Should laparoscopic lymph node biopsy be the preferred diagnostic modality for isolated abdominal lymphadenopathy?

Original Article


Should laparoscopic lymph node biopsy be the preferred diagnostic modality for isolated abdominal lymphadenopathy?


R.W.D. Gilbert, MD MSc*, B.H. Bird, MD*, M.G. Murphy, MD*§, C.J. O’Boyle, MD*||



doi: http://dx.doi.org/10.3747/co.26.4170


ABSTRACT

Background

Isolated abdominal lymphadenopathy is frequently detected, but often challenging to diagnose. To obtain a tissue diagnosis, percutaneous biopsy (pb) or laparoscopic biopsy (lb) is often undertaken. The safety profiles and diagnostic accuracy of pb and lb within the abdomen are both poorly defined.

Methods

In this retrospective analysis, we identified all patients who underwent lb or pb for isolated abdominal lymphadenopathy at our institute during 2008–2016.

Results

Of 62 patients who underwent nodal biopsy for isolated abdominal lymphadenopathy, 33 underwent lb and 29 underwent pb. For the 33 patients who underwent lb, the procedure was diagnostic in 100% of cases; for the 29 who underwent pb, the procedure was diagnostic in 18 cases (62.1%). Both procedures were safe, with similar complication rates (6.0% for lb; 7.0% for pb).

Conclusions

Our results establish that lb and pb are both safe and reliable in the setting of isolated abdominal lymphadenopathy. We also demonstrate that each procedure has situational advantages. A pb should be considered to be the upfront diagnostic modality, particularly when anatomic or disease factors favour its success. In situations in which it is felt that pb cannot safely access the lymphadenopathy or in disease states in which the yield of a core biopsy will be insufficient, lb should be strongly considered. Examples include extra-retroperitoneal lymphadenopathy and cases of suspected lymphoma.

KEYWORDS: Biopsies, laparoscopy, lymph nodes, lymphoma, medical oncology, surgical oncology

INTRODUCTION

Isolated abdominal lymphadenopathy represents a spectrum of disease ranging from benign reactive lymphadenopathy to malignancies including lymphoma, sarcoma, and metastatic spread. Regardless of the cause, tissue diagnosis is required to institute appropriate treatment.

Image-guided percutaneous core-needle biopsy (pb) has become the first-line modality for obtaining a tissue diagnosis from an isolated abdominal mass1. Various studies suggest that pb has a diagnostic accuracy in the 78%–94% range for malignancy at all anatomic sites2,3. Within the abdomen, the accuracy of pb is poorly defined because most large series tend to group peripheral and abdominal biopsies together, potentially overstating the diagnostic accuracy4.

Laparoscopic biopsy (lb) is also used for the diagnosis of abdominal lymphadenopathy. In spite of that use, relatively few case series and no prospective studies of lb for the diagnosis of isolated abdominal lymphadenopathy have been published46. The most robust data available come from three retrospective studies by groups in the United States published between 1998 and 2015, which included 222 patients46. Those three studies reported a diagnostic accuracy in the 90.4%–95.5% range for lb, a 5.94%–17.0% conversion rate, and a complication rate in the 1.0%–7.9% range, with no reported mortality. Despite that growing body of work, data about the indications for upfront lymph node lb are still lacking. With those factors in mind, the aim of the present study was to review and evaluate our institutional experience with both pb and lb for the diagnosis of isolated abdominal lymphadenopathy.

METHODS

The medical records of all patients who underwent pb or lb for computed tomography–diagnosed isolated abdominal lymphadenopathy at the Bon Secours Hospital in Cork, Ireland, during 2008–2016 were retrospectively evaluated. All data were obtained from the medical records of the patients. Patients with peripheral lymphadenopathy were excluded.

LB Approach

Procedures for patients who underwent lb were performed by a single consultant general surgeon. All surgical procedures were performed under general anesthesia, with the patient placed in the supine position on the operating table. Pneumoperitoneum was established using a modified Hasson approach. A 10 mm port was usually placed above the umbilicus, with 2 or 3 additional 5 mm ports placed. A 30-degree laparoscope was used in all cases. A combined bipolar and ultrasonic device was used to perform the dissection and obtain the biopsies. Specimens were placed in nonporous bags and retrieved through the 10 mm port on withdrawal of the laparoscope. Where lymphadenopathy was discrete, an entire node was retrieved whenever possible.

PB Approach

Procedures for pat ients who underwent computed tomography–guided pb were performed by 1 of 5 interventional radiologists. Biopsies were performed under local anesthesia and procedural sedation. The standard biopsy approach involved a single pass with 17-gauge coaxial needle through which multiple 18-gauge core biopsies were obtained. The number of biopsies obtained was determined by the quality of the core specimen as assessed by the interventional radiologist.

