microscopy This appears to be true whether pulmonary hypertension is presents· 13 or absent.r" Cystic medial necrosis of the pulmonary arteries occurs in association with Marfans syndrome and long-standing pulmonary hypertension.I.' Atherosclerotic degeneration of the pulmonary arteries has also been described with congenital heart disease and associated pulmonary hypertenston.s" Since only a small percentage of patients with pulmonary hypertension develop proximal PAA,it is speculated that a congenital defect in the connective tissue of the arterial wall is a contributing factor.' The patient presented in this report is asymptomatic and has had roentgenographically stable proximal PAAs for at least a five-year period. The etiology of her aneurysms remains unknown. The patient did not have underlying causes of secondary pulmonary hypertension such as heart disease, chronic obstructive pulmonary disease, or thromboembolic disease. Although Doppler echocardiography revealed mild pulmonary hypertension, it is unlikely that this factor should have caused such extensive aneurysm formation. Pulmonary angiography was not performed since computed tomography was diagnostic. In summary, we have described an adult patient with only mild pulmonary hypertension who presented with bilateral proximal PAAs which spared the main trunk. This is a rare presentation of a rare disease. Proximal PAA is an extremely rare disease which belongs in the differential diagnosis of hilar enlargement. Contrast-enhanced computed tomography can be a valuable noninvasive diagnostic tool as it can help to separate lymph nodes from vascular dilatation. REFERENCES
1 Trell E. Pulmonary artery aneurysm. Thorax 1973; 28:644-49 2 Bartter T, Irwin RS, Nash G. Aneurysms of the pulmonary arteries. Chest 1988; 94:1065-75 3 Deterling RA, Clagett QT. Aneurysms of the pulmonary artery: review of the literature and report of a case. Am Heart J 1947; 34:471-99 4 Chiu B, Magi} A. Idiopathic pulmonary artery trunk aneurysm presenting as cor pulmonale: report of a case. Hum Patholl985; 16:947-49 5 Barbour DJ, Roberts WC. Aneursym of the pulmonary trunk unassoeiated with intracardiac or great vesselleft-to-right shunting. Am J Cardioll987; 59:192-94 6 Arom ~ Richardson JD, Grover FL, Ferris G, Trinkle JK. Pulmonary artery aneurysm. Am Surg 1978; 44:688-92 7 Cole FH, Hanano AA, Pate.JW Peripheral pulmonary embolization from central pulmonary aneurysm. Chest 1979; 75:51718 8 Shilldn KB, Low U Chen BT. Dissecting aneurysm of the pulmonary artery J Patholl969; 96:25-29 9 Butto F, Lucas R~ Edwards JE. Pulmonary artery aneurysm: a pathologic study of6ve cases. Chest 1987; 91:237-41 10 PerlofJ JIC. Idiopathic dilatation of the pulmonary trunk. In: PerlofJ JK, 00. Clinical recognition of congenital heart disease. 3rd 00. Philadelphia: WB Saunders, 1987:220-25 11 Gould L, Yang DC, Patel C, Patel D, Lee J, Judge D, et al, Aneurysms of the pulmonary arteries: a case report. Angiology 1987; 38:474-78 12 Gould L, Reddy CVR, Yang CS. Aneurysms of the pulmonary arteries. Angiology 1977; 28:119-24 13 Finch EL, Mitchell RS, Guthaner DF, Fowles RF, Miller DC. Pulmonary artery surgical aneurysmorrhaphy: Where do we go from here? Am Heart J 1983; 106:614-18
Implantation Metastasis of Carcinoma after Percutaneous Fine-Needle Aspiration Biopsy* Nann \bravud, M.D.; Dong M. Shin, M.D.; Boupen H. Dekmezian, M.D.; Isaiah Dimery, M.D.; lin S. Lee, M.D.; and Woon ta Hong, M.D.
