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Journal of Clinical Oncology, Vol 22, No 18 (September 15), 2004: pp. 3828-3829 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.11.058
Challenging Problems in MalignancyCASE 2. Isolated Needle-Track Recurrence Following Fine Needle Aspiration for Non–Small-Cell Lung CancerDepartment of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT; Department of Pathology, The William W. Backus Hospital; and Eastern Connecticut Hematology/Oncology Associates, Norwich, CT A 68-year-old woman presented with a 4 cm peripheral spherical mass in the left lower lobe. Computed tomography (CT) of the chest, abdomen, and pelvis showed no evidence of abnormal mediastinal adenopathy or distant metastatic disease. CT-guided fine needle aspiration (Fig 1) using a 22-gauge Westcott needle revealed non–small-cell carcinoma with features of poorly differentiated squamous cell carcinoma. Postprocedure CT demonstrated a small amount of hemorrhage within the mass but no pneumothorax or hemothorax. The patient subsequently underwent resection of the left lower lobe, confirming the cytologic diagnosis (Fig 2). On pathologic examination, there was no evidence of pleural, lymphatic, or vascular invasion and the bronchial resection margin was free of tumor. Lymph nodes sampled from the left peribronchial region and left superior mediastinum were uninvolved. Therefore, the patient was staged as pT2, pN0, cM0, stage IB, and did not receive adjuvant therapy. Eleven months after surgery, the patient developed a pruritic subcutaneous nodule in the left posterior inferior chest that corresponded to the location of the initial fine needle aspiration and was several centimeters remote from the thoracotomy scar. CT of the chest, abdomen, and pelvis with intravenous contrast demonstrated a 1.0 x 1.5 cm soft tissue density that corresponded with the palpable nodule (Fig 3). Whole-body positron emission tomography showed a focus of intense metabolic activity at this location, but no other sites of active disease (Fig 4). Wide local excision revealed a poorly differentiated carcinoma, histologically similar to the initial lung primary. Although the deep margin of resection was involved, the patient's surgeon felt that additional resection was not feasible without extensive chest wall resection. Therefore, the patient received postoperative radiotherapy using 12 megaelectronvolt enface electrons delivered to a field measuring 5.7 cm by 8.5 cm and centered over the patient's scar. A total dose of 48 Gy was delivered over 12 fractions given 3 days per week. Follow-up CT of the chest 6 weeks after completion of radiotherapy showed focal consolidative changes in the lung parenchyma within the radiotherapy portal but no evidence of a persistent mass lesion, pleural effusion, pulmonary metastasis, or mediastinal adenopathy.
The risk of needle-track seeding after biopsy was initially raised by DeBakey and Oschner in 1942.1 Consistent with these concerns, initial case series reported needle-track seeding after large bore needle biopsies.2,3 However, subsequent case series reported excellent results using fine needle aspiration (FNA) with 18- to 22-gauge needles. For example, FNA with an 18- to 20-gauge needle at the Karolinska Institute (Stockholm, Sweden) resulted in only one case of implantation metastasis out of 1,064 FNAs performed on patients with primary lung cancers.3 Similarly, two other large series totaling 1,697 patients with intrathoracic malignancies found no cases of implantation metastasis after FNA with an 18-gauge needle.4,5 Although these numbers are reassuring, several potential biases may result in underreporting of this outcome. For example, the above series failed to specify their follow-up protocol. Therefore, it is possible that many cases of implantation metastasis were not captured in the analysis. Furthermore, due to the competing risks of systemic disease and death in this patient population, the reported incidence of implantation metastasis likely underestimates the risk for long-term survivors. Physicians and patients should be cognizant of a small but identifiable risk of needle-track recurrence after FNA of a malignant lung nodule. This risk is particularly important for patients with early stage non–small-cell lung carcinoma, given their relatively high cure rates. Some authors have therefore suggested that patients with chest CT findings highly suspicious for a localized primary lung neoplasm undergo video-assisted thoracoscopic surgery (VATS) with frozen section rather than CT-guided FNA.6 Even with VATS procedures, some centers now place the specimen in a small plastic bag before withdrawal from the thorax, to reduce local tumor seeding. Another approach is to carry out a biopsy via a needle within a needle. Finally, the role of positron emission tomography scanning in the evaluation of a pulmonary nodule is evolving and may alter the indications for FNA before definitive surgery. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Ochsner A, DeBakey M: Significance of metastasis in primary carcinoma of the lungs: Report of two cases with unusual site of metastasis. J Thorac Surg 11:357-387, 1942 2. Sinner WN: Complications of percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockh) 17:813-828, 1976[Medline] 3. Sinner WN, Zajicek J: Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockh) 17:473-480, 1976[Medline] 4. Lalli AF, McCormack LJ, Zelch M, et al: Aspiration biopsies of chest lesions. Radiology 127:35-40, 1978[Abstract] 5. Sagel SS, Ferguson TB, Forrest JV, et al: Percutaneous transthoracic aspiration needle biopsy. Ann Thorac Surg 26:399-405, 1978[Abstract]
6. Ost D, Fein AM, Feinsilver SH: Clinical practice. The solitary pulmonary nodule. N Engl J Med 348:2535-2542, 2003
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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