Statistical Analysis

All statistical analyses were conducted using the GraphPad Prism software application (version 8: GraphPad Software, La Jolla, CA, U.S.A.). The Student t-test was used for continuous variables, and chi-square analysis was used to compare categorical variables when indicated. Statistical significance was predefined as p < 0.05, using nonparametric Mann–Whitney tests for all analyses.

Study Ethics

Ethics approval for the project was obtained from the clinical research ethics committee at University College Cork and the Bon Secours Department of Research ethics committee.

RESULTS

Patient Details

Of the 62 patients who underwent nodal biopsy for isolated abdominal lymphadenopathy, 33 underwent lb, and 29 underwent pb. No significant differences in age, sex, body mass index, or American Society of Anesthesiologists score were evident between the patient groups (Table I).

TABLE I Baseline characteristics of the study patients by biopsy type

 

Positron-emission tomography imaging was obtained in 5 patients undergoing lb (15.2%) and in 10 patients undergoing pb (34.5%, p = 0.08). A prior pb had been undertaken in 13 patients undergoing lb (39.4%) and in 6 patients undergoing pb (20.7%, p = 0.17).

In the lb group, the most common biopsy site was mesenteric (n = 13, 39.4%), followed by multiple sites (n = 7, 21.2%), celiac axis nodes (n = 5, 15.2%), retroperitoneal nodes (n = 5, 15.2%), and portal nodes (n = 3, 9.1%). In the pb group, the most common site was retroperitoneum (n = 19, 65.5%), followed by celiac axis nodes (n = 6, 20.7%), and portal, mesenteric, and multiple (n = 4, 13.8%, Table I, Figure 1).

 


 

FIGURE 1 Lymphadenopathy by anatomic location in patients undergoing laparoscopic or percutaneous biopsy.

Diagnostic Accuracy

A definitive diagnosis was obtained in 33 lb patients (100%) and in 18 pb patients (62.1%). Most of those diagnoses were for malignancy, with 20 lb patients (60.6%) and 17 pb patients (58.6%) having a malignancy diagnosed. In the lb group, 14 patients (42.4%) had a diagnosis of lymphoma; 3 (9.1%), of carcinoma; and 2 (6.1%), of peritoneal malignancy. In the pb group, 9 patients (31.0%) had a diagnosis of lymphoma; and 7 (24.1%), of carcinoma. Of the patients with benign diagnoses, 13 belonged to the lb group (39.4%), and only 1 (3.4%) belonged to the pb group (Table II).

TABLE II Diagnosis by disease and biopsy type in the study patients

 

Missed Diagnosis

We reviewed the 11 patients who had a non-diagnostic pb (37.9%) and determined that 9 underwent an additional pb or surgical biopsy; the other 2 were lost to follow-up. Of the 9 patients who were re-biopsied, 3 had a benign diagnosis, 4 were diagnosed with lymphoma, and 2 were diagnosed with a solid tumour on their second procedure (supplementary Table I).

Procedural Details

Mean procedure length differed significantly between the two groups: lbs lasted an average of 42.79 minutes compared with 28.27 minutes for the pbs (p = 0.009). Two cases of morbidity occurred in the lb (6.0%) and pb (7.0%) groups, with no surgical morbidity in the surgical group. No conversions to laparotomy were observed in the lb group. The two groups were not significantly different with respect to 30-day readmission, and no 30-day mortality was observed in either group (Table III).

TABLE III Operative details for the study patients by biopsy type

 

DISCUSSION

Accurate diagnosis and appropriate treatment of patients with isolated abdominal lymphadenopathy relies on correct tissue diagnosis. Current diagnostic modalities have advantages and disadvantages. A pb is safe and easily performed, but lacks accuracy (62.1% definitive diagnosis in the present series). A lb is a more invasive procedure requiring general anesthetic, but provides superior diagnostic accuracy (100% definitive diagnosis in the present series). Guidelines published in 2008 by the Society of American Gastrointestinal and Endoscopic Surgeons suggest that laparoscopy can be used for tissue diagnosis of intra-abdominal lymphadenopathy in the absence of peripheral lymphadenopathy when core needle biopsy has been non-diagnostic1.

Our findings support those recommendations and suggest that pb and lb are both safe and reliable in diagnosing abdominal lymphadenopathy. However, in certain circumstances, lb might be favoured as an upfront diagnostic modality because of increased diagnostic accuracy and a comparable safety profile.

