Ultrasonically Guided Staging Splenic Tissue Core Biopsy in Patients With Non-Hodgkin’s Lymphoma

TAKE0 SUZUKI, MD, HlTOSHl SHIBUYA, MD, SHUNJI YOSHIMATSU, MD, AND SOJl SUZUKI, MD

Ultrasonically guided tissue core biopsy of the spleen was undertaken in eight patients with previously untreated non-Hodgkin’s lymphoma in the staging procedure. In all cases, the tissue core specimens that were biopsied were sufficient to diagnose the presence of involvement of non-Hodgkin’s lymphoma, and two of the eight were found to have histologic involvement. There was no complication in this series. It was concluded that this is a safe and reliable technique for the staging of malignant lymphoma.

Cancer 609379-882, 1987.

s A N IMPROVEMENT of treatment modality, accu- A rate determination of splenic involvement is indis- pensable for the initiation of treatment of non-Hodg- kin’s lymphoma. We encountered patients with non- Hodgkin’s lymphoma with slight or mild degree splenomegaly without any space-occupying finding in the organ. Invasive examination procedures, such as laparotomy, would require much time to the initiation of treatment and be accompanied by complications. Noninvasive ultrasonography, computed tomography, and percutaneous needle aspiration biopsy, however, are not sufficient for the diagnosis of lymphomatous involvement.

Eight percutaneous tissue core biopsies using 2 1 - gauge Surecut needles (TSK, Tokyo, Japan) were under- taken to ascertain the splenic involvement in the course of staging of non-Hodgkin’s lymphoma.

This is the first report of splenic tissue core biopsy in the staging of non-Hodgkin’s lymphoma. The utility and complications of this technique also are discussed.

Materials and Methods

Percutaneous splenic tissue core biopsy was under- taken in eight patients with previously untreated non- Hodgkin’s lymphoma. The patients included seven men and one woman ranging in age from 26 to 74 years.

From the Department of Radiology, Tokyo Medical and Dental University, 5-45, Yushirna I-chome, Bunkyo-ku, Tokyo I 1 3, Japan.

The authors thank Isao Okayasu, MD, Ryuichi Kamiyama, MD, Junichi Horiuchi, MD, Momoko Ishii, and Sanae Hattori for the as- sistance in manuscript preparation.

Address for reprints: Takeo Suzuki, MD, Department of Radiology. Tokyo Medical and Dental University, 5-45, Yushima I-chome, Bun- kyo-ku, Tokyo 1 13, Japan.

Accepted for publication February 26, 1987.

Most of the patients underwent abdominal computed tomography, bipedal lymphography, a gastrointestinal series, marrow biopsy, and bone scintigraphy prior to the splenic biopsy. Three of eight were diagnosed as having Stage I1 disease, one as having Stage 111, and four as having Stage IV disease according to the Ann Arbor classification.

Ultrasound scanning was performed with an elec- tronic linear scanner (Toshiba SAL 77A [Toshiba, Tokyo, Japan]), and the size and internal architecture of the spleen were evaluated prior to the biopsy. The maxi- mum length of the spleen was measured from the dia- phragmatic surface to the lower pole of the spleen and was diagnosed as splenomegaly when the spleen was more than 1 1 cm long. The prothrombin time, partial thromboplastin time, complete blood count, platelet count, and bleeding time also were checked before the examination.

The skin was sterilized, and a stylet with a 21-gauge Surecut needle was attached to the plunger.’ With the patient under local anesthesia, the Surecut needle was introduced into the spleen through an 18-gauge guide needle (Fig. 1). The tissue core biopsy was performed under ultrasonic guidance by a real-time scanner (To- shiba SAL 50A) with a puncturing probe (Toshiba GCB-306M). The biopsy specimen, approximately 3 cm in length and 0.6 mm in diameter, was expelled into 10% formalin and sent for histologic examination. The involved histologic materials of the tissue core biopsy were compared with previous pathologic specimens and classified according to Rappaport’s classification by two pathologists.

Twenty-four hours after the tissue core biopsy, ultra- sonography and a complete blood count were under- taken to ascertain the complications.

