Biopsy of potentially operable hepatic colorectal metastases-not useless but certainly dangerous.
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.
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
Competing interests:
No competing interests
21 September 2004
Oliver M Jones
Specialist Registrar in Surgery
Myrddin Rees, Consultant Hepatobiliary Surgeon; Tim G John, Consultant Hepatobiliary Surgeon; Sean Bygrave, Statistician; Graham Plant, Consultant Interventional Radiologist
North Hampshire Hospital, Aldermaston Road, Basingstoke, Hants RG24 9NA
Rapid Response:
Biopsy of potentially operable hepatic colorectal metastases-not useless but certainly dangerous.
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
Competing interests: No competing interests