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Transrectal Needle Biopsy of Extrarectal Masses
Transrectal Needle Biopsy of Extrarectal Masses MARKHAM J. ANDERSON, JR., M.D.
For the past 10 years my colleagues and I have been using a Vim-Silverman needle introduced through the rectal wall as a means of obtaining tissue specimens from extrarectal masses. That we have been pleased by the procedure, and with the diagnostic assistance it has afforded, is best indicated by the increasing frequency with which this method has been employed. Table 1 indicates not only the number of such examinations conducted each year, but also the striking increase in the proportion of the procedures that are done without the use of anesthesia. The overwhelming majority of these procedures have been performed to identify a prostatic lesion. Two previous papers from this institution have dealt with the general subject of transrectal needle biopsy2 and the case for employment of this procedure in an unanesthetized patient. 1 This paper will evaluate the usefulness of transrectal needle biopsy as it has been employed in patients with extrarectal masses thought not to be prostatic. In dealing with a tumor, a tissue diagnosis is extremely valuable to both physician and patient. The first and most important question that may be answered by examination of a sample of tissue is whether the tumor is malignant. Knowledge of the histologic nature of a tumor provides essential guidance in planning the therapeutic approach. A benign diagnosis provides the assurance that at most very conservative removal is necessary. A malignant histologic report signals the necessity of planning an extensive surgical procedure for most primary neoplasms, or serves as a guide for deciding whether to employ irradiation or chemotherapy for metastatic growths. Even when a neoplasm is found to be malignant and inoperable, the physician's opportunity to provide spiritual or psychological support to the patient is increased by the fact that the diagnosis has been proved. In this situation one can discuss the problem and offer counsel in the light of certainty rather than probability. Patients express their appreciation for an established diagnosis when they say, "At least we know what we are dealing with." Surgical Clinics of North America- Vol. 47, No.4, August, 1967
989
990
MARKHAM
Table 1.
J.
ANDERSON
Number of Transrectal Needle Biopsies Performed YEAR
WITH ANESTHESIA
WITHOUT ANESTHESIA
1956 1957 1958 1959 1960 1961 1962 1963 1964 1965
7 32 32 39 74 100 94 40 32 36
29 32 38 87 144 155 147 236 297
TOTAL
7 61 64
77 161 244 249 187 268 333
OCCASIONS FOR AND RESULTS OF BIOPSY Experience in our section has demonstrated that in the case of extrarectal tumors a tissue diagnosis can usually be obtained by means of transrectal needle biopsy. Furthermore, it is our continuing experience that this procedure is remarkably free of significant complications. This contention is supported by the records of 48 patients in whom 52 transrectal needle biopsies were performed to investigate the nature of extrarectal masses which were thought not to be prostatic in origin. The reasons for these biopsies fell nicely into the following four groups: (1) presence of a rectal shelf, (2) a question of local extrarectal recurrence after resection of a malignant lesion of the left colon or rectum, (3) an extrarectal mass in a patient who had had a primary malignant lesion in some organ other than the bowel, and (4) miscellaneous extrarectal masses concerning which the diagnosis was uncertain. In reviewing the records of our 48 patients we made notes concerning the following pertinent items: pre-biopsy impression of masses, description of the biopsy procedure, pathologists' diagnoses, treatment and disposition of patients, follow-up information gained from visits or letters. We have concerned ourselves with how often treatment and disposition of these patients were - or in some cases could have been - significantly altered by transrectal biopsy findings. While reviewing the follow-up data we have watched for any evidence of significant complications. The findings are tabulated in the four groups mentioned above. In group 1 (cases distinguished by presence of rectal shelf), 22 procedures were performed upon 20 patients. The histologic diagnosis appears to have been correct in 16 instances. In three, subsequent events showed that a benign histologic diagnosis had been incorrect. Repetition of the procedure in one of these revealed a malignant process; and one may presume that repetition might have given a correct result in the other two, but this was achieved by laparotomy instead. In the three remaining cases of group 1 the specimens obtained were inadequate to permit diagnosis. The pathologist reported a suggestion or suspicion of malignancy in each, and requested more tissue. Subsequent laparotomy or excision biopsy substantiated the presence of malignant dis-
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
991
