Role of peritoneal ultrasonography and ultrasound-guided fine needle aspiration cytology/biopsy of extravisceral masses in the diagnosis of ascites of undetermined origin

Background and study aimsAscites may be of undetermined origin despite comprehensive study. This study aimed to assess the accuracy and safety of conventional and interventional high-frequency peritoneal ultrasound in the diagnosis of patients with ascites of unclear origin.Patients and methodsA total of 62 patients were prospectively enrolled; they underwent conventional (3.5–5 MHz) and high-frequency (6–8 MHz) transabdominal peritoneal ultrasound to suggest the nature of ascites supplemented by fine needle aspiration cytology (FNAC) of ascites and/or core biopsy of the omentum or other extra-visceral masses for final histopathologic diagnosis. Laparoscopy or laparotomy was needed if biopsy was inconclusive.ResultsUltrasound-guided procedures were diagnostic in 55 (87.7%) patients. Thirty-six (58.1%) were benign, of whom 86% had tuberculous peritonitis, 26 (41.9%) were malignant, of whom 76.9% had peritoneal metastasis. High-frequency ultrasound was able to propose ultrasonographic criteria in a trial to diagnose the nature of ascites. Our proposed ultrasonographic criteria were based on the amount and texture of ascites in addition to the omental and mesenteric features. These were able to suggest the diagnosis with 80.7% sensitivity for malignant ascites and 75% specificity for benign ascites. Moreover, histopathological examination of tissues obtained by ultrasound-guided procedures increased the sensitivity to 88.5% and the specificity to 88.9% in diagnosing malignant and benign disease, respectively, with an overall diagnostic accuracy of 88.6%. These procedures were considered to be safe as only one major (haemoperitoneum) and two minor complications (temporary ascitic fistula) were reported.ConclusionHigh-frequency peritoneal ultrasound together with the minimally invasive ultrasound-guided FNAC/biopsy of extra-visceral lesions may be considered an effective and safe tool in the diagnosis of ascites of undetermined origin.     

端粒酶活性检测对良恶性腹水鉴别诊断的价值

目的 通过检测腹水脱落细胞端粒酶活性，探讨端粒酶对良恶性腹水鉴别诊断的价值。方法 用半定量端粒重复序列扩增法(TRAP)，检测38例恶性腹水患者(恶性腹水组)和22例良性腹水患者(良性腹水组)腹水中脱落细胞端粒酶活性。结果 肝硬化、结核性腹膜炎患者腹水中脱落细胞未检出端粒酶，而癌性腹水94．7％端粒酶阳性。所有细胞学检查阳性的恶性腹水中端粒酶均为阳性，而3例细胞学检查阴性但端粒酶阳性的恶性腹水，复查细胞学检查，其中1例发现了恶性瘤细胞。结论 癌性腹水端粒酶阳性。端粒酶活性检测对良恶性腹水有重要鉴别诊断价值，尤其对细胞学检查阴性的病例。     

Diagnostic value of endoscopic ultrasonography-guided fine-needle aspiration cytology of mediastinal masses in patients with intrapulmonary lesions and nondiagnostic bronchoscopy

Several procedures are available for the cytopathological diagnosis of mediastinal lesions. The purpose of this study was to evaluate the diagnostic value of endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) in patients with mediastinal mass lesions/lymph node enlargement. All patients had intrapulmonary lesions on chest X ray and/or CT scan, and inconclusive findings by endobronchial forceps biopsy and/or brush cytology. EUS-guided FNA was performed in 16 patients using a modified oblique forward-viewing gastroscope with an electronic multielement curved linear ultrasound transducer. After the region of interest was localized, a 22-gauge Vilmann-Hancke needle was introduced via the 2-mm biopsy channel. The cytological diagnosis of EUS-guided FNA was conclusive for cancer in 9 patients and in the other 7 patients the aspirated samples revealed a benign lesion. In 10 patients the final diagnosis was cancer, thus EUS-guided FNA was diagnostic for malignancy in all but 1 of the lesions (sensitivity 90.0%). In 1 patient epitheloid cell granuloma was detected by cytological examination of the FNA. Following tuberculostatic treatment the lesions disappeared completely on CT scan and EUS. The overall accuracy in this study amounted to 93.7%. From this and other studies discussed, it is assumed that the procedure is an accurate and safe technique to examine nodular lesions suggestive of metastatic lymph node involvement.     

