|Year : 1997 | Volume
| Issue : 2 | Page : 105-108
Fine needle aspiration biopsy in the diagnosis of intraocular mass lesions
MP Shanmugam, J Biswas
Sankara Nethralaya, Medical Research Foundation (MRF), Chennai, India
M P Shanmugam
Sankara Nethralaya, Medical Research Foundation (MRF), Chennai
Source of Support: None, Conflict of Interest: None
Fine needle aspiration biopsy (FNAB) was done in 5 patients who reported with atypical clinical presentation of intraocular tumour. The procedure was useful in 4 out of 5 cases and was without complications. With close co-operation between ophthalmologist and pathologist, FNAB is an useful adjunct for accurate diagnosis in selected patients.
Keywords: Fine needle aspiration biopsy, Intraocular mass lesions
|How to cite this article:|
Shanmugam M P, Biswas J. Fine needle aspiration biopsy in the diagnosis of intraocular mass lesions. Indian J Ophthalmol 1997;45:105-8
Aspiration biopsy had been first described as early as 1847, though the first report was published in 1930. Jacobiec et al proposed fine needle aspiration biopsy (FNAB) for intraocular tumours in 1979. FNAB offers a histopathologic correlation to the clinical diagnosis in the case of atypical presentation of intraocular tumours. It aids in effective planning and management; it enables histopathological diagnosis without having to sacrifice the eye or having to resort to open biopsy methods. The major deterrent to the widespread use of this technique is the fear of dissemination of the intraocular tumour through the needle tracks. Such dissemination has not been documented in any of the large series of 140 patients who underwent FNAB. This has largely been proven as a safe technique in selected patients.
We report our experience with this technique by an over view of its application along with the complications encountered and diagnostic correlation in each of the patients.
| Materials and methods|| |
In all the 5 patients reported in this communication, a transvitreal approach was employed. A 25 gauge, one and a half inch long, disposable needle attached to a short disposable plastic tube with a disposable plastic syringe was used. In three of the patients a parsplana approach was employed. A partial thickness sclerotomy with preplaced suture was prepared 180° away from the tumour. The needle was guided into the vitreous cavity and the mass under indirect ophthalmoscopic control. Once inside the mass lesion, assistant aided gentle suction was employed to aspirate the cells into the needle. After releasing the suction force the needle was guided out and immersed in sterile balanced salt solution. The contents of the needle were aspirated into the syringe with balanced salt solution. The preplaced suture was pulled up to close the sclerotomy as the needle was withdrawn. Gentle pressure on the globe was applied to control any bleeding from the perforation site.
In one adult patient with suspected retinoblastoma a clear corneal approach was employed. The needle was guided through a clear corneal wound 2 to 3 mm within the limbus through the root of the iris, the zonules, and into the vitreous and the tumour. The aspiration was performed as mentioned above and the corneal wound was self sealing. A similar technique was employed in another 7 year old patient with suspected retinoblastoma. Instead of the tumour, the vitreous seeds were aspirated in this case.
Case No 1
A 49 year old man was reported with the complaints of haziness of vision with the right eye of 20 days duration. He had undergone excision of the left submandibular salivary gland for a diagnosis of adenoid cystic carcinoma 5 years ago. His vision was 6/36 in the right eye. Fundus examination showed features of metastatic carcinoma of choroid associated with secondary retinal detachment [Figure - 1]. An MRI of the brain and orbits revealed a space occupying lesion in the left pterygoid fossa with extension into the middle cranial fossa. CT Scan of the neck revealed hilar, pre and paratracheal lymphadenopathy with a subpleural nodule in the left lung. Considering that the salivary gland tumour very rarely metastasises to the eye, and based on the CT features, a diagnosis of a second primary in the lung with metastasis to the choroid was arrived at by the oncologist.