ease in all three. Presumably, again, repetition of the needle biopsy could have established a correct diagnosis. Group 2 (possible local recurrence after surgery for carcinoma of the left colon or rectum) consisted of 12 procedures performed upon 10 patients. The diagnosis appears to have been correct eight times. It is interesting to note that two of these biopsies resulted in benign diagnoses (both in the same patient) and that follow-up of the patient for another 5 years indicated that the reassurance provided by needle biopsy in this case was well founded. Within this group there were four false negatives - benign diagnoses later disproved. In one of these cases transanal excision of a nodule from the rectal wall revealed the correct diagnosis, so there was no reason to repeat the needle biopsy. In another, prompt laparotomy revealed that the tissue in question was malignant. In the third case, when the patient was seen 5 months after transrectal needle biopsy, positive tissue was obtained from the rectal wall by the ordinary biopsy technique. Presumably in both of these cases repeated needle biopsy could have provided the correct diagnosis promptly and obviated resort to laparotomy. In the fourth false negative instance in this group, the needle biopsy was repeated successfully 1 day after the failure. In group 3 (extrarectal masses after malignant disease had been treated in other regions of the body), eight procedures were performed in eight patients; and six resulted in correct diagnoses, all malignant. The other two were false negatives. In one of these the transrectal needle biopsy was followed by needle biopsy of the liver, and whereas the transrectal biopsy disclosed only benign tissue, the liver was found to contain small-cell carcinoma, grade 4, apparently from the lung; and therefore we must assume that the extrarectal infiltration was malignant. Because the extrarectal nodule was described as 2 cm in diameter, movable, and difficult to immobilize for biopsy, perhaps transrectal needle biopsy was impractical in this case. In the other failure in this group, the diagnosis of transitional-cell epithelioma of the bladder was established by cystoscopic examination, making repeated needle biopsy unnecessary. However, the extrarectal mass was large enough so that positive tissue should have been available had another attempt been made. Group 4 (miscellaneous puzzling extrarectal masses) included 10 biopsies in 10 patients. In this group the tissue diagnoses were thought to be correct in each case. The histologic study revealed malignancy in seven specimens and a benign condition in three. The benign diagnoses were leiomyoma of the rectovaginal septum, adenomyosis, and inflammatory granulation tissue. The leiomyoma was removed conservatively. Periodic checking of the adenomyoma over a period of 6 years substantiated the correctness of that diagnosis. The patient in whom granulation tissue was reported was soon found to have pelvic actinomycosis, which ultimately produced fistulization. The above facts regarding the accuracy of the biopsy diagnoses are summarized in Table 2. Overall, this method obtained diagnostic tissue in 77% of attempts.
992
MARKHAM
Table 2. GROUP
PTS
BIOPSIES
RIGHT DIAGNOSIS
FALSE NEGATIVE
TOTAL
10
10
10
3 4 2 0
48
52
40
9
20 10 8
ANDERSON
Summary of Results of Transrectal Needle Biopsy
No. 1 2 3 4
J.
22 12 8
16 8 6
SPECIMENS INADEQUATE
Apparently Correctable
No.
Apparently Correctable
3 (1 was) 3t (1 was) It 0 7
3 0 0 0 3
3* 0 0 0 3
*Pathologist asked for more tissue, which repeated needle biopsy could have supplied; but laparotomy and excision biopsy were employed. tOne locally excised, so repeated biopsy unnecessary. tMalignancy found by liver biopsy, so not sure whether extrarectal mass was malignant.
CLINICAL SIGNIFICANCE OF FINDINGS Let us now consider what actual therapeutic guidance was afforded by the tissue diagnoses in this series. There seem to have been at least seven definable ways in which they were of aid: (1) a benign condition was demonstrated, so that little or no surgery resulted; (2) inflammation was suggested, thus leading to the diagnosis of a specific inflammatory disease for which there was specific treatment; (3) malignancy was unexpectedly found to be prostatic in origin, so that correct treatment with diethylstilbestrol (Stilbestrol) and orchiectomy was undertaken; (4) identification of the type of malignancy enabled the physician to state that use of irradiation or chemotherapy was not advisable; (5) the type of malignancy found led to the recommendation of a trial of irradiation or chemotherapy; (6) malignancy was identified so that diagnostic laparotomy was prevented (no indication was given in these cases regarding the probable usefulness of irradiation or chemotherapy, which is why they are separated from 4 and 5 above); and finally (7), in one case the discovery of a local recurrence adjacent to the rectum precipitated a prompt abdominoperineal resection. The numbers of successful procedures and the number of patients who fall into these categories of usefulness are presented in Table 3, as subdivided into the original four groups.