An automated spring-loaded needle for endoscopic ultrasound-guided abdominal paracentesis in cancer patients

AIM: To evaluate the feasibility of using an automatedspring-loaded needle device for endoscopic ultrasound(EUS)-guided abdominal paracentesis(EUS-P) to see if this would make it easier to puncture the mobile and lax gastric wall for EUS-P.METHODS: The EUS database and electronic medical records at Fukushima Medical University Hospital were searched from January 2001 to April 2011. Patients with a history of cancer and who underwent EUS-P using an automated spring-loaded needle device with a 22-gauge puncture needle were included. The needle was passed through the instrument channel and advanced through the gastrointestinal wall under EUS guidance into the echo-free space in the abdominal cavity and ascitic fluid was collected. The confirmed diagnosis of malignant ascites included positive cytology and results from careful clinical observation for at least 6 mo in patients with negative cytology. The technical success rate, cytology results and complications were evaluated.RESULTS: We found 11 patients who underwent EUS-P with an automated spring-loaded needle device. In 4 cases, ascites was revealed only with EUS but not in other imaging modalities. EUS-P was done in 7 other cases because there was minimal ascitic fluid and no safe window for percutaneous abdominal aspiration. Ascitic fluid was obtained in all cases by EUS-P. The average amount aspirated was 14.1 mL(range 0.5-38 mL) and that was sent for cytological exam. The etiology of ascitic fluid was benign in 5 patients and malignant in 6. In all cases, ascitic fluid was obtained with the first needle pass. No procedure-related adverse effects occurred.CONCLUSION: EUS-P with an automated springloaded needle device is a feasible and safe method for ascites evaluation.     

Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma

AIM： To evaluate the sensitivity of brush cytology and forceps biopsy in a homogeneous patient group with hilar cholangiocarcinoma.METHODS： Brush cytology and forceps biopsy were routinely performed in patients with suspected malignant biliary strictures. Fifty-eight consecutive patients undergoing endoscopic retrograde cholangio-pancreatography （ERCP） including forceps biopsy and brush cytology in patients with hilar cholangiocarcinoma between 1995-2005.RESULTS： Positive results for malignancy were obtained in 24/58 patients （41.4%） by brush cytology and in 31/58 patients （53.4%） by forceps biopsy. The combination of both techniques brush cytology and forceps biopsy resulted only in a minor increase in diagnostic sensitivity to 60.3% （35/58 patients）. In 20/58 patients （34.5%）, diagnosis were obtained by both positive cytology and positive histology, in 11/58 （19%） by positive histology （negative cytology） and only 4/58 patients （6.9%） were confirmed by positive cytology （negative histology）.CONCLUSION： Brush cytology and forceps biopsy have only limited sensitivity for the diagnosis of malignant hilar tumors. In our eyes, additional diagnostic techniques should be evaluated and should become routine in patients with negative cytological and histological findings.     

Role of laparoscopy in the evaluation of patients with suspected hepatic or peritoneal malignancy.

The purpose of this study was to determine the role of laparoscopy in patients with suspected hepatic or peritoneal malignancy and a normal computerized tomograph (CT). Twenty-five consecutive patients with a normal liver and no peritoneal lesions on CT were evaluated. Patients with a documented primary neoplasm or a positive ascitic fluid cytology were excluded. At laparoscopy, malignancy was documented by biopsy in 12 patients for an incidence of 48%. Of the patients with exudative ascites, 75% had peritoneal metastases. In addition seven patients had benign liver disease documented by laparoscopic biopsy. Liver enzymes were not helpful in distinguishing benign and malignant disease in this group of patients. This study indicates that a negative CT does not exclude liver or peritoneal malignancy. Laparoscopy has a significant yield in patients with a negative CT suspected of having hepatic or peritoneal malignancy and is the procedure of choice in evaluating these patients.     

