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Needle Tract Tumor Seeding Following Endoscopic Ultrasound–Guided Fine Needle Aspiration of Metastatic Squamous Cell Carcinoma
Accepted Manuscript Needle tract tumour seeding following Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of metastatic squamous cell carcinoma Dr Anurag Goel, Dr. Kenneth CA. Hon, Dr. Andre Chong
PII: DOI: Reference:
S1542-3565(17)30467-6 10.1016/j.cgh.2017.04.024 YJCGH 55209
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 16 April 2017 Please cite this article as: Goel A, Hon KC, Chong A, Needle tract tumour seeding following Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of metastatic squamous cell carcinoma, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/j.cgh.2017.04.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title Page Title : Needle tract tumour seeding following Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of metastatic squamous cell carcinoma.
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Short Title-- Needle track Tumour seeding following EUS-FNA Authors— 1. Dr Anurag Goel Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected]
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2. Dr. Kenneth CA Hon Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected]
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3. Dr. Andre Chong Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA and Dept of Gastroenterology St John of God Hospital, Murdoch WA. [email protected]
Grant Support-- Nil
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Abbreviations— 1. Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) 2. Carcinoma of unknown primary (CUP) 3. Squamous cell carcinoma (SCC)
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Correspondence— 1. Dr Anurag Goel Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected] Tel: +61424572825, +61861522827 Disclosures— 1. Dr Anurag Goel – Nil 2. Dr Kenneth Hon – Nil 3. Dr Andre Chong – Nil Writing Assistance—Nil Author Contributions— 1. Dr Anurag Goel – drafting of the manuscript; critical revision of the manuscript for important intellectual content, technical and material support
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2. Dr Kenneth Hon – drafting of the manuscript; critical revision of the manuscript for important intellectual content. 3. Dr Andre Chong – Concept and review of manuscript
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Key Words Endoscopic Ultrasound, EUS, seeding, complications
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Acknowledgements:
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Dr Kelly Chatten MRCP, for proof reading the manuscript.
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A 57 year old Caucasian male with a history of poorly differentiated carcinoma of unknown primary (CUP) presented with melaena. He was found to have a bleeding mass in the gastric cardia at the site of previous EUS-FNA (Figure A) .Three years prior to this the
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patient presented feeling unwell and was found to have cervical lymphadenopathy. Biopsy revealed a poorly differentiated carcinoma, but despite comprehensive examination and investigations a primary tumour could not be identified. He received chemotherapy
SC
(epirubicin, cisplatin, and 5-fluorouracil) following which he appeared to have complete disease resolution on imaging and normalization of tumour markers. Hence he underwent
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regular surveillance with periodic CT imaging.
Two years after disease resolution, imaging showed a mass in the coeliac axis that was FDG PET avid. Of note there was no disease recurrence in the neck where the CUP was originally
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diagnosed. He was referred to our department for EUS-FNA. EUS showed a 52mm x 50 mm heterogenous mass in the coeliac space. There was a clear fat plane between the mass and the stomach and all five layers of the stomach wall were clearly seen on EUS. On the PET CT
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scan, there was no uptake seen in the stomach wall, hence it is unlikely that there was any
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tumour infiltration of the stomach wall at this stage. FNA (2 passes) was obtained using a 19G needle (EchoTip ProCore, Cook Medical, Limerick, Ireland). Cytology showed sheets of malignant cells with fragments of keratinised spindle-shaped cytoplasm and pleomorphic nuclei with hyperchromatic and pyknotic chromatin. On cell block squamous pearls were noted. He was restarted on chemotherapy.
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Eleven months following the EUS-FNA, the patient presented with melaena. Gastroscopy revealed a 50mm exophytic ulcerated mass at the posterior gastric wall in the cardia (Figure A). This was the site through which the previous EUS-FNA had been obtained.
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Histology was reported as a poorly differentiated SCC (Figure B,C). CT showed that the coeliac mass had eroded into the stomach (Figure D) and the tumour was encasing the coeliac axis and major central vessels, making the lesion unsuitable for a proximal
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gastrectomy.
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This case is the first time seeding of a metastatic SCC to the stomach through a EUS-FNA site has been reported. Previous published case reports have documented dissemination of an intraductal papillary mucinous tumour1, 2, seeding of a melanoma3 and pancreatic adenocarcinomas4-6. Needle tract seeding is usually diagnosed on repeat endoscopy5, 6 or
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CT scans2. In a recent report it was suspected on serial PET scans7. EUS-FNA is generally considered to be a safe procedure, however with the growing number of case reports of
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needle tract tumour seeding, this complication needs to be considered seriously.
