microscopy This appears to be true whether pulmonary hypertension is presents· 13 or absent.r" Cystic medial necrosis of the pulmonary arteries occurs in association with Marfans syndrome and long-standing pulmonary hypertension.I.' Atherosclerotic degeneration of the pulmonary arteries has also been described with congenital heart disease and associated pulmonary hypertenston.s" Since only a small percentage of patients with pulmonary hypertension develop proximal PAA,it is speculated that a congenital defect in the connective tissue of the arterial wall is a contributing factor.' The patient presented in this report is asymptomatic and has had roentgenographically stable proximal PAAs for at least a five-year period. The etiology of her aneurysms remains unknown. The patient did not have underlying causes of secondary pulmonary hypertension such as heart disease, chronic obstructive pulmonary disease, or thromboembolic disease. Although Doppler echocardiography revealed mild pulmonary hypertension, it is unlikely that this factor should have caused such extensive aneurysm formation. Pulmonary angiography was not performed since computed tomography was diagnostic. In summary, we have described an adult patient with only mild pulmonary hypertension who presented with bilateral proximal PAAs which spared the main trunk. This is a rare presentation of a rare disease. Proximal PAA is an extremely rare disease which belongs in the differential diagnosis of hilar enlargement. Contrast-enhanced computed tomography can be a valuable noninvasive diagnostic tool as it can help to separate lymph nodes from vascular dilatation. REFERENCES
1 Trell E. Pulmonary artery aneurysm. Thorax 1973; 28:644-49 2 Bartter T, Irwin RS, Nash G. Aneurysms of the pulmonary arteries. Chest 1988; 94:1065-75 3 Deterling RA, Clagett QT. Aneurysms of the pulmonary artery: review of the literature and report of a case. Am Heart J 1947; 34:471-99 4 Chiu B, Magi} A. Idiopathic pulmonary artery trunk aneurysm presenting as cor pulmonale: report of a case. Hum Patholl985; 16:947-49 5 Barbour DJ, Roberts WC. Aneursym of the pulmonary trunk unassoeiated with intracardiac or great vesselleft-to-right shunting. Am J Cardioll987; 59:192-94 6 Arom ~ Richardson JD, Grover FL, Ferris G, Trinkle JK. Pulmonary artery aneurysm. Am Surg 1978; 44:688-92 7 Cole FH, Hanano AA, Pate.JW Peripheral pulmonary embolization from central pulmonary aneurysm. Chest 1979; 75:51718 8 Shilldn KB, Low U Chen BT. Dissecting aneurysm of the pulmonary artery J Patholl969; 96:25-29 9 Butto F, Lucas R~ Edwards JE. Pulmonary artery aneurysm: a pathologic study of6ve cases. Chest 1987; 91:237-41 10 PerlofJ JIC. Idiopathic dilatation of the pulmonary trunk. In: PerlofJ JK, 00. Clinical recognition of congenital heart disease. 3rd 00. Philadelphia: WB Saunders, 1987:220-25 11 Gould L, Yang DC, Patel C, Patel D, Lee J, Judge D, et al, Aneurysms of the pulmonary arteries: a case report. Angiology 1987; 38:474-78 12 Gould L, Reddy CVR, Yang CS. Aneurysms of the pulmonary arteries. Angiology 1977; 28:119-24 13 Finch EL, Mitchell RS, Guthaner DF, Fowles RF, Miller DC. Pulmonary artery surgical aneurysmorrhaphy: Where do we go from here? Am Heart J 1983; 106:614-18
Implantation Metastasis of Carcinoma after Percutaneous Fine-Needle Aspiration Biopsy* Nann \bravud, M.D.; Dong M. Shin, M.D.; Boupen H. Dekmezian, M.D.; Isaiah Dimery, M.D.; lin S. Lee, M.D.; and Woon ta Hong, M.D.