Implantation of malignant cells along the needle tract is an extremely rare but potential complication following percutaneous needle aspiration biopsy of malignant lesions. Percutaneous fine-needle aspiration biopsy (FNAB) has recently received more attention for cytologic diagnosis of bronchogenic carcinoma because of its high diagnostic yield, simplicity, and low morbidity. On the other hand, dissemination of cancer cells by needle aspiration biopsy can change a potentially resectable localized lung cancer to an unresectable one. We report two cases: one patient underwent FNAB of a metastatic left adrenal mass that seeded a paraspinal muscle implantation of malignant cells that subsequently developed a tumor mass, and the second patient had tumor cell implantation in the chest wall after FNAB of a pleural-based adenocarcinoma of the lung. The theoretical and practical importance of tumor cell spread along the needle tract is discussed. Because of its rare incidence, however, this complication should not affect the use of needle aspiration biopsy in bronchogenic carcinoma, although care should be undertaken during the procedure.
(ehe., 1992; 102:313-15)
I FNAB =fine-needle aspiration biopsy I e ~ c u ta n ~ o u s ne~dle aspiration has been widely used for diagnosis of malignant neoplasms. The common complications that might be encountered in performing needle aspiration biopsy of the lung are pneumothorax, hemorrhage, infection, and air emboli. Implantation of tumor cells along the needle tract is an extremely uncommon complication of this technique. Among thousands of fine-needle aspiration biopsies (FNAB) performed in lung cancer patients, there are only a few reports of tumor implantation after this procedure. 1,2 Most of these complications have followed the use of cutting needles or relatively large-bore needles.'... However, chest wall implantation of bronchogenic carcinoma after FNAB has occurred, although it is even more rare. 5,6 The role of immediate radiotherapy after biopsy to prevent tumor implants in the needle track was raised in one report. 7 Because of this rare but significant complication, we present herein two cases: one patient who had an adenocarcinoma of the lung and developed paras pinal muscle implantation after FNAB of his left adrenal mass; the other patient developed chest wall implantation after pleural needle biopsy was performed.
P
CASE REPORTS CASE
1
A 49-yeaN>ld man was examined for obstructive pneumonia of the left upper lobe. Bronchoscopy was done by an outside hospital *From the Departments of Medical Oncology and Pathology, The University of Texas M. D. Anderson Cancer Center, Houston. Dr. Shin is a recipient of a Clinical Oncology Career Development Award from the American Cancer Society. CHEST I 102 I 1 I JUL'f, 1992
313
FIC;URE 1. Computed tomographic scan of abdomen shows the position of the fine needle (at armw) at the time of aspiration biopsy of the left adrenal metastasis. and revealed an obstruction of the left upper and lower lobe bronchi by a mass that appeared to he a bronchogenic carcinoma. Transbronchial needle biopsy usin~ bronchoscopy demonstrated a poorly differentiated adenocarcinoma. Metastatic workup consisting of computed tomographic (Cf) scanning of abdomen revealed a left adrenal gland enlargement. Because of the possible resectability of the primary lung cancer, a FNA of the left adrenal mass was employed under CT guidancc' (Fig 1). The aspiration smears from the left adrenal gland revealed adenocarcinoma consistent with metastasis from the primary lun~ carcinoma. He was treated with one course of mitomycin and vinblastine with no response . One month after the FNA procedure, a swelling at the site of FNA was noticed . A CT scan of the abdomen indicated an enhancing mass in the left paraspinal muscle that was in the path of the original needle aspiration (Fig 2). and the tumor mass was judged to he developed fmmthe cell spillage at the tinlt'ofFNAB. Because of his progressive lung cancer, chemotherapy W,L~ changed to cisplatin and etoposide. He W,L~ subsequently treated with external irradiation to the chest. Unfortunutely, the patient eventually died of disease progression fmm the primary site and metastatic sites as well. c.~st
