Ultrasound-Guided Biopsies of Neuroendocrine Metastases

Acta Radiologica ISSN: 0284-1851 (Print) 1600-0455 (Online) Journal homepage: https://www.tandfonline.com/loi/iard20 Ultrasound-Guided Biopsies of Neuroendocrine Metastases Comparison of 0.9 and 1.2 mm biopsy-gun needle biopsies Anders Elvin, E. Wilander, K. Öberg, B. Eriksson & P. G. Lindgren To cite this article: Anders Elvin, E. Wilander, K. Öberg, B. Eriksson & P. G. Lindgren (1993) Ultrasound-Guided Biopsies of Neuroendocrine Metastases, Acta Radiologica, 34:5, 474-477 To link to this article: https://doi.org/10.3109/02841859309175386 Published online: 07 Jan 2010. Submit your article to this journal Article views: 29 View related articles Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iard20 zyx zy zyxwvutsrqpon zyxwvutsrqponm zyx zyx Aeta Radiologica 34 (1993) Fase. 5 Printed in Denmark . All rights reserved Copyright 0Acta Radiologica 1993 ACTA R A D I O L O G I C A ISSN 0248-1851 FROM THE DEPARTMENTS OF DIAGNOSTIC RADIOLOGY, INTERNAL MEDICINE AND PATHOLOGY, AKADEMISKA SJUKHUSET, UPPSALA, SWEDEN. ULTRASOUND-GUIDED BIOPSIES OF NEUROENDOCRINE METASTASES Comparison of 0.9 and 1.2 mm biopsy-gun needle biopsies A. ELVIN,E. WILANDER, K. BERG, B. ERIKSSON and P. G. LINDGREN Abstract zyxwvuts zyxwv Twenty-five patients with known neuroendocrine tumour disease were biopsied with 1.2 mm and 0.9 mm biopsy-gun needles to evaluate the respective diagnostic accuracy of the 2 needle sizes. The influence of treatment-related fibrosis on the histopathological diagnosis was also evaluated. The overall diagnostic accuracy with the 0.9 mm needle was 69% as compared to 92% with the 1.2 mm needle. This difference, however, seems more related to needle guiding difficulties with the 0.9 mm needle than to insufficient tissue yield. When the tumour was hit with both the 0.9 and the 1.2 mm needle the tissue yield was inferior with the 0.9 mm needle in only one of 16 cases. The increased amount of fibrous tissue due to interferon treatment did not seem to negatively influence the diagnostic accuracy. Key words: Endocrine glands, metastases; liver, biopsy; -, ultrasound; ultrasound equipment. Ultrasound-guided biopsy-gun biopsy is a well established method. The technique has been used for a decade and has been performed over 8000 times at our department. Initially, a 2.0 mm needle was used but for the last 6 years a 1.2 mm needle has been used in over 6000 biopsies. A core of tissue is obtained which allows for a histological diagnosis. A sufficient amount of material is also obtained to allow for multiple stainings to be performed (1, 9, 12). This is important, especially in the diagnosis of neuroendocrine tumours where at least 3 different stainings have to be performed to ensure an accurate diagnosis (21). Most of our patients are biopsied due to known or suspected malignancy and are therefore hospitalised for different examinations and treatments. The biopsies are thus performed as in-patient procedures. One advantage of this is that it allows for a close observation of the patients for 474 any potential biopsy-related complication. There are, on the other hand, a large group of patients where a transition to an out-patient procedure would be practical and economical. Fine needle aspiration biopsy (FNAB, under 1.0 mm needle diameter) is an established method with a low complication rate (14). The low risks in performing FNAB as an out-patient procedure is also well documented (18, 19). On the other hand the amount of material obtained with FNAB is sometimes insufficient to allow for a consistently high diagnostic accuracy rate (6, 16). The complication rate with the 1.2 mm biopsy-gun seems comparable with those published for FNAB (1, 9, 18, 19). However, there are some complications that occur so rarely that it has not yet been possible to make a valid comparison of complication rates with the 2 needle sizes. If the 0.9 mm biopsy-gun needle biopsy could prove to have the same diagnostic accuracy as the 1.2 mm needle (1) it would make a transition to an out-patient practice more confident. It has been shown that during interferon (INF) treatment of neuroendocrine metastases the percentage of fibrosis increases with successful treatment (3, 8). This relative decrease in tumour cell tissue could theoretically have a negative impact on the diagnostic accuracy of needle biopsy. This difference in tumour tissue yield is potentially even greater when a smaller needle size is used. To evaluate the diagnostic accuracy of the 0.9 mm needle the performance of the 0.9 and 1.2 mm needles in a group Accepted for publication 17 February 1993. ULTRASOUND-GUIDED BIOPSIES OF NEUROENDOCRINE METASTASES a zyxw 475 b zyxw zyxw zyxwvutsrqp zy Figure. Biopsy-gun biopsy from liver with 1.2-mm (a) and 0.9-mm (b) needle. It is not possible to distinguish any difference in quality between the 2 samples. of patients with neuroendocrine tumours was prospectively compared. Table 1 True-positive, false-positive and negative diagnoses Needle size Material and Methods Twenty-five patients were examined, 11 men (one biopsied twice) and 14 women ranging from 30 to 78 years of age. Twenty-two patients had carcinoid