Implantation of malignant cells along the needle tract is an extremely rare but potential complication following percutaneous needle aspiration biopsy of malignant lesions. Percutaneous fine-needle aspiration biopsy (FNAB) has recently received more attention for cytologic diagnosis of bronchogenic carcinoma because of its high diagnostic yield, simplicity, and low morbidity. On the other hand, dissemination of cancer cells by needle aspiration biopsy can change a potentially resectable localized lung cancer to an unresectable one. We report two cases: one patient underwent FNAB of a metastatic left adrenal mass that seeded a paraspinal muscle implantation of malignant cells that subsequently developed a tumor mass, and the second patient had tumor cell implantation in the chest wall after FNAB of a pleural-based adenocarcinoma of the lung. The theoretical and practical importance of tumor cell spread along the needle tract is discussed. Because of its rare incidence, however, this complication should not affect the use of needle aspiration biopsy in bronchogenic carcinoma, although care should be undertaken during the procedure.
(ehe., 1992; 102:313-15)
I FNAB =fine-needle aspiration biopsy I e ~ c u ta n ~ o u s ne~dle aspiration has been widely used for diagnosis of malignant neoplasms. The common complications that might be encountered in performing needle aspiration biopsy of the lung are pneumothorax, hemorrhage, infection, and air emboli. Implantation of tumor cells along the needle tract is an extremely uncommon complication of this technique. Among thousands of fine-needle aspiration biopsies (FNAB) performed in lung cancer patients, there are only a few reports of tumor implantation after this procedure. 1,2 Most of these complications have followed the use of cutting needles or relatively large-bore needles.'... However, chest wall implantation of bronchogenic carcinoma after FNAB has occurred, although it is even more rare. 5,6 The role of immediate radiotherapy after biopsy to prevent tumor implants in the needle track was raised in one report. 7 Because of this rare but significant complication, we present herein two cases: one patient who had an adenocarcinoma of the lung and developed paras pinal muscle implantation after FNAB of his left adrenal mass; the other patient developed chest wall implantation after pleural needle biopsy was performed.
CASE REPORTS CASE
A 49-yeaN>ld man was examined for obstructive pneumonia of the left upper lobe. Bronchoscopy was done by an outside hospital *From the Departments of Medical Oncology and Pathology, The University of Texas M. D. Anderson Cancer Center, Houston. Dr. Shin is a recipient of a Clinical Oncology Career Development Award from the American Cancer Society. CHEST I 102 I 1 I JUL'f, 1992
FIC;URE 1. Computed tomographic scan of abdomen shows the position of the fine needle (at armw) at the time of aspiration biopsy of the left adrenal metastasis. and revealed an obstruction of the left upper and lower lobe bronchi by a mass that appeared to he a bronchogenic carcinoma. Transbronchial needle biopsy usin~ bronchoscopy demonstrated a poorly differentiated adenocarcinoma. Metastatic workup consisting of computed tomographic (Cf) scanning of abdomen revealed a left adrenal gland enlargement. Because of the possible resectability of the primary lung cancer, a FNA of the left adrenal mass was employed under CT guidancc' (Fig 1). The aspiration smears from the left adrenal gland revealed adenocarcinoma consistent with metastasis from the primary lun~ carcinoma. He was treated with one course of mitomycin and vinblastine with no response . One month after the FNA procedure, a swelling at the site of FNA was noticed . A CT scan of the abdomen indicated an enhancing mass in the left paraspinal muscle that was in the path of the original needle aspiration (Fig 2). and the tumor mass was judged to he developed fmmthe cell spillage at the tinlt'ofFNAB. Because of his progressive lung cancer, chemotherapy W,L~ changed to cisplatin and etoposide. He W,L~ subsequently treated with external irradiation to the chest. Unfortunutely, the patient eventually died of disease progression fmm the primary site and metastatic sites as well. c.~st
A 32-yc'ar-oldnonsmoking woman presented with a right pleural effusion . Thoracentesis was performed , and cytologic study failed to show a malignant neoplasm . The patient then underwent percutaneous transthoracic needle aspiration hiopsv, which was
FIGURE 2. One month after FNAB of the patient in Figure 1. CT scan of abdomen demonstrated a large enhancing mass with a central necrosis (at amnc) that was developed in the left paraspinal muscle in the needle tract in the same direction of the original needle aspiration (A). 314