Procedural Selection

At our institute, all patients with isolated abdominal lymphadenopathy are discussed at a multidisciplinary meeting involving medical oncologists, surgeons, and radiologists. In our cohort, 20 of 33 patients undergoing lb (60.6%) did not previously undergo pb, indicating that lb is frequently being used as the first-line diagnostic modality (32.3% of our total cohort). The rationale for that selection is driven by anatomic preferences and disease-specific factors.

With respect to anatomy, image-guided core-needle pb is suggested to be reliable for diagnosing lymphadenopathy located in the retroperitoneum, but is often unsuccessful when adenopathy is located deep within the abdomen, especially within the mesentery5. That suggestion is likely attributable to the relative lack of obscuring structures in the retroperitoneum compared with the mesentery, where bowel loops and vasculature can make a percutaneous approach challenging and dangerous. Our results support that suggestion and indicate a preference for pb in patients with identifiable retroperitoneal nodes (19 of 29 cases). In the lb cohort, 28 patients (84.8%) had intra-abdominal, extra-retroperitoneal nodes biopsied, and only 5 patients (15.2%) had retroperitoneal adenopathy sampled.

In addition to anatomic preferences, disease-specific characteristics can also influence procedure selection. In lymphoma (one of the most common causes of isolated abdominal lymphadenopathy), accurate histologic diagnosis and molecular subtyping often require a substantial amount of tissue and an intact lymph node architecture46. With that need in mind, the European Society for Medical Oncology recommends surgical excision biopsy as the standard diagnostic intervention for lymphoma diagnosis and staging7. Our examination of the non-diagnostic biopsies in the pb group found that lymphoma and benign disease represented a significant proportion of the cases (63.6%). Additionally, most patients who proceeded directly to lb in our cohort had high clinical suspicion for lymphoma [elevated lactate dehydrogenase, B symptoms, or prior lymphoma with suspected recurrence (data not shown)].

Procedural Details and Safety

The pb and lb procedures have both been demonstrated to be safe, with low complication rates46. Morbidity from lb is reported to range from 1.0% to 7.9%, and the rate of conversion from laparoscopic to open surgery ranges from 5.94% to 17.0%46. Our cohort mirrored those results, with a 6.0% overall rate of morbidity, no surgical morbidity, and a 0% conversion rate. Our results also support the statement by Asoglu et al.5 that lb can be safely performed in patients with prior abdominal surgeries. With respect to pb, the literature is more challenging to interpret, given a lack of stratification by anatomic site. We identified one published study that evaluated pb for the diagnosis of abdominal lymphadenopathy, reporting a 7.7% complication rate (similar to our 7.0% complication rate)4. In patients likely to require numerous pbs for accurate tissue diagnosis, lb should be considered from a safety perspective. Additionally, the similar safety profiles for lb and pb support our rationale that lb can safely be used as an upfront diagnostic modality for isolated abdominal lymphadenopathy in appropriately selected patients.

CONCLUSIONS

In patients with computed tomography–diagnosed isolated abdominal lymphadenopathy, tissue diagnosis is essential for appropriate management. The pb and lb procedures are both safe and reliable diagnostic modalities, but each procedure has situational advantages. A pb should be considered to be the upfront diagnostic modality, particularly when anatomic or disease factors favour its success. In situations in which it is felt that pb cannot safely access the lymphadenopathy or that the yield of a core biopsy will be insufficient, lb should be strongly considered. Based on that rationale, we encourage the consideration of lb as the upfront diagnostic modality for lymph nodes within the extra-retroperitoneal abdomen and in patients with a high clinical suspicion for primary or recurrent lymphoma. Future work should continue to elucidate not only the safety of both pb and lb for the diagnosis of abdominal lymphadenopathy, but also cost and wait time implications.

CONFLICT OF INTEREST DISCLOSURES

We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.

AUTHOR AFFILIATIONS

*School of Medicine, University College Cork, Cork, Ireland,
Department of General Surgery, University of Ottawa, Ottawa, ON,
Department of Haematology and Oncology, Bon Secours Hospital, Cork, Ireland,
§Department of Diagnostic and Interventional Radiology, Bon Secours Hospital, Cork, Ireland,
||Department of Surgery, Bon Secours Hospital, Cork, Ireland.

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Correspondence to: Richard W.D. Gilbert, 501 Smyth Road, Ottawa, Ontario K1H 8L6. E-mail: rigilbert@toh.ca

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Supplemental material available at http://www.current-oncology.com ( Return to Text )


Current Oncology, VOLUME 26, NUMBER 3, JUNE 2019








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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)