COMPLICATIONS Our experience with transrectal needle biopsy of masses that were not prostatic has shown that there are almost no significant complications related directly to the procedure. When the prostate is involved, one must warn the patient of the possibility of transient hematuria. In nearly all cases we make a practice of prescribing an antibacterial drug to be taken prophylactically for 5 days following biopsy. Such medication seems most important with prostatic biopsy, which may be followed by acute prostatitis. The bleeding that occasionally occurs at the puncture site almost always responds promptly to direct pressure. In one instance
993
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
Table 3. Therapeutic Helpfulness of Correct Diagnoses From Transrectal Needle Biopsy GROUP USEFUL RESULTS
PTS
1
BIOP.
GROUP
2
PTS
BIOP.
1
2
GROUP PTS
3
BIOP.
GROUP PTS
4
BIOP.
TOTALS PTS
BIOP.
1. Benignity
established 2. Inflammation indicated 3. Prostatic origin of malignancy identified 4. Irradiation or chemotherapy contraindicated 5. Irradiation or chemotherapy indicated 6. Laparotomy obviated 7. Abdominoperineal resection indicated TOTALS
2
3
1
1 4
4
6
6
2
2
15
16
1
2
2
5
7
1
1
2
2
4
4
5
5
3
17
17
1
5
5
10
1 38
1 40
1 5
1 7
5
1 8
3
3
2
2
6
6
3
10
we found it necessary to place a stick tie on an arterial bleeder, but this was accomplished transanoscopically in the office. Such bleeding may be minimized by introducing the needle at a point as high as practical above the hermorrhoidal zone.
TECHNIQUE The technique of transrectal needle biopsy is rather easily learned. We have found the Franklin modification of the Vim-Silverman needle to be ideal for the procedure. In Figure 1 the three parts of the needle are shown, and in the enlarged view of the tip the most important feature
~~~~~~
-
wt4
~~~~~~==~~~~.
,~
I
Figure 1. Franklin modification of Vim-Silverman needle. Above, Hollow outer needle or sheath. Middle, Obturator for use during insertion of outer needle. Below, Divided inner needle for trapping core of tissue.
994
Figure 2. canal.
MARKHAM
J.
ANDERSON
Method of holding sheath with obturator for introduction through anal
of this particular needle is demonstrated. The fact that the tips of both sides of the divided needle have been filled seems to account for the consistency with which one can obtain a good core of tissue with this instrument. As one prepares to perform transrectal needle biopsy, it seems to help the patient if the physician explains the procedure to him in a confident manner. Reasonably stable patients tolerate the procedure nicely if they realize that although they will have some discomfort, almost surely it amounts to no more than the sting of a bee. For most patients the discomfort is much less than that of a bee sting and for some the process is actually painless. After having explained the procedure to the patient, the physician next performs a careful digital examination of the lesion in question. Then the needle, with the obturator in place, is palmed along the left index finger as shown in Figure 2, so that it may be carried into the rectum without causing discomfort or trauma to the patient. The needle tip is led directly to the exact place from which one needs a tissue specimen (Fig. 3), and as the finger palpates the lesion the needle is pushed firmly through the rectal wall and barely into the abnormal tissue. Now the obturator is removed and replaced by the divided inner needle. Continuing to palpate the extrarectal mass as the inner needle is advanced into it, one can visualize mentally the relative positions of the needle and the mass, and therefore can advance the needle in the proper direction while holding it in the most advantageous plane (Fig. 4). During the advancement of the inner needle into the abnormal tissue, the apparatus is handled much as a syringe (Fig. 2), by stabilizing the flanged head of the outer needle between the tips of the right forefinger and middle finger and advancing the inner needle by pressing on its broad head with the right thumb. The inner needle should be ad-
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
995
vanced as far as possible beyond the tip of the outer needle, usually until its head is seated against the head of the outer needle, except that such extreme depth may not be necessary or desirable if one is dealing with a small nodule or is concerned about penetrating the peritoneal cavity. After the inner needle has been inserted to the proper depth, the forefinger is withdrawn from the rectum.
Figure 3. Sheath with obturator, placed to puncture rectal wall and reach tumor.
Figure 4. Inner split needle (replacing obturator) advanced into tumor, obtaining core of tissue.
996
MARKHAM
J.
ANDERSON
Figure 5. Outer sheath advanced over split needle nearly to its tips, forcing split needle to close and thus trapping core of tissue.
