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Transrectal Cytologic Aspiration in the Diagnosis of Prostatic Carcinoma
Vol. 108, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
TRANSRECTAL CYTOLOGIC ASPIRATION IN THE DIAGNOSIS OF PROSTATIC CARCINOMA JOSEPH A. LINSK, HERBERT D. AXILROD, RICHARD SOLYN
AND
CLAUDE DELAVERDAC
From the Departments of Pathology and Urology, The Atlantic City Hospital, Atlantic City, New Jersey
needle is re-attached and the aspirate is expressed onto a glass slide, after which it is evenly distributed, air-dried and stained with Wright's stain.
Cytologic aspiration biopsy has been used in tumor diagnosis for many years. 1 • 2 Transrectal prostatic needle biopsy, yielding a tissue core for routine histological examination, is also well known. 3 However, there are no reports in the American literature of thin-needle cytologic aspiration yielding a smear of prostatic cells for diagnosis. During a 6-month period we studied 27 cases of suspected prostatic carcinoma using a transrectal cytologic aspiration technique. Herein we describe this simple, rapid, atraumatic method and correlate it with other diagnostic parameters and histopathology.
MATERIAL AND RESULTS
Study was carried out on 27 patients admitted to the Atlantic City Hospital during a period of 6 Summary of clinical parameters of 27 cases of suspected prostatic carcinoma
Parameter
TECHNIQUE OF ASPIRATION
The apparatus consists of a 27 gauge, long, straight needle, a 10 cc syringe with a special handle and a Luer-lock attachment (a Kifa-Franzen syringe) and a specially designed needle holder (Kifa-Franzen) (fig. 1). No anesthesia or preoperative preparation is required. The patient may be placed in the lithotomy or knee-chest position. A glove is placed on the palpating hand and the needle guide drawn over the gloved finger. A finger cot is placed over the finger and the attached needle guide, holding it in place (fig. 2). The finger is then introduced into the rectum and the suspicious area palpated. The finger should advance just beyond the biopsy site so that the needle will enter directly into the suspicious area. The long aspiration needle attached to the Luer-lock syringe is threaded through the needle guide. T\1e needle passes through the tip of the guide and finger cot and transrectally into the palpated mass. The plunger of the syringe is drawn back as far as possible, creating a vacuum in the system (fig. 3). The needle is moved back and forth several millimeters within the mass with negative pressure applied. The plunger is then released and pressure within the syringe is equalized to prevent the aspiration of material high up in the needle. The needle is withdrawn and is briefly separated from the syringe. Air is drawn into the syringe, the Accepted for publication December 17, 1971. Read at annual meeting of North Central Section, American Urological Association, Detroit, Michigan, September 22-25, 1971. 1 Koss, L. G.: Diagnostic Cytology and its Ristopathologic Bases, 2nd ed. Philadelphia: J.B. Lippincott Co., 1968. 2 Lopes Cardozo, P.: Clinical Cytology Using the May-Griinwald-Giemsa Stained Smear. Leiden: L. Stafleu, vol. I, 1954. 3 Scott, R. J., Jr.: Needle biopsy in carcinoma of the prostate. J.A.M.A., 201: 958, 1967.
Rectal palpation
Core biopsy
TUR
No.
Cytologically Positive Aspirations (20)
Cytologically N egative Aspirations* (5) 5*
2f
0
0
27
+
20 0
4
+
1 3
15
+
g
+
10
27
[> 1.1 B.U.]
Acid phosphatase
Cytologically Equivocal Aspirationst (2)
2*
1 1*
lf
10
l*
0
10
4
2f
10 Alkaline phosphatase
27
+
[> 35 I.U.]
Bone marrow aspirations
15
+
2 12
1* 0
Bone x-ray and survey
20
+
10
0
Ii
4
2
+
1 0
0
Bone scan
* One of these patients had known carcinoma and was on estrogens. Cytology revealed squamous metaplasja. t In one of these patients sufficient material was not obtained, despite 5 aspirations. He had prostatic carcinoma at autopsy.
months. On rectal palpation, prostatic carcinoma was suspected in all cases. Routinely, there were 2 aspirations and occasionally a third; in 1 case 5 aspirations were made. Cytologic preparations were interpreted in accordance with well established cytological criteria. 4 The table summarizes the findings. Diagnostic 4 Esposti, P. L.: Cytologic diagnosis of prostatic tumors with the aid of transrectal aspiration biopsy. A critical review of 1,110 cases and a report of morphologic and cytochemical studies. Acta Cytol., 10: 182, 1966.
