Gastrointest Radiol 16:67-69 (1991)
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc.1991
Percutaneous Fine-Needle Aspiration Biopsy of the Pancreas Resulting in Death Daniel P. Levin and Patrice M. Bret Department of Diagnostic Radiology, Montreal General Hospital, Montreal, Quebec, Canada
Abstract. Percutaneous fine-needle aspiration biopsy of the pancreas presents a slightly higher risk of complications than does biopsy of other abdominal organs, occasionally leading to death. In the case we discuss, computed tomographic (CT)-guided percutaneous fine-needle aspiration biopsy of a pseudolesion of the uncinate process resulting in hemorrhagic pancreatitis and the death of the patient within 1 week of the procedure. Key words: Pancreas, percutaneous fine-needle biopsy - Hemorrhagic pancreatitis.
Percutaneous fine-needle aspiration biopsy is increasingly used to diagnose pancreatic lesions. In the diagnosis of pancreatic carcinoma, the procedure is reported to have a sensitivity of greater than 80% with a specificity of 100% [1, 2]. The accepted indication for percutaneous biopsy is for the diagnosis of an undetermined focal pancreatic lesion. As complications of fine-needle biopsy of pancreatic lesions are very rare, the procedure is commonly done on an outpatient basis. In contrast to biopsy of other intraabdominal sites, complications of pancreatic biopsy, when they occur, may be very severe, occasionally leading to death [3, 4]. The patient we discuss died of complications associated with hemorrhagic pancreatitis after fineneedle biopsy.
prostatectomy. The assessment included computed tomography (CT) of the abdomen to determine the extent of the prostatic disease. Incidentally noted was a poorly defined 3 cm in diameter mass in the uncinate process of the pancreas. The contours of the uncinate process appeared distorted, and the mass was hypodense relative to the remainder of the pancreas (Fig. 1). Sonographic examination (US) again identified a lobulated hypoechoic solid mass of the uncinate process associated with pancreatic duct dilatation (Fig. 2). Both studies demonstrated pancreatic duct dilatation. Endoscopic retrograde pancreatography (ERCP) demonstrated marked dilatation of the pancreatic duct, without obstruction. Some irregularities in the collateral branches were suggestive, but not diagnostic, of chronic pancreatitis (Fig. 3). The diagnosis of tumor of the uncinate process was suggested and, under CT guidance, a biopsy of the pancreatic mass was performed using 22-gauge Chiba needles in tandem (Fig. 4). In total, three passes were made. The procedure went well and after a period of observation, the patient was discharged home. The biopsy showed normal pancreatic tissue. The patient returned to the emergency department within 24 h, complaining of abdominal pain and distention which had begun the night of the biopsy. Vital signs were stable and his abdominal examination showed only diffuse tenderness. White blood cell count was 23.5 x 109 cells/L (normal, 4.8-10.8), and amylase was 4276 U / L (normal, 60-185). He was taken to the intensive care unit where he remained stable with decreasing amylase. Seventy-two hours after admission the patient suddenly became hypotensive and had a cardiac arrest. He was unconscious after resuscitation, and he died 12 h later with progressive hypotension unresponsive to vasopressor therapy. At autopsy, the cause of death was determined to be a combination of extensive pulmonary edema and hypotension. There was severe hemorrhagic and edematous pancreatitis with extensive surrounding fat necrosis. Thorough examination of the pancreas revealed no gross or microscopic evidence of tumor.
Discussion Case Report A 73-year-old man with a history of prostatic carcinoma was evaluated at the Montreal General Hospital after transurethral Address offprint requests to: Patrice M. Bret, M.D., Department of Radiology, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4 Canada
Complications of percutaneous fine-needle biopsy of the pancreas are rare. Pancreatitis, hematocrit drop, tumor seeding of the needle tract, and postbiopsy sepsis have been reported [5, 6]. Pancreatitis is the most potentially serious complication, but its frequency is difficult to assess. The reported
68
D.P. Levin and P.M. Bret: Complication of PFNAB of the Pancreas
Fig. 1. This transaxial slice through the level of the uncinate process of the pancreas demonstrates a 3 cm, hypodense pancreatic lesion ( ~ ) surrounded by normal pancreatic parenchyma (~). Incidentally noted is a large right renal cyst (C). Fig. 2. A lobulated hypoechoic lesion ( ~ ) is identified by US in the uncinate process. The pancreatic duct is dilated (~). SMA, superior mesenteric artery, SMV, superior mesenteric vein. Fig. 3. ERCP shows marked pancreatic duct dilatation. Fig. 4. Placement of the needle tip within the lesion is confirmed by CT.
