Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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FNAC Not useless. Less invasive but with a risk!
- Fraser M Brown (28 February 2004)
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The place of fine needle aspiration
- Álvaro Sanz, Maria L. del Valle (28 February 2004)
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BMJ enters the arena of tabloid journalism
- Anton E Joseph (29 February 2004)
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FNAC in liver secondaries
- ammar a haydar, OL1 2JH (1 March 2004)
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Useless and dangerous??
- Simon Knowles (2 March 2004)
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TUMOR-SEEDING AFTER LIVER BIOPSY: EMOTION-BASED OR EVIDENCE-BASED RECOMMENDATIONS?
- Giuseppe Civardi, Elisabetta Buscarini - Gastroenterology Unit, Ospedale Maggiore, Crema, Italy (12 March 2004)
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Useless and dangerous statement about FNAC from liver metastasis from colo-rectal cancer
- Bjorn Skjoldbye, Christian Nolsoe, Nis Norgaard, Torben Lorentzen (19 March 2004)
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Some "anecdotal" thoughts.
- Hilary Butler (21 March 2004)
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Biopsy of potentially operable hepatic colorectal metastases-not useless but certainly dangerous.
- Oliver M Jones, Myrddin Rees, Consultant Hepatobiliary Surgeon; Tim G John, Consultant Hepatobiliary Surgeon; Sean Bygrave, Statistician; Graham Plant, Consultant Interventional Radiologist (21 September 2004)
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Fraser M Brown, Radiologist/Nuclear Medicine specialist Western Hospital, Footscray Victoria 3011 Australia
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This single case does highlight the risks of a FNA procedure and is a stimulus for followup of FNAC procedures at our hospital. A cytological diagnosis was obtained in this case, albeit with sequelae. Rather than a plethora of tests(PET or laparascopic biopsy)which respectively cannot give definitive histology or require a GA, FNA of the liver lesion does provide a less invasive single-step cytological diagnosis. The use of coaxial technique with FNAC may reduce risk of tumour seeding to that of laparoscopy biopsy. What is the documented rate of abdominal wall metastsases with laparoscopic access? Morbidity due to port insertion must also be considered. How often are there cytological differences between liver metastases and the primary colonic lesion? There was difference in response of the liver and abdominal wall metastasis. Was there a post treatment effect/further differentiation due to the chemotherapy making the abdominal wall lesion more difficult to treat? My concerns are that although the primary tumour treatment was effective and there was a complication fom a single diagnostic test, we are being told that complex tests should replace less complex tests, without regard to costs of these tests. The specific tumour histology could have also been discussed further. Radiology is an effective modality that reflects pathology, but it always needs pathological and clinical correlation. If there is a 3% risk of abdominal wall seeding, co-axial technique may be more cost effective than the PET or laparoscopic techniques that have been proposed. Competing interests: None declared |
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Álvaro Sanz, Oncology Department Hospital Clínico Universitario, 47005 Valladolid, Spain, Maria L. del Valle
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The authors underline the risks of fine needle aspiration cytology (FNAC) for hepatic colorectal metastases. But their proposed contraindication of FNAC and the possible diagnostic alternatives for liver lesions without apparent primary malignancy are not evidence-based. For instance, in suspected metastases of unknown origin, they recommend that “the investigations (…) should be directed to detect the primary lesion”, something clearly opposed to nowadays guidelines for the diagnostic work up of unknown primary tumours that limit diagnostic approaches. Routine use of invasive surgery for the diagnosis of liver lesions implies a risk of procedure-associated morbidity and morbidity that may be not reasonable in some patients with advanced cancer. Positron emission tomography can not be considered the gold standard to differentiate between benign and malignant lesions as its sensitivity is not significantly different to that of FNAC. And, finally, we suspect that even the authors will not accept for themselves their proposed “natural selection” criterion consisting in a three months delay to confirm that a suspected benign (and resectable) lesion has become unresectable and fatal. Competing interests: None declared |