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It has been suggested that the risk of EUS-FNA tumour seeding might be underestimated and mortality from disease may occur before tumour seeding is documented5, 8. Additionally, pre-operative biopsy may result in deposition of malignant cells outside the surgical resection field resulting in an occult reservoir, which may lead to disease progression that is incorrectly attributed to incomplete resection or local recurrence8
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Several strategies have been proposed to reduce tumour seeding. EUS-FNA should be avoided if curative surgery is being contemplated or if the result does not alter management8. The number of needle passes should be minimised, especially if the needle
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tract site is not included in the surgical resection field4. FNA should be obtained with the shortest possible space between the echoendoscope and the target site8. Adjuvant
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chemotherapy could be considered if the needle tract site is not surgically removed4.
References:
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1. Hirooka Y, Goto H, Itoh A, et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. Journal of gastroenterology and hepatology. 2003;18(11):1323-1324. 2. Yamabe A, Irisawa A, Shibukawa G, et al. Rare condition of needle tract seeding after EUSguided FNA for intraductal papillary mucinous carcinoma. Endoscopy international open. 2016;4(7):E756-758. 3. Shah JN, Fraker D, Guerry D, et al. Melanoma seeding of an EUS-guided fine needle track. Gastrointest Endosc. 2004;59(7):923-924. 4. Paquin SC, Gariepy G, Lepanto L, et al. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc. 2005;61(4):610-611. 5. Chong A, Venugopal K, Segarajasingam D, et al. Tumor seeding after EUS-guided FNA of pancreatic tail neoplasia. Gastrointest Endosc. 2011;74(4):933-935. 6. Tomonari A, Katanuma A, Matsumori T, et al. Resected tumor seeding in stomach wall due to endoscopic ultrasonography-guided fine needle aspiration of pancreatic adenocarcinoma. World Journal of Gastroenterology : WJG. 2015;21(27):8458-8461. 7. Kita E, Yamaguchi T, Sudo K. A case of needle tract seeding after EUS-guided FNA in pancreatic cancer, detected by serial positron emission tomography/CT. Gastrointest Endosc. 2016;84(5):869-870. 8. Fujii LL, Levy MJ. Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them. Endosc Ultrasound. 2014;3(1):35-45.
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PII: DOI: Reference:
S1542-3565(17)30467-6 10.1016/j.cgh.2017.04.024 YJCGH 55209
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 16 April 2017 Please cite this article as: Goel A, Hon KC, Chong A, Needle tract tumour seeding following Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of metastatic squamous cell carcinoma, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/j.cgh.2017.04.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title Page Title : Needle tract tumour seeding following Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of metastatic squamous cell carcinoma.
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Short Title-- Needle track Tumour seeding following EUS-FNA Authors— 1. Dr Anurag Goel Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected]
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2. Dr. Kenneth CA Hon Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected]
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3. Dr. Andre Chong Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA and Dept of Gastroenterology St John of God Hospital, Murdoch WA. [email protected]
Grant Support-- Nil
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Abbreviations— 1. Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) 2. Carcinoma of unknown primary (CUP) 3. Squamous cell carcinoma (SCC)
AC C
EP
Correspondence— 1. Dr Anurag Goel Dept of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA. [email protected] Tel: +61424572825, +61861522827 Disclosures— 1. Dr Anurag Goel – Nil 2. Dr Kenneth Hon – Nil 3. Dr Andre Chong – Nil Writing Assistance—Nil Author Contributions— 1. Dr Anurag Goel – drafting of the manuscript; critical revision of the manuscript for important intellectual content, technical and material support
ACCEPTED MANUSCRIPT
2. Dr Kenneth Hon – drafting of the manuscript; critical revision of the manuscript for important intellectual content. 3. Dr Andre Chong – Concept and review of manuscript
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Key Words Endoscopic Ultrasound, EUS, seeding, complications
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Acknowledgements:
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M AN U
Dr Kelly Chatten MRCP, for proof reading the manuscript.
ACCEPTED MANUSCRIPT
A 57 year old Caucasian male with a history of poorly differentiated carcinoma of unknown primary (CUP) presented with melaena. He was found to have a bleeding mass in the gastric cardia at the site of previous EUS-FNA (Figure A) .Three years prior to this the
RI PT
patient presented feeling unwell and was found to have cervical lymphadenopathy. Biopsy revealed a poorly differentiated carcinoma, but despite comprehensive examination and investigations a primary tumour could not be identified. He received chemotherapy
SC
(epirubicin, cisplatin, and 5-fluorouracil) following which he appeared to have complete disease resolution on imaging and normalization of tumour markers. Hence he underwent
M AN U
regular surveillance with periodic CT imaging.