Role of galectin-3 immunodetection in the cytological diagnosis of thyroid cystic papillary carcinoma

OBJECTIVE: Cystic thyroid lesions can harbour an occult papillary carcinoma, which fine needle aspiration (FNA) biopsy may fail to detect. Recently, new markers such as galectin-3 lectin have been proposed to distinguish benign from malignant thyroid lesions of follicular origin. The aim of this study was to assess the role of galectin-3 immunodetection in a series of FNA cytological samples of benign and malignant thyroid cystic nodules. METHODS: We retrospectively analysed galectin-3 expression by immunoperoxidase staining on 32 cytological paraffin-embedded samples of cystic papillary carcinoma and on 12 samples of benign cysts, both obtained by FNA biopsy. Specificity, sensitivity, positive/negative predictive values, and accuracy of standard cytological examination and galectin-3 immunodetection were assessed. RESULTS: Among cystic papillary carcinomas, 29 of 32 samples were galectin-3 positive, whereas standard FNA cytology made a correct diagnosis in only 25 of 32 samples. All the benign cysts were negative for galectin-3. In comparing the sensitivity and specificity of the two methods, it appeared that both had a 100% specificity, whereas the sensitivity of cytological examination alone was 75% versus 89.3% obtained by galectin-3 immunohistochemistry. CONCLUSIONS: Galectin-3 immunostaining represents a valid pre-operative adjunct to pick up malignant cells in those cases where a very poor number of epithelial cells may lead to a cytological misdiagnosis. Therefore, we suggest that in poorly cellular FNA biopsies of simple or complex thyroid cysts, galectin-3 expression by epithelial cells is consistent with a cystic carcinoma and supports surgical treatment indication.     

端粒酶检测对良恶性腹水鉴别诊断的价值

目的检测腹水脱落细胞端粒酶活性，探讨端粒酶对良恶性腹水的鉴别诊断价值。方法用半定量TRAP-银染法检测38例恶性腹水和20例良性腹水(对照组)脱落细胞端粒酶活性。结果肝硬化、结核性腹膜炎腹水脱落细胞不能检出端粒酶活性，而癌性腹水94．7％端粒酶阳性。所有细胞学检查阳性的恶性腹水端粒酶均为阳性，而3例细胞学检查阴性但端粒酶阳性的恶性腹水，当复查细胞学检查时，其中1例发现了恶性瘤细胞。结论癌性腹水端粒酶阳性。端粒酶活性检测对良恶性腹水有重要鉴别诊断价值，尤其对细胞学检查阴性的患者。     

Cytodiagnosis in the management of extrahepatic biliary stricture.

A total of 117 patients presenting with extrahepatic biliary strictures between 1981 and 1989 had 206 cytological examinations of the bile duct or bile (153 non-operative, 53 intraoperative) to establish the presence of malignancy. A final diagnosis of cholangiocarcinoma was made in 88 patients, with 29 patients having benign biliary strictures. The cytological techniques used were fine needle aspiration (n = 102) or brushing (n = 24) of the bile duct, or exfoliative cytology of bile (n = 80). Forty one patients with malignancy had two or more examinations with differing results between samples in 20 cases. The overall sensitivity was 72%. There was only one false positive result, giving a patient predictive value of positive cytology of 98%. Intraoperative cytology was more sensitive than non-operative examination (80% v 42%). Overall, the sensitivity of fine needle aspiration (67%) was greater than that of brush cytology (40%) or exfoliative cytology (30%). No complications were encountered. Cytodiagnosis of extrahepatic biliary strictures is a safe procedure which is not technically demanding, and as it has a high sensitivity and predictive value for positive cytology, cytological confirmation of malignancy should be sought in all clinically and radiologically suspicious cases.     

Evaluation of tumor markers for the differential diagnosis of benign and malignant ascites

Introduction. The diagnosis of malignant ascites is a challenging problem in clinical practice, non-invasive techniques should be developed to improve diagnostic accuracy. The diagnostic performances of tumor markers in malignant ascites remained unsettled. Our aim was to evaluate diagnostic performance of tumor markers in differential diagnosis of benign and malignant ascites.Material and methods. A total of 437 patients were enrolled, and the relevant parameters of the patients were analyzed for the differentiation of benign ascites from malignant ascites.Results. At the predetermined cutoff values of tumor makers, tumor markers in ascitic fluid showed better diagnostic performance than those in serum. Combined use of tumor markers and the cytology increased the diagnostic yield of the latter by 37%. In cytologically negative malignant ascites, tumor markers provided assistance in differentiating malignant ascites from benign ascites, and the combination of ascitic tumor markers yielded 86% sensitivity, 97% specificity.Conclusion. Use of a panel of tumor markers exhibited excellent diagnostic performance in diagnosing malignant ascites, which indicated the detection of tumor markers may represent a beneficial adjunct to cytology, thus guiding the selection of patients who might benefit from further invasive procedures.