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Anton E Joseph, Consultant radiologist, (flexible career scheme) Mayday University Hospital, Croydon Surrey CR7 7YE
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It is most surprising that the BMJ has decided to publish the article with a title, eye catching as it might be, but smacks of tabloid journalism. To dismiss outright as useless and dangerous the procedure of FNAC of suspected colo rectal meatstases will raise doubts in the minds of many clinicians of the safety of this procedure not only in colorectal metastases but in any liver metastases. It certainly raises medico legal implications for those who perform FNAC of liver metastases. There have been recent examples of chaos and confusion caused in the minds of the public and the medical profession resulting from publications based on inadequate, inaccurate or biased data. I hope the BMJ will show some restraint in the use of attention seeking titles till there has been more debate on the subject. There are many of us in this country who have peroformed several hundreds of FNAC and percutaneous biopsies without encountering so many complicaions from seeding. Admittedly we may not have been aware of our own complication rates and I shall be strenuously attempting to gather data from my own series and look forward to making it public. The views of the oncologists need to be canvassed as to how essential it is for them to have cytological or histological diagnosis specially with the increasing possibility of targeted chemotherapy. Many FNAC are performed to provide the information for the oncologist. CT, MR, US, PET cannot provide a conclusive histological diagnosis in many instances. Clearly tissue characterisation using these techniques may be a solution but is in the distant future. The authors do not raise a great deal of confidence in that the management pathway reported leaves something to be desired if it is not a case of negligence. Having found a tumour which given the circumstances might have been suggestive of colorectal metastasis there is no evidence that there had been a search for a primary site at the time of the ultasound examination. Competing interests: I have receently been granted patents in the United States and in Europe for enhanced visualisation of devices for ultrasound guided interventional work and are in the commercialisation phase of this invention. |
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ammar a haydar, hospital doctor royal oldham hospital oldham lancashire, OL1 2JH
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the author states 'if a hepatic lesion is discovered at the same time or after a primary colorectal malignancy is diagnosed, and if it appears to be malignant either on imaging or on appearences at laparotomy, then it should be treated as such, without biopsy'. I would like to ask, if he commences anti-cancer therapy for presumed liver metastasis that do not turn out to be malignant, then how could he defend himself. I would say that histological confirmation is crucial before committing the patient to any form of cancer therapy. The author also mentions that in equivocal situations were it is difficult to be certain about the nature of the liver lesion, then a three months wait is recommended followed by repeat imaging. I would like to state that it is not fair to keep patients waiting for three months in such situations before a diagnosis is confirmed. And what if the liver lesions have not changed on repeat imaging, would he wait another three months. If the author is against FNAC for the reasons he mentioned,then the answer is to perform another procedure for histological confirmation, such as laparoscopic biopsy, and not to do without histology. regards A Haydar Competing interests: None declared |
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Simon Knowles, Cytopathologist Somerset Pathology Service
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Well the damage is done now. Thank you BMJ. No amount of evidence based, reasoned debate is likely to undo the damage that your Grubb-street one-liner has caused to an inexpensive, relatively non-invasive and often very useful technique. I would suggest that the only thing that is useless and dangerous here is an inappropriate title attached to a rather slight case report. If the title is the authors (it does sound a bit surgical) then you should have changed it. If it is yours then you should be ashamed. An exchange of correspondence buried in a subsequent edition of your tabloid will not fix this one. A reflective editorial on the importance of maintaining standards in medical journalism might. Useless and dangerous?? I should say so. Simon Knowles Competing interests: I'm a cytopathologist. |
