Affiliations: Istanbul, Turkey,
Toneyama National Hospital
Correspondence to: Akif Turna, MD, Cami Sok, Muminderesi Yolu, Emintas Camlik Sit, No:32/22, Sahrayicedid, Kadikoy 81080 Istanbul, Turkey; e-mail: firstname.lastname@example.org
We read with great interest the article by Sawabata and
associates1in CHEST (October 2000). The
authors present data of a study concerning the potential of malignant
cell spread with fine-needle aspiration. Although physicians in some
institutions perform fine-needle aspiration routinely and safely in
order to obtain histologic diagnosis of thoracic masses with a high
rate of accuracy,2 a number of centers do not utilize this
method because of possible complications, such as seeding and
pneumothorax, especially in patients with COPD. We would like to
express a few of our comments on that study.
Firstly, concerning the utilized model of the study, the lung was
deflated during and after fine-needle aspiration. Therefore, there is a
lack of a counter-balancing effect against the chest wall and a lack of
sealing function against the shedding possibility of tumor cells. Since
the opposed tissue pressure created by inflated airways and alveoli was
decreased in a deflated lung, theoretically tumor cells might
anticipate less intercellular pressure of extracellular matrix;
therefore, the possible chance for tumor cells to exfoliate outside the
lung could be suggested to be higher than that of living lung. That
hypothesis could have been tested by comparison of the presence of
tumor cells in the pleural irrigation fluid from the fine-needle
aspirated deflated and artificially reinflated specimens. We think that
that would be the necessary negative control of the study group.
In the study, it was reported that the number of spilled tumor cells
was found to be higher, but increased tumor cell shedding does not
necessarily result in successful implantation of the tumor cell
population because of the resistance of immune system of the host
against tumor cells as proposed by the “immune surveillance”
theory.3In order to test this possibility, aspiration
tracts could be pathologically examined. Implantation of tumor cells
has been known to be extremely rare, such as 1 in 4,000 transthoracic
needle biopsy procedures,4 and has been the subject of a
few case reports in medical journals.
This study also inspired us to search for evidence of poorer survival
in inoperable stage-matched patients who underwent fine-needle
aspiration for diagnosis. We were unable to find any study on this
respect. For this reason, we think it is unlikely that needle
aspiration has a perilous tumor seeding effect in terms of tumor
implantation risk in those patients. We are also grateful for that
hypothesis-creating innovative study, which could be a basis of further
I appreciate the response to our article1
concerning the potential of malignant cell spread following fine-needle
aspiration cytology (FNAC) from Dr. Bedirhan and Dr. Turna. They
pointed out the dissociation between an in vivo and ex
vivo lung. As they said, the inflated lung over the tumor can
protect against the spread of malignant cells through the tract
following FNAC. However, most of the tumors that underwent FNAC were
peripherally located and associated with pleural indentation. Thus, the
lung over the tumor does not seem to be completely inflated. And so I
believe the possibility of spreading tumor cells is similar between an
in vivo and ex vivo lung.
I also believe in the “immune surveillance theory.”
Effusion-associated lymphocytes are revealed to have depressed cellular
function in the malignant effusion with lung cancer.2And
so it is speculated that the spread of malignant cells has a low
potential of implantation. Surgical patients with lung cancer have a
good performance status and may have a normal immune function. We have
performed a retrospective study,3 which revealed the
technique did not affect relapse and survival. By contrast, patients
with advanced lung cancer may have a depressed immune system.
Therefore, it is important to search for evidence of pleural
carcinomatosis and poorer survival in inoperable patients with advanced
To summarize our opinion, FNAC has the potential to seed malignant
cells that rarely implant among operable patients, but the possibility
of implantation is controversial among inoperable patients with
advanced lung cancer.
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