:
2
A 32-yc'ar-oldnonsmoking woman presented with a right pleural effusion . Thoracentesis was performed , and cytologic study failed to show a malignant neoplasm . The patient then underwent percutaneous transthoracic needle aspiration hiopsv, which was
FIGURE 2. One month after FNAB of the patient in Figure 1. CT scan of abdomen demonstrated a large enhancing mass with a central necrosis (at amnc) that was developed in the left paraspinal muscle in the needle tract in the same direction of the original needle aspiration (A). 314
FIGURE 3 . Computed tomographic scan of chest illustrates an enhancing mass (at arrow) in the lateral chest wall at the site of previous needle aspiration two months after a FNAB . positive for adenocarcinoma. An exploratory thoracotomy revealed multiple nodules on the right pleura and a 3.5-
1 Trell E. Pulmonary artery aneurysm. Thorax 1973; 28:644-49 2 Bartter T, Irwin RS, Nash G. Aneurysms of the pulmonary arteries. Chest 1988; 94:1065-75 3 Deterling RA, Clagett QT. Aneurysms of the pulmonary artery: review of the literature and report of a case. Am Heart J 1947; 34:471-99 4 Chiu B, Magi} A. Idiopathic pulmonary artery trunk aneurysm presenting as cor pulmonale: report of a case. Hum Patholl985; 16:947-49 5 Barbour DJ, Roberts WC. Aneursym of the pulmonary trunk unassoeiated with intracardiac or great vesselleft-to-right shunting. Am J Cardioll987; 59:192-94 6 Arom ~ Richardson JD, Grover FL, Ferris G, Trinkle JK. Pulmonary artery aneurysm. Am Surg 1978; 44:688-92 7 Cole FH, Hanano AA, Pate.JW Peripheral pulmonary embolization from central pulmonary aneurysm. Chest 1979; 75:51718 8 Shilldn KB, Low U Chen BT. Dissecting aneurysm of the pulmonary artery J Patholl969; 96:25-29 9 Butto F, Lucas R~ Edwards JE. Pulmonary artery aneurysm: a pathologic study of6ve cases. Chest 1987; 91:237-41 10 PerlofJ JIC. Idiopathic dilatation of the pulmonary trunk. In: PerlofJ JK, 00. Clinical recognition of congenital heart disease. 3rd 00. Philadelphia: WB Saunders, 1987:220-25 11 Gould L, Yang DC, Patel C, Patel D, Lee J, Judge D, et al, Aneurysms of the pulmonary arteries: a case report. Angiology 1987; 38:474-78 12 Gould L, Reddy CVR, Yang CS. Aneurysms of the pulmonary arteries. Angiology 1977; 28:119-24 13 Finch EL, Mitchell RS, Guthaner DF, Fowles RF, Miller DC. Pulmonary artery surgical aneurysmorrhaphy: Where do we go from here? Am Heart J 1983; 106:614-18
Implantation Metastasis of Carcinoma after Percutaneous Fine-Needle Aspiration Biopsy* Nann \bravud, M.D.; Dong M. Shin, M.D.; Boupen H. Dekmezian, M.D.; Isaiah Dimery, M.D.; lin S. Lee, M.D.; and Woon ta Hong, M.D.
Implantation of malignant cells along the needle tract is an extremely rare but potential complication following percutaneous needle aspiration biopsy of malignant lesions. Percutaneous fine-needle aspiration biopsy (FNAB) has recently received more attention for cytologic diagnosis of bronchogenic carcinoma because of its high diagnostic yield, simplicity, and low morbidity. On the other hand, dissemination of cancer cells by needle aspiration biopsy can change a potentially resectable localized lung cancer to an unresectable one. We report two cases: one patient underwent FNAB of a metastatic left adrenal mass that seeded a paraspinal muscle implantation of malignant cells that subsequently developed a tumor mass, and the second patient had tumor cell implantation in the chest wall after FNAB of a pleural-based adenocarcinoma of the lung. The theoretical and practical importance of tumor cell spread along the needle tract is discussed. Because of its rare incidence, however, this complication should not affect the use of needle aspiration biopsy in bronchogenic carcinoma, although care should be undertaken during the procedure.