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Giuseppe Civardi, chair Internal Medicine Unit, Ospedale Civile, Fiorenzuola d’Arda, Italy, Elisabetta Buscarini - Gastroenterology Unit, Ospedale Maggiore, Crema, Italy
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In a recent paper a new case of tumour seeding after a fine needle aspiration cytology (FNAC) performed in a patients with liver metastasis from colon cancer is reported (1). On the basis of fatal outcome of this, yet anedoctal, report authors emphasize the danger of fine needle biopsy and suggest “that FNAC should be avoided when hepatic colorectal metastasis are suspected”. Authors support this advice with the results of a recent paper (their reference 13) where the seeding rate after FNAC in 51 patients with liver metastasis from colon cancer was 10% while it was 1.3% in the other biopsied patients (106 with primary liver tumours; 46 with non colorectal liver metastasis). However some weak points should be noted in this paper: 1. the period of recruitment is very long (1973-1997) so that in a part of the patients the biopsy was performed blindly or on the guidance of palpation; 2. the number of needle passes in the lesions is not reported; 3. reported specificity of FNAC is unacceptably low (67%); 4. the seeding rate is strongly fluctuating in the various subgroups of patients, ranging from 0% in the largest subgroup to 12% in the smallest. Therefore because of its shortcomings this paper should not be cited to support recommendations about the use of FNAC. Other series cited by Metcalfe and coworkers (their references 3-7) are related to patients with hepatocellular carcinoma (HCC), where seeding rate ranged between 0.6% to 5.1%. Seeding rate of FNAC (generally considered very low) is probably underestimated as available data are retrospective and follow-up of patients is often missing or insufficient. It is thus particularly interesting to examine data on complication rate of percutaneous treatments of liver tumors, radiofrequency thermal ablation and percutaneous ethanol injection. A recent paper reporting on complications in 166 patients (114 with HCC and 52 with metastasis, mainly colorectal one) treated by percutaneous radiofrequency ablation (expandable system), who all had a prior FN biopsy (cytology needle or cutting needle). Tumour seeding was observed in 1 patient with HCC (0.6%) (2); this seeding rate is similar to that observed in a large multicenter study with another RF system (cooled needle electrode calibre) applied in 2320 patients (1610 with HCC; 683 with metastasis) where 12 (0.5%) patients had tumour seeding (3), or to the the 0.6% seeding rate reported in a multicenter study on complications of percutaneous ethanol injection (PEI) in 1066 patients with HCC (4); in both these series a part of the patients had a prior FN biopsy. These altogether 3552 patients were certainly at higher risk of seeding in comparison with patients receiving FNAC alone, both because they received (in a part of cases) FNAC and percutaneous tumor treatment, and because in RF treatments large needles are employed which remain in the tumor for at least 15 minutes; in PEI treatment a fine needle is used but the puncture is repeated many times (in the cited paper a mean of 6.7 times). Keeping thus in mind that for FNAC a lesser seeding rate should be expected, data on tumor seeding reported in these papers can be considered a reliable reference as the patients were carefully followed up for a period generally long enough to identify this complication. Because of overemphasized seeding risk of FNAC Metcalfe and coworkers suggest to use, instead of FNAC, a radiologic work up (1) whose sensitivity is considered about 91% but whose specificity is about 85% (their reference 14), claiming these values are similar to that of FNAC whereas they are clearly poorer. FN biopsy has a very high sensitivity and excellent specificity: in a large study on 2091 FN biopsy either in HCC and liver metastasis they resulted 91.1% and 99.5% respectively and overall diagnostic accuracy was 93.4% (5). Nowadays there is a tremendous literature evidence that in experienced hands these results are easily repeatable. On the other hand the use of a radiologic work up without biopsy induces in about 1.9% of patients a surgical resection for a benign lesion (Metcalfe reference 14). This figure is similar to that found in a