FIGURE 3 . Computed tomographic scan of chest illustrates an enhancing mass (at arrow) in the lateral chest wall at the site of previous needle aspiration two months after a FNAB . positive for adenocarcinoma. An exploratory thoracotomy revealed multiple nodules on the right pleura and a 3.5-<:m tumor mass in her right upper lobe . Right pleurectomy and lung resection were done subsequently. Two months after pleural biopsy, she was found to have a chest wall mass at the site of previous needle biopsy (Fig 3). Percutaneous fine needle aspiration of this chest wall lesion demonstrated the same histologic features as those of the lung lesion . Metastatic workup showed bilateral small ovarian lesions and low attenuation areas in the liver. To rule out the possibility of primary ovarian cancer. she then underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and liver biopsy There were small microfoci of metastatic deposits in the ovaries and omentum and multiple liver metastases that were consistent with metastatic adenocarcinoma from primary lung cancer. She received three courses of combination chemotherapy consisting of ifosfamide, eisplatin, and etoposide and immunotherapy without response. She subsequently died of disease progression from primary lung cancer and metastatic sites. DISCUSSION
Needle aspiration biopsy is a well-established technique for cytologic diagnosis of malignant neoplasm. One rare complication of this procedure is implantation seeding of malignant cells within the needle tract, resulting in a metastatic tumor mass. Experimentally, it has been demonstrated that fluid seeded through the needle puncture (18-gauge) of a transplanted malignant lymph node in a rabbit contained malignant cells.' The risk of needle tract metastasis in humans was raised by Oschner and Debakey" as early as 1942. Patients with an otherwise resectable lesion may have an unfavorable prognosis should this sequela occur. Fortunately, it is a very rare complication of the percutaneous transthoracic FNAB procedure. Sinner" reported one such case among 5,300 needle biopsies performed on 2,726 patients (0.02 percent). Kline and Neal" reported more than 3,000 FNABs, while Lalli et al" reported more than 1,500 aspirations without a single incidence of needle tract metastasis. It is more commonly associated with the use of the Vim-Silverman cutting needle, which has a larger bore, because such methods usually yield more sizable stromal fragments.7•13. " It is, therefore, feasible that contamination by more cancer cells and the presence of tissue stroma provide a better opportunity for tumor cells to be seeded and to grow along the needle tract. To our knowledge, no Implantation Metastasls 01Clln:Inoma (Vorevudet aJ)
case reports of paraspinal muscle implantation of lung cancer after a FNAB of an adrenal gland mass have been documented. At necropsy, up to 27 percent of lung cancer patients show spontaneous adrenal metastasis, 1.~. I~ contrast, skeletal muscle metastases are particularly rare despite the fact that muscle mass is much greater than the adrenal gland. Collectively these experimental and clinical observations support the seed-and-soil hypothesis, which states that differential tumor cell and host organ interactions can occur, which are more or less favorable for metastatic development. 16.17 The prevention and the management of implantation metastasis after percutaneous needle aspiration biopsy will remain undetermined until a larger number of such cases are available for analysis. One patient still developed tumor implantation in the chest wall after needle aspiration biopsy of the primary lung adenocarcinoma despite having received radiotherapy after biopsy 7 A case of chest wall implantation of adenocarcinoma of the lung after FNAB has been successfully treated with radical full-thickness excision of the chest wall and immediate reconstruction with a large rectus abdominus musculocutaneous flap. The patient continues to show no evidence of residual disease 15 months after the lobectomy 5 If the patients have no metastasis other than tumor implantation by FNAB, it is our opinion that patients should be treated with radical excision and irradiation if surgery is not feasible, or combined approach. In the present cases, we did not attempt aggressive surgical resection or irradiation to the implanted sites because both patients had already distant metastasis. Needle aspiration biopsy remains an effective alternative to exploratory surgery when clinical signs of unresectability indicate a need for tissue diagnosis. Implantation metastasis is rare and should not be a contraindication to the use of FNAs in lung cancer patients. However, its risk should be kept in mind when percutaneous needle aspiration biopsy of the adrenal gland has been advocated and when preoperative CT scanning evaluation for resectable non-small cell lung cancer reveals an isolated unilateral adrenal gland enlargement in the absence of other metastatic disease. 18 Any subsequent implantation metastasis of lung cancer would create a new problem for the patient with otherwise potentially resectable disease. Special care, such as using a smaller-bore needle or a single passage rather than multiple passages during aspiration, should be taken whenever these procedures are performed. ACKNOWLEDGMENTS: The authors thank Terry Saulsberry and Patricia Coldiron for their secretarial assistance.
