Endoscopic Aspiration Biopsy of the Pancreas

Vol. 73 , No.5

GASTROENTEROLOGY 73:1050-1052, 1977 Copyright © 1977 by the American Gastroenterological Association

Printed in U.S A.

ENDOSCOPIC ASPIRATION BIOPSY OF THE PANCREAS RYOICHI TsucHIYA, M.D., TAKEHIKO HENMI, M.D., NAoTsuau KoNDO, M.D., MrTsuHrRo AKASHI, M.D., AND NoBoRu HARADA, M.D. Second Department of Surgery, Nagasaki University School of Medicine , Nagasaki , Japan

Preoperative endoscopic aspiration biopsies were performed on 51 patients with pancreatic lesions using either a duodenal or gastric fiberscope and a newly designed biopsy needle. The accuracy of this method in the diagnosis of carcinoma of the pancreas was 84.0%. Although there were three false-negative diagnoses, there were no false-positives. No complications that could be attributed to this procedure were encountered. In recent years, fine needle aspiration biopsy for cyto- trofiberscope GF type B2 was used. After a 6-hr fast, the logical diagnosis has been utilized during laparotomy in patient receives intramuscular injections of both hyoscine bupatients with pancreatic lesions and has proved to be of tylbromide (Buscopan, C. H . Boehringer, Ingelheim, West high diagnostic value. The authors have used this Germany), 20 mg, and atropine, 0.5 mg, as a premedication 15 method since September 1969, using a 5-ml syringe and to 30 min before the procedure. In order to remove air bubbles a 21-gauge needle. They thought that a definitive diag- and mucus, 1 ml of dimethylpolysiloxane is given orally. Then nosis of carcinoma of the pancreas could be made before the pharynx is anesthesized with 5 ml of 2% viscous lidocaine (Xylocaine) given orally. During the procedure an additional surgery by passing a fine needle endoscopically into the 20 to 40 mg of hyoscine butylbromide may be required in some pancreas from the inside of the duodenal or gastric patients. With the patient in the left lateral decubitus posilumen. In 1971, the authors performed endoscopic aspi- tion, the fiberscope is passed and advanced into the stomach or ration biopsy of the pancreas using a duodenal or gastric the duodenum. The site for aspiration biopsy is where a protufiberscope and a specially designed long needle. The berance of the duodenal or gastric mucosal surface is endoscoppurpose of this study is to evaluate the diagnostic accu- ically observed. When a protuberance is not seen, the site of racy of the endoscopic aspiration biopsy for malignant biopsy should be 4 em distal to the papilla of Vater, where the lesions of both the periampullary region and the pan- head of the pancreas is located very close to the duodenal wall. The aspiration biopsy may be repeated in several sites and at creas itself. Materials A retrospective analysis of endoscopic aspiration biopsies performed at the Second Department of Surgery, Nagasaki University Hospital, from October 1971 to August 1975 was carried out. Endoscopic aspiration biopsies were performed on 51 patients with pancreatic or periampullary lesions. All but one had laparotomies and their diagnoses were confirmed by histological study of the resected specimens or incisional biopsies of the pancreas. The patient who did not undergo laparotomy died of adenocarcinoma of the pancreas, confirmed at autopsy. Twenty-nine patients were men and 22 were women; their ages ranged from 32 to 77, the average being 54.5 years old. Twenty-five patients had malignant lesions and 26 had benign lesions.

Methods To obtain biopsy specimens from the head of the pancreas or the periampullary region , transduodenal aspiration biopsy was performed using the Olympus side-viewing duodenofiberscope JF type B2 (Olympus Optical Company, Limited, Tokyo, Japan). In those cases where samples were obtained from the body and tail of the pancreas, the Olympus side-viewing gasReceived June 8, 1976. Accepted May 18, 1977. Address requests for reprints to: Ryoichi Tsuchiya, M.D. , Second Department of Surgery, Nagasaki University School of Medicine 7-1 , Sakamoto-Machi, Nagasaki City, Nagasaki, Japan. This study was supported by grants for cancer research from the Ministry of Health and Welfare, Japan.