previous paper where a radiologic work-up plus a dosage of alphafetoprotein (AFP) and carcinoembrionic antigen (CEA) without liver biopsy were performed in 160 patients with liver lesions. In that series 4 patients (2.5%) with non malignant lesion were surgically treated (6). We deem hardly acceptable to expose 1.9%-2.5% of subjects with benign liver lesions to a risk of liver resection to avoid a tumor seeding rate probably less than 0.5-0.6%. However we would point out that a non-invasive diagnostic approach has to be preferred whenever possible and reliable, as it has been advised for hepatocellular carcinoma: for a tumor greater than 2 cm, two positive imaging techniques or one positive imaging technique and AFP values higher than 400 ng/ml suffice for diagnosis (7). Debate on seeding risk deserve also some technical considerations: the use of laparoscopic biopsy suggested by Metcalfe when a pathologic diagnosis is mandatory does not eliminate the seeding risk and introduces the risk of port insertion; in patients eligible to a curative resection FNAC can be instead performed by using a coaxial technique, which can eliminate seeding risk. It is well known that number of needle passes can influence tumor seeding rate: for this reason we have proposed the use of an immediate staining (8) to reduce the number of needle passes. Another factor influencing cell dragging during biopsy is irregularity of needle surface, and we have thus suggested to avoid needles with the so-called echo markers (9). Track for FNAC of a liver lesion should be cautiously chosen so as to traverse normal adjacent liver parenchyma prior to entering a metastatic deposit, especially if a peripherally-based one, to reduce the likelihood of malignant cutaneous seeding. Finally, a clinical remark: it should be recalled that tumour implantation in more than half of reported cases did not influence patient outcome. We therefore think statements of Metcalfe and coworkers clashes against literature evidences: FNAC of liver tumors is a powerful diagnostic tool, which, as every invasive test, should be restricted to situations in which its result have an impact on patient management; FNAC is certainly safe when performed with appropriate operating procedures based on the sound principles of biopsy technique. References 1. Metcalfe MS, Bridgewater FH, Mullin EJ, Maddern GJ Useless and dangerous—fine needle aspiration of hepatic colorectal metastases BMJ 2004; 328: 507-508 2. Buscarini E, Buscarini L Radiofrequency thermal ablation with expandable needle of focal liver malignancies: complication report Eur Radiol 2004;14:31-37 3. Livraghi T. Solbiati L, Meloni F, Scott-Gazelle G, Halpern EF, Goldberg SN Treatment of focal liver tumors with percutaneous radio-frequency ablation: complications encountered in a multicenter study. Radiology 2003; 226:441–45 4. Di Stasi M, Buscarini L, Livraghi T, Giorgio A, Salmi A, De Sio I, Brunello F, Solmi L, Caturelli E, Magnolfi F, Caremani M, Filice C Percutaneous ethanol injection in the treatment of hepatocellular carcinoma. A multicenter survey of evaluation practices and complication rates. Scand J Gastroenterol 1997; 32: 1168-1173 5. Buscarini L, Fornari F, Bolondi L, Colombo P, Livraghi T, Magnolfi F, Rapaccini GL, Salmi A Ultrasound-guided fine-needle biopsy of focal liver lesions: techniques, diagnostic accuracy and complications. A retrospective study on 2091 biopsies. J Hepatol 1990; 11: 344-348 6. Torzilli G, Minagawa M, Takayama T, Inoue K, Hui AM, Kubota K, Ohtomo K, Majuuchi M Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy Hepatology 1999; 30: 889-893 7. Bruix J, Sherman M, Llovet JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. J Hepatol 2001; 35: 421-30 8. Civardi G, Fornari F, Cavanna L, Di Stasi M, Sbolli G, Buscarini L Value of rapid staining and assessment of ultrasound guided aspiration biopsies. Acta Cytol 1988; 32: 552-554 9. Buscarini E, Foroni R, Rossi S, Di Stasi M, Silva M, Marinone G, Degli Antoni G, Buscarini L Fine needles with echo markers: increasing cell dragging during biopsy. Acta Cytol 1997; 41: 1246-1249 Competing interests: None declared |
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Bjorn Skjoldbye, senior consultant Herlev University Hospital ; DK-2730 Herlev Copenhagen Denmark, Christian Nolsoe, Nis Norgaard, Torben Lorentzen