A pars plana FNAB was done to define the site of the primary malignancy consistent with the diagnosis of metastatic tumour of choroid. The patient subsequently had an intracranial biopsy of the intracranial extension which also proved to be an extension from the salivary gland tumour. FNAB speciment showed focal collection of neoplastic cells with occasional cells exhibiting eccentric nuclei and eosinophilic cytoplasm and a background of necrotic cells. The cells resembled those obtained by biopsy of the intracranial extension, which was characteristic of adenoid cystic carcinoma of salivary gland. He underwent irradiation of the right eye and left pterygoid fossa. Following radio therapy and subsidence of retinal detachment, his vision in the right eye improved to 6/9 [Figure - 2].
| Case No. 2|| |
A 21-year-old man was seen with complaints of black floaters in the right eye of one month duration. There was no family history of retinoblastoma. He had a visual acuity of 6/6 in the right eye. Fundus examination of the right eye showed a yellowish mass measuring 5 mm vertically, 3 mm horizontally and 1.7 mm in height [Figure - 3]. This mass had intra tumour vascular channels, and vitreous seeds. There was no associated retinal detachment or intraocular inflammation. Ultrasound and CT scan examination confirmed the presence of calcium within the mass lesion. Based on clinical and ancillary studies, a diagnosis of atypical presentation of retinoblastoma was made. The patient was subjected to clear corneal FNAB. The cytology specimen was consistent with the diagnosis of retinoblastoma [Figure - 4]. The patient underwent irradiation and chemotherapy with regression of the mass.
| Case No. 3|| |
A 31-year-old man was seen with a history of gradual painless decrease of vision in the left eye of 10 years duration. He had taken treatment for pulmonary tuberculosis. The visual acuity was hand movements in the left eye. Fundus examination of the left eye showed a yellow submacular large mass lesion in the posterior pole with localised retinal detachment. A clinical diagnosis of tuberculoma of the choroid was made. Diagnostic vitreous biopsy did not reveal acid fast bacilli on smear study and culture. There was no evidence of active tuberculosis elsewhere in the body. A pars plana FNAB showed multiple uveal pigments and acellular eosinophilic material. No cellular elements were found. No further treatment was advised for the patient as there was no active inflammation. In this case, FNAB did not provide any additional information.
| Case No. 4|| |
A 38-year-old woman was seen with a history of gradual decrease of vision in the right eye for 4 weeks. She had a history of radical mastecectomy, with enbloc dissection of the axillary lymph nodes for carcinoma of the left breast 3 months back and was currently on chemotherapy. One of the 9 axillary lymph nodes showed evidence of invasion. There was no evidence of metastatic disease elsewhere in the body. The right eye vision was 2/60 and left eye vision was 6/6. Fundus examination of the right eye showed a posterior pole subretinal yellow coloured mass lesion of 15 mm X 15 mm X 2.9 mm in size. There was associated secondary retinal detachment. The clinical picture was suggestive of metastatic carcinoma of the choroid. Fundus of the left eye was normal. A diagnostic FNAB was done. The cytology specimen showed abnormal epithelial cells. However, the origin of the cells could not be elucidated and a cytological diagnosis of metastatic carcinoma was made. The patient was advised irradiation of this eye.
| Case No. 5|| |
A 7-year-old boy presented with a history of white reflex in the right eye noted one month back by his parents. His family history and birth history were non-contributory. On examination, his visual acuity was counting fingers at one and half meters in the right eye and 6/6, N6 in the left eye. Slit lamp examination showed no abnormality in both eyes. Intraocular pressure digitally was normal in both eyes. Fundus examination showed multiple vitreous seedings, which obscured the retinal details except superiorly where the retina was attached. The optic nerve was also obscured by the vitreous seedings. Suspicion of retinoblastoma was entertained. An ultrasound examination of right eye revealed the vitreous cavity filled with multiple intragel debris of low to moderate reflectivity and an ill-defined mass over the optic nerve with calcification. CT scan revealed a small irregularly outlined calcified mass with no extraocular or intracranial extension. Ultrasound and CT scan features indicated the possibility of retinoblastoma. While FNAB of vitreous seeds under direct visualisation was planned, consent was obtained from the parents for enucleation in the same sitting on event of cytological confirmation of retinoblastoma.
Fine needle aspiration was done through a clear corneal route as detailed earlier and needle track was marked with cautry.