455
456
LINSK AND ASSOCIATES
FIG. 1. A, Kifa-Franzen syringe. B, needle guide. C, needle
FIG. 2. Needle guide with aspirating needle in place
material was obtained in 26 of the 27 cases. In 20 cases the cytological aspirate was positive for prostatic carcinoma. In 4 of the 20 the diagnosis was not supported by any other parameter except palpation. In the 5 patients whose aspirate was cytologically negative, subsequent transurethral resection (TUR) in one revealed adenocarcinoma. In the remaining 4 patients the diagnosis of carcinoma by palpation
has yet to be supported by other criteria of malignancy. TURs were carried out in 15 cases. In 12 of these the resected tissue confirmed the cytological diagnosis and in 3 cases it did not. Conventional core biopsies were carried out in 4 cases and failed to show carcinoma in 3 cases in which cytological aspiration was positive.
TRANSRECTAL CYTOLOGIC ASPIRATION
457
Fm. 3. Sagittal section of pelvis with aspiration being performed
Fm. 4. Cytological preparation of well differentiated prostatic carcinoma. Reduced from X600
Acid and alkaline phosphatase determinations were done in all cases. Eleven cancer patients had normal acid phosphatase levels and 12 had elevations ranging from 1.3 to 20 Bodansky units. Alkaline
phosphatase was elevated in 11 patients with values ranging from 40 to 326 international units. Of the 15 bone marrow aspirations, carcinoma was found in 3. In 10 of the 20 bone x-ray surveys, metastases
458
LINSK AND ASSOCIATES
Fm. 5. Cytological preparation of moderately differentiated prostatic carcinoma. Reduced from X600 were demonstrated. In 1 case with normal x-rays, a bone scan was suspicious for metastasis in the lumbar spine, sacrum and hip. Rone scan in another case was negative. DISCUSSION
The cytological criteria for diagnosing prostatic as well as other carcinomas are described in numerous publications. 1 • 2 • 5 - 7 The recognition of prostatic carcinoma cells in material obtained by this method requires experience in correlative study of cytology and histology of prostatic carcinoma. Cytological examples of carcinoma are seen in figures 4 and 5. Figure 6 represents a benign smear. Benign smears are characterized by fairly uniform cells forming a mosaic pattern often in sheets. The nuclei are regular and the nucleo-cytoplasmic ratio is nor5 Franzen, S. and Zajicek, J.: Aspiration biopsy in diagnosis of palpable lesions of the breast. Critical review of 3479 consecutive biopsies. Acta Radiol., 7:
241, 1968. 6 Einhorn, J. and Franzen, S.: Thin-needle biopsy in the diagnosis of thyroid disease. Acta Radio!., 58:
3;n, 19G2.
7 Franzen, S., Giertz, G. and Zajicek, J.: Cytological diagnosis of prostatic tumours by transrectal aspiration biopsy: a preliminary report. Brit. J. Urol., 32: 193, 1960.
mal. In contrast, carcinoma cells are often in aggregates with overlapping cells. The nuclei are enlarged and irregular and there is an increase in the nucleo-cytoplasmic ratio. In well differentiated types, acinar patterns may be seen (fig. 4). In poorly differentiated lesions, the cancer cells are often dissociated. There was no falsely positive diagnosis in the original report using this technique. 7 In the review of 1,110 cases by Esposti, prostatic carcinoma was diagnosed cytologically in 336 cases (30 per cent) and none of them was considered falsely positive. 4 Histologic diagnosis was obtained in 162 of these. Of this group, 55 were cytologically cancer of which 52 were confirmed histologically. That study indicated that falsely negative _diagnoses occurred in about 10 per cent of cases. In the present series there was 1 falsely negative aspiration in which a diagnosis of carcinoma was established by TUR. A selection of cases, as in the present series, in which there are clinical criteria of malignancy, reduces incorrect cytological diagnosis to negligible proportions. With less selectivity, the number of benign cytological aspirations, including false negatives, will rise. Clinical management should depend on all diagnostic parameters and not be over-influenced by a negative report. The lithotomy position was used in the original
459
TRANSRECTAL CYTOLOGIC ASPIRATION
I
I
Fm. G. Cytological preparation of benign prostate. Hednced from X 1,000 report. 7 In this series, the knee-chest position was used to accentuate the target area (fig. 3). It also facilitates the use of this method as an outpatient procedure. Simplicity, lack of trauma, ease of repetition and speed in obtaining the preparation, staining and reporting of results, are distinct advantages of this method. Repeat aspiration is encouraged and readily done in cytologically negative cases in which other parameters are highly suggestive of carcinoma.