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Useless and dangerous statement about FNAC from liver metastasis from colo-rectal cancer. A comment to ”Useless and dangerous fine-needle aspiration of hepatic colorectal metastasis”, Metcalfe et al; BMJ vol.328; 28.febr.2004: 507-508 Bjørn Skjoldbye, Christian Nolsoe, Nis Norgaard and Torben Lorentzen Herlev University Hospital, Copenhagen, DK-2730 Denmark. E-mail: bos@dadlnet.dk The title seems improperly tabloid since the content of the paper does not validate that FNAC is useless or dangerous. Thousands of FNAC procedures are performed world wide every day with a very low complication rate. Based on a case story and referring to a material of 51 patients of whom 5 (10%) had needle tract metastasis after FNAC, the authors contradict original papers based on thousands of patients (1) and reported results from other authors presented in reviews (2,3,6) in which an overall complication rate to interventional ultrasound is approx. 0.20%. A 10% needle tract metastasis rate seem incredible high and should be subject to a further investigation of the biopsy procedure. If these figures were valid our hospitals would be filled with patients suffering of cutaneous metastasis after FNAC - which is not the case. In a case report the authors describe a patient with a liver metastasis confirmed by FNAC after radical resection of a Duke C colon tumor. After hemi-hepatectomy a subcutaneous metastasis develops. The authors do not present any facts about the biopsy procedure and seem to exclude drainage ports and the surgical procedure as possible origins. In the discussion the authors advocate biopsy through laparoscopic ports without discussion of port-metastasis in connection herewith. Admittedly, needle tract metastasis do occurs. It is a known, but rare, complication to FNAC from the liver. And , the issue to substitute FNAC with tumor characteristics achieved by non-invasive imaging has been considered before (4). However, imaging diagnostic features of a liver tumor combined with FNAC provides an unsurpassed diagnostic tool which is to the benefit to the majority of patients undergoing major surgery and/or chemo therapy. US-guided FNAC is a safe procedure (1,2,3) using ultrasound guidance preferably with needle steering device and performing only one or maximally two needle insertions (5) with a 0.6 (23G) or 0.7 (22G) mm Ciba needle. PET-CT, MRI and contrast enhanced ultrasound are promising modalities which may reduce the need for FNAC in the near future. Until solid evidence of the opposite, FNAC remains a well established tool for rational patient management before major liver surgery, irradiation and chemo therapy. US-guided FNAC provides an excellent cost-benefit ratio and a low complication rate. It is not dangerous and far from useless. References 1. Nolsoe C, Nielsen L, Torp-Pedersen S, Holm HH. Major complications and deaths due to interventional ultrasound: A review of 8000 cases. J Clin Ultrasound 1990;18:179-184 2. Holm HH, Skjoldbye B. Interventional Ultrasound. Ultrasound in Med & Biol. 1996;vol 22, No. 7 :773-789 3. Holm HH, Skjoldbye B. Interventional Procedures. Ultrasound in Med & Biol 1998;vol26, Suppl.1:131-134 4. Khattar SC, Torp-Pedersen S, Lorentzen T, Nolsoe C, Skjoldbye B, Court-Payen M, Holm HH. Liver metastasis: is biopsy verification necessary when sonographic assessment is certain? European Journal of Ultrasound 1994;1:67-70 5. Skjoldbye B, Horn T, Torp-Pedersen S, Court-Payen M, Khattar SC, Lorentzen T. Ultrasound guided fine needle aspiration biopsies from the liver. How many needle passes? European Journal of Ultrasound 1996;4:43-47 6. Smith EH. Complication of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991; 178:253-8 Competing interests: None declared |
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Hilary Butler, Freelance journalist home
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Dear Sir, In 1980, a friend of mine who worked in medical research in USA, was diagnosed, along with two of his colleagues, with early stage prostate cancer. We did not know this, until 1995, when there was a campaign here advising men to get tested for prostate cancer. I discussed this with my friend. He said to me "If this test comes back positive, do not let them do a fine needle aspiration." I asked "Why?" He said "Because when they pull the needle out, the suction created pulls back into the body, along the exit tract, cells, .... which if cancerous, then have direct access to the rest of the body." I said to him "I've never read that. How do you know this?" He replied with word to this effect "It is a matter of debate amongst my colleagues at the moment. Some of us are extremely concerned about this. Some say the rate of needle tract metastasis is only around 5 - 10%. I believe that figure is incorrect because it covers all fine needle aspirations, not just those found to contain malignant cells. If you don't have cancer cells, you won't get needle tract metastases. I believe that the rate for those with