metastases and one had endocrine pancreatic tumour metastases to the liver. One patient had been operated for an ilia1 carcinoid and had a suspected recurrence in the left kidney and one had carcinoid metastases to mesenteric lymph nodes. The diagnoses were histologically verified by operation and/or biopsy. The patients were examined with ultrasound (Acuson Mountain View, CA, 3.5 and 5 MHz transducers) previous to the biopsy to evaluate the size of the tumours and determine whether it was feasible to do a biopsy in an appropriate pathway. If multiple lesions were present, a lesion in the right lobe of the liver was usually chosen, using an intercostal route. The biopsies were performed with a biopsy-gun (Biopty, Bard Urological, Covington, GA) according to the (12). One biopsy each was method described by LINDGREN taken with the 1.2 and 0.9 mm needles (Radimedical, Uppsala, 160 mm in length with a 17-mm sampling notch) from the periphery of the tumours to ensure that active tumour tissue would be obtained. An additional 2 biopsies were taken with the 1.2 mm needle for other diagnostic purposes; the 1.2 mm biopsies were performed first. All biopsies were performed by the same radiologist (A. E.). The samples were divided and fixed in 10% buffered formalin and in Bouin’s fluid, dehydrated and embedded in paraffin wax. Sections about 4 pm thick were cut and stained with haematoxylin-eosin, van Gieson’s stain, the argentafin reaction of Masson and the argyrophil reactions of Grimelius (21). The diagnostic accuracy of the respective needle sizes was evaluated by the pathologist (E. W.). The quantitative investigation was made without knowledge of clinical and laboratory data. A light microscope was used with 16x magnification using an ocular with a squared 21 x 21 matrix grid. For each biopsy the amount of tumour 1.2 mm True-positive True-negative False-positive False-negative Inconclusive Failed sample Total 24 (92%) 0 0 2 (8%) 0 0 26 0.9 mm 18 (69%) 0 0 4 (15%) 2 (8%) 2 (8%) 26 zyxwvutsrq tissue, connective tissue and other tissue elements at each crossing-point were registered. A tumour index was calculated by dividing the points crossing tumour tissue with the total number of points crossing tumour tissue, connective tissue and other tissue elements. The amount of connective tissue was calculated in a corresponding way. The patients were recommended bedrest for 4 hours post biopsy and stayed in the hospital overnight for observation and further investigations. Results In 24 patients comparable tissue could be obtained (Figure, Table 1). On 2 occasions the 0.9-mm needle could not be advanced into the tumour; these were reported as failed samples. In one case the whole needle bent while attempting to penetrate the intercostal muscles and in the other the inner needle could not be inserted into the fibrotic tumour itself by the biopsy-gun. On both these occasions the 1.2mm needle biopsy was diagnostic. In 2 patients with liver metastases the 0.9-mm needle showed nonrepresentative tissue which did not occur with the 1.2-mm needle. On 4 occasions the 0.9-mm needle only showed normal liver tissues whereas the 1.2-mm needle showed an endocrine tumour, i.e., the 0.9-mm needle missed the lesion; the reverse was true in 2 cases. In one case the 0.9-mm needle only 476 zyxwvutsr zyxwvutsrqp A. ELVIN ET AL. zyxwvutsrqpo zyxwvu zyxwvuts zyxwvutsrq Table 2 Diagnostic accuracy in relation to treatment, needle size and tissue composition 0.9 < 1.2 0.9 > 1.2 0.9 = 1.2 Tumour, Untreated Treated Total 6 3 9 2 - 2 6 9 15 YO Connective tissue, YO 70 (SD+13) 61 (SDk23) 30 39 provided material enough for 2 of the 3 stainings routinely performed. This means that the 1.2-mm needle was better in 9 cases, the 0.9-mm needle better in 2, and the results equal in 15 cases. In one of these last cases the material with both the 0.9-mm and 1.2-mm needles did not provide material for more than 2 of the 3 stainings routinely performed. The neuroendocrine nature of the tumour could in spite of this be established. The tumours biopsied had a mean size of 4 cm (range 0.5-12 cm). The average size of the 8 tumours that were missed with one of the needles (6 with 0.9-mm and 2 with 1.2-mm needle) was 3 cm (range 0.5-10 cm). Fourteen patients were untreated at the time of biopsy and the rest had been treated with interferon for a mean period of 21 months (median 10 months). The amount of tumour tissue and connective tissue in the biopsies from the untreated and treated groups are summarised in Table 2. No difference in diagnostic yield was observed between these 2 groups. The treated group includes the 2 patients in whom the 0.9-mm needle could not be inserted. Both needle sizes were equally accurate in diagnosing the patient with endocrine pancreatic tumour (ZollingerEllison) and the patient with a suspected recurrence of carcinoma in the left kidney which proved to be a second malignancy, hypernephroma. The biopsy procedure was well accepted by the patients and no complications were noted during the observation period. preserved tissue architecture to perform these multiple tests ( I , 13, 20). From a diagnostic point of view a large bore needle thus seems to be