Needle tract seeding after bone marrow biopsy in non-Hodgkin lymphoma

Endovascular management of iatrogenic arterial injury post bone marrow biopsy: A report of 3 cases

Bone marrow biopsy is an important tool for the evaluation of malignant and benign hematologic disorders. Performed blindly, usually with a Jamshidi biopsy needle penetrating the posterior iliac crest bone, the procedure is generally considered safe but rarely complications are observed; vascular complications associated with bleeding are the most serious and potentially life-threatening. We describe 3 cases of arterial injury following a bone marrow biopsy procedure, all treated successfully with minimal invasive endovascular management, and emphasize the need for clinical awareness and recognition of this rare complication in order to facilitate rapid diagnostic and minimal invasive therapeutic interventions, when appropriate, for successful outcomes.

PET/CT-based bone-marrow assessment shows potential in replacing routine bone-marrow biopsy in part of patients newly diagnosed with extranodal natural killer/T-cell lymphoma

PURPOSE

This study aimed to determine the potential of positron emission tomography/computed tomography (PET/CT) in replacing routine bone-marrow biopsies (BMB) in newly diagnosed extranodal natural killer/T-cell lymphoma (ENKTCL).

METHODS

Newly diagnosed patients underwent PET/CT imaging and routine BMB to assess bone/bone marrow involvement (BMI). Clinical stage and treatment plan were determined, and survival was compared.

RESULTS

In a total of 101 patients, 78 were diagnosed as stage I/II and 23 as stage III/IV without using the BMB results. No BMB-positive patients were identified in stages I/II, and therefore, the BMB results did not alter the stage and treatment choice in any patients. The sensitivity and specificity of focal skeletal PET/CT lesion(s) in assessing BMI was 100% and 92.8%, respectively, taking routine BMB as the reference standard. The overall survival (OS) and progression-free survival (PFS) of BMB-positive patients was significantly inferior (P = 0.0011 and 0.0465, respectively, in advanced-stage patients; both P < 0.0001 in all patients), and this was corroborated by the PET/CT findings (P = 0.0006 and 0.0116, respectively, in advanced-stage patients; both P < 0.0001 in all patients).

CONCLUSIONS

Based on the results, PET/CT demonstrated satisfactory predictive performance in terms of staging and prognosis in ENKTCL. BMB did not influence staging and treatment in newly diagnosed ENKTCL, and routine non-targeted BMB is not obligatory for early stage patients undergoing PET/CT. Targeted BMB is recommended to confirm BMI in advanced-stage patients.

Association of core needle biopsy tract resection with local recurrence in extremity soft tissue sarcoma

OBJECTIVE

Due to minimal tissue violation in percutaneous core needle biopsy (CNB), in contrast to open biopsy, the risk of tumor seeding and subsequent local recurrence (LR) along the biopsy tract remains unclear in extremity soft tissue sarcoma (STS). This study sought to examine the association of CNB tract resection on LR in a large STS institutional database.

MATERIALS AND METHODS

After a retrospective review of the 116 patients who underwent CNB prior to surgery for previously untreated non-metastatic extremity STS, 36 patients who did not have CNB tracts resected (CNB-NR) were matched with 36 who had CNB tracts resected (CNB-R) for the factors that are known to affect LR.

RESULTS

Two patients (6%) developed LR in the CNB-R group, whereas three patients (8%) developed LR in the CNB-NR group (P = 0.643). On Kaplan-Meier analysis, there was no significant difference in LR-free survival between the two groups (94.3% ± 3.9 for the CNB-R group vs. 93.8% ± 4.3 for the CNB-NR group, P = 0.747).

CONCLUSION

Our data suggest any influence of a CNB tract resection on LR, within the limitations of this study, is likely to be of minor clinical importance in extremity STS. Although it would be prudent to resect the CNB tract in most cases, not resecting the CNB tract is a feasible option if identification or removal of the CNB tract proves difficult.

TUMOR CONTAMINATION IN THE BIOPSY PATH OF PRIMARY MALIGNANT BONE TUMORS

Objective: To study factors possibly associated with tumor contamination in the biopsy path of primary malignant bone tumors. Method: Thirty-five patients who underwent surgical treatment with diagnoses of osteosarcoma, Ewing's tumor and chondrosarcoma were studied retrospectively. The sample was analyzed to characterize the biopsy technique used, histological type of the tumor, neoadjuvant chemotherapy used, local recurrences and tumor contamination in the biopsy path. Results: Among the 35 patients studied, four cases of contamination occurred (11.43%): one from osteosarcoma, two from Ewing's tumor and one from chondrosarcoma. There was no association between the type of tumor and presence of tumor contamination in the biopsy path (p = 0.65). There was also no association between the presence of tumor contamination and the biopsy technique (p = 0.06). On the other hand, there were associations between the presence of tumor contamination and local recurrence (p = 0.01) and between tumor contamination and absence of neoadjuvant chemotherapy (p = 0.02). Conclusion: Tumor contamination in the biopsy path of primary malignant bone tumors was associated with local recurrence. On the other hand, the histological type of the tumor and the type of biopsy did not have an influence on tumor contamination. Neoadjuvant chemotherapy had a protective effect against this complication. Despite these findings, tumor contamination is a complication that should always be taken into consideration, and removal of the biopsy path is recommended in tumor resection surgery.

