiration biopsy the surgeons were unable to find any evidence of previous biopsy. In order to determine the effect of the needle's passing through the abdominal viscera, several percutaneous biopsies were performed in 6 dogs prior to laparotomy. The abdominal organs were then inspected and the findings were normal; in most cases there was no evidence of trauma. The lack of complications and the excellent results of the fine needle aspiration biopsy of lymph nodes and abdominal masses make it a useful tool for obtaining diagnostic verification of otherwise demonstrated masses and metastases. Jesus Zornoza, M.D. Department of Diagnostic Radiology The University of Kansas Medical Center College of Health Sciences and Hospital Rainbow Blvd. at 39th Kansas City, Kansas 66103
REFERENCES 1. Berg JW: The aspiration biopsy smear. [In] Koss LG, Durfee GR, eds: Diagnostic Cytology and Its Histopathologic Bases. Philadelphia, J. B. Lippincott, 1961, pp 311-321 2. Goldstein HM, Zornoza J, Wallace S, et al.: Percutaneous fine needle aspiration biopsy of pancreatic and other abdominal masses. Radiology 123:319-322, May 1977 3. Gothlin JH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy. Radiology 120:205-207, Jul 1976 4. Wallace S, Jing BS, Zornoza J: Lymphangiography in the determination of the extent of metastatic carcinoma. The potential value of percutaneous lymph node biopsy. Cancer 39:706-718, Feb 1977 5. Zajicek J: Aspiration biopsy cytology, part I: Cytology of supradiaphragmatic organs. [In] Wied GD, ed: Monographs in Clinical Cytology. Basel, Switzerland, S. Karger, 1974, pp 90-124 6. Zornoza J, Wallace S, Goldstein HM, et al: Transperitoneal percutaneous retroperitoneal lymph node aspiration biopsy. Radiology 122:111-115, Jan 1977
Fine Needle Aspiration Biopsy of Retroperitoneal Lymph Nodes and Abdominal Masses: An Updated Report 1 Jesus Zornoza, M.D.,2 Kjell Jonsson, M.D., Sidney Wallace, M.D., and John M. Lukeman, M.D. Percutaneous fine needle aspiration biopsy of retroperitoneal lymph nodes and abdominal masses was performed in 109 patients. Eighty-five per cent of the aspiration biopsies yielded sufficient cytologic material for a correct diagnosis. Indications include confirmation of Iymphangiographic findings and the establishment of a histologic diagnosis in lieu of surgery. No significant complications were encountered. INDEX TEAMS:
Biopsies, technique. Lymph nodes, neoplasms, 9[9].321
Radiology 125:87-88, October 1977
of a malignant neoplasm is essential prior to instituting therapy. Angiography, venography, lymphangiography, ultrasound, and computed tomography assist in establishing the extent of disease. Histologic verification can be accomplished by percutaneous aspiration biopsy (2, 3, 6). This report presents our updated experience with fine needle (23 gauge) aspiration biopsy of lymph nodes and retroperitoneal and abdominal masses in 109 patients.
S
TABLE
TAGING
I:
PERCUTANEOUS NEEDLE BIOPSY OF LYMPH NODES
Carcinoma Lymphoma Carcinoma Lymphoma Carcinoma Lymphoma
True positives True negatives False negatives
37
6 13 3 8
5
72
Total Correct diagnosis
TABLE
TECHNIQUE
II:
82%
PERCUTANEOUS NEEDLE BIOPSY (ABDOMINAL MASS LOCATION)
49
TOTAL
11 11 11
Retroperitoneal Liver Pelvic area Intraperitoneal Kidney Paraspinal Adrenal
The biopsy technique employed has been previously described in detail (6). The passage of the fine caliber 23 gauge needle3 through the abdominal wall was consistently accomplished. Two to 6 passes were usually required to ensure retrieval of sufficient material. The lymph nodes were visualized by lymphangiography. The masses were localized by barium studies, angiography, venography, and ultrasound.
8 4 3 1
CLINICAL MATERIAL
RESULTS
The series includes 121 consecutive proved biopsies performed upon 109 patients between September 1975 and March 1977. There were 49 male and 60 female patients aged 6 to 81 years. Lymph nodes were biopsied in 72 instances and other mass lesions in 49. In 9 patients biopsies of lymph nodes in both the external iliac and para-aortic regions were performed, while in 2 patients the same external iliac node was aspirated on two occasions. Only one patient with an abdominal mass had two biopsies performed. The majority of the biopsies were performed with the patient in the supine position, with an anterior approach. Only four biopsies of paravertebral masses were done through a posterior approach with the patient in the prone position. Confirmation of the biopsy results was obtained by clinical follow-up, surgery, and/or autopsy.