Now the right hand, steadied against the patient's buttock, holds the inner needle perfectly still while the left hand forces the outer needle forward to cover it, thus forcing its tips together (Fig. 5). At times rotation of the outer needle in a to-and-fro manner is helpful in accomplishing this maneuver. Sometimes it is impossible to cover the inner needle completely with the outer needle unless one draws the inner needle back slightly into the outer needle. However, when this compromise is necessary one should be certain that the tips of the inner needle are entirely covered by the outer needle before the tip of the outer needle has been extracted from the extrarectal mass. Then when the entire needle has been removed from the rectum the inner needle is withdrawn from the outer needle, its two halves separated, and the core of tissue removed. The tissue specimen may be placed directly in formaldehyde for fixation, or if frozen sections are to be made the tissue should be deposited in gauze soaked with normal saline solution. The puncture site should then be inspected for bleeding.
SUMMARY AND CONCLUSIONS Performance of transrectal needle biopsy of extrarectal masses thought not to have prostatic origins provided correct diagnoses in 40 (77%) of 52 instances; and presumably repetition of the procedure would have afforded correct diagnoses in 10 more. The successful biopsies gave significant therapeutic guidance in all cases. No important complications were experienced. The technique of the procedure, as described, is not difficult to learn. My colleagues and I believe that when a tumor is present a tissue diagnosis is therapeutically and psychologically profitable to both the
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
997
physician and to the patient. In the case of extrarectal masses, many of which are manifestations of metastatic malignancy, it is desirable to procure a tissue specimen with the least possible risk, expense, and disturbance to the patient. Transrectal needle biopsy seems to be the method of choice under these circumstances. It appears that the rate of success in our series could be increased if the method were employed more aggressively-that is, if biopsy were repeated after apparent failure and before resorting to diagnostic laparotomy.
REFERENCES 1. Anderson, M. J., Jr.: Transrectal needle biopsy as an office procedure. Dis Colon Rectum 7:23-29 (Jan.-Feb.) 1964. 2. Emmett, J. L., Barber. K. W., Jr., and Jackman, R. J.: Transrectal biopsy to detect prostatic carcinoma: A review and report of 203 cases. Trans Amer Ass Genitourin Surg 53:85-99, 1961.
For the past 10 years my colleagues and I have been using a Vim-Silverman needle introduced through the rectal wall as a means of obtaining tissue specimens from extrarectal masses. That we have been pleased by the procedure, and with the diagnostic assistance it has afforded, is best indicated by the increasing frequency with which this method has been employed. Table 1 indicates not only the number of such examinations conducted each year, but also the striking increase in the proportion of the procedures that are done without the use of anesthesia. The overwhelming majority of these procedures have been performed to identify a prostatic lesion. Two previous papers from this institution have dealt with the general subject of transrectal needle biopsy2 and the case for employment of this procedure in an unanesthetized patient. 1 This paper will evaluate the usefulness of transrectal needle biopsy as it has been employed in patients with extrarectal masses thought not to be prostatic. In dealing with a tumor, a tissue diagnosis is extremely valuable to both physician and patient. The first and most important question that may be answered by examination of a sample of tissue is whether the tumor is malignant. Knowledge of the histologic nature of a tumor provides essential guidance in planning the therapeutic approach. A benign diagnosis provides the assurance that at most very conservative removal is necessary. A malignant histologic report signals the necessity of planning an extensive surgical procedure for most primary neoplasms, or serves as a guide for deciding whether to employ irradiation or chemotherapy for metastatic growths. Even when a neoplasm is found to be malignant and inoperable, the physician's opportunity to provide spiritual or psychological support to the patient is increased by the fact that the diagnosis has been proved. In this situation one can discuss the problem and offer counsel in the light of certainty rather than probability. Patients express their appreciation for an established diagnosis when they say, "At least we know what we are dealing with." Surgical Clinics of North America- Vol. 47, No.4, August, 1967
989
990
MARKHAM
Table 1.
J.