Neoplasm seeding in biopsy tract of the musculoskeletal system. A systematic review

To identify, through a systematic literature review, the characteristics of neoplasm seeding in biopsy performed on the musculoskeletal system. We performed a search on PubMed, MEDLINE, LILACS and SciELO from August to October 2010. We included articles that addressed the neoplasm seeding in biopsy performed on the musculoskeletal system. The search was limited to English, Spanish and Portuguese as publication languages, but it was not limited by year of publication. We retrieved 2858 articles, but only seven were selected based on inclusion and exclusion criteria. Other four papers were found in the references of selected articles, totalizing 11 articles that were used to perform this systematic review. Issues may be raised in the literature: age and gender don't seem to influence the occurrence of neoplasm seeding; without resection of the biopsy tract, the possibility of local recurrence is very real; the influence of the type of tumor in the occurrence of neoplasm seeding is uncertain; it is impossible to conclude whether the closed biopsy technique has a lower chance of neoplasm seeding; it is likely that adjuvant chemotherapy has a protective effect against neoplasm seeding; an unfavorable prognosis is expected according to neoplasm seeding results.

Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.

Needle-tract seeding after percutaneous vertebroplasty: a case report

STUDY DESIGN

A case report.

OBJECTIVE

We report a case of needle-tract seeding (NTS) of adenocarcinoma of the lung in the thoracic spine that manifested after vertebroplasty (VP).

SUMMARY OF BACKGROUND DATA

NTS after a biopsy is sometimes observed. However, NTS after an injection, as in VP, is a very rare complication.

METHODS

A 61-year-old female presented with a painful back mass and weakness in both lower extremities. She had been diagnosed with adenocarcinoma of the lung 2 years previously. The patient had complained of severe back pain 5 months before and was diagnosed with a metastatic pathological fracture of T4-T6. She underwent uneventful percutaneous VP at T4-T6 followed by radiation therapy at that time.

RESULTS

Magnetic resonance imaging revealed that the subcutaneous mass extended to the right T5 pedicle with an extension to the adjacent epidural space of T4-T7. Paramedian skin incision was made like a spindle and the back mass was totally removed with the covering skin and surrounding soft tissue. The tumor was connected with lamina, but ribs and pleura were clear. We performed T4-T7 laminectomy, right T5 pediculectomy, epidural tumor curettage, pedicle screw placement at T2-T3, T6-T9. Histological analysis confirmed the diagnosis of metastatic adenocarcinoma of the lung. The patient recovered after the operation, and her back pain and weakness had improved.

CONCLUSION

NTS can be caused by even VP in patients with a pathological fracture. NTS needs to be considered in cases where it is difficult to inject polymethyl methacrylate.

Adult soft tissue sarcoma local recurrence after adjuvant treatment without resection of core needle biopsy tract

BACKGROUND

Core needle biopsies of sarcomas allow a diagnosis in a high percentage of patients with few complications. However, it is unclear whether the tract needs to be excised to prevent recurrences.

QUESTIONS/PURPOSES

We therefore determined the rates of recurrence and metastases in patients with Stage III extremity sarcomas, who underwent wide local resection without excision of the needle tract and also received adjuvant treatment.

METHODS

We retrospectively reviewed 59 adult patients with deep, larger than 5 cm, high-grade soft tissue sarcomas of the upper or lower extremity treated between January 1999 and April 2009. All the patients underwent a core needle biopsy. Resection was performed with wide margins. The biopsy tract was not resected during the definitive surgery. Fifty-seven patients (97%) received preoperative and/or postoperative radiation, whereas 49 patients (83%) received chemotherapy. Local recurrence and distant recurrence rates were determined. The minimum followup was 24 months (median, 56 months; range, 24-122 months).

RESULTS

The local recurrence rate was 9%. Fifteen patients (25%) developed metastasis after diagnosis. Seven of the 59 patients (12%) had microscopic positive margins at resection.