frequency of complications from all intraabdominal fine-needle biopsies range from much less than I to 3 % of biopsies, although no prospective evaluations are available [3, 7]. This case is very similar to previously reported cases of percutaneous fine-needle biopsy of the pancreas in which serious complications were en-
countered [3, 4]. In this case, the biopsy was done with a 22-gauge needle; other patients who have developed pancreatitis have been biopsied with 20or 22-gauge needles [3, 4]. At autopsy, no pancreatic lesion was found in our patient. As in other cases, a mass lesion was clearly identified by CT, US, and ERCP. Although it is possible that a small tumor may be hidden by the extensive surrounding changes of pancreatitis, it is likely that this lesion represents a pseudotumor. In other reports, these pseudotumors are described as small lesions, less than 3 cm and usually located in the uncinate process of the pancreas [3, 4]. The exact nature of these pseudolesions is unclear. However, it is possible that in our case it represented a focal area of acute edematous pancreatitis. Complications have also occurred with biopsy of small neoplasms of the pancreas which were under 3 em in size [3]. Biopsy of these lesions appears to carry a higher risk than does biopsy of larger lesions. Pancreatitis is more likely when
D.P. Levin and P.M. Bret: Complication of PFNAB of the Pancreas
normal pancreatic tissue is traversed or when there is leakage of pancreatic enzymes after puncture of the pancreatic duct or its branches [3]. Although we do not know the exact cause of acute pancreatitis, in our case the two mechanisms are either pancreatic fluid leakage, if the needle traversed the dilated pancreatic duct, or exacerbation of edematous pancreatitis by the needle. The injury from the needle is not tolerated well by normal or edematous pancreas. In larger lesions, surrounding fibrous tissue may limit the damage to adjacent normal pancreas, but this may not be the case in biopsy of smaller lesions. There is a similar experience in ERCP, where inadvertent cannulization of a normal pancreatic duct has led to fulminant pancreatitis [8]. Biopsy of pancreatic masses at surgery also carries risks of pancreatitis and other complications [9]. Death after percutaneous fine-needle biopsy, ERCP, or surgical biopsy may result either from hemorrhagic pancreatitis or from its complications [3, 8, 9]. The occurrence of serious complications after percutaneous fine-needle biopsy of the pancreas is rare [7, 8], but must be considered. In patients with lesions larger than 3 cm the risk of complications is very low and percutaneous fine-needle biopsy is a safe and cost-effective diagnostic method. For those patients with small or questionable lesions, in whom early nonsurgical diagnosis may be the most helpful, the risk of complication is higher and caution must be exercised. This risk,
69
however, must be weighed against the risk of pancreatectomy performed for a pseudolesion. References 1. Taavitsainen M, Koivuniemi A, Bondestam S, Kivisaari L, Tierala E: Ultrasonically guided fine-needle aspiration biopsy in focal pancreatic lesions. Aeta Radiol 28:541-543, 1987 2. Bret PM, Nicolet V, Labadie M: Percutaneous fine-needle aspiration biopsy of the pancreas. Diagn Cytopathol 2:221-227, 1986 3. Mueller PR, Miketic LM, Simeone JF, et al. : Severe acute pancreatitis after percutaneous biopsy of the pancreas. Am J Radiol 151:493--494, 1988 4. Evans WK, Ho CS, McLoughlin M J, Tao LC: Fatal necrotizing pancreatitis following fine-needle aspiration biopsy of the pancreas. Radiology 141 : 61-62, 1981 5. Bergenfeldt M, Genell S, Lindholm K, Ekberg O, Aspelin P: Needle-tract seeding after percutaneous fine-needle biopsy of pancreatic carcinoma. Acta Chir Scand 154: 77-79, 1988 6. Ferucci JT, Wittenberg J, Mueller PR, et al: Diagnosis of abdominal malignancy by radiologic fine-needle aspiration biopsy. Am J Radiol 134: 323-330, 1980 7. Smith EH: Is percutaneous biopsy a hazard? An update (abstract). Presented at the Annual Meeting of the Radiological Society of North America, Chicago, IL, December 1987 8. Levitt MD, Eckfeldt JH : Diagnosis of acute pancreatitis.In Go VLW, et al. (eds): The Exocrine Pancreas - Biology, Pathobiology, and Diseases. New York: Raven Press, 1986, pp 481-502 9. Cohan RH, Illescas FF, Braun SD, Newman GE, Dunnick NR: Fine needle aspiration biopsy in malignant obstructive jaundice. Gastrointest Radiol 11:145-150, 1986 Received: March 12, 1990; accepted: May 20, 1990
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc.1991
Percutaneous Fine-Needle Aspiration Biopsy of the Pancreas Resulting in Death Daniel P. Levin and Patrice M. Bret Department of Diagnostic Radiology, Montreal General Hospital, Montreal, Quebec, Canada
Abstract. Percutaneous fine-needle aspiration biopsy of the pancreas presents a slightly higher risk of complications than does biopsy of other abdominal organs, occasionally leading to death. In the case we discuss, computed tomographic (CT)-guided percutaneous fine-needle aspiration biopsy of a pseudolesion of the uncinate process resulting in hemorrhagic pancreatitis and the death of the patient within 1 week of the procedure. Key words: Pancreas, percutaneous fine-needle biopsy - Hemorrhagic pancreatitis.
