Eur J Cardiothorac Surg 2007;32:171-173. doi:10.1016/j.ejcts.2007.03.041
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Chest wall implantation of thymic cancer after computed tomography-guided core needle biopsy
Keitarou Matsumotoa,*,
Kazuto Ashizawab,
Tsutomu Tagawaa,
Takeshi Nagayasua
a Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
b Department of Radiology and Radiation Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
Received 10 January 2007;
received in revised form 14 March 2007;
accepted 19 March 2007.
* Corresponding author. Tel.: +81 95 849 7304; fax: +81 95 849 7306. (Email: kmatsumo{at}net.nagasaki-u.ac.jp).
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Abstract
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Percutaneous core needle biopsy is a useful procedure for diagnosing lung and mediastinal tumors. However, it has the potential to spread malignant cells from the tumor to the chest wall and pleural cavity. We report the case of a patient with thymic cancer who developed a metastatic tumor at the transthoracic needle biopsy site following a curative resection. The patient underwent an additional chest wall resection, but she developed recurrence in the pleural cavity 1 month after the second operation. The risk of tumor implantation and the related complications that can occur with transthoracic needle biopsy should be considered in patients with a malignant tumor. The indications for transthoracic needle biopsy should be restricted.
Key Words: Transthoracic core needle biopsy • Thymic cancer • Chest wall implantation
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1. Introduction
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Core needle biopsy is a well-established and useful procedure for diagnosing lung and mediastinal tumors. On the contrary, it carries the risk of several complications, such as pneumothorax, bleeding, infection, and tumor dissemination. In particular, dissemination is a serious problem with this procedure; thus, the use of this procedure for lung and mediastinal tumor patients is still controversial. We report the case of a patient with thymic cancer who developed a metastatic tumor at the transthoracic needle biopsy site following a curative resection.
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2. Case report
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A 30-year-old woman was referred to our department with a diagnosis of thymic cancer, based on a transthoracic core needle biopsy (Fig. 1A). The procedure had been performed twice using an 18-Gauge FINE CORE (18G x 150 mm, TORAY, Tokyo, Japan) due to the request of the pathologists and the hematologists involved in the case in order to obtain larger specimens, since malignant lymphoma was considered in the differential diagnosis. The patient had left anterior and posterior chest pain of 1-month duration; her past medical history was unremarkable. Computed tomography (CT) revealed a 5.0 cm x 5.0 cm heterogeneous mass in the anterior mediastinum, with suspected invasion of the main pulmonary artery (Fig. 1A). On CT, there was no evidence of enlarged mediastinal lymph nodes or distant metastases.
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Fig. 1. Computed tomography scans showing core needle biopsy to the primary mediastinal tumor (arrow) (A) and implantation metastasis in the left chest wall (B).
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Induction chemotherapy was chosen because it was judged that complete resection of the tumor would be difficult given the invasion of the pulmonary artery. The patient was given two cycles of preoperative chemotherapy (cisplatin 80 mg/m2 on day 1 and etoposide 100 mg/m2 on days 1, 2, and 3 of each 21-day cycle). The patient achieved a partial response with induction chemotherapy: the degree of tumor invasion and the tumor size decreased. Thus, at that time, it was judged that complete resection was possible, and the patient underwent an extended thymothymectomy with partial resection of the left upper lobe of the lung, pericardium, and left phrenic nerve, and a mediastinal lymphadenectomy via a total median sternotomy. Macroscopically, the resection appeared complete. Histological examination revealed moderately differentiated squamous cell carcinoma of the thymus without any involvement of mediastinal lymph nodes and the resection margins. Adjuvant mediastinal radiation therapy was started on the 27th postoperative day.
On the 33rd postoperative day, an anterior chest wall mass was found on physical examination. Chest CT performed at that time revealed a 2.2 cm mass located on the left anterior chest wall at the site of the previous needle biopsy (Fig. 1B). A biopsy was done, and the diagnosis was squamous cell carcinoma, which correlated with the original tumor, thus strongly suggesting implantation metastasis. Part of the chest wall, including the second and third ribs, and the tumor were resected. Macroscopically, the resection appeared complete. After surgery, a total of 45 Gy (in 1.8-Gy fractions) of mediastinal radiation was given, followed by additional sequential chemotherapy. However, 1 month after the second operation, intrathoracic metastasis was found. The patient was given the same chemotherapy as had been given preoperatively, as well as another regimen (docetaxel 50 mg/m2 on day 1). However, treatment was not effective, and she died of metastasis 9 months after the second operation.
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3. Discussion
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Core needle biopsy is a well-established and useful procedure for diagnosing lung and mediastinal tumors; it has a high sensitivity and a low mortality. The incidence of complications following core needle biopsy, such as pneumothorax, infection, bleeding, air embolism, and implantation metastasis, is low [1,2]. In both experimental models [3,4] and clinical cases [5,6], tumor dissemination has been reported following transthoracic needle biopsy. The overall reported incidence of tumor dissemination in the needle tract is less than 1% [7]; it was reported to be 0.02% of a total of 5300 cases [8]. This is the first case of implantation metastasis in our institution. It has been suggested that the true incidence of tumor implantation along the needle site track is underestimated, since not all cases are diagnosed or reported, and many of the patients die before the metastases become clinically apparent [5].
Some reports have shown that, in non-small cell lung cancer, the incidence of implantation metastasis depends on the size of the needle that is used [6,9]. Fine needle aspiration (FNA) techniques are usually adequate for diagnosing carcinomatous lesions. However, a cutting needle biopsy should be done whenever possible when lymphoma, thymoma, or neural masses are suspected in order to obtain the larger specimens required for more accurate histological diagnosis. Morrissey and associates demonstrated that core needle biopsy is a useful and accurate procedure [10]. For this reason, core needle biopsy with 18-gauge needles is our general practice. Although implantation is a cause of concern, it is not sufficient to contraindicate the use of this procedure, as there is no alternative procedure for diagnosing mediastinal tumors.
There have been no previously published reports dealing with chest wall implantation of thymic cancer following fine needle aspiration cytology, though there have been some reports on implantation in lung cancer cases, which reported that implantation metastasis occurred from 2 to 26 months after needle biopsy [6]. During follow-up, the needle biopsy site should be examined so that an early diagnosis can be made.
The treatment strategy for implantation metastasis in patients with lung cancer is controversial. Seyfer and associates suggested that, if there is no evidence of distant metastases, a wide en bloc resection should be done [7]. Joo and associates performed wide and complete excision, followed by local radiation [6], although they did not report the effect of postoperative radiation. Furthermore, they found that the implantation metastases that recurred after chest wall resection were larger than 2.5 cm at the time of diagnosis. Consequently, they advocate that implantation metastasis should be diagnosed as early as possible to achieve cure with chest wall resection [6]. In the present case, although the size of the implantation metastasis was 2.2 cm, and complete resection was performed, the patient died of intrathoracic metastases. It is known that even with small lesions, it is difficult to manage cases of pleural carcinomatosis.
In conclusion, if implantation metastasis is found early when the nodule is small, surgical resection will have an acceptable result. The possibility of implantation metastasis should not be used as an argument against the use of percutaneous needle biopsy. However, the indications for doing percutaneous needle aspiration biopsy should be restricted.
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References
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- Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Pearson MC. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989;48:284-286.[Abstract]
- Sinner WN, Zajicek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockholm) 1976;17:473-480.
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- Morrissey B, Adams H, Gibbs AR, Crane, MD. Percutaneous needle biopsy of the mediastinum: review of 94 procedures. Thorax 1993;48:632-637.[Abstract/Free Full Text]
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Abstract
1. Introduction