least three or four specimens should be taken. The biopsy needle , shown in figure 1, consists of a guide tube and an inner tube which is made from a long fine Teflon tube. This is 1790 mm long with 0.46-mm internal diameter and 0.92-mm external diameter for the duodenal fiberscope, and 1542 mm long with 0.5-mm internal diameter and 1.0-mm external diameter for the gastric fiberscope. A metal needle 6 mm long, 26-gauge in the duodenal fiberscope , or 7 mm long, 23-gauge in the gastric fiberscope is attached at the distal end of the Teflon tube which is connected proximally with a specially designed syringe adaptor which has "on" and "off' positions marked. Before passing the biopsy needle through the biopsy channel, the inner tube is inserted into the guide tube and set at the off position. After endoscopic observation, the site of biopsy is selected. The inner tube is then filled with physiological saline solution using a standard 20-ml syringe containing 1 ml of saline and is connected with the adaptor of the inner tube. The biopsy needle is then passed through the biopsy channel. As soon as the tip of the instrument is recognized, the inner tube is placed at the on position. Then the metal needle is seen protruding from the tip of the guide tube . The needle is directed to the site of biopsy or to the mucous membrane rectangularly and passed into it. An en face view of the site of biopsy facilitates this maneuver. The plunger is pulled back with one hand, creating a negative pressure in the system. Before removing the needle the pressure is gently taken off by releasing the plunger. The needle is removed from the site of biopsy. The inner tube is then placed at the off position and the whole needle is drawn back from the instrument. The aspirate, usually present in the fine metal needle, is carefully ejected with 1 ml of saline from the syringe into a centrifuge cup

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ENDOSCOPIC ASPIRATION BIOPSY OF PANCREAS 3 4

5

FIG. 1. Instruments for endoscopic aspiration biopsy of the pancreas: 1542-mm long guide wire tube for gastrofiberscope (1), and 1790-mm long guide wire tube for duodenofiberscope (2) at the "off" position; 7-mm long 23-gauge metal needle for gastrofiberscope (4), and 6-mm long 26-gauge metal needle for duodenofiberscope ( 6) , attached to the tips of the Teflon inner tubes; (3) and (5) show the metal needles protruding from the guide wire tubes at the "on" position.

which contains 2 ml of 99.5% ethyl alcohol. As a result the biopsy material is fixed in 70% ethyl alcohol. The cup is centrifuged and the sediment is spread on a clean, dry microscope slide, air dried and stained using Papanicolaou's or hematoxine-eosin stain.

Results Of 10 patients who underwent transduodenal aspiration biopsy, malignant cells were cytologically identified in 7. These included 4 patients with carcinoma of the head of the pancreas and 3 with ampullary carcinoma. Suspicion of malignancy was diagnosed in 1 case of ampullary carcinoma. Cytological diagnoses were negative in the remaining 2 patients with carcinoma of the body and tail of the pancreas. Transgastric aspiration biopsy should have been done in these 2 (table 1). Transgastric aspiration biopsy was performed on 11 patients. Of them, 7 had carcinoma of the body and tail of the pancreas, 2 had carcinoma of the entire pancreas, and the remaining 2 had carcinoma of the periampullary region. Malignant cells were cytologically diagnosed in 10 of the 11. In the remaining patient with cystadenocarcinoma of the pancreas, well differentiated adenocarcinoma cells were misdiagnosed for benign atypical cells. Both transduodenal and transgastric aspiration biopsies were carried out on 4 patients. Of the 4, 1 patient with carcinoma of the entire pancreas had a positive diagnosis shown by either aspiration biopsy. In the remaining 3 patients, 1 had carcinoma of the body and tail of the pancreas and the other 2 had carcinoma of the entire pancreas. Cytological diagnoses were positive on transgastric biopsy but negative on the transduodenal one. Malignant cells were cytologically identified in 21 of 25 patients with carcinoma. Over-all diagnostic accuracy was 84.0%. Of the 7 radically resected

cases, preoperative diagnoses based on endoscopic aspiration biopsy were positive in 5, suspicious for malignancy in 1, and negative in 1. The smallest lesion able to be diagnosed by the procedure was 1.0 by 1.2 em in ampullary carcinoma, 1.0 by 1.5 em in carcinoma of the head of the pancreas, and 5.0 by 5.8 em in carcinoma of the body and tail of the pancreas. Transduodenal aspiration biopsy was performed on 20 patients with benign lesions such as chronic pancreatitis, adenoma of the papilla of Vater, duodenal duplication, and heterotopic pancreas. A transgastric procedure was done in 6 patients with pancreatic pseudocyst or chronic pancreatitis. There were no false-positive diagnoses in these 26 patients (table 2). Discussion A fine needle aspiration biopsy has been well accepted in the literature for the definitive diagnosis of carcinoma of the pancreas during laparotomy. 1- 3 It has been also used at the Second Department of Surgery, Nagasaki University Hospital since September 1969 and proved to be a simple, safe, and useful procedure. We thought that it would be possible endoscopically to pass a fine needle into the pancreas from the inside of the gastric and duodenal lumen by using either the gastroor duodenofiberscope. In 1971, a long aspiration biopsy needle applicable to the fiberscope was made by us in cooperation with Olympus Optical Company, Limited, and has been used for the preoperative diagnosis of TABLE 1. Results of endoscopic aspiration biopsy of carcinoma of pancreas and periampullary region Pancreas Peri amTotal Procedure pullary Body and Entire region Head tail Transduodenal Positive Suspicious Negative Trans gastric Positive Suspicious Negative Both Positive Suspicious Negative