Percutaneous fine-needle aspiration biopsy is increasingly used to diagnose pancreatic lesions. In the diagnosis of pancreatic carcinoma, the procedure is reported to have a sensitivity of greater than 80% with a specificity of 100% [1, 2]. The accepted indication for percutaneous biopsy is for the diagnosis of an undetermined focal pancreatic lesion. As complications of fine-needle biopsy of pancreatic lesions are very rare, the procedure is commonly done on an outpatient basis. In contrast to biopsy of other intraabdominal sites, complications of pancreatic biopsy, when they occur, may be very severe, occasionally leading to death [3, 4]. The patient we discuss died of complications associated with hemorrhagic pancreatitis after fineneedle biopsy.
prostatectomy. The assessment included computed tomography (CT) of the abdomen to determine the extent of the prostatic disease. Incidentally noted was a poorly defined 3 cm in diameter mass in the uncinate process of the pancreas. The contours of the uncinate process appeared distorted, and the mass was hypodense relative to the remainder of the pancreas (Fig. 1). Sonographic examination (US) again identified a lobulated hypoechoic solid mass of the uncinate process associated with pancreatic duct dilatation (Fig. 2). Both studies demonstrated pancreatic duct dilatation. Endoscopic retrograde pancreatography (ERCP) demonstrated marked dilatation of the pancreatic duct, without obstruction. Some irregularities in the collateral branches were suggestive, but not diagnostic, of chronic pancreatitis (Fig. 3). The diagnosis of tumor of the uncinate process was suggested and, under CT guidance, a biopsy of the pancreatic mass was performed using 22-gauge Chiba needles in tandem (Fig. 4). In total, three passes were made. The procedure went well and after a period of observation, the patient was discharged home. The biopsy showed normal pancreatic tissue. The patient returned to the emergency department within 24 h, complaining of abdominal pain and distention which had begun the night of the biopsy. Vital signs were stable and his abdominal examination showed only diffuse tenderness. White blood cell count was 23.5 x 109 cells/L (normal, 4.8-10.8), and amylase was 4276 U / L (normal, 60-185). He was taken to the intensive care unit where he remained stable with decreasing amylase. Seventy-two hours after admission the patient suddenly became hypotensive and had a cardiac arrest. He was unconscious after resuscitation, and he died 12 h later with progressive hypotension unresponsive to vasopressor therapy. At autopsy, the cause of death was determined to be a combination of extensive pulmonary edema and hypotension. There was severe hemorrhagic and edematous pancreatitis with extensive surrounding fat necrosis. Thorough examination of the pancreas revealed no gross or microscopic evidence of tumor.
Discussion Case Report A 73-year-old man with a history of prostatic carcinoma was evaluated at the Montreal General Hospital after transurethral Address offprint requests to: Patrice M. Bret, M.D., Department of Radiology, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4 Canada
Complications of percutaneous fine-needle biopsy of the pancreas are rare. Pancreatitis, hematocrit drop, tumor seeding of the needle tract, and postbiopsy sepsis have been reported [5, 6]. Pancreatitis is the most potentially serious complication, but its frequency is difficult to assess. The reported
68
D.P. Levin and P.M. Bret: Complication of PFNAB of the Pancreas
Fig. 1. This transaxial slice through the level of the uncinate process of the pancreas demonstrates a 3 cm, hypodense pancreatic lesion ( ~ ) surrounded by normal pancreatic parenchyma (~). Incidentally noted is a large right renal cyst (C). Fig. 2. A lobulated hypoechoic lesion ( ~ ) is identified by US in the uncinate process. The pancreatic duct is dilated (~). SMA, superior mesenteric artery, SMV, superior mesenteric vein. Fig. 3. ERCP shows marked pancreatic duct dilatation. Fig. 4. Placement of the needle tip within the lesion is confirmed by CT.
