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Fluoroscopy-guided percutaneous transperitoneal fine needle biopsy of renal masses
FLUOROSCOPY-GUIDED TRANSPERITONEAL
PERCUTANEOUS
FINE NEEDLE
BIOPSY OF RENAL MASSES JAN H. GijTHLIN, ZORAN
M.D.
L. BARBARIC,
M.D.
From the Department of Diagnostic Radiology, of Rochester School of Medicine and Dentistry, Rochester, New York
University
ABSTRACT - Percutaneous transperitoneal fine needle biopsy is a harmless, easy to perform, and most direct procedure used to diagnose uncertain causes of ureteral obstruction and displacement of various parts of the urinary tract system. Frequently it is the least invasive method that can decide further treatment.
Since retroperitoneal neoplasms commonly involve the urinary tract system, the urologist is frequently the one who will be confronted with the management problems of such patients. Before deciding on the treatment for ureteral obstruction or for the masses displacing the urinary tract system, cytologic diagnosis is often desirable. Is the lesion inflammatory, fibrotic, neoplastic, metastatic, or primary tumor? Should the patient be operated on or not? Percutaneous, transperitoneal fine needle aspiration biopsy of lymph nodes, under fluoroscopic control, has proved to be of value.’ The same technique was used in 6 patients with upper urinary tract obstruction or displacement. In another 3 patients the translumbar approach was used. Method
and Material
Technique No premeditation is given. The area to be biopsied is identified using single plane fluoroscopy after intravenous urography or retrograde or antegrade pyelography. Local anesthesia is administered into the skin, musculature, and peritoneum of the anterior abdominal wall, perpendicular to the lesion to be biopsied. A biopsy needle, OD/ID 0.9/0.6 mm., 20 cm. long, is in-
300
troduced into the area to be biopsied using fluoroscopic control. This is done rapidly with the patient in apnea. In most cases it is possible to feel the tip of the needle entering the tumor as a firm resistance. Aspiration is then made with the aid of a lo-ml. syringe while the tip is moved up and down 2 to 3 mm. Specimen is smeared on glass slides and immediately fixed with 95 per cent ethyl alcohol. Hematoxylineosin stain is immediately performed in the pathology department and the slides reviewed. If there is inadequate tissue in the specimen, the procedure can be repeated. The translumbar approach is identical, except that the patient is placed in the prone position. Clinical
material
Clinical material is presented in Table I. In most patients it was important to differentiate whether or not the obstruction (Fig. 1A and D) or displacement (Fig. 1B and C) was due to the neoplasm or a benign stricture. The type of neoplasm could always be determined. In cases in which biopsy yielded non-neoplastic tissue or in which the cytopathologist was uncertain about the specific tissue type of the malignancy found (Cases 1 and 2), exploratory surgery was performed. In Cases 2, 6, and 9 translumbar biopsies were performed.
UROLOGY
/ MARCH 1978 / VOLUME
XI, NUMBER 3
FIGURE 1. (A) Case 1. Translumbar antegrade p yleogram; h ydronephrosis due to midureteral obstruction. Transperitoneal biopsy performed at point of obstruction. Cytologic report: fibrous tissue. (9) Case 2. Intravenous urogram; retroperitoneal mass displaces left kidney. There is osteolytic bony destruction of second lumbar vertebra. Cytologic report: lymphosarcoma. (C) Case 3. Intravenous p yelogram; displacement of right ureter by enlarging mass. Cytologic report: fibrous tissue. (D) Case 4. Intravenous urog :ram; partial obstruc Zion of at pelvic inlet. left ureter Biop sy at point of obstl ruction revel aled metasta ses fro?; n prostate. Cytologic report: metastasis f rom carcin loma.
TABLE ClUe No.
Procedures
I.
Intravenous Urography
and findings
Other Radiologic Examinations
Noniimctioning R. kidney Mass displacing L. kidney and ureter
Antegrade pyelogram: hydronephrosis .
Mass displacing R. ureter Midureteral obstruction on L. Bilateral pelvic Angiogram: angiomyohpoma of R. kidney. ?Liver masses; large R. kidney, status after metastasis nephrectomy Bilateral suprarenal masses
Angiogram: hypovascular suprarenal masses
.
