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| Cosmetic Surgery \ Infiltration |
Article - Fine Needle Aspiration
| FINE-NEEDLE ASPIRATION FOR DIAGNOSIS OF INTRANODAL SQUAMOUS-CELL CARCINOMA METASTATIC FROM THE SKIN
Ray Parker, M.D., Scott M. Dinehart, M.D., Richard G. Bennett, M.D., Houn-yee Houn, M.D.
Dr. Parker is Dermatology Resident, and Dr. Dinehart is Assistant Professor, Department of Dermatology, and Dr. Houn is Assistant Professor Department of Pathology, University of Arkansas for Medical Science, Little Rock, Arkansas.
Dr. Bennett, Clinical Professor, University of Southern California, Los Angeles, California.
Address, correspondence to: Scott M. Dinehart, M.D., Department of Dermatology, University of Arkansas for Medical Science, Slot 567, Little Rock, AR 72205.
ABSTRACT. Fine-needle aspiration is a useful way to determine the presence of squamous-cell carcinoma in enlarged lymph nodes of patients at high risk for metastases. Advantages include a high degree of accuracy, outpatient as well as inpatient availability, and negligible potential for seeding of malignant cells. Cutaneous oncologists should consider using this technique on patients with lymphadenopathy and a previous history of cutaneous squamous cell carcinoma.
J Dermatol Surg. Oncol 1990;16:1134-1137.
Cutaneous squamous cell carcinoma is a potentially metastatic tumor. Metastases from cutaneous squamous cell carcinoma occur often enough to be of major concern to cutaneous oncologists. Most metastases occur within 6 months of surgery and almost all occur within 2 years. The development of metastatic disease often portends a poor prognosis. In one study only 25% of patients with metastatic cutaneouse squamous cell carcinoma were alive 5 years following diagnosis. Successful intervention and expedient and timely identification of metastatic disease. We present three cases of cutaneous squamous-cell carcinoma in which cyologic interpretation of material obtained by fine-needle aspirations documented the presence of metastasis.
MATERIALS AND METHODS
This technique of fine-needle aspiration used in this study was similar to the technique described by Franzen and Zajicek. We used an ink marker to outline the mass and cleansed the overlying skin with a suitable surgical antiseptic preparation. If local anesthesia was desired, lidocaine 1% with epinephrine 1 : 100,000 was injected into the skin overlaying the mass. A 10-mL syringe with a 1 inch 23- or 25- gauge needle held in a Frazen single handgrip syringe holder was used for aspiration. While stabilizing the mass between the fingers and thumb of one hand, the other hand held the syringe and introduced the needle into the mass. Negative pressure was then applied to the syringe by pulling the plunger. With the needle firmly within lesion, the needle tip was guided back and forth with short movements in order to loosen tumor cells from the target tissue. Before removing, negative pressure was released by allowing the plunger of the syringe to return to its resting position. As a result, the aspiration remained in the needle. Another reason for releasing negative pressure before withdrawing the needle was to avoid sucking up subcutaneous tissue into the aspirate on the way out of the lesion. The needle tip was then removed from the mass and the specimen within the needle was expelled onto a glass slide. Two slides were prepared immediately. One was stained with May-Grunwald-Giemsa (Diff-Quik) for rapid interpretation by the pathologist and the other was fixed in 95% ethyl alcohol and stained with the Papanicolaou stain for examination at a later date. The 95% ethyl alcohol provided immediate fixation of the sample. The technique described above can be repeated several times to ensure adequate tissue specimens. Before being discarded, the needle was washed with ethyl alcohol and polyethylene glycol to obtain further cells that could be made later into a cell block.
CASE REPORTS
CASE 1
A 73 year old man with a 4 x 5 cm ulcerative nodule overlaying the area of the left parotid gland. Histopathology revealed a poorly differentiated cutaneous squamous-cell carcinoma. Wide local excision of the mass was performed, followed by post-operative radiotherapy. Following radiotherapy, the preauricular area remained swollen and enlarged. Fine-needle aspiration of a capreauricular lymph node confirmed the presence of a matastatic squamous-cell carcinoma. A left superficial parotidectomy and left modified radical neck dissection were then undertaken.
CASE 2
A 71 year old white man presented with a cutaneous mass located over his anterior chest. Wide local excision and skin grafting were performed after a histologic diagnosis of cutaneous squamous-cell carcinoma was made. Six months later, a firm, non-tender left anterior neck mass was discovered. Panendoscopy of the upper aerodigestive tract did not reveal a second primary tumor, so a left radical dissection was performed. Fine-needle aspiration of an enlarged axillary lymph node three weeks later revealed squamous-cell carcinoma. Subsequently, a regimen of x-ray therapy to the axillary area was begun.