3

7

4

2

2 2

6

2

10 0

3

4 0 0

1" 1

" Patient with cystadenocarcinoma. TABLE 2. R esults of endoscopic aspiration biopsy of pancreas with benign disease Transgastric Transduodenal procedure procedure Diagnosis

Negative Falsepositive

Chronic pancreatitis

Adenoma

ofpapilla of Vater

Pseudo- Total cyst of pan-

Heteratopic pancreas

Duodena! duplication

Chronic pancreatitis 4

2

26

0

0

0

ere as

17

1

1

1

0

0

0

0

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Vol. 73 , No.5

TSUCHIYA ET AL.

carcinoma of the pancreas. Transgastric aspiration biopsy is suitable in obtaining specimens from the body and tail of the pancreas, whereas transduodenal aspiration biopsy is indicated for lesions in the periampullary region and the head of the pancreas. Diagnostic accuracy of the procedure for carcinoma of the pancreas was as high as 84.0%. In order to avoid false-negative diagnoses, however, it is important to select either transduodenal or transgastric procedure, depending upon the location of the lesion in the organ, or to do both procedures. Of 10 patients who underwent merely transduo:lenal aspiration biopsy, 2 with carcinoma of the body and tail of the pancreas were misdiagnosed. Iftransgastric procedure had been performed in these 2 patients, the accuracy of diagnosis might have been much higher than 84.0%. In 1 patient, highly differentiated malignant cells obtained from cystadenocarcinoma were erroneously interpreted as benign atypical cells. However there were no false-positive diagnoses in 26 patients with benign disease. The length ofthe metal needle of the inner tube is certainly limited to 6 or 7 mm. It is difficult to get one longer than this, as long as we use the above-described type of the endoscope. In order to obtain the biopsy specimens, either in the duodenum or the stomach, we should use a side-viewing fiberscope instead of a forward-viewing one. The biopsy channel in a side-viewing fiberscope is curved rectangularly near the tip of the endoscope. The tip of the guide tube which is passed through the channel should not be flexible but firm enough to support the metal needle. The length of the solid portion of the guide tube is limited to 5 mm, because of the curve of the biopsy channel. This is why the metal needle can not exceed 6 or 7 mm in length. The possibility of disseminating tumor cells by needle puncture must be taken into account. Crile and Hazard4 found that 1 year after biopsy of a papillary carcinoma of the thyroid, tumor growth was present at the site of the

needle puncture of th~ skin. Labardini and Nesbit5 reported perineal extension of adenocarcinoma of the prostate gland after needle biopsy. However these authors used a Vim-Silverman needle. Whenever a fine needle was used, no recorded cases of tumor extension have been reported. Tajima et al. 6 observed no clinical evidence oflocal tumor growth or a distant metastasis after fine needle aspiration biopsy in a follow-up study of patients with breast carcinoma. Engzell et al. 7 investigated the possibility of spread of tumor cells in connection with aspiration biopsy in experiments in rabbits. The findings showed that fine needle aspiration of a tumor did not cause an increase in vascular dissemination of cancer cells. From this data it seems possible that fine needle aspiration biopsy can be done without any fear of spreading tumor cells. It is clear that endoscopic aspiration biopsy is valuable in establishing the diagnosis of carcinoma of the pancreas. REFERENCES 1. Christoffersen P, Poll P: Preoperative pancreas aspiration biop-

sies. Acta Pathol Microbiol Scand (Suppl) 212:28-32, 1970 2. Forsgren L, Orell S: Aspiration cytology in carcinoma of the pancreas. Surgery 73:38-42, 1973 3. Arnesjo B, Stormby N, Ackerman M: Cytodiagnosis of pancreatic lesions by means of fine-needle biopsy during operation. Acta Chir Scand 138:363-369, 1972 · 4. Crile G, Hazard JB: Classification of thyroiditis, with special reference to the use of needle biopsy. J Clin Endocrinol Metab 11:1123-1127, 1951 5. Labardini MM, Nesbit RM: Perineal extension of adenocarcinoma of the prostate gland after punch biopsy. J Urol97:891-893 , 1967 6. Tajima M, Yamagishi K, Tohma H , et al: Studies on the usefullness of cytological criteria of breast cancer by aspiration smear for population screening. J Jpn Soc Clin Cytol11 :115-133, 1972 7. Engzell U, Esposti PL, Sigurdson RA, et al: Investigation on tumor spread in connection with aspiration biopsy. Acta Radio! [Ther) (Stockh) 10:385-398, 1971 ·