Delayed manifestation of needle track metastasis after radical cholecystectomy: is needle track mapping needed?

Abstract

This surgical perspective paper highlights the importance and rationale of performing a needle biopsy of a gallbladder mass though the future anticipated surgical incision site. It is a simple, and cost-effective technique, requiring close collaboration between the surgeon and the radiologist.

Gallbladder cancer (GBC) is the most common malignancy of the extrahepatic biliary tract, ranking sixth among all gastrointestinal cancers. ¹ However, the reported incidence for GBC exhibit marked variability, among different regions and ethnicities. Northern and Central India are among the regions with highest reported incidence of GBC in the world. ² The clinical presentation of GBC is often non-specific resulting in significant delay in the diagnosis and management. Despite the advancements in diagnostic imaging, GBC is often diagnosed at an advanced stage with nearly one-third of all patients having distant metastases at the time of diagnosis. ³ Besides various imaging investigations, a needle aspiration/biopsy is usually necessary in the diagnosis of GBC. A histopathological proof of malignancy is a mandate prior to neoadjuvant or palliative chemotherapy. ⁴ Now with the understanding of better chemotherapy regimen and tumour biology, an increasing number of patients are being subjected to percutaneous needle biopsy (NB) for subsequent chemotherapy and to guide further management. However, the possibility of tumour cell seeding along the needle track is a recognised complication and a cause of concern especially in an aggressive malignancy as GBC. ⁵

Malignant cells lose cohesiveness and lack orderliness of normal tissue, due to which they get dislodged from the primary tumour and tend to colonise the needle tract. ⁶ Tumour cell dissemination along the NB tract has been reported for malignancies such as hepatocellular carcinoma (HCC), pleural mesothelioma, testicular tumours and breast cancer. ⁷ The risk of track seeding after NB has been estimated to be around 0.01%. ⁸ However, recent studies have reported higher rates of track seedings (upto 5%), usually for HCC. ⁵ In few reports, the incidence of needle track seedings was upto 3% with the use of wide bore percutaneous radiofrequency ablation needles, ⁹ implying a higher risk with the increasing diameter of the needle used. The exact incidence of malignant needle track seedlings is however, difficult to estimate because of the challenges to trace biopsy-induced tumour cell dissemination in excised tissues or organs.

The literature on biopsy site recurrences in GBC is limited to few case reports. ¹⁰ The risk of needle insertion site tumour implantation has often been discounted owing to the paucity of published literature of its occurrence. This can be attributed to the fact that most of the GBC are diagnosed at advanced stages, with median survival of 3–6 months. ¹¹ Also, it may take years for the surviving tumour cells to multiple and reach the size of clinically detectable growth. Long-term follow-up is required to estimate the incidence, and the true incidence may not be noted as this complication may go unreported or the patient may be lost to follow-up. The authors noted one such case of NB site recurrence, detected 1 year following radical cholecystectomy for a pT2N0 GBC (Figures 1 and 2).

Figure 1.

This 58-year-old male was diagnosed to have gallbladder cancer on FNAC and was referred to our centre. He underwent radical cholecystectomy (arrowhead showing the incision site) and had an uneventful recovery. Histopathology showed pT2 adenocarcinoma of gallbladder. 1 year following index surgery, he noticed a lump (arrow) at the previous FNAC site, which slowly increased in size. FNAC, fine needle aspiration cytology.

Figure 2.

Axial (a) and sagittal (b) CT images show a soft tissue nodule in the subcutaneous plane of the anterior abdominal wall (arrow). Wide local excision specimen of the lump revealed adenocarcinoma, suggestive of fine needle aspiration cytology site recurrence of gall bladder adenocarcinoma.

With the advances in surgery and better understanding of the use of chemotherapy regimens, the overall survival of GBC patients has improved. ¹² There is now increasing literature with long-term follow-up. ¹³ In the contemporary world, with the advent of minimally invasive surgery, where we have moved from comparing just the survival outcome to considering the quality-of-life outcome for patients with GBC, a NB site tumour recurrence must be prevented. Implantation along needle tract may upstage the tumour, converting a resectable/borderline resectable tumour into an inoperable one. Various pre-procedural, procedural and post-procedural measures have been sought to decrease the risk of needle site tumour implantation. ⁷ Use of smaller bore needles and single pass, instead of multiple passes during aspiration may help to reduce the risk of needle tract seeding. Using biopsy needles with covering sheath or co-axial technique may preclude direct cancer seeding into the needle tract. Radiofrequency (RF) ablation is being explored as a percutaneous treatment option for needle tract seeding. Application of RF pulses to denature any malignant cells and heat sterilise the tract may prevent tumour implantation. ¹⁴ We propose a simple technique of performing a percutaneous NB of the GB mass through the marked future surgical incision site. Complete resection of the biopsy tract traditionally has been recommended in musculoskeletal oncology guidelines, as that tract is considered potentially seeded with tumour cells. ¹⁵ However, to the best of our knowledge, no such recommendation exists with respect to percutaneous NB in GB masses. Performing NB through the marked future incision site ensures that the site is excised/ablated in future surgical exploration. This technique requires close collaboration between the attending hepatobiliary surgeon and interventional radiologist. The surgeon marks the site of future skin incision and the interventional radiologist performs the NB using a co-axial technique through the marked incision site. It is simple technique to reduce the chances of abdominal wall tumour implantation, that has been regularly followed in soft tissue sarcomas and breast cancer. The technique is based on the understanding of the significance of inserting the needle through the planned incision site to reduce the risk of biopsy site tumour recurrence. This technique can be easily implemented in all the hepatobiliary oncology units without any technical or financial hurdle. The routine implementation of performing the percutaneous NB of GB masses through the future incision site may help to avoid the potential catastrophic complication of NB site tumour recurrence.

Learning points

• With the increasing literature on neoadjuvant therapy for GBC, there is an increasing number of percutaneous needle biopsies performed. Percutaneous needle biopsy of GB mass has a potential risk of tumour implantation along the needle track and can convert a resectable disease to an unresectable one.

• Performing a needle biopsy through the marked future incision site is a simple and cost-effective measure to reduce the risk of biopsy site recurrence.