Lymph nodes: 58 biopsies were performed in patients with lymph node metastasis and 14 in patients with lymphoma. The primary neoplasms in metastatic lymph nodes and their frequency of occurrence were: carcinoma of the cervix 32, carcinoma of the prostate 11, endometrial carcinoma 3, carcinoma of the bladder 4, testicular carcinoma 2, urethral carcinoma 2, melanoma 2, ovarian carcinoma 1, and unknown primary 1. In a patient with carcinoma of the bladder, the aspirated tissue was considered to have abnormal lymphocytes, probably lymphoma. Subsequent surgical biopsy results revealed histiocytic lymphoma. A true positive diagnosis was obtained from the results of 43 biopsies; 16 yielded true negatives and 13 yielded false negatives. The overall success rate was 82 % and results tabulated according to the patients' primary tumors
1 From the Departments of Diagnostic Radiology (J. Z., K. J., S. W.) and Pathology (J.M.L.), The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, Houston, Texas 77030. Accepted for publication in May 1977. 2 Present address: Department of Diagnostic Radiology, University of Kansas Medical Center, College of Health Sciences & Hospital, Rainbow Blvd. at 39th, Kansas City, Kansas 66103. 3 Available from Cook, Inc., Bloomington, Indiana and from Johannah Medical Services, Inc., Minneapolis, Minnesota. shan
87
88
JESUS ZORNOZA AND OTHERS
are summarized in TABLE I. Biopsy results yielded correct diagnosis in 50 (86 %) patients with metastatic carcinoma while results for 8 (14 %) remained inconclusive. In patients with lymphoma, 9 (64 %) biopsy specimens revealed adequate cytologic material for a correct diagnosis while 5 (36 % ) were inadequate. External iliac lymph nodes were biopsied in 50 patients and para-aortic lymph nodes in 22. Forty-three (86 %) biopsy specimens from nodes in the external iliac region yielded successful diagnoses whi Ie 7 (14 %) yielded no interpretable material. Para-aortic lymph nodes were correctly diagnosed in 16 patients (72 %), while 6 (28 % ) yielded inconclusive results. Masses: The locations of the masses upon which biopsies were performed are summarized in TABLE II. Of the 49 biopsies performed, 35 yielded true positive diagnoses, 9 true negatives, and 5 false negatives for a success rate of 90 %. In 42 cases there was a known primary neoplasm (carcinoma 32, lymphoma 4, sarcoma 4, leukemia 2) and in 7 no primary tumor had been previously known. Cytologic material provided the definite diagnosis in 5 of the 7 patients. In the other 2, no malignant cells were found. The results of posterior surgical biopsies revealed a granuloma of the abdominal wall in 1 case and disseminated peritoneal tuberculosis in the other. The biopsy specimen of a pelvic mass in a patient with leukemia yielded a diagnosis of ovarian dysgerminoma. In the 5 cases in which biopsy results were inconclusive, surgical exploration revealed 4 as having metastatic malignant neoplasms and the other as having an exoenteric gastric leiomyoma. Complications: In none of the 109 patients did percutaneous aspiration biopsy cause significant complications. The patients who subsequently underwent surgery or autopsy did not show any evidence of perforation, vascular damage or bleeding although most patients did experience discomfort in biopsies performed in the para-aortic region. DISCUSSION
Although lymphangiography has an accuracy rate of
90-95 % when considered positive, needle aspiration biopsy of opacified pathologic lymph nodes can confirm the presence of a neoplasm (4). In patients with abdominal masses the primary purpose is to obtain histologic material, thereby obviating the need for exploratory laparotomies. A correct diagnosis was obtained from 86 % of the biopsies of the external iliac lymph nodes and 72 % of the para-aortic lymph nodes. This lower success rate at the para-aortic region may be due to the difficulty in guiding the needle, as at this level more tissue is traversed.
October 1977
The results of aspiration biopsy of lymph nodes containing metastatic carcinoma were more successful than those involving lymphoma. Eighty-six per cent of the diagnoses of patients with metastatic carcinoma and 64 % of the lymphoma patients were correct. Epithelial metastases are frequently highly cellular and readily distinguishable from the normal cells of a lymph node (1). In lymphomas a correct diagnosis is more difficult to obtain, especially as to histologic type. Histiocytic lymphoma and Hodgkin's disease are less difficult to diagnose, and in Hodgkin's disease a definite diagnosis is reported to be possible in 70 % of the cases (5). Proper handling of the cytologic material is critical to a high diagnostic yield. The aspirated material should be smeared properly onto the glass slides and quickly fixed in 95 % ethyl alcohol or a similar solution to avoid drying the cells. The smearing technique is readily accomplished by the radiologist. In several patients subjected to laparotomy after a negative aspiration biopsy the surgeons were unable to find any evidence of previous biopsy. In order to determine the effect of the needle's passing through the abdominal viscera, several percutaneous biopsies were performed in 6 dogs prior to laparotomy. The abdominal organs were then inspected and the findings were normal; in most cases there was no evidence of trauma. The lack of complications and the excellent results of the fine needle aspiration biopsy of lymph nodes and abdominal masses make it a useful tool for obtaining diagnostic verification of otherwise demonstrated masses and metastases. Jesus Zornoza, M.D. Department of Diagnostic Radiology The University of Kansas Medical Center College of Health Sciences and Hospital Rainbow Blvd. at 39th Kansas City, Kansas 66103
REFERENCES 1. Berg JW: The aspiration biopsy smear. [In] Koss LG, Durfee GR, eds: Diagnostic Cytology and Its Histopathologic Bases. Philadelphia, J. B. Lippincott, 1961, pp 311-321 2. Goldstein HM, Zornoza J, Wallace S, et al.: Percutaneous fine needle aspiration biopsy of pancreatic and other abdominal masses. Radiology 123:319-322, May 1977 3. Gothlin JH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy. Radiology 120:205-207, Jul 1976 4. Wallace S, Jing BS, Zornoza J: Lymphangiography in the determination of the extent of metastatic carcinoma. The potential value of percutaneous lymph node biopsy. Cancer 39:706-718, Feb 1977 5. Zajicek J: Aspiration biopsy cytology, part I: Cytology of supradiaphragmatic organs. [In] Wied GD, ed: Monographs in Clinical Cytology. Basel, Switzerland, S. Karger, 1974, pp 90-124 6. Zornoza J, Wallace S, Goldstein HM, et al: Transperitoneal percutaneous retroperitoneal lymph node aspiration biopsy. Radiology 122:111-115, Jan 1977
