Editor—We have followed with interest the debate about tumour seeding in the aftermath of fine needle aspiration cytology (FNAC) in patients with potentially resectable hepatic colorectal liver metastases.1 The verdict of Metcalfe et al of “useless and dangerous” seems to have provoked strong emotions among some of your readers, and we should like to contribute two observations.
Our staging protocol comprises liver specific magnetic resonance imaging, chest tomography, and the selective use of positron emission tomography, laparoscopy, or a “trial of time,” but excluding biopsy. Since 1986 we have undertaken more than 1000 liver resections for metastatic cancer without resort to preoperative biopsy or FNAC, with only seven false positives. In two patients, hepatic cysts were diagnosed at operation and resection was deferred, whereas liver resection was undertaken without complication in the other five (three haemangiomas and two cysts).
A recent analysis of 598 consecutive patients undergoing radical resection of colorectal liver metastases examined specifically the 90 patients in whom diagnostic biopsy had been performed before referral.2 Histologically confirmed tumour seeding at the site of biopsy was confirmed in 17 patients (19%). This concurs with the findings of another two recent studies.3,4 In every patient in our series, these deposits on the chest and abdominal wall were excised at the time of liver resection. Nevertheless, our analysis showed that survival after liver resection was substantially diminished compared with well matched patients in whom no biopsy or FNAC had been attempted.5
In our experience, the non-invasive evaluation of potentially resectable colorectal liver metastases is at least 99% specific. Furthermore, the violation of tissue planes by biopsy or FNAC compromises patients' survival. We believe therefore that Metcalfe et al's choice of title is apt. Consultation with a specialist hepatobiliary surgical team is recommended before a “tissue diagnosis” is attempted in such patients.
Competing interests: None declared.
References
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