CASE 3
An 87 year old white man presented with a 2-3 month history of a progressively enlarged non-tender mass behind the right ear. Physical examination revealed a 1.5 x 2.0 cm raised, firm tumor with central ulceration. The patient underwent wide excisions of this area and pathology confirmed the diagnosis of cutaneous squamous-cell carcinoma. Seven months later a mass in the right jugulodigastric area was discovered. Fine-needle aspiration of this mass revealed squamous-cell carcinediately. Following diagnosis, the patient was immediately begun on radiation therapy.
DISCUSSION
Fine-needle aspiration is a minimally invasive method of tissue diagnosis in which a small amount of tissue is aspirated from a lesion with a syringe and a small-bored needle. The aspiration material is then studied microscopically and accuracy rates of 90-98% have been reported in diagnosing metastatic malignancy. Martin and Ellis were the first to describe a technique of needle aspiration using an 18-gauge needle in the 1930s. Scandinavian investigators of head and neck and breast cancer used smaller gauge needles and further refined and developed the technique for large scale use. Since then, fine-needle aspiration has become increasingly popular among head and neck surgeons and general surgeons in the United States. We advocate its use in patient suspected of having metastatic squamous-cell carcinoma from the skin.
When planning follow-up of patients with cutaneous squamous-cell carcinoma it should be taken into consideration that most patients with clinically appear metastasis will present with palpable lymphadenopathy. Because most cutaneous squamous-cell carcinomas occur on the head and neck, metastatic disease will present most often as cervical or parotid adenopathy. If this occurs, a thorough physical examination of the head and neck is mandatory. In one study involving head and neck cancer patient, 28% of these enlargements were benign. A significant delay often occurs if patients with lymphadenopathy and a history of squamous-cell carcinoma of the skin are placed on antibiotics or followed clinically for long periods of time before open biopsy and lymph node dissection. Because open biopsies are often planned under general anesthesia in a hospital setting, physicians are often reluctant to recommend this avenue as a first alternative. Fine-needle aspiration is a safe, economical, and highly accurate alternative for these patients.
Certainly, metastatic disease from cutaneous cancer is not the only possible cause of enlarged lymph nodes in a patient with a prior history of cutaneous squamous-cell carcinoma. Besides inflammatory causes of adenopathy, it is possible that an adenopathy could result from another non-cutaneous malignancy. Often this malignancy has its origin in the head and neck because lymphatic drainage is similar to that of many head and neck skin cancers. Before the use of fine needle biopsy, the physician often delayed histology diagnosis of the cause of lymphadenopathy while the head and neck surgeon examined and biopsied other possible primary tumor sites. While not all investigators agree, one reason often stated for this that the inappropriate biopsy of squamous-cell carcinoma not of the skin which is metastatic to a cervical node may double both the subsequent rates of local recurrence and distant metastasis. Currently, it is felt that because fine-needle aspiration does not influence prognosis of head and neck cancers, the procedure can be used as son as lymphadenopathy is detected clinically. If the fine-needle aspiration demonstrates epidermoid carcinoma, it could represent either a primary site in the skin or mucosa of the hand and neck region.
Complications of fine-needle aspiration are unusual. The initial concern that fine-needle aspiration could spread tumor at the time of aspiration biopsy has not been confirmed after considerable experience with the procedure. Fine-needle aspiration causes minimal distortion of lymph node architecture and does not interfere with subsequent histologic evaluation of lymphadenopathy. It is important to realize that a negative fine-needle aspiration carries great weight but does not totally exclude malignancy. The specificity of the procedure is greater than 95% for most series, indicating that false positive reports are infrequent. Although accuracy rates are generally above 90%, the sensitivity of the test can range 10% lower.
Fine-needle aspiration can be performed by the clinician or pathologist. The microscopic slides should be examined by an experienced cytopathologist; experience generally increased cytopathologist; experience generally increase the yield of the procedure. It should be noted that other methods are available to diagnose primary tumors of the skin. Primary malignant melanomas should not be diagnosed by fine-needle aspiration because it is the opinion of some that the technique induces inflammation that confuses subsequent histology and may facilitate deeper spread. Previously it was thought that because lymphomas require examination of the entire lymph node for an accurate diagnosis, fine-needle aspiration should not be thought of as a diagnostic procedure when this condition is suspected. However, new evidence suggests that under certain circumstances, fine-needle aspiration can be used in the diagnosis of leukemic lymphadenopathy.
