ANNALS OF CLINICAL AND LABORATORY SCIENCE, Vol. 9, No. 1 Copyright 1979, Institute for Clinical Science, Inc. Peroperative Pancreatic Aspirations ROBERTA K. NIEBERG, M.D. Department of Pathology, Harbor General Hospital, Torrance, CA 90509 ABSTRACT Peroperative fine needle pancreatic aspirations were performed on 16 patients with suspected es during 1976 and 1977. Seven of the 16 aspirates dem onstrated benign cells. Nine of the 16 revealed m alignant cells, eight of which could be classified as to tumor type. This procedure provided a definitive diagnosis resulting in the appropriate surgery. The aspiration technique is highly accurate, rapid, uncomplicated and elim inates the problems associated with biopsy of this organ. Fine n eedle aspiration cytology is recognized as an accurate and sim ple diagnostic technique performed in a variety of organ sites.3 It therefore seem ed reasonable to utilize this m ethod for the evaluation of es. Differen tia tio n b e tw e en benign pan creatic processes and malignant masses may be aided by radiography, palpation and other techniques, but definitive diagnosis requires morphologic confirmation. Biopsy of the pancreas prior to major surgery has been the m ethod of choice for many years, but owing to the ensuing m orbidity and difficulties in obtaining and in te rp re tin g biopsy tissue, other means becam e necessary to define the disease process. This report describes our experience w ith peroperative pancreatic aspirations. M aterials and Methods D uring 1976 and 1977, fine needle aspiration of the pancreas was perform ed during exploratory laparotom y on 16 patie n ts w ith a su sp ecte d p a n c re a tic neoplasm. The patients ranged in age from 37 to 86 years, w ith varying sym ptom s of abdom inal pain, w eight loss, anorexia and. A 12 cc disposable syringe with a 22 gauge needle attached is used by the surgeon (figure 1). U nder direct visualization, the needle is inserted into the suspicious area of the pancreas and moved back and forth under negative pressure in the puncture channel. Before the needle is removed, the pressure is equilibrated to p rev en t aspiration of blood and to retain the cellular m aterial w ithin the n eed le. T here should be no m aterial observed in the syringe. The entire procedure is lim ited to a few seconds. The syringe and needle is handed to the cytotechnologist in the operating room who, with the drops from the tip of the needle, makes several (4 to 6) smears w ith slides previously w etted w ith 95 11 0091-7370/79/0100-0011 $00.90 Institute for Clinical Science, Inc.
12 N IEB ER G in a 3 ml alcohol-saline mixture (one part 70 percent ethyl alcohol to five parts normal saline in a 13 x 100 mm screw cap tube).2 This fluid is later processed as a m illipore filter preparation. On rare occasion, sufficient material is obtained for a cell button. The smears are stained with both Papanicolaou and hematoxylin and eosin stains, and the diagnosis is given to the operating room w ithin 20 to 30 m inutes. Fig u re 1. pancreas. T echnique o f n eed le aspiration of percent ethyl alcohol. The smears are immediately placed in a bottle of 95 percent ethyl alcohol. The technologist then takes the needle and syringe and rinses it Results Correct cytologic diagnoses were made in all 16 cases in this series. There were seven negative aspirates which contained norm al pancreatic cells (table I). Although all of these patients presented with a mass in the area of the pancreas b ased on rad io g rap h ic, ultrasonic or radioisotopic studies, the index of suspicion for m alignancy was low in five. Ultim ately, th ree w ere found to have a pseudocyst, one a pancreatic abscess and one a su b cap su lar sp len ic cystic hematoma. Two patients had an enlarged head of the pancreas secondary to chronic pancreatitis. All of these patients have TABLE I Negative P ancreatic A spirations P a t i e n t A g e H i s t o r y D i a g n o s t i c I m a g in g P o s t - o p D i a g n o s i s 1 39 Alcoholic; weight Ultrasound: sonolucent mass, Cystic hematoma, spleen; loss left of spleen chronic pancreatitis 2 44 Alcoholic; Ultrasound: enlarged Chronic pancreatitis abdominal pain pancreatic head 3 38 Alcoholic; Ultrasound: sonolucent mass, P seudocyst; chron ic abdominal pain area of pancreas pancreatitis 4 47 Alcoholic; weight Ultrasound: calcified and Pseudocyst; chronic loss cystic mass, area of pancreas pancreatitis 5 45 Alcoholic; Ultrasound: sonolucent mass, Pseudocyst; chronic abdominal pain area of pancreas pancreatitis 6 37 Alcoholic; Ultrasound: sonolucent mass, Pancreatic abscess; abdominal pain; area of pancreas chronic pancreatitis weight loss 7 37 Alcoholic; Upper gastro-intestinal series: Chronic pancreatitis abdominal pain; duodenal bulb defects nausea and vomiting
