EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma

BACKGROUND: The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. OBJECTIVES: To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy, and evaluate the impact of EUS-FNA on patient selection for liver transplantation. DESIGN: Retrospective case series. SETTING: Tertiary referral EUS unit. PATIENTS: Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. INTERVENTIONS: EUS-FNA. MAIN OUTCOME MEASUREMENTS: Lymph-node morphology and echo features. RESULTS: EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity, with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy. The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. LIMITATIONS: Single institution, retrospective analysis. CONCLUSIONS: EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.     

Is EUS-FNA of solid-pseudopapillary neoplasms of the pancreas as a preoperative procedure really necessary and free of acceptable risks?

BackgroundSolid-pseudopapillary neoplasms (SPNs) of the pancreas are infrequent tumors since, as of 2014, only 2744 patients have been described. Its rarity, unclear histogenesis, pleomorphic aspect on radiology (cystic, solid or mixed) and unpredictable biological behavior with an insidious high-grade malignant potential make SPN difficult to recognize preoperatively even in its target patient population which is predominantly composed of young women (about 87% of cases).MethodsEndoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed to improve the preoperative diagnostic yield for this tumor and obviate the risks formerly given by percutaneous biopsy.ResultsIn light of our experience, such a procedure could not be so innocuous as generally acknowledged.ConclusionWe report the first case of rupture of pancreatic SPN following EUS-FNA and entertain both the actual and potential complications ensuing from this type of mishap.     

Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions

BackgroundCytologic diagnosis by endoscopic ultrasound-guided fine needle aspiration is associated with low sensitivity and adequacy. A newly designed endoscopic ultrasound-guided fine needle biopsy device, endowed with a side fenestration, is now available.AimsWe carried out a study with the aim of evaluating the feasibility, safety, and diagnostic yield of the 22-gauge needle with side fenestration for endoscopic ultrasound fine needle aspiration and biopsy of pancreatic cystic lesions.Methods58 patients with 60 pancreatic cystic lesions consecutively referred for endoscopic ultrasound guided-fine needle aspiration were enrolled in a prospective, dual centre study, and underwent fine needle aspiration and biopsy with the 22-gauge needle with side fenestration.ResultsFine needle aspiration and biopsy was technically feasible in all cases. In 39/60 (65%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. In lesions with solid components, and in malignant lesions, adequacy was 94.4% (p = 0.0149) and 100% (p = 0.0069), respectively. Samples were adequate for histologic evaluation in 18/39 (46.1%) cases. There were only 2 (3.3%) mild complications.ConclusionsFine needle aspiration and biopsy with the 22-gauge needle with side fenestration is feasible, and superior to conventional endoscopic ultrasound-guided fine needle aspiration cytology from cystic fluid, particularly in pancreatic cystic lesions with solid component or malignancy, with a higher diagnostic yield and with no increase in complication rate.     

胰头部肿块定性诊断

常见的胰头部肿块包括胰头癌、慢性肿块型胰腺炎、胰腺内分泌肿瘤和囊(实)性肿块(包括囊实性假乳头状肿瘤、囊腺瘤、假性囊肿、真性囊肿).胰头部肿块的定性诊断,尤其胰头部实质性肿块的诊断十分辣手.     

Ultrasound techniques in the evaluation of the mediastinum,part 2: mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques,clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node (MLN) staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [endoscopic ultrasound fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all MLNs can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review in two integrative parts is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part 1 deals with an introduction into ultrasound techniques, MLN anatomy and diagnostic reach of ultrasound techniques and part 2 with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.