(ehe., 1992; 102:313-15)
I FNAB =fine-needle aspiration biopsy I e ~ c u ta n ~ o u s ne~dle aspiration has been widely used for diagnosis of malignant neoplasms. The common complications that might be encountered in performing needle aspiration biopsy of the lung are pneumothorax, hemorrhage, infection, and air emboli. Implantation of tumor cells along the needle tract is an extremely uncommon complication of this technique. Among thousands of fine-needle aspiration biopsies (FNAB) performed in lung cancer patients, there are only a few reports of tumor implantation after this procedure. 1,2 Most of these complications have followed the use of cutting needles or relatively large-bore needles.'... However, chest wall implantation of bronchogenic carcinoma after FNAB has occurred, although it is even more rare. 5,6 The role of immediate radiotherapy after biopsy to prevent tumor implants in the needle track was raised in one report. 7 Because of this rare but significant complication, we present herein two cases: one patient who had an adenocarcinoma of the lung and developed paras pinal muscle implantation after FNAB of his left adrenal mass; the other patient developed chest wall implantation after pleural needle biopsy was performed.
P
CASE REPORTS CASE
1
A 49-yeaN>ld man was examined for obstructive pneumonia of the left upper lobe. Bronchoscopy was done by an outside hospital *From the Departments of Medical Oncology and Pathology, The University of Texas M. D. Anderson Cancer Center, Houston. Dr. Shin is a recipient of a Clinical Oncology Career Development Award from the American Cancer Society. CHEST I 102 I 1 I JUL'f, 1992
313
FIC;URE 1. Computed tomographic scan of abdomen shows the position of the fine needle (at armw) at the time of aspiration biopsy of the left adrenal metastasis. and revealed an obstruction of the left upper and lower lobe bronchi by a mass that appeared to he a bronchogenic carcinoma. Transbronchial needle biopsy usin~ bronchoscopy demonstrated a poorly differentiated adenocarcinoma. Metastatic workup consisting of computed tomographic (Cf) scanning of abdomen revealed a left adrenal gland enlargement. Because of the possible resectability of the primary lung cancer, a FNA of the left adrenal mass was employed under CT guidancc' (Fig 1). The aspiration smears from the left adrenal gland revealed adenocarcinoma consistent with metastasis from the primary lun~ carcinoma. He was treated with one course of mitomycin and vinblastine with no response . One month after the FNA procedure, a swelling at the site of FNA was noticed . A CT scan of the abdomen indicated an enhancing mass in the left paraspinal muscle that was in the path of the original needle aspiration (Fig 2). and the tumor mass was judged to he developed fmmthe cell spillage at the tinlt'ofFNAB. Because of his progressive lung cancer, chemotherapy W,L~ changed to cisplatin and etoposide. He W,L~ subsequently treated with external irradiation to the chest. Unfortunutely, the patient eventually died of disease progression fmm the primary site and metastatic sites as well. c.~st
:
2
A 32-yc'ar-oldnonsmoking woman presented with a right pleural effusion . Thoracentesis was performed , and cytologic study failed to show a malignant neoplasm . The patient then underwent percutaneous transthoracic needle aspiration hiopsv, which was
FIGURE 2. One month after FNAB of the patient in Figure 1. CT scan of abdomen demonstrated a large enhancing mass with a central necrosis (at amnc) that was developed in the left paraspinal muscle in the needle tract in the same direction of the original needle aspiration (A). 314
FIGURE 3 . Computed tomographic scan of chest illustrates an enhancing mass (at arrow) in the lateral chest wall at the site of previous needle aspiration two months after a FNAB . positive for adenocarcinoma. An exploratory thoracotomy revealed multiple nodules on the right pleura and a 3.5-