P E R O P E R A T IV E P A N C R E A T IC A SPIR A TIO N S follow ed a b e n ig n course from six to 21 m onths. O n e p a tie n t re tu rn e d w ith ja u n d ic e 18 m o n th s la te r. At e x p lo ra to ry surgery, m u ltip le aspirations w ere taken and all w e re neg ativ e. T he com m on bile d u ct was o b stru cted at the am pulla ow ing to an en larg ed, chro n ically inflam ed h ea d of th e p ancreas. N in e a s p ir a te s r e v e a le d m a lig n a n t cells, an d th e ty p e o f m alignant neoplasm co u ld b e id e n tifie d in eig h t cases (table II). S ev en o f th e n in e c o n ta in e d cells c o n s is te n t w ith a w e ll d if f e r e n tia te d aden o carcin o m a, o ne o f w hich was a re c u rre n c e from a p re v io u sly d ia g n o s e d and re se c te d d u o d en a l ad en o carcin o m a (figure 2). O n e p a tie n t had u n d erg o n e a p u lm o n a ry lo b ecto m y tw o years p re v i ou sly for a w ell d iffe re n tia te d k e ra tin iz in g s q u a m o u s ce ll c a rc in o m a of th e lu n g a n d was b e lie v e d to be tree of dis ease u n til he b ecam e ja u n d ic e d. A single F i g u r e 2. Cells charac teristic o f adenocar cinom a (P apanicolaou stain, x 400). * 13 p an c rea tic tu m o r was see n at surgery, and th e a s p ira te r e v e a le d ce lls c o n s is te n t w ith a w ell d iffe ren tiated squam ous car cinom a. As a re su lt, th e su rg eo n s p e r form ed a by-pass cholecystojejunostom y ra th e r than a W h ip p le pro ced u re. T h e p a tie n t ex p ire d six m onths later from m e ta static b ro n ch o g en ic carcinom a (figure 3). T h e final positive aspirate c o n ta in e d a p a u c ity o f c e llu la r m aterial. T h e ce lls w e re single, poorly d iffe ren tiated w ith a very large n u clear/cy to p lasm ic ratio. T h e m alig n an t cells p re se n t w ere in te rp re te d as b e in g co n sisten t w ith e ith e r m alig n an t ly m p h o m a or poorly d iffe re n tia te d car cinom a. F ro zen sectio n o f a m esen te ric ly m p h no d e also re v e a le d a m alig n a n t tum or w hich co u ld not be fu rth er d iffe r e n tia te d. T he clin ical p ictu re at surgery su g g e ste d a m a lig n an t lym phom a, a n d th e p e rm a n e n t sections su b stan tiated this im pression.
N IE B E R G 14 TABLE I I P o s itiv e P a n c re a tic A sp ira tio n s P a tie n t Age 8 40 9 63 10 50 11 45 12 60 13 45 14 71 15 65 16 86 H is to r y Weight loss nausea Anorexia; "spruce" Anorexia; D ia g n o s tic Ultrasound : Gallium scan:: retroperitoneal tumor Ultrasound: ; ultrasound: Courvosier GB Ultrasound: Ultrasound: duodenal T issu e co n firm ation w as o b ta in e d in seven o f th e n in e m alig n an t cases. F o u r of th e n in e p atien ts are alive and, a t the tim e o f th is rep o rt, h ave ex ten siv e m eta static d isease. F iv e have ex p ire d from d issem in ated carcinom a. T h e re w e re no erro n eo u s diag n o ses am ong the 16 asp i Figure 3. stain x 600). I m a g in g P o s t-o p D ia g n o s is Histiocytic lymphoma Metastatic squamous cell carcinoma of lung Metastatic adenocarcinoma duodenum rates, nor w ere th e re any com plications re su ltin g from th e p ro ced u re. Discussion T he diagnosis o f carcinom a o f th e p an creas has b e e n notoriously difficult. F or Cells characteristic o f w ell differentiated keratinizing squamous cell (Hematoxylin and eosin
PERO PERA TIV E PANCREATIC ASPIRATIONS 15 the patient presenting w ith a clinical picture suggesting a, radiographic procedures have been the major non-invasive tool for establishing a diagnosis. The fact that there are at least eight major diagnostic im aging procedures attests to the fact that none are sufficiently accurate in defining pancreatic carcinom as.4 Surgeons have been loath to biopsy the pancreas because of the complications that follow, i.e., pancreatitis, bleeding, fistulation, pseudocyst formation, subphrenic abscess and w ound infection. A nother deterren t to biopsy is the difficulty of obtaining the proper tissue for histologic examination, owing either to the deep location of the tum or or to the presence of fibroblastic tissue surrounding the tumor. Visualization of the tumor and palpation of a d istin ct mass may therefore be impossible, and the choice of tissue for biopsy becomes uncertain. W ell-differentiated adenocarcinom a of th e pancreas m ay sim u late e ith e r atrophic or benign proliferating ducts; therefore, interpretation of both frozen and perm anent sections may sometimes pose a sizable problem.1 E valuation of asp irated m aterial is based on cytologic rather than histologic criteria since the specim en consists of isolated cells. The problems associated w ith the biopsy techniq u e are elim i nated. The effectiveness of the cytologic m ethod obviously depends upon obtaining adequate cellular material as well as cytopathologic expertise. Considerable cytopathologic experience is required to interpret correctly this material. T he technique described here is sim ple, rapid, without complications and has a high degree of accuracy. It also makes accessible deeply situated lesions in the pancreas and allows for m ultiple cellular sam pling w ithout risk. Peroperative pancreatic aspiration cytopathology should b e included in the arm am entaria of proc e d u re s for diagnosis of p a n creatic masses. References 1. ARNESJO, B., Storm by, N., and Akem an, M.: Cytodiagnosis of pancreatic lesions by means of fine-needle biopsy during operation. Acta Chir. Scand. 138-,363-369, 1972. 2. Colem an, D., D esa i, S., D u d ley, H., H o l- LOWELL, S., and H u l b e r t, M.: Needle aspiration of palpable breast lesions: a new application of the membrane filter technique and its results. Clin. Oncol. 1 :27-32, 1975. 3. KLINE, T. and N e a l, H.: Needle aspiration biopsy: a critical appraisal. J. Amer. Med. Assn. 239:36-39, 1978. 4. MacD o n a ld, J., Wid e r l it e, L., and Sc h ein, P.: Current diagnosis and management o f pancreatic carcin om a. J. N atl. C an cer Inst. 56:1093-1099, 1976.