CONCLUSIONS

Our data demonstrate no increase in local recurrence rates or rates of metastatic disease compared with previously published studies when resection of the core biopsy tract was not performed.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Endoscopic ultrasound staging of cholangiocarcinoma

PURPOSE OF REVIEW

Cholangiocarcinoma is a malignancy arising from biliary tract epithelium that is increasing in incidence and is associated with a poor prognosis. The difficulty in diagnosis and relatively poor staging accuracy complicate management. In this review we examine the utility of endoscopic ultrasound (EUS), which is increasingly used in this setting to overcome the limitations of other imaging and biopsy techniques.

RECENT FINDINGS

Inherent limitations of current approaches to cholangiocarcinoma diagnosis and staging have driven the pursuit of new technologies including EUS. However, there remains a relative paucity of data and some uncertainty as to the role of EUS within the diagnostic algorithm for patients with suspected or known cholangiocarcinoma. In addition, there is controversy regarding the role of EUS fine-needle aspiration, the findings of which may enhance diagnosis, but may also predispose to tumor seeding and iatrogenic upstaging.

SUMMARY

An emerging indication for EUS is the diagnosis and staging of cholangiocarcinoma. This information may be used to help guide patient care and improve outcomes, but may also be employed in a manner that risks patient well being.

Does the taking of biopsies affect the metastatic potential of tumours? A systematic review of reports on veterinary and human cases and animal models

Clinicians and pathologists are sporadically asked by owners whether the taking of tumour biopsies may affect the behaviour of the tumour, including its potential to metastasise. Unfortunately, systematic studies on this subject are unavailable in veterinary medicine, and the aim of this study was to estimate the risk of adverse effects of biopsy taking on tumour progression in animals. A systematic review of veterinary and human case reports and clinical studies as well as experimental animal models of biopsy-induced tumour metastasis was undertaken. There were only two veterinary case reports of needle tract metastases (NTM) following the taking of needle biopsies from urogenital and pulmonary tumours. Seventeen experimental studies found a high incidence of NTM but only a rat osteosarcoma and a hamster squamous carcinoma model showed an increased incidence of distant or regional metastases after incision or excision biopsy. In human medicine, the occurrence of NTM has been reported after the taking of biopsies from mesotheliomas (15%), melanomas (11%) and gall bladder tumours (11%), liver metastases of colon carcinomas (4%) and mammary carcinomas (4%) but an incidence of only <1% for all other tumours. Circulating tumour cells increased immediately after the taking of biopsies from human squamous cell, prostate, breast and hepatocellular carcinomas. Although no increased risk of biopsy-induced distant metastasis has been reported for any type of tumour, this is inconclusive due to a lack of non-biopsied control groups in human studies. Reports of biopsy-induced metastasis in animal tumours indicate that the taking of transcutaneous biopsies from urogenital tumours may be associated with a risk of NTM. However, there is no evidence of a general increase in risk of distant metastases in any tumour type in people or animals. The overall risk therefore appears to be negligible when compared to the valuable information obtained from biopsies in veterinary practice.

Prospective cytological assessment of gastrointestinal luminal fluid acquired during EUS: a potential source of false-positive FNA and needle tract seeding

OBJECTIVES

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) can result in false-positive cytology and can also cause needle tract seeding. Our goal was to evaluate a potential cause, namely, the presence of malignant cells within gastrointestinal (GI) luminal fluid, either as a result of tumor sloughing from luminal cancers or secondary to FNA of extraluminal sites.

METHODS

During EUS, luminal fluid that is usually aspirated through the echoendoscope suction channel and discarded was instead submitted for cytological analysis among patients with cancer and benign disease. Pre- and post-FNA luminal fluid samples were collected to discern the role of FNA in inducing a positive cytology. When not performing FNA, one sample was collected for the entire examination. The final diagnosis was based on strict clinicopathological criteria and >or=2-year follow-up. This study was conducted in a tertiary referral center.

RESULTS

We assessed the prevalence of luminal fluid-positive cytology among patients with luminal (e.g., esophageal), extraluminal (e.g., pancreatic), and benign disease. Among the 140 patients prospectively enrolled with sufficient sampling and follow-up, an examination of luminal fluid cytology showed positive results for malignancy in luminal and extraluminal cancer patients, 48 and 10%, respectively. This included 8 out of 23 esophageal, 4 of 5 gastric, and 9 of 15 rectal cancers. The positive luminal fluid cytology rate with luminal cancers was not affected by performing FNA. Post-FNA luminal fluid cytology was positive in 3 out of 26 with pancreatic cancers. Cytological examination of luminal fluid aspirates did not demonstrate malignant cells in any patient with nonmalignant disease.

CONCLUSIONS

Malignant cells are commonly present in the GI luminal fluid of patients with luminal cancers and can also be found in patients with pancreatic cancer after EUS FNA. Further study is needed to determine the impact of these findings on cytological interpretation, staging, risk of needle tract seeding, and patient care and outcomes.