Skin cancer surgeons are presented frequently with the difficulties of metastatic squamous-cell carcinoma from the skin. Continued observations and study of these patients will help lower the associated morbidity and mortality currently experienced. The use of increasingly sophisticated diagnostic techniques, such as fine-needle aspiration, will help expedite selection of treatment options for these patients.
REFERENCE
1. Dinehart SM, Pollack SV, Metastases from squamous cell carcinoma of the skin and lip. An analysis of 27 cases, J Amer Acad Dermatol 21:241-248, 1989.
2. Epstein E. Malignant sun-induced squamous-cell carcinoma of the skin. J Dermatol Surg Oncol 99:505-506, 1983.
3. Franzen S, Zajicek J. Aspiration biopsy in diagnosis of palpable lesions of the breast. Critical review of 3,479 consecutive biopsies. Acta Radiol Ther Phys Biol 7:241-262, 1968.
4. Sismanis A, Strong MS, Merrian J. Fine needle aspiration biopsy diagnosis of neck masses. Otolaryngol Clin North Am 13:421-4299, 1980.
5. Feldman PS, Kaplan MJ, Johns ME, Cantrell RW. Fine-needle aspiration in squamous cell carcinoma of the head and neck. Arch Otolaryngol 109:735-742, 1983.
6. Frable WJ, Frable MA. Thin-needle aspiration biopsy: The diagnosis of head and neck tumors revised. Cancer 43:1541-1548, 1979.
7. Meyers DS, Templer J. Davis WE, et al. Aspiration cytology for diagnosis of head and neck surg 86:650-655, 1978.
8. Russ JE, Scanlon EF, Christ MA Aspiration cytology of head and neck masses. Am J Surg 136 :342-347, 1978.
9. Young JE, Archibald SD, Shier KJ. Needle aspiration cytologic biopsy in head and neck tumor masses, Am J Surg 142:484-489, 19981.
10. Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 992:169-181, 1930.
11. Martin HE Ellis EB. Aspiration biopsy. Surg Gynecol Obstet 59:5788-589, 1934.
12. Sako K, Pradier RN, Marchetta FC, et al. Fallibility of palpation in the diagnosis of metastases to cervical nodes. Surg Gynecol Oncol 118:989-990, 1964.
13. Razack K, Sako K, Marchetta FC, Influence of initial neck node biopsy on the incidence of recurrence in the neck and survival in patients who subsequently undergo curative resectional surgery. J Surg Oncol 9:347-352, 1977.
14. Gooder, P, Palmer M. Cervical Lymph biopsy- a study of its morbidity. J.Laryngol Otol 98:1031-1040, 1984.
15. Johnson JT, Newman RK. The anatomic location of neck metastasis from occult squamous cell carcinoma. Otolaryngl Head Neck Surg 89:54-58,1981.
16. McGuit WF, McCabe BF. Significance of node biopsy before definitive treatment of cervical metstatic carcinoma. Laryngoscope 88: 597-1978.
17. Muller NL, Bergin CJ, Miller RR, Ostrow DN, Seeding of malignant cells into the needle track after lung and pleural biopsy. J Can Assoc Radiol 37:192-194,1986
18. Sinner WN, Zajicek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn 17:473-480, 1976.
19. Engzell u, Jakobsson PA, Sigurdson A, Zajicek J. Aspiration biopsy of matastatic carcinoma in lympnodes of the neck. A review of 1,101 consecutive cases. Acta Otolaryngol 72:138-147, 1971.
20. Piscioli F, Polla E, Pusiol T, Zumiani G, Cristofolini M, Aspiration cytology of cutaneous metastatic melanoma and epidermoid carcinoma of the penis. Amer J Dermatopathol 8:472-477, 1986.
21. Behm FG, O'Dowd GJ, Frable WJ. Fine-needle aspiration effects on benign lymph node histology. Ann J Clin Pathology. Ann J Clin Pathol 82:19995-198, 1984.
22. Lever JV, Trott PA, Webb AJ. Fine needle aspiration cytology. Ann J Clin Pathol 38:1-11, 1985.
23. Dunphy CH, Katz RL, Fanning CV, Dalton WT Jr. Leukemic lymphadenopathy: Diagnosis by fine needle aspiration. Hematol Pathol 3:35-44, 1989.
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