preferable. Against this is the concern about complications, which are definitely more frequent with needle sizes around 2.0 mm than with smaller needles, especially FNAB needles with a diameter of less than 1.0 mm (4-7, 11, 17). Even though the rate of complications for the 1.2mm needle is in the range of those published for 0.9-mm needles (2, 9, 16, 19) a switch to the smaller needle size might be advantageous if no loss in diagnostic accuracy could be achieved. Macro- and microscopically it was difficult to see the 0.3mm difference of the tissue cores from the different needles. The smaller amount of material that was obtained with the 0.9-mm needle did not negatively affect the diagnostic accuracy when the tumour was actually punctured. In only one of the 9 cases where the 0.9-mm needle performed worse than the 1.2-mm needle (Table 1) was this due to an insufficient amount of tissue material. In the other 8 cases the tumour was missed in 6 cases and in 2 the needle bent when the biopsy was attempted. The misses can be explained by the flexibility of the 0.9-mm needle. The 0.9-mm needle often deviated from the attempted biopsy tract and compensations had to be made to reach the periphery of the tumour. The 1.2-mm needle was more rigid and in only 2 cases was the tumour missed with this needle size. It would seem easy to perform a biopsy on the relatively large tumours in this series, which had a mean diameter of 4 cm. The size in itself does not seem to be the limiting factor, however, as 7 of the tumours were 1.5 cm or less in diameter and all of these were adequately punctured with the 1.2-mm needle. Five of these were also punctured with the 0.9-mm needle and 2 were missed, showing either normal liver or muscle tissue. The active tumour tissue is located in the periphery of the tumour and is often only a few mm thin border of the otherwise necrotic/fibrotic tumour (1 5). The needles were therefore aimed to hit the extreme periphery of the tumour so the risk of missing the tumour was substantial. Some of the tumours had a hypoechoic peripheral zone from where the biopsy was taken because this is believed to be an active part of the tumour (15). On some of these occasions the pathology report showed normal liver and, on some, tumour. We have not scrutinised this issue but there is some debate in the literature regarding the explanation for this hypoechoic rim (15). To overcome the disadvantage of needle flexibility, a shorter needle design of the 0.9-mm needle will make it more rigid. Since the majority of liver metastases are located superficially they would be reachable with a 100-mm-long needle. The increased amount of connective tissue due to interferon treatment did not pose a diagnostic problem. The lower tumour tissue yield with the 0.9-mm needle (Table 2) does not seem to have a great impact on the diagnostic accuracy zyxwvut Discussion The larger amount of tissue retrieved by a 1.2-mm needle has been shown to allow for a higher diagnostic accuracy rate than a 0.6-mm needle in a cancer patient population with liver metastases from breast, lung and the gastrointestinal tract (16). In a similar study by HAAGAet al. (1 1) the larger needle allows for a more specific and detailed diagnosis in over 50% of the cases. A relatively large amount of material, with preserved tissue architecture, is needed in the diagnosis of neuroendocrine tumours (21) as multiple stainings are required. In therapy monitoring, quantitative histological evaluation (3, 8) has also proven to be important and immunohistochemistry is also increasingly used (10, 13, 21). The 1.2-mm biopsy-gun needle biopsies have been shown to retrieve a sufficient amount of material with zyxwv 471 zyxwvutsr zyxw ULTRASOUND-GUIDED BIOPSIES OF NEUROENDOCRINE METASTASES when the biopsy specimen was taken from the correct site. In only one of the 16 cases where both the 0.9 and 1.2 mm needles were correct, was the 0.9-mm needle tissue yield inferior to that of the 1.2-mm needle. Conclusions. The 0.9-mm biopsy-gun needle did not have the same diagnostic accuracy rate as the 1.2-mm needle; 69Y0 and 92%, respectively. This difference was not due to an inferior tissue yield with the 0.9-mm needle but more to needle guiding difficulties. If the design of the 0.9-mm needle is changed, resulting in a reduction of the needle flexibility, it would facilitate correct steering of the needle, which would significantly increase the amount of sample obtained. With such a needle, it would be possible to perform an adequate biopsy in most of the patients in this series. This paves the way for performance of this procedure on an out-patient basis. The increase in connective tissue content in neuroendocrine tumours during interferon treatment does not seem to negatively influence the diagnostic accuracy of decreased needle size biopsies. biopsy of renal allografts. Comparison of two techniques. Radiology 174 (1990), 273. 6. CHARBONEAU J. W., READING C. C. & WELCHT. J.: CT and sonographically guided needle biopsy. Current techniques and new innovations. AJR 154 (1990). I . 7. COZENS N. J. A., MURCHISON J. T., ALLANP. L. & WINNEYR. 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