Partial obstruction of distal L. ureter
Partial obstruction of L. midureter Bilateral midureteral obstruction
*No complications
UROLOGY
/
Ultrasound: retroperitoneal masses; retrograde ureteral catheters for drainage
occurred
MARCH
in 9 patients Clinical
with urinary
tract lesions* Biopsy
Problem
Cause for the ureteral
obstruction
Lymphoma versus metastasis or primary retroperitoneal neoplasm History of schistosomiasis. Is mass malignant? Prostatic carcinoma. Is obstruction due to metastasis? Small, l-cm. carcinoma within large angiomyoIipomatous L. kidney one year ago. Are pelvic masses angiomyolipomas or metastasis? ?Metastasis. Patient had pneumonectomy for bronchogenie carcinoma two years ago Irradiation for bladder carcinoma one year ago. Is obstruction due to metastasis or postradiation fibrosis? Seminoma. Is obstruction due to metastasis or stricture? Renal failure; no lymph nodes palpable. Cause for obstruction?
Fibrous
tissue
Lymphosarcoma
Disposition Surgery: retroperitoneal fibrosis Surgery: lymphosarcoma
Metastasis
Treated for schistosomiasis Palliative therapy
Metastasis
Palliative
therapy
Metastasis; bronchogenic carcinoma Metastasis
Palliative
therapy
Palliative
therapy
Metastasis
Lymphangiogram; radiation therapy Radiation therapy; obstruction relieved
Fibrous
tissue
Lymphocytic lymphoma
in the 9 cases.
1978
/
VOLUME
XI, NUMBER
3
301
No complications were encountered. The patients experienced minimal discomfort during the introduction of the local anesthesia and even less discomfort during the biopsy. Comment Thin needle aspiration biopsy of pulmonary nodules has been used extensively for several years, differentiating benign disease from malignant. Transperitoneal approach for biopsing retroperitoneal and indeed intraperitoneal masses offers a new and very direct means of arriving at the definitive diagnosis. The need for elaborate diagnostic workup including angiography, computerized axial tomography, and exploratory surgery can be diminished. There is very little discomfort to the patients, and no complications have been encountered. In all patients adequate specimens could be obtained at the first punctures. The anterior approach has certain advantages over the posterior, translumbar approach. The posterior approach is more difficult because of the firmer musculature, transverse processes of the vertebral bodies, and iliac bone but can be done in large lesions (Fig. 1B). Despite the bowel and vessels, no complications have occurred because of the small outer diameter of the needle. The common fear of seeding the tumor through the needle tract is an objection to the procedure. Perusal of the literature does not
302
verify this fear. In 1,264 cases of malignant lung lesions biopsied with a thin needle there was only one needle tract seeding of the tumor.’ In patients with renal carcinoma deliberately biopsied, no seeding of the tumor was reported.3*4 The diagnostic accuracy of transperitoneal biopsies of lymph node metastases has been 100 per cent.’ Twenty-five biopsies of the pancreas have been reported using transperitoneal approach.’ The development of transperitoneal aspiration biopsy using the thin bore needle promises to expand the diagnostic acumen that radiology has to offer and will decrease the suffering and expense in a significant number of patients. Department of Diagnostic Radiology UCLA School of Medicine Los Angeles, California 90024 (DR. BARBARIC) References 1. Gijthlin JH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy, Radiology 120: 205 (1976). 2. Sinner WN, and Zajicek J: Implantation metastasis after percutaneous transthoracic needle aspiration biopsy, Acta Radial. Diag. 17: 473 (1976). 3. von Schreeb T, Amer 0, Skovsted G, and Winstad N: Renal adenocarcinoma; is there a risk of spreading tumor cells in diagnostic puncture? Stand. J. Ural. Nephrol. 1: 270 (1967). 4. Kristensen JK, Holm HH, Rasmussen SN, and Barlebo H: Ultrasonically guided percutaneous puncture of renal masses, ibid. (Suppl.) 15: 49 (1972). 5. Hancke S, Holm HH, and Koch F: Ultrasonically guided percutaneous fine needle biopsy of the pancreas, Surg. Gynecol. Obstet. 140: 361 (1975).