SUMMARY
A transrectal cytological aspiration biopsy method for diagnosing carcinoma of the prostate was used in 27 patients. Findings were correlated with other diagnostic criteria. It was found that the method had a high degree of diagnostic accuracy. The technique lends itself readily to use in the urologist's private office, as well as in the clinic, as part of a routine prostatic evaluation.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
TRANSRECTAL CYTOLOGIC ASPIRATION IN THE DIAGNOSIS OF PROSTATIC CARCINOMA JOSEPH A. LINSK, HERBERT D. AXILROD, RICHARD SOLYN
AND
CLAUDE DELAVERDAC
From the Departments of Pathology and Urology, The Atlantic City Hospital, Atlantic City, New Jersey
needle is re-attached and the aspirate is expressed onto a glass slide, after which it is evenly distributed, air-dried and stained with Wright's stain.
Cytologic aspiration biopsy has been used in tumor diagnosis for many years. 1 • 2 Transrectal prostatic needle biopsy, yielding a tissue core for routine histological examination, is also well known. 3 However, there are no reports in the American literature of thin-needle cytologic aspiration yielding a smear of prostatic cells for diagnosis. During a 6-month period we studied 27 cases of suspected prostatic carcinoma using a transrectal cytologic aspiration technique. Herein we describe this simple, rapid, atraumatic method and correlate it with other diagnostic parameters and histopathology.
MATERIAL AND RESULTS
Study was carried out on 27 patients admitted to the Atlantic City Hospital during a period of 6 Summary of clinical parameters of 27 cases of suspected prostatic carcinoma
Parameter
TECHNIQUE OF ASPIRATION
The apparatus consists of a 27 gauge, long, straight needle, a 10 cc syringe with a special handle and a Luer-lock attachment (a Kifa-Franzen syringe) and a specially designed needle holder (Kifa-Franzen) (fig. 1). No anesthesia or preoperative preparation is required. The patient may be placed in the lithotomy or knee-chest position. A glove is placed on the palpating hand and the needle guide drawn over the gloved finger. A finger cot is placed over the finger and the attached needle guide, holding it in place (fig. 2). The finger is then introduced into the rectum and the suspicious area palpated. The finger should advance just beyond the biopsy site so that the needle will enter directly into the suspicious area. The long aspiration needle attached to the Luer-lock syringe is threaded through the needle guide. T\1e needle passes through the tip of the guide and finger cot and transrectally into the palpated mass. The plunger of the syringe is drawn back as far as possible, creating a vacuum in the system (fig. 3). The needle is moved back and forth several millimeters within the mass with negative pressure applied. The plunger is then released and pressure within the syringe is equalized to prevent the aspiration of material high up in the needle. The needle is withdrawn and is briefly separated from the syringe. Air is drawn into the syringe, the Accepted for publication December 17, 1971. Read at annual meeting of North Central Section, American Urological Association, Detroit, Michigan, September 22-25, 1971. 1 Koss, L. G.: Diagnostic Cytology and its Ristopathologic Bases, 2nd ed. Philadelphia: J.B. Lippincott Co., 1968. 2 Lopes Cardozo, P.: Clinical Cytology Using the May-Griinwald-Giemsa Stained Smear. Leiden: L. Stafleu, vol. I, 1954. 3 Scott, R. J., Jr.: Needle biopsy in carcinoma of the prostate. J.A.M.A., 201: 958, 1967.
Rectal palpation
Core biopsy
TUR
No.
Cytologically Positive Aspirations (20)
Cytologically N egative Aspirations* (5) 5*
2f
0
0
27
+
20 0
4
+
1 3
15
+
g
+
10
27
[> 1.1 B.U.]
Acid phosphatase
Cytologically Equivocal Aspirationst (2)
2*
1 1*
lf
10
l*
0
10
4
2f
10 Alkaline phosphatase
27
+
[> 35 I.U.]
Bone marrow aspirations
15
+
2 12
1* 0
Bone x-ray and survey
20
+
10
0
Ii
4
2
+
1 0
0
Bone scan
* One of these patients had known carcinoma and was on estrogens. Cytology revealed squamous metaplasja. t In one of these patients sufficient material was not obtained, despite 5 aspirations. He had prostatic carcinoma at autopsy.
months. On rectal palpation, prostatic carcinoma was suspected in all cases. Routinely, there were 2 aspirations and occasionally a third; in 1 case 5 aspirations were made. Cytologic preparations were interpreted in accordance with well established cytological criteria. 4 The table summarizes the findings. Diagnostic 4 Esposti, P. L.: Cytologic diagnosis of prostatic tumors with the aid of transrectal aspiration biopsy. A critical review of 1,110 cases and a report of morphologic and cytochemical studies. Acta Cytol., 10: 182, 1966.