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880 CANCER A21g14~1 15 1987 Vol. 60

TABLE I . Patients and Results of Biopsies

Spleen Patient Histologic size Histologic

no. Age/sex subtype (max:cm) Internal echo diagnosis

I 2 3

4 5

6 7 n

55/M 27/M 41/F

47/M 69/M

74fM 48/M 57fM

DH DPDL DMHL

DH DH

DH DMHL DH

10.5 11.5 11.0

9 .o 9.0

9 .o 13.0 14.0

Homogeneous Homogeneous Homogeneous

Homogeneous Homogeneous

Homogeneous Homogeneous Homogeneous

Negative Negative Diffuse

involvement Negative Small nodular

involvement Negative Negative Negative

DH: diffuse, histiocytic; DPDL: diffuse, poorly differentiated lymphocytic: DMHL: diffuse, mixed histiocytic, and lymphocytic.

Results

The results of ultrasonography and the histologic ex- amination are shown in Table 1. Two of the eight splenic tissue biopsies demonstrated histologic involve- ment (Figs. 2A AND 2B, 3A AND 3B). The two patients showed no splenomegaly or space-occupying lesions ul- trasonographically (9 cm and 1 1 cm in maximum length) and showed homogenous internal textures (Fig. FIG. 1 . Biopsy needle echo (arrows) in the spleen. Patient 8.

FIGS. 2A AND 2B. (A) Histologic section of splenic tissue core biopsy taken from Patient 3. Splenic architecture is diffusely involved with lymphoma cells (H & E, X130). (B) Large and small atypical lymphoid cells with pyknotic and pleomorphic nuclei. Mixed histiocytic and lymphocytic lymphoma (H & E. X340).

FIGS. 3A AND 3B. (A) Histologic section of splenic tissue core biopsy taken from Patient 5. Notice local involvement of lymphoma cells at its central portion (H & E, X 130). (B) Predominant cell type is large atypical lymphoid cells with prominent nucleolus and narrow rim of cytoplasm. Histiocytic lymphoma (H & E, X340).

FIG. 4. Ultrasonography of the involved spleen showing homogenous internal textures. Patient 5.

882 CANCER August I5 1987 Vol. 60

4). Three patients had splenomegaly ( 1 1.5 cm, 13 cm, and 14 cm, respectively, in maximum length) that showed no histologic involvement. The three patients had no history of liver disease, nor was liver disease found clinically. The remaining three showed no pathol- ogy, either ultrasonically or histologically.

No complication was found in or about the spleen on the ultrasonic examination done 24 hours after the biopsy, nor was there any change in complete blood count in the course of splenic tissue core biopsy.

Discussion

Splenic involvement is not uncommon in patients with non-Hodgkin’s lymphoma, and the determination of splenic involvement is indispensable at the start of therapy. The incidence of splenic involvement has been said to be as high as 32% in the patients with non-Hodg- kin’s lymphoma at initial pre~entat ion.~

Ultrasonography and computed tomography are noninvasive methods and have been said to be useful in the evaluation of splenic involvement. Splenomegaly, however, is not always compatible with splenic involve- ment, and the differential diagnosis between lympho- matous involvement and other splenic disease by imag- ing methods alone is very It also is difficult to detect small tumor foci of less than 1.0 cm in diame- ter in the spleen by these imaging

Percutaneous splenic aspiration biopsy may give good information regarding the diagnosis of splenic involve-

Splenic involvement by well-differentiated lymphocytic lymphoma, however, could not always be differentiated from normal splenic cell populations by aspiration cytology alone.” Lymphoma cells for marker studies could not be separated easily from the material obtained by aspiration cytology.

Histologic confirmation is, therefore, indispensable in the diagnosis of lymphomatous involvement in the spleen.’.’ ‘ , I 2 In our series, sufficient tissue material was obtained by a 2 1-gauge Surecut needle to allow histo- logic subtyping of non-Hodgkin’s lymphoma. The speci- mens obtained by this procedure also were sufficient for the immunologic marker studies. We could separate the tumor-containing piece from the long material obtained by tissue core biopsy.

The incidence of complications in splenic needle biopsy has been said to be from 0% to 0.5%.’”14 Meng- hini insisted that the incidence of risk increases with the increase of the caliber of the biopsy needle in patients with abdominal tumor biopsy.15 In our study, there were no complications in the course of tissue core biopsy using a 2 1 -gauge Surecut needle.

The present study suggests that ultrasonically guided splenic tissue core biopsy is a safe and useful method to determine the splenic involvement in the staging of non-Hodgkin’s lymphoma. In addition, this technique allows multiple successive biopsies to ascertain the re- sults of treatment and relapse in the spleen.

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