UROLOGY
/
MARCH
1978
/
VOLUME
XI, NUMBER
3
PERCUTANEOUS
FINE NEEDLE
BIOPSY OF RENAL MASSES JAN H. GijTHLIN, ZORAN
M.D.
L. BARBARIC,
M.D.
From the Department of Diagnostic Radiology, of Rochester School of Medicine and Dentistry, Rochester, New York
University
ABSTRACT - Percutaneous transperitoneal fine needle biopsy is a harmless, easy to perform, and most direct procedure used to diagnose uncertain causes of ureteral obstruction and displacement of various parts of the urinary tract system. Frequently it is the least invasive method that can decide further treatment.
Since retroperitoneal neoplasms commonly involve the urinary tract system, the urologist is frequently the one who will be confronted with the management problems of such patients. Before deciding on the treatment for ureteral obstruction or for the masses displacing the urinary tract system, cytologic diagnosis is often desirable. Is the lesion inflammatory, fibrotic, neoplastic, metastatic, or primary tumor? Should the patient be operated on or not? Percutaneous, transperitoneal fine needle aspiration biopsy of lymph nodes, under fluoroscopic control, has proved to be of value.’ The same technique was used in 6 patients with upper urinary tract obstruction or displacement. In another 3 patients the translumbar approach was used. Method
and Material
Technique No premeditation is given. The area to be biopsied is identified using single plane fluoroscopy after intravenous urography or retrograde or antegrade pyelography. Local anesthesia is administered into the skin, musculature, and peritoneum of the anterior abdominal wall, perpendicular to the lesion to be biopsied. A biopsy needle, OD/ID 0.9/0.6 mm., 20 cm. long, is in-
300
troduced into the area to be biopsied using fluoroscopic control. This is done rapidly with the patient in apnea. In most cases it is possible to feel the tip of the needle entering the tumor as a firm resistance. Aspiration is then made with the aid of a lo-ml. syringe while the tip is moved up and down 2 to 3 mm. Specimen is smeared on glass slides and immediately fixed with 95 per cent ethyl alcohol. Hematoxylineosin stain is immediately performed in the pathology department and the slides reviewed. If there is inadequate tissue in the specimen, the procedure can be repeated. The translumbar approach is identical, except that the patient is placed in the prone position. Clinical
material
Clinical material is presented in Table I. In most patients it was important to differentiate whether or not the obstruction (Fig. 1A and D) or displacement (Fig. 1B and C) was due to the neoplasm or a benign stricture. The type of neoplasm could always be determined. In cases in which biopsy yielded non-neoplastic tissue or in which the cytopathologist was uncertain about the specific tissue type of the malignancy found (Cases 1 and 2), exploratory surgery was performed. In Cases 2, 6, and 9 translumbar biopsies were performed.
UROLOGY
/ MARCH 1978 / VOLUME
XI, NUMBER 3
FIGURE 1. (A) Case 1. Translumbar antegrade p yleogram; h ydronephrosis due to midureteral obstruction. Transperitoneal biopsy performed at point of obstruction. Cytologic report: fibrous tissue. (9) Case 2. Intravenous urogram; retroperitoneal mass displaces left kidney. There is osteolytic bony destruction of second lumbar vertebra. Cytologic report: lymphosarcoma. (C) Case 3. Intravenous p yelogram; displacement of right ureter by enlarging mass. Cytologic report: fibrous tissue. (D) Case 4. Intravenous urog :ram; partial obstruc Zion of at pelvic inlet. left ureter Biop sy at point of obstl ruction revel aled metasta ses fro?; n prostate. Cytologic report: metastasis f rom carcin loma.
TABLE ClUe No.
Procedures
I.
Intravenous Urography
and findings
Other Radiologic Examinations
Noniimctioning R. kidney Mass displacing L. kidney and ureter
Antegrade pyelogram: hydronephrosis .
Mass displacing R. ureter Midureteral obstruction on L. Bilateral pelvic Angiogram: angiomyohpoma of R. kidney. ?Liver masses; large R. kidney, status after metastasis nephrectomy Bilateral suprarenal masses
Angiogram: hypovascular suprarenal masses
.