REFERENCES 1 Berger R, Dargan E, Huang B. Dissemination of cancer cells by needle biopsy of the lung. J Thorac Cardiovasc Surg 1972; 63:430-32 2 Ferrucci JT, Wittenberg J, Margolies MN. Malignant seeding of the track after thin needle aspiration biopsy Radiology 1979; 130:345-46 3 Moloo Z, Finley RJ, Lefcoe MS, Turner-Smith L, Craig ID. Possible spread of carcinoma to the chest wall after a transthoracic fine needle aspiration biopsy. Acta Cytoll985; 29:167-69 4 Muller N, Bergin C, Miller R, Ostrow D. Seeding of the malignant cells into the needle track after lung and pleural biopsy. J Can Assoc Radioll986; 37: 192-94
5 Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH. Chest wall implantation of lung cancer after thin-needle aspiration biopsy. Ann Thorac Surg 1989; 48:284-86 6 Sinner WN, Zajicek J. Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diag 1976; 7:473-80 7 Wolinsky H, Lischner M. Needle tract implantation of tumor after percutaneous lung biopsy Ann Intern Med 1969; 71:35962 8 Engzell U, Esposti PL, Rubio C, Sigurdson A, Zajcek J. Investigation on tumor spread in connection with aspiration biopsy. Acta Radiol Ther Phys Bioi 1971; 10:385-98 9 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; 11:357-87 10 Sinner WN. Complication of percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diag 1976; 17:813-28 11 Kline TS, Neal HS. Needle aspiration biopsy: critical appraisal: eight years and 3,267 specimens later. JAMA 1978; 239:36-9 12 Lalli AF, McCormack LJ, Zelch M, Reich NE, Belovich D. Aspiration biopsies of chest lesions. Radiology 1978; 127:35-40 13 Dutra F, Geraci C. Needle biopsy of the lung. JAMA 1954; 155:21-4 14 Aronovitch M, Chartier J, Kahana L, Merkins J, Groszman M. Needle biopsy as an aid to the precise diagnosis of intrathoracic disease. Can Med Assoc J 1963; 88:120-27 15 Mathews MJ. Problems in morphology and behavior ofbronchopulmonary malignant disease. In: Israel L, Chahanian ~ eds. Lung cancer: natural history, prognosis, and therapy. New York: Academic Press, 1976:23-62 16 Fidler IJ. Rationale and methods for the use of nude mice to study the biology and therapy of human cancer metastasis. Cancer Metastasis Rev 1986; 5:29-49 17 Murthy SM, Goldschmidt RA, Rao LN, Ammirati M, Buchmann T, Scanlan EF. The influence of surgical trauma on experimental metastasis. Cancer 1989; 64:2035-44 18 Oliver TW: Bernadine ME, Miner JI, Mansour K, Greene D, Davis WA. Isolated adrenal masses in non-small cell bronchogenic carcinoma. Radiology 1984; 153:217-24
Erythropoietin Therapy Obviates the Need for Recurrent Transfusions in a Patient with Severe Hemolysis due to Prosthetic Valves· Ran Kornotvs1d, M.D.; Doron Schwartz, M.D.; Anat jaffe, M.D.; Amos Pines, M.D.; Dan Aderka, M.D.; and Yoram Leoo, M.D.t
Erythropoietin has been proved extremely effective in ameliorating the anemia of chronic renal failure and is currently under intensive investigation. We describe a patient with severe anemia and secondary hemochromatosis due to prosthetic valves, who has been successfully treated with erythropoietin. During 12 months' follow-up, an acceptable hemoglobin level was maintained without any need for blood transfusions; in addition, there was evidence indicating regression of hemochromatosis. This patient illustrates that erythropoietin therapy might prove beneficial for similar cases. (Chest 1992; 102:315-16) *From the Department of Medicine 'I;' Ichilov Hospital, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. tProfessor of Medicine. CHEST I 102 I 1 I JUL~