ANDERSON
Number of Transrectal Needle Biopsies Performed YEAR
WITH ANESTHESIA
WITHOUT ANESTHESIA
1956 1957 1958 1959 1960 1961 1962 1963 1964 1965
7 32 32 39 74 100 94 40 32 36
29 32 38 87 144 155 147 236 297
TOTAL
7 61 64
77 161 244 249 187 268 333
OCCASIONS FOR AND RESULTS OF BIOPSY Experience in our section has demonstrated that in the case of extrarectal tumors a tissue diagnosis can usually be obtained by means of transrectal needle biopsy. Furthermore, it is our continuing experience that this procedure is remarkably free of significant complications. This contention is supported by the records of 48 patients in whom 52 transrectal needle biopsies were performed to investigate the nature of extrarectal masses which were thought not to be prostatic in origin. The reasons for these biopsies fell nicely into the following four groups: (1) presence of a rectal shelf, (2) a question of local extrarectal recurrence after resection of a malignant lesion of the left colon or rectum, (3) an extrarectal mass in a patient who had had a primary malignant lesion in some organ other than the bowel, and (4) miscellaneous extrarectal masses concerning which the diagnosis was uncertain. In reviewing the records of our 48 patients we made notes concerning the following pertinent items: pre-biopsy impression of masses, description of the biopsy procedure, pathologists' diagnoses, treatment and disposition of patients, follow-up information gained from visits or letters. We have concerned ourselves with how often treatment and disposition of these patients were - or in some cases could have been - significantly altered by transrectal biopsy findings. While reviewing the follow-up data we have watched for any evidence of significant complications. The findings are tabulated in the four groups mentioned above. In group 1 (cases distinguished by presence of rectal shelf), 22 procedures were performed upon 20 patients. The histologic diagnosis appears to have been correct in 16 instances. In three, subsequent events showed that a benign histologic diagnosis had been incorrect. Repetition of the procedure in one of these revealed a malignant process; and one may presume that repetition might have given a correct result in the other two, but this was achieved by laparotomy instead. In the three remaining cases of group 1 the specimens obtained were inadequate to permit diagnosis. The pathologist reported a suggestion or suspicion of malignancy in each, and requested more tissue. Subsequent laparotomy or excision biopsy substantiated the presence of malignant dis-
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
991
ease in all three. Presumably, again, repetition of the needle biopsy could have established a correct diagnosis. Group 2 (possible local recurrence after surgery for carcinoma of the left colon or rectum) consisted of 12 procedures performed upon 10 patients. The diagnosis appears to have been correct eight times. It is interesting to note that two of these biopsies resulted in benign diagnoses (both in the same patient) and that follow-up of the patient for another 5 years indicated that the reassurance provided by needle biopsy in this case was well founded. Within this group there were four false negatives - benign diagnoses later disproved. In one of these cases transanal excision of a nodule from the rectal wall revealed the correct diagnosis, so there was no reason to repeat the needle biopsy. In another, prompt laparotomy revealed that the tissue in question was malignant. In the third case, when the patient was seen 5 months after transrectal needle biopsy, positive tissue was obtained from the rectal wall by the ordinary biopsy technique. Presumably in both of these cases repeated needle biopsy could have provided the correct diagnosis promptly and obviated resort to laparotomy. In the fourth false negative instance in this group, the needle biopsy was repeated successfully 1 day after the failure. In group 3 (extrarectal masses after malignant disease had been treated in other regions of the body), eight procedures were performed in eight patients; and six resulted in correct diagnoses, all malignant. The other two were false negatives. In one of these the transrectal needle biopsy was followed by needle biopsy of the liver, and whereas the transrectal biopsy disclosed only benign tissue, the liver was found to contain small-cell carcinoma, grade 4, apparently from the lung; and therefore we must assume that the extrarectal infiltration was malignant. Because the extrarectal nodule was described as 2 cm in diameter, movable, and difficult to immobilize for biopsy, perhaps transrectal needle biopsy was impractical in this case. In the other failure in this group, the diagnosis of transitional-cell epithelioma of the bladder was established by cystoscopic examination, making repeated needle biopsy unnecessary. However, the extrarectal mass was large enough so that positive tissue should have been available had another attempt been made. Group 4 (miscellaneous puzzling extrarectal masses) included 10 biopsies in 10 patients. In this group the tissue diagnoses were thought to be correct in each case. The histologic study revealed malignancy in seven specimens and a benign condition in three. The benign diagnoses were leiomyoma of the rectovaginal septum, adenomyosis, and inflammatory granulation tissue. The leiomyoma was removed conservatively. Periodic checking of the adenomyoma over a period of 6 years substantiated the correctness of that diagnosis. The patient in whom granulation tissue was reported was soon found to have pelvic actinomycosis, which ultimately produced fistulization. The above facts regarding the accuracy of the biopsy diagnoses are summarized in Table 2. Overall, this method obtained diagnostic tissue in 77% of attempts.
