Usefulness of EUS-guided fine needle aspiration (EUS-FNA) in the diagnosis of functioning neuroendocrine tumors

BACKGROUND: Localization of neuroendocrine tumors may be challenging. The role of EUS-FNA in this setting is unknown. METHODS: Ten patients with clinically suspected functioning neuroendocrine tumors (hormonal disturbances) underwent EUS-FNA to determine the location and to confirm the diagnosis cytologically. OBSERVATIONS: EUS identified 14 tumors in these 10 patients. In all but one patient CT did not demonstrate the tumor or missed at least one of multiple lesions. Mean tumor size was 12 mm (range 4-25 mm). Tumor locations were pancreas (n = 13) and duodenal wall (n = 1). Eleven of the 14 detected lesions were aspirated under EUS with accurate diagnosis in all cases. Surgical confirmation of EUS-FNA findings was available in 7 patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS is a highly accurate technique for visualization of small functioning neuroendocrine tumors not evident on CT and for identification of patients with multiple lesions. EUS-FNA safely provides cytologic confirmation with high accuracy in these patients.     

EUS-guided fine needle aspiration of idiopathic abdominal masses

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) has significantly increased the diagnostic capability of EUS. FNA can also be helpful in the diagnosis of non-GI disorders. The role of EUS-FNA in the diagnosis of idiopathic abdominal masses has not been determined. This study evaluated the diagnostic accuracy of EUS-FNA of abdominal masses of unknown cause and its impact on subsequent evaluation and therapy. METHODS: Thirty-four patients from 5 tertiary referral centers (21 women, 13 men; mean age 54 years, range 27-72 years) with idiopathic abdominal masses underwent EUS-FNA. Presenting symptoms included the following: pain (29 patients), weight loss (15), altered bowel habits (7), nausea/vomiting (6), abnormal liver function tests (4), palpable mass (4), and urinary retention (1). Four patients had a history of intra-abdominal cancer (2 cervical, 1 ovarian, 1 colon). A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available in all patients. Abdominal masses were classified into 3 disease categories: infectious, benign/inflammatory, and malignant. RESULTS: Final diagnosis included infectious (5), benign/inflammatory (6), and malignant (23) abdominal mass. Overall, EUS-FNA established a tissue diagnosis in 29 of 34 patients (85%) in all 3 categories (infectious, 80%; benign/inflammatory, 67%; malignant, 91%). EUS-FNA was instrumental in directing subsequent evaluation in 29 patients (85%) and therapy in 26 (77%). The number of fine needle passes for adequate tissue sampling was lower for nonmalignant (2.2-3.2) versus malignant diseases (4.6). One complication occurred (perirectal abscess) and was treated successfully with antibiotics. CONCLUSIONS: EUS-FNA of idiopathic abdominal masses is safe and accurate and helps to guide subsequent evaluation and therapy in the majority of patients. The most common and promising area seems to be EUS-FNA of malignant abdominal masses. Transluminal EUS-FNA provides minimally invasive tissue sampling and obviates the need for exploratory laparotomy.     

Isolated pancreatic metastasis from a malignant pleural mesothelioma diagnosed using endoscopic ultrasonography-guided fine needle aspiration biopsy

To the Editor: Malignant pleural mesothelioma is a rare and aggressive form of cancer with a poor prognosis[1].Its progression is mainly a direct invasion from ...     

Mammary hydatid cyst diagnosed by fine needle aspiration

INTRODUCTION: Echinococcal involvement of the breast is extremely rare and usually not included in the differential diagnosis of breast lumps. OBSERVATION: This is an unreported case of a 56-year-old woman who came with a 3 cm mammary mass. Mammography showed a dense well-circumscribed lesion with calcifications. The diagnosis was established by fine needle aspiration and confirmed by pathological study. CONCLUSION: Hydatid cyst of the breast is rare. The diagnosis by fine needle aspiration is controversial. The treatment is based on complete excision of the cyst.     

Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) is a highly accurate method of detecting malignant lymphadenopathy. The optimal methods for performing EUS-FNA to maximize sensitivity and to minimize the number of needle passes necessary are unknown. This is a report of the results of a prospective randomized controlled trial to determine the effect of suction, the site of FNA (edge or center of lymph node), and the method of preparation of cytologic specimens on accuracy, number of needle passes needed, and specimen quality. METHODS: Consecutive patients with lymphadenopathy detected by EUS underwent FNA. Each lymph node was sampled with or without suction and from the edge or center in a 2 x 2 factorial design. The samples were expressed onto slides for cytology, and the residual material in the needle was analyzed by the cytospin-cellblock technique. Each aspirate was individually characterized for a diagnosis of malignancy, cellularity, and bloodiness. RESULTS: Forty-three patients with a total of 46 lymph nodes were evaluated. The final lymph node diagnosis was benign in 22 (48%), "suspicious for malignancy" in 6 (13%), and malignant in 18 (39%). The use of suction was associated with an increase in the cellularity of the specimen, but did not improve the likelihood of obtaining a correct diagnosis (OR 1.52: 95% CI [0.81, 2.85]). Samples obtained with suction were of worse quality because of excessive bloodiness (OR 4.7: 95% CI [1.99, 11.24]). Aspiration from the edge of the lymph node (compared with the center) did not increase the likelihood of a correct diagnosis (OR 1.16: 95% CI [0.42, 3.21]). For 78% of malignant lymph nodes, the correct diagnosis was obtained on the first needle pass and for 100% by the third pass. Cytospin-cellblock methods did not add any additional diagnostic information compared with direct smear cytology. CONCLUSIONS: The traditional method of applying suction during EUS-FNA does not improve diagnostic accuracy and worsens specimen bloodiness compared with FNA without suction. The site of FNA within the lymph node does not affect accuracy. When EUS-FNA is necessary, our recommendation is up to 3 FNAs without suction from the most convenient and safe location within abnormal-appearing lymph nodes.     

EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unknown etiology

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) has significantly expanded the diagnostic capability of GI EUS. FNA technology can also be helpful in the diagnosis of non-GI disorders. The role of EUS-guided FNA in the diagnosis of mediastinal lymphadenopathy of unknown etiology has not been described. The aim of this study was to evaluate the diagnostic accuracy and impact on subsequent evaluation and therapy of EUS-FNA in mediastinal lymphadenopathy of unknown cause. METHODS: Sixty-two patients (40 men, 22 woman; mean age 56 years, range 16-91 years) with mediastinal lymphadenopathy of unknown etiology underwent EUS-FNA at 6 tertiary referral centers. Presenting symptoms included the following: dysphagia, 6 patients; night sweats, 14; cough, 8; chest pain, 10; odynophagia, 10; fever, 6; weight loss, 8; and asymptomatic/abnormal radiograph, 12. A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available for all patients. EUS-FNA results were classified under 3 disease categories: (1) benign/infectious; (2) malignant pulmonary; and (3) malignant mediastinal (e.g., lymphoma, metastatic malignancy). Four EUS features were used as criteria for lymph node metastases: size greater than 1 cm, round shape, sharp border, and homogeneous/hypoechoic echo pattern. RESULTS: Final diagnoses included benign/infectious lymph nodes, 26; malignant pulmonary, 24; and malignant mediastinal, 12. EUS-FNA established a tissue diagnosis in 56 of 62 patients (90%). EUS criteria for malignant lymph nodes were more frequently present in malignant pulmonary (mean 2.6 features) and malignant mediastinal (mean 2.8) than benign/infectious (mean 1.9) lymph nodes. EUS results influenced subsequent evaluation in 87% and therapy in 87% of patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS-FNA in patients with mediastinal lymphadenopathy is safe and guides subsequent therapy in the great majority of cases. Transesophageal EUS-FNA of mediastinal lymph nodes provides minimally invasive tissue sampling, obviating the need for mediastinoscopy or bronchoscopy.     

Usefulness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for undiagnosed intra-abdominal lymphadenopathy

Background  The differentiation between benign and malignant abdominal lymph nodes is difficult, especially if no primary site is evident or if cancer resection was remote in time. The aim of this study was to evaluate the yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in patients with undiagnosed intra-abdominal lymphadenopathy. Methods  Fifty-seven consecutive patients with undiagnosed abdominal lymphadenopathy who were registered in our EUS-FNA database from January 1997 to December 2007 were reviewed. EUS-FNA was carried out using a 22-G needle. The final pathological diagnosis was based on the cytopathological, histological, and immunohistochemical (IHC) findings. Results  Adequate specimens were obtained in 93% cases. The final diagnoses included local recurrence of malignancy after resection (n = 16), lymphoma (n = 12), and benign/reactive changes (n = 17). The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of EUS-FNA were 94, 100, 100, 90 and 96%, respectively. In addition, it was also possible to classify lymphoma subtypes in 83% of cases. No complications occurred during the procedures. Conclusions  EUS-FNA is clinically very useful for establishing the diagnosis of abdominal lymphadenopathy of unknown cause and can provide sufficient tissue for IHC and subtyping of lymphomas.     

Retroperitoneal choriocarcinoma diagnosed by endoscopic ultrasonography-guided fine needle aspiration biopsy

A 25-year-old man, with a retroperitoneal bulky mass invading the posterior pancreas head, was referred to investigate and treat his rapidly advancing disease. An endoscopic ultrasonography guided-fine needle aspiration biopsy (EUS-FNAB), performed the next day, and followed by immunostaining for human chorionic gonadotropin (hCG), led to a histological diagnosis of choriocarcinoma. An elevated level of serum hCG also supported the diagnosis. Systemic chemotherapy by etoposide and cisplatin was initiated within a week, with precautions taken to avoid tumour lysis syndrome and choriocarcinoma syndrome. EUS-FNAB enabled a prompt diagnosis and suitable treatment for choriocarcinoma and was considered as an effective diagnostic tool for rare tumours with rapid progression.     

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

BACKGROUNDPancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.CASE SUMMARYWe reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.CONCLUSIONAccurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.