455
456
LINSK AND ASSOCIATES
FIG. 1. A, Kifa-Franzen syringe. B, needle guide. C, needle
FIG. 2. Needle guide with aspirating needle in place
material was obtained in 26 of the 27 cases. In 20 cases the cytological aspirate was positive for prostatic carcinoma. In 4 of the 20 the diagnosis was not supported by any other parameter except palpation. In the 5 patients whose aspirate was cytologically negative, subsequent transurethral resection (TUR) in one revealed adenocarcinoma. In the remaining 4 patients the diagnosis of carcinoma by palpation
has yet to be supported by other criteria of malignancy. TURs were carried out in 15 cases. In 12 of these the resected tissue confirmed the cytological diagnosis and in 3 cases it did not. Conventional core biopsies were carried out in 4 cases and failed to show carcinoma in 3 cases in which cytological aspiration was positive.
TRANSRECTAL CYTOLOGIC ASPIRATION
457
Fm. 3. Sagittal section of pelvis with aspiration being performed
Fm. 4. Cytological preparation of well differentiated prostatic carcinoma. Reduced from X600
Acid and alkaline phosphatase determinations were done in all cases. Eleven cancer patients had normal acid phosphatase levels and 12 had elevations ranging from 1.3 to 20 Bodansky units. Alkaline
phosphatase was elevated in 11 patients with values ranging from 40 to 326 international units. Of the 15 bone marrow aspirations, carcinoma was found in 3. In 10 of the 20 bone x-ray surveys, metastases
458
LINSK AND ASSOCIATES
Fm. 5. Cytological preparation of moderately differentiated prostatic carcinoma. Reduced from X600 were demonstrated. In 1 case with normal x-rays, a bone scan was suspicious for metastasis in the lumbar spine, sacrum and hip. Rone scan in another case was negative. DISCUSSION
The cytological criteria for diagnosing prostatic as well as other carcinomas are described in numerous publications. 1 • 2 • 5 - 7 The recognition of prostatic carcinoma cells in material obtained by this method requires experience in correlative study of cytology and histology of prostatic carcinoma. Cytological examples of carcinoma are seen in figures 4 and 5. Figure 6 represents a benign smear. Benign smears are characterized by fairly uniform cells forming a mosaic pattern often in sheets. The nuclei are regular and the nucleo-cytoplasmic ratio is nor5 Franzen, S. and Zajicek, J.: Aspiration biopsy in diagnosis of palpable lesions of the breast. Critical review of 3479 consecutive biopsies. Acta Radiol., 7:
241, 1968. 6 Einhorn, J. and Franzen, S.: Thin-needle biopsy in the diagnosis of thyroid disease. Acta Radio!., 58:
3;n, 19G2.
7 Franzen, S., Giertz, G. and Zajicek, J.: Cytological diagnosis of prostatic tumours by transrectal aspiration biopsy: a preliminary report. Brit. J. Urol., 32: 193, 1960.
mal. In contrast, carcinoma cells are often in aggregates with overlapping cells. The nuclei are enlarged and irregular and there is an increase in the nucleo-cytoplasmic ratio. In well differentiated types, acinar patterns may be seen (fig. 4). In poorly differentiated lesions, the cancer cells are often dissociated. There was no falsely positive diagnosis in the original report using this technique. 7 In the review of 1,110 cases by Esposti, prostatic carcinoma was diagnosed cytologically in 336 cases (30 per cent) and none of them was considered falsely positive. 4 Histologic diagnosis was obtained in 162 of these. Of this group, 55 were cytologically cancer of which 52 were confirmed histologically. That study indicated that falsely negative _diagnoses occurred in about 10 per cent of cases. In the present series there was 1 falsely negative aspiration in which a diagnosis of carcinoma was established by TUR. A selection of cases, as in the present series, in which there are clinical criteria of malignancy, reduces incorrect cytological diagnosis to negligible proportions. With less selectivity, the number of benign cytological aspirations, including false negatives, will rise. Clinical management should depend on all diagnostic parameters and not be over-influenced by a negative report. The lithotomy position was used in the original
459
TRANSRECTAL CYTOLOGIC ASPIRATION
I
I
Fm. G. Cytological preparation of benign prostate. Hednced from X 1,000 report. 7 In this series, the knee-chest position was used to accentuate the target area (fig. 3). It also facilitates the use of this method as an outpatient procedure. Simplicity, lack of trauma, ease of repetition and speed in obtaining the preparation, staining and reporting of results, are distinct advantages of this method. Repeat aspiration is encouraged and readily done in cytologically negative cases in which other parameters are highly suggestive of carcinoma.
SUMMARY
A transrectal cytological aspiration biopsy method for diagnosing carcinoma of the prostate was used in 27 patients. Findings were correlated with other diagnostic criteria. It was found that the method had a high degree of diagnostic accuracy. The technique lends itself readily to use in the urologist's private office, as well as in the clinic, as part of a routine prostatic evaluation.