Haematoxylineosin stained slide of a cytospin preparation revealed multiple basophilic tumour cells with hyperchromatic nuclei and scanty cytoplasm [Figure - 5]. Cytologic study was consistent with retinoblastoma. Enucleation of the eye was done in the same sitting. Histopathologic examination of the pupiloptic nerve section of the globe revealed vitreous cavity filled with multiple necrotic tumour cells with very few foci of calcifi cation. Except a small tumour mass over the optic disc, no other definite tumour mass was seen. Multiple sections of the eye showed the needle track through peripheral corneal stroma, iris root and ciliary body, but tumour cells were not seen in any of the sections.
| Discussion|| |
Fine needle aspiration biopsy has been recommended in (i) cases where the diagnosis is difficult, distinction between malignant and benign is not clear, and where the therapeutic decision will be made based on the cytologic findings; (ii) patients with metastatic disease of choroid but with no known primary; (iii) cases where the patient refuses recommended therapy until histopathological confirmation is obtained.
In our first patient, the site of the primary was doubtful and FNAB helped locate the primary site; in the second, the clinical diagnosis of atypical presentation of retinoblastoma could be confirmed; the fourth patient, the metastatic nature of the lesion could be proved; and in the fifth patient, retinoblastoma could be confirmed despite presentation at older age. The FNAB was, however, not useful in the third case.
The FNAB has a sensitivity and specificity rate of 84% and 98% respectively. The reported complications of this procedure have been intraocular haemorrhage and retinal break formation.
Intraocular haemorrhage as a complication of FNAB occurs virtually everytime and is usually leads to some degree of vitreous and subretinal bleeding. This bleeding is usually controlled by application of pressure to the globe. These haemorrhages are of small quantity and clears with time. In all our patients, some degree of localised vitreous and subretinal bleeding did occur but was controlled adequately with pressure on the eye ball and the haemorrhage cleared adequately within 4 to 6 weeks.
Retinal break is created when a transvitreal approach is used to pierce the tumour through the retina. This break almost never leads to a rhegmatogenous retinal detachment as it gets sealed by the blood clot. Even in the presence of minimal subretinal fluid overlying the mass lesion, when the break is created, the detachment seldom becomes rhegmatogenous. In three of our patients, retinal breaks were created. In two of the three, rhegmatogenous detachment did not occur. The other patient was lost to follow up. In the patient with secondary retinal detachment, the detachment settled with radiotherapy. It was not possible to identify the retinal break after retinal reattachment.
There have been few experimental studies on needle track dissemination., These studies were carried out on enucleated eye balls. Karcioglu et al found evidence of tumour seeding in 6 of 11 needle tracks. Glasgow et al found tumour cells in 67% of direct needle tracks (direct penetration of sclera over tumour) and in 53% of indirect needle tracks (transvitreal approach). However, it was concluded that the number of cells seeded were not large enough for tumour growth in experimental animals. Further, they found that indirect aspirate (transvitreal approach) containes a significantly less number of cells than direct aspirate. We have not noticed any needle track dissemination as yet in the eye. In case 5 where the eye was enucleated soon after FNAB, histopathological examination of the enucleated globe, sectioned at various levels, showed the needle track without malignant cells in the track. One additional factor curtailing needle track dissemination is the prompt treatment of the malignancy with appropriate therapy, once the diagnosis is established.
In general FNAB should not be attempted in a retinoblastoma as it is a friable tumour and carries risk of extraocular seeding with FNAB. It is to be employed only in an atypical situation as in the cases reported here. In such events, a transcorneal approach is preferred. This approach decreases the chances of tumour dissemination because of the presence of multiple ocular buffer zones encountered by the nee- dle.
There are few modifications of the technique, particularly useful for anterior chamber and subretinal lesions. In the presence of an iris or a ciliary body tumour in the anterior chamber, the needle is passed through the clear cornea into the tumour without crossing the pupil, and the cells can be aspirated. In a subretinal mass lesion associated with a bullous retinal detachment, a subretinal approach can be employed through a posterior sclerotomy overlying the area of greatest detachment.
Fine needle aspiration biopsy is a specialised technique which is not to be used for routine diagnosis of intraocular tumours since risks exist for tumour dissemination and other complications. It is to be used judiciously in selected groups of patients. With given caution, it could be of immense value in diagnosis and therapy of undermined tumours.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]