Partial obstruction of distal L. ureter
Partial obstruction of L. midureter Bilateral midureteral obstruction
*No complications
UROLOGY
/
Ultrasound: retroperitoneal masses; retrograde ureteral catheters for drainage
occurred
MARCH
in 9 patients Clinical
with urinary
tract lesions* Biopsy
Problem
Cause for the ureteral
obstruction
Lymphoma versus metastasis or primary retroperitoneal neoplasm History of schistosomiasis. Is mass malignant? Prostatic carcinoma. Is obstruction due to metastasis? Small, l-cm. carcinoma within large angiomyoIipomatous L. kidney one year ago. Are pelvic masses angiomyolipomas or metastasis? ?Metastasis. Patient had pneumonectomy for bronchogenie carcinoma two years ago Irradiation for bladder carcinoma one year ago. Is obstruction due to metastasis or postradiation fibrosis? Seminoma. Is obstruction due to metastasis or stricture? Renal failure; no lymph nodes palpable. Cause for obstruction?
Fibrous
tissue
Lymphosarcoma
Disposition Surgery: retroperitoneal fibrosis Surgery: lymphosarcoma
Metastasis
Treated for schistosomiasis Palliative therapy
Metastasis
Palliative
therapy
Metastasis; bronchogenic carcinoma Metastasis
Palliative
therapy
Palliative
therapy
Metastasis
Lymphangiogram; radiation therapy Radiation therapy; obstruction relieved
Fibrous
tissue
Lymphocytic lymphoma
in the 9 cases.
1978
/
VOLUME
XI, NUMBER
3
301
No complications were encountered. The patients experienced minimal discomfort during the introduction of the local anesthesia and even less discomfort during the biopsy. Comment Thin needle aspiration biopsy of pulmonary nodules has been used extensively for several years, differentiating benign disease from malignant. Transperitoneal approach for biopsing retroperitoneal and indeed intraperitoneal masses offers a new and very direct means of arriving at the definitive diagnosis. The need for elaborate diagnostic workup including angiography, computerized axial tomography, and exploratory surgery can be diminished. There is very little discomfort to the patients, and no complications have been encountered. In all patients adequate specimens could be obtained at the first punctures. The anterior approach has certain advantages over the posterior, translumbar approach. The posterior approach is more difficult because of the firmer musculature, transverse processes of the vertebral bodies, and iliac bone but can be done in large lesions (Fig. 1B). Despite the bowel and vessels, no complications have occurred because of the small outer diameter of the needle. The common fear of seeding the tumor through the needle tract is an objection to the procedure. Perusal of the literature does not
302
verify this fear. In 1,264 cases of malignant lung lesions biopsied with a thin needle there was only one needle tract seeding of the tumor.’ In patients with renal carcinoma deliberately biopsied, no seeding of the tumor was reported.3*4 The diagnostic accuracy of transperitoneal biopsies of lymph node metastases has been 100 per cent.’ Twenty-five biopsies of the pancreas have been reported using transperitoneal approach.’ The development of transperitoneal aspiration biopsy using the thin bore needle promises to expand the diagnostic acumen that radiology has to offer and will decrease the suffering and expense in a significant number of patients. Department of Diagnostic Radiology UCLA School of Medicine Los Angeles, California 90024 (DR. BARBARIC) References 1. Gijthlin JH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy, Radiology 120: 205 (1976). 2. Sinner WN, and Zajicek J: Implantation metastasis after percutaneous transthoracic needle aspiration biopsy, Acta Radial. Diag. 17: 473 (1976). 3. von Schreeb T, Amer 0, Skovsted G, and Winstad N: Renal adenocarcinoma; is there a risk of spreading tumor cells in diagnostic puncture? Stand. J. Ural. Nephrol. 1: 270 (1967). 4. Kristensen JK, Holm HH, Rasmussen SN, and Barlebo H: Ultrasonically guided percutaneous puncture of renal masses, ibid. (Suppl.) 15: 49 (1972). 5. Hancke S, Holm HH, and Koch F: Ultrasonically guided percutaneous fine needle biopsy of the pancreas, Surg. Gynecol. Obstet. 140: 361 (1975).
UROLOGY
/
MARCH
1978
/
VOLUME
XI, NUMBER
3