Needle Biopsy for Suspicious Lesions of the Head of the Pancreas: Pitfalls and Implications for Therapy Kamal M.E Itani, M.D., Thomas V. Taylor;,M.D., Linda K. Green, M.D. Controversy continues to exist concerning the optimal diagnostic approach to a pancreatic head lesion suspected of being a neoplasm. The objective of this study was to evaluate the impact of needle biopsy in suspicious pancreatic head neoplasia and its effect on therapy and outcome. Seventy-three patients with symptoms or signs of periampullary neoplasia and a pancreatic head lesion identified on CT scan were re- viewed retrospectively. Forty patients with potentially resectable lesions underwent intraoperative trans- duodenal core needle biopsy of the head of the pancreas. Thirty-three patients underwent CT-guided percutaneous fine-needle aspiration. The sensitivity and specificity of core needle biopsy were 76% and 100%, respectively. One death was directly related to the procedure and therapy was adversely affected in one patient with a false negative result. The sensitivity and specificity of percutaneous fine-needle as- piration were 85% and 92%, respectively, and were not significantly different from the core needle biopsy results (P >0.3). Three false negative fine-needle aspiration biopsies occurred in patients with potentially resectable lesions and a low clinical suspicion for malignancy. In patients with a mass in the head of the pancreas on CT scan, fine-needle aspiration biopsy offers results similar to those of intraoperative trans- duodenal core needle biopsy. In patients estimated to have resectable disease, a pancreaticoduodenec- tomy should be performed without a biopsy. For patients with unresectable disease, cytologic examina- tion of fine-needle aspirate should be performed. If this examination is positive, it offers the advantage of facilitating the construction of a rational plan for palliation. (J GASTROPOTEST SURG 1997;1:337-341.) Despite the recent development of a variety of ra- diologic, endoscopic, and laparoscopic tools, the pathologic diagnosis of a mass in the head of the pan- creas remains elusive. Even at laparotomy, the nature of a palpable pancreatic mass may be difficult to de- termine. Attempts at pathologic diagnosis have in- cluded wedge biopsy performed operatively with frozen section examination, 1 core needle biopsy per- formed transduodenally with frozen sections obtained during surgery, 1,2 cytologic examination of fine-needle aspirate performed intraoperatively, 3-13and preopera- tive cytologic examination of fine-needle aspirate per- formed under ultrasound or CT guidance. 2,4,1~ Each of these procedures has been reported to have advantages and disadvantages. Among the intraoper- ative procedures, wedge biopsy may be associated with a higher rate of complications, 2 whereas trans- duodenal core needle biopsy offers the advantage of supplying a core piece of tissue rather than the few cells obtained on fine-needle aspiration and thus pro- viding a possible higher diagnostic yield. A major ad- vantage of the percutaneous technique over other pancreatic biopsy procedures is the possibility of avoiding surgery in selected cases. In this report we examine the value ofintraoperative core needle biopsy and percutaneous CT-guided cytologic examination of fine-needle aspirate and determine how the biopsy results affected therapy and outcome. MATERIAL AND METHODS All pancreatic biopsies submitted to the pathology depariJuent at the Houston Veterans Administration Medical Center between October 1987 and 1994 were reviewed. Biopsies of the body or tail of the pan- creas as well as wedge biopsies were excluded. Sev- enty-three patients were identified who had under- gone one form of needle biopsy of the head of the pancreas, the choice of which was determined by the primary clinician. These patients were all men with a From the Departmentsof Surgery(K.M.EI. and T.V.T.)and Pathology (L.K.G.), Houston VeteransAdministration MedicalCenter and BaylorCollege of Medicine,Houston, Tex. Reprint requests:KamalItani, M.D., Departmentof Surgery(112A),2002 HolcombeBlvd.,Houston, TX 77030. 337