992
MARKHAM
Table 2. GROUP
PTS
BIOPSIES
RIGHT DIAGNOSIS
FALSE NEGATIVE
TOTAL
10
10
10
3 4 2 0
48
52
40
9
20 10 8
ANDERSON
Summary of Results of Transrectal Needle Biopsy
No. 1 2 3 4
J.
22 12 8
16 8 6
SPECIMENS INADEQUATE
Apparently Correctable
No.
Apparently Correctable
3 (1 was) 3t (1 was) It 0 7
3 0 0 0 3
3* 0 0 0 3
*Pathologist asked for more tissue, which repeated needle biopsy could have supplied; but laparotomy and excision biopsy were employed. tOne locally excised, so repeated biopsy unnecessary. tMalignancy found by liver biopsy, so not sure whether extrarectal mass was malignant.
CLINICAL SIGNIFICANCE OF FINDINGS Let us now consider what actual therapeutic guidance was afforded by the tissue diagnoses in this series. There seem to have been at least seven definable ways in which they were of aid: (1) a benign condition was demonstrated, so that little or no surgery resulted; (2) inflammation was suggested, thus leading to the diagnosis of a specific inflammatory disease for which there was specific treatment; (3) malignancy was unexpectedly found to be prostatic in origin, so that correct treatment with diethylstilbestrol (Stilbestrol) and orchiectomy was undertaken; (4) identification of the type of malignancy enabled the physician to state that use of irradiation or chemotherapy was not advisable; (5) the type of malignancy found led to the recommendation of a trial of irradiation or chemotherapy; (6) malignancy was identified so that diagnostic laparotomy was prevented (no indication was given in these cases regarding the probable usefulness of irradiation or chemotherapy, which is why they are separated from 4 and 5 above); and finally (7), in one case the discovery of a local recurrence adjacent to the rectum precipitated a prompt abdominoperineal resection. The numbers of successful procedures and the number of patients who fall into these categories of usefulness are presented in Table 3, as subdivided into the original four groups.
COMPLICATIONS Our experience with transrectal needle biopsy of masses that were not prostatic has shown that there are almost no significant complications related directly to the procedure. When the prostate is involved, one must warn the patient of the possibility of transient hematuria. In nearly all cases we make a practice of prescribing an antibacterial drug to be taken prophylactically for 5 days following biopsy. Such medication seems most important with prostatic biopsy, which may be followed by acute prostatitis. The bleeding that occasionally occurs at the puncture site almost always responds promptly to direct pressure. In one instance
993
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
Table 3. Therapeutic Helpfulness of Correct Diagnoses From Transrectal Needle Biopsy GROUP USEFUL RESULTS
PTS
1
BIOP.
GROUP
2
PTS
BIOP.
1
2
GROUP PTS
3
BIOP.
GROUP PTS
4
BIOP.
TOTALS PTS
BIOP.
1. Benignity
established 2. Inflammation indicated 3. Prostatic origin of malignancy identified 4. Irradiation or chemotherapy contraindicated 5. Irradiation or chemotherapy indicated 6. Laparotomy obviated 7. Abdominoperineal resection indicated TOTALS
2
3
1
1 4
4
6
6
2
2
15
16
1
2
2
5
7
1
1
2
2
4
4
5
5
3
17
17
1
5
5
10
1 38
1 40
1 5
1 7
5
1 8
3
3
2
2
6
6
3
10
we found it necessary to place a stick tie on an arterial bleeder, but this was accomplished transanoscopically in the office. Such bleeding may be minimized by introducing the needle at a point as high as practical above the hermorrhoidal zone.
TECHNIQUE The technique of transrectal needle biopsy is rather easily learned. We have found the Franklin modification of the Vim-Silverman needle to be ideal for the procedure. In Figure 1 the three parts of the needle are shown, and in the enlarged view of the tip the most important feature
~~~~~~
-
wt4
~~~~~~==~~~~.
,~
I
Figure 1. Franklin modification of Vim-Silverman needle. Above, Hollow outer needle or sheath. Middle, Obturator for use during insertion of outer needle. Below, Divided inner needle for trapping core of tissue.
994
Figure 2. canal.
MARKHAM
J.