malignant cancer cells aspirated by the needle could be around 100%" He then proceeded to tell me about his two colleagues whose samples were "malignant", and how they both died very quickly from cancers that rapidly spread through their bodies. He chose to do it "his" way. In 1999, after a bout of the flu, he got pain in the hip, and went to a US hospital, where they told him his cancer had now spread. He chose hormone treatment only, refusing anything else they had to offer. He was given three years to live. He is still alive today. In this debate above, there are those who say that the study published is not scientific. Ever since 1995, I have kept an eye on FNAC of any sort. It seems to me that the reason there is very little "scientific" evidence as to what the rates of secondary infection are, as a direct result of this procedure, is because medical people have assumed that the risks outweighed the benefits in the ABSENCE of good science. It also seems to me, that this situation continues to this day because those who use and advocate this procedure in their practice have neither the interest or inclination to do proper studies to find out the answers. Some might ask why that would be. The answer to that question should not be that hard to pinpoint.... Sincerely, Hilary Butler. Competing interests: None declared |
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Oliver M Jones, Specialist Registrar in Surgery North Hampshire Hospital, Aldermaston Road, Basingstoke, Hants RG24 9NA, Myrddin Rees, Consultant Hepatobiliary Surgeon; Tim G John, Consultant Hepatobiliary Surgeon; Sean Bygrave, Statistician; Graham Plant, Consultant Interventional Radiologist
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We have followed with interest the recent debate regarding tumour seeding in the aftermath of fine needle aspiration cytology (FNAC) in patients with potentially resectable hepatic colorectal liver metastases (1). Metcalfe and colleagues’ verdict of “useless and dangerous” seems to have provoked strong emotions amongst some of your readers, and we should like to contribute two observations. Our staging protocol comprises liver-specific MRI, chest CT and the selective use of PET, laparoscopy and / or a “trial of time”, but excluding biopsy. Since 1986 we have undertaken more than a thousand liver resections for metastatic cancer without resort to pre-operative biopsy or FNAC with only seven ‘false positives’. In two patients, hepatic cysts were diagnosed at operation and resection was deferred, whilst liver resection was undertaken without complication in the other five (three haemangiomas and two cysts). Recent analysis of 598 consecutive patients undergoing radical resection of colorectal liver metastases examined specifically the 90 patients in whom diagnostic biopsy had been performed prior to referral (2). Histologically-confirmed tumour seeding at the site of biopsy was confirmed in 17 patients (19%). This concurs with the findings of another two recent studies (3,4). In every patient in our series, these chest and abdominal wall deposits were excised at the time of liver resection. Nevertheless, our analysis showed that survival after liver resection was substantially and significantly diminished compared to well-matched patients in whom no biopsy or FNAC had been attempted (5). In our experience, the non-invasive evaluation of potentially resectable colorectal liver metastases is at least 99% specific. Furthermore, the violation of tissue planes by biopsy or FNAC significantly compromises patient survival. We believe, therefore, that Metcalfe and colleagues’ choice of title is apt. Consultation with a specialist hepatobiliary surgical team is recommended before a ‘tissue diagnosis’ is attempted in such patients. 1. Metcalfe MS, Bridgewater FHG, Mullin EF, Maddern GJ. Useless and dangerous-fine needle aspiration of hepatic colorectal metastases. BMJ 2004; 328:507-8. 2. Jones OM, Rees M, John TG, Bygrave S, Plant G. Resectable colorectal liver metastases: to biopsy or not to biopsy? Colorectal Disease 2004; 6:1-34. 3. Rodgers MS, Collinson R, Desai S, Stubbs RS, McCall JL. Risk of dissemination with biopsy of colorectal liver metastases. Dis Colon Rectum 2003; 46:454-8. 4. Ohlsson B, Nilsson J, Stenram U, Akerman M, Tranberg KG. Percutaneous fine-needle aspiration cytology in the diagnosis and management of liver tumours. Br J Surg 2002;89:757-62. 5. Jones OM, Rees M, John TG, Bygrave S, Plant G. Biopsy of colorectal metastases causes tumour dissemination and adversely affects survival following liver resection. Br J Surg 2004 (in press). Competing interests: None declared |
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