Two years after disease resolution, imaging showed a mass in the coeliac axis that was FDG PET avid. Of note there was no disease recurrence in the neck where the CUP was originally
TE D
diagnosed. He was referred to our department for EUS-FNA. EUS showed a 52mm x 50 mm heterogenous mass in the coeliac space. There was a clear fat plane between the mass and the stomach and all five layers of the stomach wall were clearly seen on EUS. On the PET CT
EP
scan, there was no uptake seen in the stomach wall, hence it is unlikely that there was any
AC C
tumour infiltration of the stomach wall at this stage. FNA (2 passes) was obtained using a 19G needle (EchoTip ProCore, Cook Medical, Limerick, Ireland). Cytology showed sheets of malignant cells with fragments of keratinised spindle-shaped cytoplasm and pleomorphic nuclei with hyperchromatic and pyknotic chromatin. On cell block squamous pearls were noted. He was restarted on chemotherapy.
ACCEPTED MANUSCRIPT
Eleven months following the EUS-FNA, the patient presented with melaena. Gastroscopy revealed a 50mm exophytic ulcerated mass at the posterior gastric wall in the cardia (Figure A). This was the site through which the previous EUS-FNA had been obtained.
RI PT
Histology was reported as a poorly differentiated SCC (Figure B,C). CT showed that the coeliac mass had eroded into the stomach (Figure D) and the tumour was encasing the coeliac axis and major central vessels, making the lesion unsuitable for a proximal
SC
gastrectomy.
M AN U
This case is the first time seeding of a metastatic SCC to the stomach through a EUS-FNA site has been reported. Previous published case reports have documented dissemination of an intraductal papillary mucinous tumour1, 2, seeding of a melanoma3 and pancreatic adenocarcinomas4-6. Needle tract seeding is usually diagnosed on repeat endoscopy5, 6 or
TE D
CT scans2. In a recent report it was suspected on serial PET scans7. EUS-FNA is generally considered to be a safe procedure, however with the growing number of case reports of
EP
needle tract tumour seeding, this complication needs to be considered seriously.
AC C
It has been suggested that the risk of EUS-FNA tumour seeding might be underestimated and mortality from disease may occur before tumour seeding is documented5, 8. Additionally, pre-operative biopsy may result in deposition of malignant cells outside the surgical resection field resulting in an occult reservoir, which may lead to disease progression that is incorrectly attributed to incomplete resection or local recurrence8
ACCEPTED MANUSCRIPT
Several strategies have been proposed to reduce tumour seeding. EUS-FNA should be avoided if curative surgery is being contemplated or if the result does not alter management8. The number of needle passes should be minimised, especially if the needle
RI PT
tract site is not included in the surgical resection field4. FNA should be obtained with the shortest possible space between the echoendoscope and the target site8. Adjuvant
SC
chemotherapy could be considered if the needle tract site is not surgically removed4.
References:
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EP
TE D
M AN U
1. Hirooka Y, Goto H, Itoh A, et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. Journal of gastroenterology and hepatology. 2003;18(11):1323-1324. 2. Yamabe A, Irisawa A, Shibukawa G, et al. Rare condition of needle tract seeding after EUSguided FNA for intraductal papillary mucinous carcinoma. Endoscopy international open. 2016;4(7):E756-758. 3. Shah JN, Fraker D, Guerry D, et al. Melanoma seeding of an EUS-guided fine needle track. Gastrointest Endosc. 2004;59(7):923-924. 4. Paquin SC, Gariepy G, Lepanto L, et al. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc. 2005;61(4):610-611. 5. Chong A, Venugopal K, Segarajasingam D, et al. Tumor seeding after EUS-guided FNA of pancreatic tail neoplasia. Gastrointest Endosc. 2011;74(4):933-935. 6. Tomonari A, Katanuma A, Matsumori T, et al. Resected tumor seeding in stomach wall due to endoscopic ultrasonography-guided fine needle aspiration of pancreatic adenocarcinoma. World Journal of Gastroenterology : WJG. 2015;21(27):8458-8461. 7. Kita E, Yamaguchi T, Sudo K. A case of needle tract seeding after EUS-guided FNA in pancreatic cancer, detected by serial positron emission tomography/CT. Gastrointest Endosc. 2016;84(5):869-870. 8. Fujii LL, Levy MJ. Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them. Endosc Ultrasound. 2014;3(1):35-45.
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