ANDERSON
Method of holding sheath with obturator for introduction through anal
of this particular needle is demonstrated. The fact that the tips of both sides of the divided needle have been filled seems to account for the consistency with which one can obtain a good core of tissue with this instrument. As one prepares to perform transrectal needle biopsy, it seems to help the patient if the physician explains the procedure to him in a confident manner. Reasonably stable patients tolerate the procedure nicely if they realize that although they will have some discomfort, almost surely it amounts to no more than the sting of a bee. For most patients the discomfort is much less than that of a bee sting and for some the process is actually painless. After having explained the procedure to the patient, the physician next performs a careful digital examination of the lesion in question. Then the needle, with the obturator in place, is palmed along the left index finger as shown in Figure 2, so that it may be carried into the rectum without causing discomfort or trauma to the patient. The needle tip is led directly to the exact place from which one needs a tissue specimen (Fig. 3), and as the finger palpates the lesion the needle is pushed firmly through the rectal wall and barely into the abnormal tissue. Now the obturator is removed and replaced by the divided inner needle. Continuing to palpate the extrarectal mass as the inner needle is advanced into it, one can visualize mentally the relative positions of the needle and the mass, and therefore can advance the needle in the proper direction while holding it in the most advantageous plane (Fig. 4). During the advancement of the inner needle into the abnormal tissue, the apparatus is handled much as a syringe (Fig. 2), by stabilizing the flanged head of the outer needle between the tips of the right forefinger and middle finger and advancing the inner needle by pressing on its broad head with the right thumb. The inner needle should be ad-
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
995
vanced as far as possible beyond the tip of the outer needle, usually until its head is seated against the head of the outer needle, except that such extreme depth may not be necessary or desirable if one is dealing with a small nodule or is concerned about penetrating the peritoneal cavity. After the inner needle has been inserted to the proper depth, the forefinger is withdrawn from the rectum.
Figure 3. Sheath with obturator, placed to puncture rectal wall and reach tumor.
Figure 4. Inner split needle (replacing obturator) advanced into tumor, obtaining core of tissue.
996
MARKHAM
J.
ANDERSON
Figure 5. Outer sheath advanced over split needle nearly to its tips, forcing split needle to close and thus trapping core of tissue.
Now the right hand, steadied against the patient's buttock, holds the inner needle perfectly still while the left hand forces the outer needle forward to cover it, thus forcing its tips together (Fig. 5). At times rotation of the outer needle in a to-and-fro manner is helpful in accomplishing this maneuver. Sometimes it is impossible to cover the inner needle completely with the outer needle unless one draws the inner needle back slightly into the outer needle. However, when this compromise is necessary one should be certain that the tips of the inner needle are entirely covered by the outer needle before the tip of the outer needle has been extracted from the extrarectal mass. Then when the entire needle has been removed from the rectum the inner needle is withdrawn from the outer needle, its two halves separated, and the core of tissue removed. The tissue specimen may be placed directly in formaldehyde for fixation, or if frozen sections are to be made the tissue should be deposited in gauze soaked with normal saline solution. The puncture site should then be inspected for bleeding.
SUMMARY AND CONCLUSIONS Performance of transrectal needle biopsy of extrarectal masses thought not to have prostatic origins provided correct diagnoses in 40 (77%) of 52 instances; and presumably repetition of the procedure would have afforded correct diagnoses in 10 more. The successful biopsies gave significant therapeutic guidance in all cases. No important complications were experienced. The technique of the procedure, as described, is not difficult to learn. My colleagues and I believe that when a tumor is present a tissue diagnosis is therapeutically and psychologically profitable to both the
TRANSRECTAL NEEDLE BIOPSY OF EXTRARECTAL MASSES
997
physician and to the patient. In the case of extrarectal masses, many of which are manifestations of metastatic malignancy, it is desirable to procure a tissue specimen with the least possible risk, expense, and disturbance to the patient. Transrectal needle biopsy seems to be the method of choice under these circumstances. It appears that the rate of success in our series could be increased if the method were employed more aggressively-that is, if biopsy were repeated after apparent failure and before resorting to diagnostic laparotomy.
REFERENCES 1. Anderson, M. J., Jr.: Transrectal needle biopsy as an office procedure. Dis Colon Rectum 7:23-29 (Jan.-Feb.) 1964. 2. Emmett, J. L., Barber. K. W., Jr., and Jackman, R. J.: Transrectal biopsy to detect prostatic carcinoma: A review and report of 203 cases. Trans Amer Ass Genitourin Surg 53:85-99, 1961.