frequency of complications from all intraabdominal fine-needle biopsies range from much less than I to 3 % of biopsies, although no prospective evaluations are available [3, 7]. This case is very similar to previously reported cases of percutaneous fine-needle biopsy of the pancreas in which serious complications were en-
countered [3, 4]. In this case, the biopsy was done with a 22-gauge needle; other patients who have developed pancreatitis have been biopsied with 20or 22-gauge needles [3, 4]. At autopsy, no pancreatic lesion was found in our patient. As in other cases, a mass lesion was clearly identified by CT, US, and ERCP. Although it is possible that a small tumor may be hidden by the extensive surrounding changes of pancreatitis, it is likely that this lesion represents a pseudotumor. In other reports, these pseudotumors are described as small lesions, less than 3 cm and usually located in the uncinate process of the pancreas [3, 4]. The exact nature of these pseudolesions is unclear. However, it is possible that in our case it represented a focal area of acute edematous pancreatitis. Complications have also occurred with biopsy of small neoplasms of the pancreas which were under 3 em in size [3]. Biopsy of these lesions appears to carry a higher risk than does biopsy of larger lesions. Pancreatitis is more likely when
D.P. Levin and P.M. Bret: Complication of PFNAB of the Pancreas
normal pancreatic tissue is traversed or when there is leakage of pancreatic enzymes after puncture of the pancreatic duct or its branches [3]. Although we do not know the exact cause of acute pancreatitis, in our case the two mechanisms are either pancreatic fluid leakage, if the needle traversed the dilated pancreatic duct, or exacerbation of edematous pancreatitis by the needle. The injury from the needle is not tolerated well by normal or edematous pancreas. In larger lesions, surrounding fibrous tissue may limit the damage to adjacent normal pancreas, but this may not be the case in biopsy of smaller lesions. There is a similar experience in ERCP, where inadvertent cannulization of a normal pancreatic duct has led to fulminant pancreatitis [8]. Biopsy of pancreatic masses at surgery also carries risks of pancreatitis and other complications [9]. Death after percutaneous fine-needle biopsy, ERCP, or surgical biopsy may result either from hemorrhagic pancreatitis or from its complications [3, 8, 9]. The occurrence of serious complications after percutaneous fine-needle biopsy of the pancreas is rare [7, 8], but must be considered. In patients with lesions larger than 3 cm the risk of complications is very low and percutaneous fine-needle biopsy is a safe and cost-effective diagnostic method. For those patients with small or questionable lesions, in whom early nonsurgical diagnosis may be the most helpful, the risk of complication is higher and caution must be exercised. This risk,
69
however, must be weighed against the risk of pancreatectomy performed for a pseudolesion. References 1. Taavitsainen M, Koivuniemi A, Bondestam S, Kivisaari L, Tierala E: Ultrasonically guided fine-needle aspiration biopsy in focal pancreatic lesions. Aeta Radiol 28:541-543, 1987 2. Bret PM, Nicolet V, Labadie M: Percutaneous fine-needle aspiration biopsy of the pancreas. Diagn Cytopathol 2:221-227, 1986 3. Mueller PR, Miketic LM, Simeone JF, et al. : Severe acute pancreatitis after percutaneous biopsy of the pancreas. Am J Radiol 151:493--494, 1988 4. Evans WK, Ho CS, McLoughlin M J, Tao LC: Fatal necrotizing pancreatitis following fine-needle aspiration biopsy of the pancreas. Radiology 141 : 61-62, 1981 5. Bergenfeldt M, Genell S, Lindholm K, Ekberg O, Aspelin P: Needle-tract seeding after percutaneous fine-needle biopsy of pancreatic carcinoma. Acta Chir Scand 154: 77-79, 1988 6. Ferucci JT, Wittenberg J, Mueller PR, et al: Diagnosis of abdominal malignancy by radiologic fine-needle aspiration biopsy. Am J Radiol 134: 323-330, 1980 7. Smith EH: Is percutaneous biopsy a hazard? An update (abstract). Presented at the Annual Meeting of the Radiological Society of North America, Chicago, IL, December 1987 8. Levitt MD, Eckfeldt JH : Diagnosis of acute pancreatitis.In Go VLW, et al. (eds): The Exocrine Pancreas - Biology, Pathobiology, and Diseases. New York: Raven Press, 1986, pp 481-502 9. Cohan RH, Illescas FF, Braun SD, Newman GE, Dunnick NR: Fine needle aspiration biopsy in malignant obstructive jaundice. Gastrointest Radiol 11:145-150, 1986 Received: March 12, 1990; accepted: May 20, 1990
