Metastasis to the chest wall after fine-needle aspiration: A rare complication

Surgical Rounds®, September 2007, Volume 0, Issue 0

Lance K. Burns, Surgical Resident, Department of Surgery, Tulane University School of Medicine, New Orleans, LA; Bassam Abi-Rachad, Attending Surgeon, Department of Surgery, Rapides Medical Center, Alexandria, LA; Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Lance K. Burns, MD

Surgical Resident

Department of Surgery

Tulane University School of Medicine

New Orleans, LA

Bassam Abi-Rachad, MD

Attending Surgeon

Department of Surgery

Rapides Medical Center

Alexandria, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University School of Medicine

New Orleans, LA

Introduction: Percutaneous transthoracic fine-needle aspiration (FNA) biopsy is a relatively safe procedure that is commonly used to evaluate bronchogenic masses. A rare risk is implantation of malignant cells along the needle tract with subsequent tumor dissemination or chest wall implantation.

Results and discussion: This paper describes a case where malignant cells were implanted in the patient's chest wall as a result of percutaneous FNA of a primary lung carcinoma. The risks of FNA are discussed, and criteria for its use are suggested.

Conclusion: The risk of seeding the tract by FNA should be avoided in patients with potentially curative lung lesions, and a more direct surgical approach may be indicated.

Percutaneous transthoracic fine-needle aspiration (FNA) biopsy is a well-established technique for cytologic evaluation of bronchogenic masses. Although relatively safe, risks include pneumothorax, hemorrhage, air embolus, and hemoptysis. Implantation of malignant cells along the needle tract with subsequent tumor dissemination or chest wall implantation occurs rarely, and only a few such cases have been reported in the literature. We report a case of malignant cells being implanted in the chest wall as a result of percutaneous FNA of a primary lung carcinoma, highlighting the potential of tumor dissemination. We discuss the risks of FNA and suggest criteria for its use.

Case report

A previously healthy 46-year-old African American woman presented to the emergency department with an asthma exacerbation. A chest radiograph showed an incidental mass of the left lung. A computed tomography (CT) scan was performed, which revealed a 3 x 2-cm spiculated mass in the left upper lobe of the lung. There were enlarged lymph nodes in the anterior mediastinum and subcarinal regions. A positron emission tomography scan showed intense uptake within the primary mass, two lymph nodes in the aortopulmonary window, and one node in the precarinal region. There was no evidence of distant metastasis. A CT-guided percutaneous FNA was performed using a 21-gauge needle (Figure 1). The cytology report revealed malignant cells characteristic of non-small cell carcinoma. The patient was started on neoadjuvant chemotherapy and radiation. After the treatment was completed, a left wedge resection with sampling of mediastinal lymph nodes was performed without complications. The tumor did not extend to the pleura. The histology confirmed a non-small cell carcinoma (Figure 2).

Seven months later, the patient underwent a mammogram, which showed a mass in the left breast that was not present on her last mammogram. A CT scan revealed a left breast mass extending from the subcutaneous tissue through the deep pectoralis muscle down to the chest wall (Figure 3). A biopsy was performed. Surgical pathology revealed a moderately differentiated adenocarcinoma consistent with metastatic lung carcinoma (Figure 4).

Discussion

Although first described in 1883, percutaneous needle biopsy was not used regularly until the 1940s.1 Since that time, FNA has gained acceptance as a reliable diagnostic tool for lung masses. The obvious benefits of FNA are its simplicity, high diagnostic yield, infrequency of infection, and low morbidity rates.2 FNA has been performed in countless patients with relatively few complications. A critical risk factor, first recognized by Oschner and DeBakey in 1942, was the possibility of needle tract implantation and subsequent metastasis.3 Fortunately, implantation of neoplastic cells resulting in a secondary tumor is an uncommon complication.

Experimental animal studies have shown that needle tract malignant dissemination is relatively common.1 These models state that up to 90% of needle tracts contain malignant cells but carry only a small risk of seeding a macroscopic metastatic tumor.1 In contrast, most human series report a clinical incidence of needle tract metastasis of less than 1%.4,5 There were several reported cases of needle tract implantation in earlier literature, especially in the 1980s. Nearly all of these occurred with the use of a larger bore Vim-Silverman cutting needle.6,7 There have been few reported cases of implantation or metastasis with the use of small bore needles.

The specimen received from FNA is usually suitable for cytologic evaluation, but it is not necessarily accurate for determining cell type or tumor origin.8 Another important issue is that of sampling, and a negative aspirate does not absolutely exclude the diagnosis of cancer. The false-negative rate of FNA has been reported to be between 5% and 10%.9 Lillington compared the results of immediate thoracostomy with initial needle biopsy in the management of solitary lung nodules and found that thoracostomy provided better overall survival rates when the probability of the mass being malignant was high (>70%).10

Metastatic seeding along the needle tract likely has been underreported. Many patients die before adequate follow-up can be performed after FNA biopsy of a lung mass.11 In cases where needle tract metastases occur, patients with initially resectable carcinomas may develop unresectable lesions and be converted to an unfavorable prognosis.

Conclusion

Although the development of needle tract metastases following FNA is rare, the consequences of this sequela are critical. The CT images and pathology results in our patient document this clearly. Each patient must be evaluated carefully. If the patient is a good operative candidate and has a primary lung carcinoma that is resectable by all clinical criteria, surgical intervention might be warranted without preoperative biopsy. The risk of seeding the tract, resulting in local implantation, should be avoided in patients with a potentially curable lung mass.

References

  1. Seyfer AE, Walsh DS, Graeber GM, et al. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg. 1989;48(2):284-286.
  2. Voravud N, Shin DM, Dekmezian RH, et al. Implantation metastasis of carcinoma after percutaneous fine-needle aspiration biopsy. Chest. 1992;102(1):313-315.
  3. Oschner A, DeBakey M. Significance of metastasis of primary carcinoma of the lungs: report of two cases with unusual site of metastasis. J Thorac Surg. 1942;11:357-387.
  4. Dick R, Heard BE, Hinson KF, et al. Aspiration needle biopsy of thoracic lesions: an assessment of 227 biopsies. Br J Dis Chest. 1974;68(2):86-94.
  5. Sinner WN, Zajicek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockh). 1976;17(4):473-480.
  6. Aronovitch M, Chartier J, Kahana M, et al. Needle biopsy as an aid to the precise diagnosis of intrathoracic disease. Can Med Assoc J. 1963;88:120-127.
  7. Wolinsky H, Lischner MW. Needle track implantation of tumor after percutaneous lung biopsy. Ann Intern Med. 1969; 71(2):359-362.
  8. Sing RF, Kefalides PT, Mette SA, et al. Chest wall metastasis after percutaneous fine-needle aspiration biopsy. J Am Osteopath Assoc. 1996;96(9):546-547.
  9. Levitt RG. Needle aspiration in lung cancer. Chest. 1990; 98(6):1539-1540.
  10. Lillington GA. Hazards of transthoracic needle biopsy of the lung. Ann Thorac Surg. 1989;48(2):163-164.
  11. Glaser KS, Weger AR, Schmid KW, et al. Is fine-needle aspiration of tumours harmless? Lancet. 1989;1(8638):620.